Iatrogenic Complex Hilar Biliary Strictures: Management Strategies and Long-term Outcome

Management of patients with benign biliary strictures (BBS) involving the hepatic hilar confluence needs a focused strategy for preoperative, intraoperative and postoperative interventions to ensure good long-term outcome. An analysis of patients operated for BBS between 2008 and 2019 was conducted by review of patients’ database. Complex hilar biliary strictures (CHBS) were defined as Bismuth type IV/V strictures or a strictured Roux-Y hepaticojejunostomy (RYHJ) at the hilum. Clinical details, operative approach, outcomes and follow-up data were reviewed. Of 65 patients with BBS, 58 (89%) were post-cholecystectomy. Nineteen (29%), with median age 35 (22–68) years, 6 of which being males, satisfied the definition of CHBS. Seven of these 19 had strictured RYHJ from prior repair. The median injury-repair interval was 8 (1–228) months. Seven (36.8%) had preoperative percutaneous transhepatic biliary catheter (PTBC) placement to facilitate intra-operative identification of segmental ducts. All patients underwent reconstruction with RYHJ. One needed right hepatectomy. In four, transanastomotic stents were retained; they underwent early protocol-based postoperative balloon dilatation of the anastomosis. There was no perioperative mortality/bile leak. The median duration of follow-up was 85 (15–129) months. One patient presented with anastomotic stricture of the right hepatic duct 7 years later. All others remain asymptomatic with normal liver function tests. A standardized approach with preoperative identification of all ducts, placement of PTBC into isolated ducts and selective use of transanastomotic stents, early balloon dilatation results in excellent long-term outcomes.