Jejunal Mucosal Graft A Sutureless Technic for Repair of High Bile Duct Strictures

Marvin J. Wexler, MSc, MD, CM, FRCS(C),”

Montreal, Canada

Rodney Smith, MS, FRCS (Eng), London, England

The number of times the average surgeon is called on to repair secondarily a traumatic stricture of the biliary tree, usually the result of inadvertent and unrecognized injury to the common bile duct at the time of previous cholecystectomy, is extremely small. As a result, the success rate of such reconstructive surgery is notoriously poor. However, even in the hands of biliary experts at referral centers, initial failure rates of 35 to 50 per cent are not uncommon [l-4]. Numerous operations have been proposed and employed for re-establishing the flow of bile from the liver into the intestinal tract. Their diversity is indicative of the many difficulties associated with the postoperative course of patients requiring such measures. Most surgeons would today agree that some form of hepaticojejunostomy should be selected in most cases [3-6]. The principles for successful repair of a biliary stricture are basic and well established. The anastomosis should be large, with minimal encroachment on, or irregularity of, the lumen. Epithelial to epithelial apposition at all points is desirable. There must be an adequate blood supply and no tension on the suture line. Unfortunately, the injury to the duct, in most instances, is so high and the duct itself so encased in dense scar tissue that by

From the Surgical Services, St. George’s Hospital, London; S.W.l, England. Reprint requests should be addressed to Dr Marvin J. Wexler, Department of Suroarv. Roval Victoria lios~ftal. Montreal. Quebec. Canada. Presented at the ktaenth Ann& Meeting of tile So&y for Surgery of the Alimentary Tract, San Francisco. California, May 21 and 22, 1974. Centennial Fellow, Medical Research Council of Canada. ??

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any normal suture mechanism, the principles just outlined are impossible to achieve with resultant restenosis at the anastomosis. In 1967 an entirely new principle was first applied in an attempt to solve these problems [7]. This technic was called a jejunal “mucosal graft” operation [8]. It is the purpose of this communication to describe and evaluate the technic and its newer and more recent modifications that we have now applied in over one hundred such operations since 1969. Operative Technic The porta hepatis is exposed by freeing the numerous adhesions to the liver capsule and widely mobilizing and retracting the hepatic flexure of the colon inferiorly and the right lobe of the liver superiorly. The biliary tree is usually located through the dense scar tissue by needle aspiration or by carefully, but blindly, transecting the scar in the liver hilum with a small scalpel blade until a trickle of bile is seen. (Figure 1.) No attempt is made to dissect or isolate the duct itself. Dilators are introduced, enlarging the opening in the scar which is then incised, widely split anteriorly, and everted by quadrilateral sutures placed through the full thickness of the duct and liver substance. (Figure 2a.) The intrahepatic ducts are probed and irrigated and a cholangiogram is obtained through a large occluding rubber catheter to ensure that both right and left hepatic ducts are patent, and above the point at which we have entered the biliary tree. Through this opening a curved

The American Journal ol Surgery

Jejunal Mucosal Graft

Desjardins gallstone forceps is passed into the left hepatic duct as far as possible toward the anterior surface of the liver. (Figure 2a.) It is then passed through the remaining liver substance anteriorly and a latex rubber tube, just slightly smaller than the duct itself, is grasped and drawn through the liver and out the opening of the hepatic duct. (Figure 2b.) Roux-en-Y jejunostomy with a 10 to 12 inch defunctionalized limb is fashioned in an antecolic position and the upper end closed. (Figure 3a.) A small disk of the seromuscular coat is removed carefully near the end of the Roux-en-Y loop, and a protruding mucosal diverticulum created with a tiny central hole. (Figure 3b.) Side holes are made at appropriate sites in the rubber catheter which is then passed into and anchored to the Roux-en-Y loop through the opening in the previously created mucosal diverticulum. (Figure 4.) This is done with two heavy chromic sutures placed through the jejunal and anterior catheter wall. The tube is pulled back through the liver, carrying with it the sleeve of jejunal mucosa up into the duct system and into contact with the epithelium of the dilated intrahepatic bile ducts. (Figure 5.) The tube is exteriorized through a separate stab wound on the anterior abdominal wall. The seromuscular layer of the jejunum around the “graft” is firmly anchored with two or three sutures placed through the thickened liver capsule and scar tissue around the duct in order to prevent undue tension on the graft or Roux-en-Y loop in the postoperative period.

Figure 1. The biiiafy tree is located through the dense scar tissue by aspiration of transecting in the liver hi/urn. No attempt is made to dissect the duct itseit.

A drain is placed in the subhepatic space. The transhepatic tube is placed on suction during the initial postoperative days which effectively prevents biliary leakage around and out the graft site. This tube is eventually placed on simple gravity drainage and clamped for increasing periods of time and then continuously, except for daily irrigations, to wash out any accumulated sludge in the biliary tree. It is removed after three months. More recently, and in cases in which the duct system is damaged above the level of the junction of the right and left hepatic ducts, the same technic is used, but two transhepatic tubes are employed. One tube is brought through the left hepatic duct and the second through an anterior branch of the

WtketWdmvm through theliver

a

Figure 2. The duct opening is widely split and everted by quadrilateral sutures. A curved gaiistone forceps is passed into the ieft hepatic duct through the liver surface anterioriy (a). A latex rubber tube is drawn through the liver out the hepatic duct opening (b).

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Figure 3. Roux-en-Y jejunostomy with a 70 to 12 inch detunctionaitxed limb is constructed (a). A small seromusculaf dish is removed near the end of the loop and a protruding mucosai divertkuium created with a tiny central hole (b).

Figure 4. The transhepatic tube with appropriate side hoies is passed into the mucosai divertkutum and anchored to the Roux-en-Y loop.

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Figure 5. The sieeve of jejunal mucosa is carried up into the intrahepatk bile ducts by withdrawing on the transhepatk tube. The jejunal wati is then anchored to the liver capsule.

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right hepatic duct. Both tubes are separately inserted and fixed in the same jejunal diverticulum and the “mucosal graft” is drawn into the hilum of the liver, as previously described, by simultaneously drawing both transhepatic tubes through the liver.

Material and Results From January 1969 through January 1972, over one hundred bile duct reconstructions for benign strictures have been performed at St. George’s Hospital, London, England. Sixty-one repairs utilizing the principles of this sutureless technic were performed in fifty patients and form the substance of the present report. All patients who had malignant neoplasms or sclerosing cholangitis or in whom a low enough stricture was found which permitted easy performance of direct suture choledochointestinal anastomosis, end to end reanastomosis of the duct, or dilatation and plasty of previous repairs were excluded. All were patients referred after previous biliary tract operations and all except five had had failure of at least one previous attempt at repair whereas six had had between three and seven attempts before referral. A total of eighty unsuccessful attempts at repair had been made before referral whereas an additional thirteen operations had been performed at our hospital prior to the period under consideration in which a technic other than a mucosal graft procedure was usually utilized. There was thus an average of 1.86 unsuccessful reconstructions or 2.86 previous biliary tract operations per patient. A detailed analysis and correlation of the presenting history, signs and symptoms, serial liver function tests, liver biopsies, bacteriologic studies, and postoperative course, complications, and results will form the subject of a separate communication. Tables I, II, and III briefly summarize this experience. The majority of the patients were seriously ill with jaundice and hepatomegaly, recurring episodes of cholangitis, or chronic fistulas. (Table I.) Many had subhepatic abscesses. The average age was 45.6 (range, eighteen to seventy-three years) with a ratio of two females to every male. The usual operative time was 1.5 hours and the average postoperative hospital stay was 19.6 days (range, ten to fifty-one days). Morbidity was extremely low, the major complication being local infection around the cutaneous site of the transhepatic tube (40 per cent) or wound sepsis (24.6 per cent). Renal and pulmonary complications were almost negligible.

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TABLE

I

Presenting Signs and Symptoms Mucosal Graft Operations) Signs and Symptoms

Clinical jaundice Recurrent cholangitis Hepatomegaiy Pruritis Abdominal colic Chronic fistulas Sepsis Malabsorption Other (ascites, varices,

(Sixty-One _ Per cent 77.0 75.4 55.7 37.7 36.1 19.7 11.5 6.6 8.0

and splenomegaly)

Three patients died immediately postoperatively. One was a seventy-three year old woman who had massive hematemesis on the twelfth postoperative day; she died three days later. It was not certain whether this was from the liver substance, jejunal suture line, or stress ulcer. The second patient was a fifty-five year old man in whom massive bleeding developed on the eleventh postoperative day with hematemesis and bleeding out the transhepatic tube. Reoperation several days later revealed a large amount of blood in the TABLE II

Results of Sixty-One Mucosal Graft Repairs in Fifty Patients (January 1969 to January 1972)

Results Excellent (no jaundice, no cholangitis) Good (established biliarycirrhosis, jaundice, no cholangitis, well) Poor (recurrent cholangitis) Failed Operative death Subsequent death (liver disease) Reoperation (recurrent cholangitis) Inadequate follow-up data Total

TABLE III

No. of Patients

Per cent

40

65.6

3

4.9

2

3.3

3 1 11

24.6

1 61

1.6 100

Results of Fifty Patients Undergoing Sixty-One Mucosal Graft Operations (January 1969 to January 1972)

Results Well Jaundiced (established cirrhosis, stable, well) Ill (recurrent bouts cholangitis) Operative death Subsequent death (hepatic dysfunction) Unknown Total

No. of Patients

Per cent

40 3

80 6

2 3 1

4 6 2

1 50

2 100

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Roux-en-Y loop. The transhepatic tube was removed, but bleeding recurred. At postmortem examination, blood clot was found in the bile duct in which the transhepatic tube had been placed. The third patient was a thirty year old who, on the first postoperative day, experienced sudden high fever, hypotension, and cardiac arrest presumably from massive septicemia. Bile cultures grew Klebsiella and Staphylococcus pyogenes. The latter is an uncommon organism in our experience. Although 82 per cent of the patients had positive bile cultures at surgery, they were usually mixed gram-negative coli, Klebsielinfections consisting of Escherichia la, Proteus, and Streptococcus fecalis in decreasing frequency and occasionally alpha hemolytic streptococcus or Pseudomonas. Gram-negative antibiotic coverage is routinely given preoperatively although these organisms show various patterns of resistance due to long courses of antimicrobial treatment for cholangitis before referral. These same organisms were usually the cause of the wound infections and infections around the transhepatic tube. The bile rarely becomes sterile as long as the transhepatic tube is in place, and occasional mild episodes of cholangitis are not uncommon until the tube is removed. Three other patients had significant septicemia in the immediate postoperative period which was successfully treated. All patients were carefully and regularly seen at follow-up examinations and clinical and biochemical data were examined. The shortest postoperative assessment period was six months, the majority being over eighteen months. Results are summarized in Tables II and III. Approximately 70 per cent of the repairs were “successful” whereas 85 per cent of the patients have an ultimately successful result with an operative mortality of 6 per cent. Three patients, who had established biliary cirrhosis at the time of repair, remain jaundiced but are relatively well and working. Included in these results are all patients in whom the procedure was a sutureless “mucosal graft” technic regardless of the type of internal stent used. In the early part of the series, an internal Y tube was used, as previously reported [B], rather than the presently described technic with a transhepatic tube. Comments

It is a common occurrence that a patient who has sustained an initially unrecognized injury to the common bile duct (more often, the common hepatic duct) undergoes a series of operations,

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each one apparently successful for a while but each one later followed by furt,her obstructive jaundice and cholangitis. The immediate flow of bile through the newly constructed channel is usually satisfactory in experienced hands that can adequately locate the duct. As healing takes place, the duct often becomes narrowed and contracted by scar tissue. If what has been joined to the Roux-en-Y loop of jejunum or duodenum is merely a cylinder of scar tissue without an epithelial lining, as is often the case, it is certain to contract and the final result will be a new stricture. This occurs whenever there is inadequate mucosa to mucosa apposition. The most important objective is to perform the anastomosis between two mucosa-lined structures. Another major complication of this difficult anastomosis is bile leakage at the suture line. The mesodermic tissue responds to the toxic insult of contact with bile, especially chronically infected bile, with profound inflammatory reaction leading to either formation of dense cicatrix, breakdown of the suture line, or both. Satisfactory healing of the anastomosis also requires that it be protected from tension. This is difficult to achieve with technics that involve resection of the stricture [I] or wide mobilization of a scarred duodenal loop [2]. Also, the scarred duct, widely dissected from its adjacent structures in order to be anastomosed, may have an insufficient blood supply. Poor healing and actual necrosis of the wall result. Our experience parallels that of Warren et al [3,9], Lindenauer [5], and others [IO] in that the site of damage is usually high, just below the junction of the hepatic ducts in the common hepatic duct. Furthermore, with the postoperative bile leakage and inflammatory reaction that usually accompany the injury, the duct system undergoes further contraction and encasement in scar tissue, such that there is obliteration of most of the extrahepatic biliary tree between the hilum of the liver and the duodenum. This is invariably the case when there have been previous attempts at dissection and repair of the injury, as in the group being discussed. The problem, then, is how to perform an anastomosis of this kind technically but safely, with a minimal chance of restenosis. We agree strongly with Way and Dunphy [4] that there is an inverse relation between the technical difficulties encountered and the eventual results. The technic described has evolved over a period of many years in an attempt to develop a technically simple repair that adheres to the principles previously outlined.

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Modifications are continually precise analysis of results tages, we think, are obvious.

being made, difficult. The

making advan-

It is relatively simple and easy to perform. It requires no difficult and tedious dissection of the duct system itself, and there is no difficult choledochojejunal anastomosis to perform. This is particularly so when presented with a biliary fistula from a nondilated duct high in the liver hilum. The average operating time is only 1.5 hours. Mucosa to mucosa approximation is achieved with no sutures through or near the mucosa to compromise blood supply and prevent primary healing or promote scar tissue through foreign body reaction. As stated by Thorbjarnarson [II], healing by scar tissue may be aggravated by some of the current methods used for restoring continuity between the bile duct and intestine, such as dissection of the proximal end of the duct and joining it to the intestine by direct suture when this is technically feasible. Roth tend t.o compromise the already marginal intramural blood supply of the duct. Healing then occurs secondarily with epithelialization over a granulating surface. We firmly believe that mucosa to mucosa apposition is important to achieve, although some excellent results have recently been reported by Lane et al [6] using the Kirtley technic of hepatocholangiojejunostomy which makes no attempt to do this. Yet even these investigators accept the fact that such an objective is desirable if possible. This method does permit this apposition even in the highest of strictures. The use of indwelling tubes and splints and the length of time they should be used have long been a subject of controversy. When the “mucosal graft” operation was first developed, we employed a special internal latex rubber Y tube to hold the graft in place and act as a stent [7]. We found, as have Warren, Poulantzas, and Kune [3], that these tubes are often retained indefinitely and become occluded by biliary debris and sludge followed by cholangitis necessitating a second operation for its removal. More often, however, in many of our patients the tube dropped spontaneously into the bowel in the first few weeks and passed per rectum with early loss of the stent and resulting restenosis. Hertzer et al [IO] in their analysis of one hundred patients with biliary reconstruction at the Cleveland Clinic conclude that there is no evidence that prolonged use of a bile duct splint leads to better results than does short-term use of six weeks to three months. Indeed, some of the best results were obtained in the group of ten patients in whom no splint was used. Yet, these latter ten

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were patients in whom “the bile ducts were so dilated and thickened that a splint was not deemed necessary.” Moreover, analysis of their results shows that of a total of twenty-nine poor results, thirteen were in patients whose T tube splints were removed in less than three months; eight were in patients in whom the tube was an indwelling straight rubber catheter segment which passed spontaneously into the intestine usually “within a matter of weeks.” Moreover, 60 per cent had not had previous attempts at bile duct repair and a choledochorather than hepaticointestinal anastomosis was possible. At the opposite extreme, the Lahey Clinic group have long advocated prolonged internal splinting. They have recently reported their four year experience in forty patients with a modified Y tube splint [9]. This contains an additional solid core limb that is brought to the exterior and can be removed by gentle traction on the external limb when recurrent cholangitis occurs due to plugging, which invariably happens. They usually leave the tube in place for more than a year or until such symptoms as chills and fever occur as a result of the development of intrabiliary debris. This removal was necessary in eleven patients at an average of 8.2 months after insertion. A second operation for repair was required in seven of these patients. In twenty-one cases the tube was removed an average of sixteen months after insert,ion because of the “personal circumstances of the patient.” In an additional 10 per cent the external limb pulled off the Y tube without it, being removed and a second operation was required in half of these patients. We believe that the use of a transhepatic tube, as originally described in 1964 [12], is a more satisfactory alternative. Its employment in this technic is necessary for drawing along the mucosal graft through the scar tissue under t,he liver and into contact with the epithelium of the bile ducts and for initially maintaining it in this position. It then acts as a stent tube holding open the internal lumen of the mucosal graft against the ductal mucosa during the period of early healing. It can be anchored firmly, yet easily removed when desired without reoperation. It also provides access to the biliary tree for daily irrigations. Since it. is irrigated from the proximal end of the tube and thus throughout its entire length, the buildup of sludge in the tube and biliary tree is diminished. Periodic radiography and direct bile sampling for culture are also possible. In the early postoperative period it is placed on suction. This serves to minimize and

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prevent biliary leakage around and out the graft site with its attendant fibroblastic reaction which contributes to secondary periductal fibrosis. However, it is often a significant annoyance and inconvenience to the patient with local infection at the cutaneous exit site. It is routinely removed in three or four months at which time we believe there is no longer danger of early inflammatory stricture formation, and scar retraction is complete. Further maintenance invites bacterial infection, foreign body reactions, and sludging which may be detrimental. We agree with Aust et al [13] that the chronic foreign body irritation produced by an indwelling tube may promote rather than diminish the amount of scarring at the anastomosis but believe that a period of three months of internal splinting is essential. A detailed analysis of our failures with sixty-one mucosal grafts reveals that many were in the earlier group of patients in whom the internal Y tube was being used [8] and these patients invariably had passed their tubes spontaneously in the first two to four postoperative weeks. Even in the later group in which transhepatic tubes were used, it appears that in many of the failures the tube was inadvertently pulled out or fell out in the early postoperative period due to inadequate skin fixation or sloughing of the retaining stitch secondary to cutaneous infection around the tube. Only four patients have had major complications from the use of the transhepatic tube. Three patients had early biliary leakage at the site of exit of the tube from the surface of the liver which resulted in subphrenic collections requiring drainage. This can generally be avoided by choosing a tube of a diameter only slightly smaller than that of the duct into which it is passed. One of the deaths can be attributed to the use of the transhepatic tube which resulted in hematobilia. It is wise to caution against its use in patients with severely cirrhotic or fibrosed livers when the forceps may pass up the intrahepatic duct only with considerable difficulty. Saypol and Kurian [14] have described a technic using a transhepatic tube which safeguards against premature dislodgement. They believe that the stent should remain in place for two years, and their technic allows replacement of a plugged tube without reoperation. This, however, is untried in human subjects and has a number of potential hazards. It is well to recognize and emphasize that not all strictures can be fixed permanently regardless of the technic or care and skill of the surgeon. Although the ultimate measure of acceptance and

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success of any procedure

is permanence of the results obtained, in this case the restoration of a free flow of bile from the liver to the upper intestinal tract must be accomplished as safely and quickly as possible and with a minimum of morbidity and hospitalization time. The average operating time with this technic was 1.5 hours and the mean postoperative hospital stay was 19.6 days. For these reasons alone, we believe that this technic deserves serious consideration. We do not hesitate to reoperate at the earliest signs of restenosis as evidenced by recurrent clinical attacks of cholangitis, because of the ease and low morbidity with which further repair can be performed. It no longer becomes a major, tedious, and dreaded procedure. Pulmonary and renal complications have been almost negligible. We attribute this to the short operating time and the routine use of hypotensive epidural anesthesia, with intraoperative mannitol infusion in patients with significant jaundice. Our results (Tables II and III) compare most favorably with those of any recent series [46,9,10,13]. We recognize that the follow-up period is short and thus inadequate to assess the full percentage of recurrence. The superiority of the results obtained will undoubtedly decrease with time; however, the preliminary results are most encouraging, particularly if the severe problems of the group under analysis are considered. Before referral, all except five patients had had previous unsuccessful attempts at repair in addition to the original biliary tract surgery. Such tertiary and quaternary biliary tract surgery is complicated by obliterated landmarks, distorted anatomy, and severe scarring. Furthermore, the most favorable cases in any series, those with sufficient length and dilatation of the proximal duct system to permit a direct suture cho!edochointestinal ansstomosis, end to end reanastomosis of the duct, or dilatation and plasty of a previous repair, have been eliminated from consideration, not being part of this series and analysis. In the excellent results reported from the Cleveland Clinic [IO], only forty of one hundred patients had had a previous attempt at repair and in only nine patients was there insufficient proximal duct that hepaticointestinal rather than choledochointestinal anastomosis was necessary. Similarly, in the series reported by Way and Dunphy [4], only twenty-seven of eighty-seven patients had previous attempts at repair. The most likely time for permanent cure to be obtained is at the first attempt at repair. The severity of the problems in our group is further reflected by the high percentage of patients who present on refer-

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ral with recurrent cholangitis and hepatomegaly, indicating prolonged obstruction and significant delay between the original injury and referral. Protracted therapy with antibiotics for repeated episodes of cholangitis results not only in eventual biliary cirrhosis and inevitable unmanageable sepsis, but also in a progressive compromise in the quality of the intrahepatic and proximal biliary duct system with choledochitis and scarring that may result, in recurrent strictures. In our experience, if failure of a mucosal graft repair is going tr occur, it is usually clinically obvious within six months after removal of the transhepat,ic tube and often within a matter of weeks after its removal. This suggests that healing of the intrahepatically apposed and unsutured mucosa to mucosa anastomosis may be quite different from that of a sutured hepaticojejunal anastomosis at the hilum and perhaps may not be subject to the gradual and progressive contraction that may occur with the latter anastomosis. If an initially good mucosal positioning is obtained and then maintained with the internal splint, the results will be satisfactory; if not, the anastomosis will fail as soon as the internal conduit is removed.

Summary A simplified sutureless technic for the repair of hieh bile duct strictures is described. The technic combines the principle of a transhepatic tube together with a mucosal graft formed by removing a seromuscular patch near the end of a Roux-en-Y loop of jejunum creating a mucosal outpouching. The biliary tree is entered at the hilum of the liver and a latex rubber tube is drawn through the liver and anchored to the Roux-en-Y loop through the previously created mucosal diverticulum. The tube is nulled back into the liver carrving with it the sleeve of jejunal mucosa into the duct system in contact with the epithelium of the intrahepatic ducts. The technic is simple, easy, and quick. There is no difficult and tedious duct dissection or hepaticodochojejunal anastomosis to perform. It pror

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vides mucosa to mucosa approximation and eliminates the need for sutures through or near the mucosa to compromise the blood supply and prevent primary healing. The stent tube is easily removed without reoperation when desired. Finally, there is access to the biliary tree for daily irrigation, radiography, and cultures. From 1969 to 1972, sixty-one repairs were performed in fifty seriously ill patients utilizing the principles of this sutureless technic. All had had failure of previous attempts at repair with an average of 2.86 previous biliary tract operations per patient. Eight-five per cent of the patients have had an ultimately successful result. The mean postoperative hospital stay was only 19.6 days. Although the follow-up period is still short, these preliminary results are most encouraging. References 1. Cattell RB, Braasch JW: Primary repair of benign strictures of the bile duct. Surg GynecolObstet 109: 531, 1959. 2. Walters W, Ramsdell JA: Study of three-hundred eight operations for stricture of bile ducts. Follow-up periods of one to five or fiie to twenty years. JAMA 171: 872. 1959. 3. Warren KW. Poulantzas JK, Kune GA: Use of a Y-tube splint in the rep&r of biliary strictures. Surg Gynecol Obsfet 122: 785. 1966. 4. Way LW, Dunphy JE: Biliary stricture. Am J Surg 124: 287, 1972. 5. Lindenauer SM: Surgical treatment of bile duct strictures. Surgery 73: 875, 1973. 6. Lane CE, Sawyers JL, Riddell DH, Scott HW Jr: Long-term results of Roux-en-Y hepatocholangiojejunostomy. Ann Surg 177: 714, 1973. 7. Smith R: Strictures of the bile ducts. Proc R SOC Med 62: 131. 1969. 8. Smith R: Strictures of bile ducts, p 157. Progress in Surgery, vol 9. Basel, Karger, 197 1. 9. Warren KW, Mountain JC. Gray LW: Use of the modified Y tube splint in the repair of biliary strictures. Sufg Gynecol Obstef 134: 665, 1972. 10. Het-tzer NR, Gray HW, Hoerr SO, Hermann RE: The use of T-tube splints in bile duct repairs. Surg @neco/ Obstef 137: 413,1973. 11. Thorbiarnarson B: Repair of common bile duct injury. Surg GyhecolObstet 133: 293, 1971. 12. Smith R: Hepaticojejunostomy with transhepatic intubation. A technique for very high strictures of the hepatic ducts. BrJSurg51: 186, 1964. 13. Aust JB, Root HD, Urdaneda L, Varco RL: Biliary stricture. Surgery62: 601, 1967. 14. Saypol G, Kurian G: A technique of repair of stricture of the bile duct. Surg Gynecd Obstet 128: 1070, 1969.

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Jejunal mucosal graft: a sutureless technic for repair of high bile duct strictures.

A simplified sutureless technic for the repair of high bile duct strictures is described. The technic combines the principle of a transhepatic tube to...
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