Abstracts
2000 Digestive Disease Week

# 2282 Subparietal Hepaticojejunal Access Loop for Intrahepatic Stones.
Jake E. J. Krige, Stephen J. Beningfield, Philippus C. Bornman, John Terblanche, Cape Town, South Africa

The natural history of primary intrahepatic stones and strictures is characterized by progression with recurrent biliary sepsis. AIM: This study evaluated the efficacy of surgery with a subparietal hepaticojejunal biliary access loop for recalcitrant intrahepatic stones not amenable to endoscopic extraction. METHOD: Twenty three symptomatic adult patients (15 women; 8 men : mean age 34 years; range 22-64 years) with intrahepatic stones and strictures secondary to iatrogenic hepatic duct injury (n=5) Caroli’s disease (n=2) choledocal cyst (n=2) and primary intrahepatic stones (n=14) were treated during a ten year period. All patients underwent laparotomy, bile duct exploration, intraoperative stricture dilatation, stone extraction and construction of a Roux-en-Y side-to-side hepaticojejunostomy with a 12 cm jejunal access loop marked with silver clips and attached to the subparietal anterior abdominal wall. Subsequent postoperative percutaneous transjejunal biliary dilatation of residual or recurrent intrahepatic strictures and stone extraction was performed using a biliary guide-wire, co-axial catheter and 7 Fr Gruntzig angioplasty balloon catheter. Patients were followed prospectively and details of the number and type of procedures performed, stone clearance rates, morbidity and subsequent outcome were recorded with a median follow up of 47 months. RESULTS: The distribution of intrahepatic stones was predominantly left sided [left lobe was the site of disease in 61% (14/23), right lobe in 1 (4%) and bilateral disease in 35% (8/23)]. Six patients underwent additional left lobectomy at the initial operation because of associated atrophy of the left lobe. Following surgery, stone removal and/or stricture dilatation was performed on 101 occasions [median (range) of 4(1-20) procedures per patient]. Complete stone clearance was achieved in 83% (19/23) of patients with partial clearance in the remaining four. There were no major complications and no mortality associated with the procedures. CONCLUSION: The combined radiological and surgical approach using a Roux-en-Y hepaticojejunostomy and biliary access loop with post-operative percutaneous transjejunal biliary dilatation and stone extraction provides an effective method of treating symptomatic patients with complex residual or recurrent intrahepatic strictures and stones.