Duodenotubular Flap-New Biliary Reconstructive Procedure

Although Roux-en-Y hepaticojejunostomy is considered the gold standard of biliary reconstruction after excision of a choledochal cyst, there is increasing popularity of hepaticoduodenostomy, as it is easier to perform laparoscopically and provides physiologic bile drainage into the duodenum. Our animal research study had the goal to develop and test a new biliary reconstructive procedure (the duodenotubular flap [DTF]), with the advantages of providing physiological bile flow into the duodenum, technical simplicity of duodenal conduit construction, and ability of endoscopic assessment in case of complications. The DTF procedure consists of transection of the common bile duct (CBD), construction of the DTF from the second part of the duodenum, and biliary-enteric anastomosis. The first group of 6 dogs underwent reconstruction as a single surgical procedure. The second group of 4 dogs underwent the DTF procedure after the preparatory step of laparoscopic clipping of the CBD (for 7 days), to simulate the pathology of the choledochal cyst (extrahepatic biliary obstruction) and to ease the anastomosis. Laboratory analyses were performed pre- and postoperatively. From the first group, 3 dogs developed a postoperative leak at the biliary-enteric anatomosis. The leak was recognized on postoperative day 4 in 2 dogs. They underwent an emergency abdominal exploration with redo anastomosis and had a complete recovery. The third dog died suddenly on postoperative day 10. Autopsy revealed incomplete disruption of the biliary-enteric anastomosis. In the second group, 3 dogs had an uneventful recovery, but 1 died on postoperative day 3. Autopsy revealed intraperitoneal bleeding with intact anastomotic and staple sites. None of the dogs in either group experienced leak at the staple lines, and none of the 8 surviving dogs developed postoperative cholangitis during the follow-up period from 15 to 20 months. The DTF procedure is feasible, simple, and quick, simulating physiological anatomy. Regarding the safety, a wide anastomosis seems to be the core of success.