title: Factors predicting failure following high bilio-enteric anastomosis for post-cholecystectomy benign biliary strictures.
abstract: BACKGROUND
  Failures following Roux-en-Y hepatico-jejunostomy (HJ) for post-cholecystectomy benign bile duct strictures (BBS) pose significant challenge. This study was aimed to find out the factors predicting failure after surgical repair in patients with BBS.
  
  
  METHODS
  Between January 1989 and May 2007, 364 patients underwent Roux-en-Y HJ to the hilum for BBS. With a median follow-up of 61 (6-212) months, 334 (92%) patients had successful outcome and 30 (8%) had failure. A multivariate analysis was performed to find out the factors predicting failure.
  
  
  RESULTS
  Thirty patients who had failure became symptomatic after a median of 35 months (3 days-190 months) after surgical repair. Out of 30 patients, 11 (37%) were experiencing occasional episodes of cholangitis responding to antibiotics. All have patent anastomosis on nuclear scintigraphy and/or cholangiography. Cholangiogram demonstrated anastomotic stricture in 19/30 (63%) patients. Eighteen patients underwent re-intervention for re-strictures (nine--percutaneous balloon dilatation of the stricture, five--revision HJ, one--right hepatectomy, three--a combination of interventions). One patient refused to undergo a planned percutaneous balloon dilatation. Out of 18 patients, 12 (67%) had successful outcome following re-interventions. One patient who underwent revision HJ after a failed percutaneous balloon dilatation died in the immediate postoperative period. Preoperative bilirubin (p = 0.001), attempted bilio-enteric anastomosis before referral (0.004), cirrhosis (0.006), portal hypertension (p = 0.056), repair in the presence of external biliary fistula (0.000), and spontaneous bilio-enteric fistula (p = 0.011) were the factors found to be predicting failure of surgical repair on multivariate analysis.
  
  
  CONCLUSIONS
  Previous attempts of repair and delay in repair which predispose cirrhosis and portal hypertension may cause failure of surgical management in patients with BBS. In patients presenting with external biliary fistula, for a better outcome, surgical repair may be delayed till the fistula resolves.
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, 226014, UP, India.
authors.forename: Biju
authors.initials: B
authors.lastname: Pottakkat
authors.forename: Ranjit
authors.initials: R
authors.lastname: Vijayahari
authors.forename: Anand
authors.initials: A
authors.lastname: Prakash
authors.forename: Rajaneesh Kumar
authors.initials: RK
authors.lastname: Singh
authors.forename: Anu
authors.initials: A
authors.lastname: Behari
authors.forename: Ashok
authors.initials: A
authors.lastname: Kumar
authors.forename: Vinay K
authors.initials: VK
authors.lastname: Kapoor
authors.forename: Rajan
authors.initials: R
authors.lastname: Saxena
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects; D002763:Cholecystectomy / Q000009:adverse effects*; D002768:Choledochostomy / Q000009:adverse effects; D002779:Cholestasis / Q000453:epidemiology* / Q000209:etiology / Q000601:surgery; D003135:Common Bile Duct / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007194:India / Q000453:epidemiology; D007583:Jejunum / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D015996:Survival Rate / Q000639:trends; D017211:Treatment Failure; D055815:Young Adult