Methods of repair of noncircumferential bile duct defects.

Although noncircumferential bile duct defects are uncommon, they are important because they require careful repair to avoid subsequent biliary stricture. I have encountered three of these defects in more than 1000 biliary operations. The method of repair chosen for a particular case depends on the pathologic defect, the potency of the ampulla, and the tissues available for use. If the ampulla must be bypassed, a Roux-en-Y jejunal reconstruction is applicable for most biliary defects. An anastomosis between the bile duct and duodenum may be suitable to repair low biliary defects. Occasionally, the gallbladder can be used as a conduit between the bile duct defect and the duodenum or jejunum. If the ampulla need not be bypassed, a Heineke-Mikulicz repair is suitable only for very short defects. A patch technique is a better choice for larger defects. Patches can be made of autogenous vein, gallbladder, knitted Teflon, or a serosal onlay patch of duodenum or jejunum. A vein patch is especially appealing because it will easily cover any extrahepatic defect. A different method was chosen in each of three cases. Side-to-side Roux-en-Y hepaticojejunostomy was used to repair a large cholecystocholedochal fistula with associated pancreatitis. Heineke-Mikulicz repair was employed for a short hepatic duct stricture. Saphenous vein patch was used to repair a long bile duct defect during a left hepatectomy for hepatocellular carcinoma. This patient presumably represents the second successful reported vein patch repair and the only one with subsequent studies showing the fate of the vein patch. The vein patch apparently acts as a temporary scaffold allowing the outgrowth of biliary epithelium from the remaining bile duct wall. Careful initial repair of these noncircumferential bile duct defects is essential to avoid a subsequent biliary stricture with its disastrous consequences.