Laparoscopic biliary bypass with an autologous tubed gastric flap: a pilot study.
ABSTRACT Although biliary bypass technique which used jejunum as a conduit is a common procedure in open technique of hepatobiliary tract surgery, its complicated technique made it is not feasible for laparoscopic surgery. Before 1960, stomach was used vastly for biliary drainage but late stricture which resulted from too much tension along suture line made it not much acceptable. The authors report surgical technique of laparoscopic gastric tube flap for biliary bypass in order to made it practicable for laparoscopic surgery.
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ABSTRACT: Endoscopic retrograde cholangiopancreatography (ERCP) access to the biliary tract is sometimes impossible and percutaneous access has the disadvantages of increased morbidity and patient discomfort. We present our first results with an alternative technique: endoscopic ultrasonography (EUS)-guided transgastric biliary drainage. 11 patients (7 men, mean age 64 years) were referred for failed ERCP and biliary obstruction (malignancy n = 8, benign conditions n = 3). The retrograde approach via the papilla had been impossible due to surgical anatomy, duodenal stenosis, and hilar stricture with occlusion of the left side. EUS-guided drainage was done with endoscopic and fluoroscopic monitoring. After puncture of the left biliary duct a guide wire was inserted into it followed by tract dilation using a cystostome. A plastic or a metallic stent was placed through this gastrobiliary fistula for bile drainage. EUS-guided left hepaticogastrostomy was successfully performed in 10/11 cases, with one failure of guide wire insertion after puncture. Plastic and covered metal stents were inserted in seven and three patients, respectively. Complications in the plastic stent group included one early occlusion requiring stent replacement, and one transient ileus. In the metallic stent group there was one bilioma and one cholangitis, due to stent shortening. Clinically, the stent was efficacious in all 10 cases; during a mean follow-up of 213 days (range 3-610), two patients presented with stent occlusion and one with stent migration, with successful endoscopic treatment in all. EUS-guided hepaticogastrostomy is an efficient technique and could be a future alternative to percutaneous biliary drainage or palliative surgical drainage.Endoscopy 05/2007; 39(4):287-91. · 5.74 Impact Factor
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ABSTRACT: Five patients with obstructive jaundice caused by malignant periampullary biliary stenosis underwent EUS-guided choledochoduodenostomy (EUS-CDS) from the first portion of the duodenum using a convex echoendoscope and a needle knife. All the steps of the procedure including passage dilatation and the plastic stent placement were performed through the accessory channel of the echoendoscope over the guide wire. Stent insertion was technically successful in all five patients. The procedure was also clinically effective in relieving jaundice in all cases. One patient developed pneumoperitoneum, which resolved with conservative management. Stent exchange was successful in seven of eight attempts in patients with stent occlusion. One failure was due to tumor invasion to the choledochoduodenal fistula. Stent patency was maintained in the remaining patients throughout their survival period. The average stent patency was 211.8 days. EUS-CDS from the first portion of the duodenum appears to be feasible and safe in cases of obstructive jaundice caused by distal bile duct obstruction.Endoscopy 05/2008; 40(4):340-2. · 5.74 Impact Factor
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ABSTRACT: The purpose of this study is to demonstrate the feasibility, safety, and success of percutaneous transhepatic biliary drainage (PTBD) using a combination of ultrasound and fluoroscopy guidance in patients with nondilated bile ducts. Between January 2005 and July 2007, 50 patients with nondilated bile ducts underwent ultrasound-and-fluoroscopy guided PTBD. The underlying disease processes were divided into biliary obstruction (n = 38) and bile leakage (n = 12). We used ultrasound guidance when puncturing a bile duct and during cholangiography. We punctured along the course of the targeted bile duct or portal vein when the bile duct was not visualized, which we termed the "parallel technique." This method made it possible for us to cannulate the peripheral bile duct successfully, even when its course was not visualized well by sonography. We then installed a drainage catheter under fluoroscopy guidance. The technical success and complications of the procedure were evaluated. Neither significant complications nor technical failures were observed. There were only four minor complications: transient hemobilia (n = 3) and fever (n = 1). Ultrasound-and-fluoroscopy guided PTBD in patients with nondilated bile ducts is a safe, feasible, and efficient procedure for the palliation of biliary obstruction and leakage.Abdominal Imaging 03/2008; 33(5):555-9. · 1.91 Impact Factor
J Med Assoc Thai Vol. 93 Suppl. 2 2010 S39
Correspondence to: Akranurakkul P, Department of Surgery,
Srinakharinwirot University, Bangkok 10110, Thailand. Fax:
037-395-271. E-mail: firstname.lastname@example.org
Laparoscopic Biliary Bypass with an Autologous Tubed
Gastric Flap: A Pilot Study
Prinya Akranurakkul MD*,
Somkiat Wattanasirichaigoon MD*, Ekkit Surakarn MD*
*Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
Although biliary bypass technique which used jejunum as a conduit is a common procedure in open
technique of hepatobiliary tract surgery, its complicated technique made it is not feasible for laparoscopic
surgery. Before 1960, stomach was used vastly for biliary drainage but late stricture which resulted from too
much tension along suture line made it not much acceptable. The authors report surgical technique of
laparoscopic gastric tube flap for biliary bypass in order to made it practicable for laparoscopic surgery.
Keywords: Laparoscopic surgery, Biliary bypass technique, Gastric tube flap, Biliary-gastric bypass, Animal
J Med Assoc Thai 2010; 93 (Suppl. 2): S39-42
Full text. e-Journal: http://www.mat.or.th/journal
Obstructive jaundice is one of the most com-
mon surgical problems which caused from both benign
and malignant conditions. Biliary drainage can be done
by many techniques including endoscopy(1-4), inter-
vention radiology(5)or surgical drainage(6). In addition
to relief symptoms of obstructive jaundice, the proce-
dure should resemble to normal physiology of biliary
system. Since 1940, many biliary bypass techniques
have been developed such as hepatico-gastrostomy,
hepaticoduodenostomy, hepaticojejunostomy (Roux-
en-Y or Braun’s loop); most of them have different ad-
vantages and disadvantages. Among them, jejunum
has been used widely as a conduit for biliary drainage
particularly in open surgery because it easily acces-
sible and movable to proximal bile duct anatomosis.
Laparoscopic surgery has developed rapidly
and gained much acceptable among surgeons. Some
techniques cholecystectomy have replaced traditional
operations such as laparoscopic. However, laparos-
copic biliary bypass using jejunum as a conduit is time-
consuming procedure and needs experienced
laparoscopic surgeon. Before 1960, hepaticogas-
trostomy was used as a biliary bypass procedure, but
anastomosis stricture which caused from too much ten-
sion along the suture line resulted in poor outcome.
The authors introduced a new technique by using au-
tologous tubed gastric flap (ATGF) as a conduit for
biliary bypass in order to decrease tension at the anasto-
motic site. Additionally, an ATGF can be done easier
than jejunal conduit under laparoscopic technique.
Material and Method
Three pigs which weigh 20-30 kilograms were
selected for the experiment. The operations were done
under general anesthesia using laparoscopic technique.
The authors resected part of stomach to create a tubular
structure (ATGF) which could be easily anastomosed
to the gallbladder as a part of biliary system.
Basic laparoscopic set, 0° and 30° 10-mm tele-
scope, Multi-fired Endo GIA 60 were used in this
A 10-mm trocar was inserted at supraumbilicus
for camera port, then two 5-mm trocars were inserted at
the right and left subcostal margin along anterior axillary
line. Lastly, two 10-mm trocars were placed at right and
left midclavicular line between the previous two ports.
The surgeon stood on the left side of the table and the
first assistance stood on the right (Fig. 1).
S40 J Med Assoc Thai Vol. 93 Suppl. 2 2010
Each pig underwent endotrachial general an-
esthesia. The pig’s abdomen was sterilely prepped
and drapped. In addition, it was placed on supine
position and elevated the head up to 30% (reverse
Trendelenburg position). Nasogastric tube was inser-
ted. The first camera port was done by open technique
at supraumbilicus. Air was inflated until air pressure
was approximately 14 mmHg in order to create sufficient
working space, then other trocars were inserted in
sequential under direct vision. After abdominal cavity
was entered, stomach and its blood supply along the
greater curvature especially the junction between the
right and left gastroepiploic vessels were identified (Fig.
Initially, the nasogastric tube was placed along
the greater curvature with its tip pointing to the fundus
of stomach. The tube was seized with a laparoscopic
atraumatized instrument. The gastrocolic omentum was
divided and dissected from stomach edge. Stomach
transection was started at the greater curvature where
the tip of nasogastric tube located at the junction
between the right and the left gastroepiploic vessels.
Guided with nasogastric tube, a tubular structure along
the greater curvature of stomach was created with two
or three Multi-fired Endo GIAs. After development of
an ATGF with approximately 3 centimeters proximal to
the pylorus (Fig. 3), a 2-0 vicryl stitch was done at an
angle between the base of gastric tube and antrum in
order to secure the angle of suture line. Consequently,
the 2-centimeters suture line was performed by
continuous running suture with 3-0 vicryl between the
end of gastric tube and the gallbladder (Fig. 4). The
nasogastric tube was passed through the anastomotic
site for postoperative contrast study. Bleeding was
secured and abdominal wall was closed as usual. No
drain was needed.
Immediately after the operation, the contrast
media was fed through nasogastric tube to demon-
strate the patency of anastomotic site (Fig. 5). All pigs
were started feeding after starving for 72-hours. There
was no immediate or late complication. After 6-8 weeks,
all three pigs were killed; their livers, gallbladders, extra-
hepatic biliary systems and stomachs were sent for
Post-operative imaging study in all pigs
showed no leakage, good functioning and patent of
anastomotic site. Pathologic examination of stomach
and gallbladder also revealed the patency of anasto-
mosis, mild generalized gastritis at gastric tube and no
abnormality in hepatobiliary system (Fig. 6).
Although the development in laparoscopic
surgery techniques and instruments make it worldwide
acceptable and useful, its disadvantages are still an
obstacle to most surgeons, especially in some compli-
cated operations which require experienced surgical
Fig. 1 Reverse trendelenburg position (A), Port position (B)
Fig. 2 Identification the junction of right and left gastroepi-
ploic vessels on stomach Wall
J Med Assoc Thai Vol. 93 Suppl. 2 2010 S41
skills. The authors developed a new technique for
laparoscopic biliary bypass which using gastric tube
as a conduit for biliary bypass from gallbladder to
stomach. This technique is less complicated than
traditional Roux-en-Y jejunal bypass and more com-
pliant to laparoscopic surgery. Though the stomach
wall is thicker than jejunum, there was no technically
difference in performing anastomosis between
stomach and gallbladder. Due to its length and mobi-
lity, we can also use gastric tube for proximal biliary
bypass such as hepaticogastrostomy without any prob-
lem of over-tension along the suture line.
From the authors’ point of view, there is the
difference between pig’s stomach and human’s. In
general, pig’s stomach is bigger than men’s which
makes performing gastric conduit in pig much easier.
Fig. 3 Application of the stapler are made all the way to
approximately 3 cm proximal to pyrolus
Fig. 4 The Autolonous Tubed Gastric Flap is mobilized upward, it is positioned with ante gastric fashion (A) then anasto-
mosed to gallbladder (B)
Fig. 5 Postoperative contrast study (A), contrast media was fed through nasogastric tube to demonstrate gastric tube (B).
S42 J Med Assoc Thai Vol. 93 Suppl. 2 2010
One drawback from cholecystogastrostomy is bile ir-
ritation which results in generalized gastritis in
the gastric tube. Other late complications such as
prolonged gastitis, ascending cholangitis and anasto-
mosis stricture may be further investigated as the
results from long-term study.
1. Bories E, Pesenti C, Caillol F, Lopes C, Giovannini
M. Transgastric endoscopic ultrasonography-
guided biliary drainage: results of a pilot study.
Endoscopy 2007; 39: 287-91.
2. Rerknimitr R, Attasaranya S, Kladchareon N,
Mahachai V, Kullavanijaya P. Feasibility and
complications of endoscopic biliary drainage in
patients with malignant biliary obstruction at King
Chulalongkorn Memorial Hospital. J Med Assoc
Thai 2002; 85 (Suppl 1): S48-53.
3. Fujita N, Noda Y, Kobayashi G, Ito K, Obana T,
Horaguchi J, et al. Temporary endosonography-
guided biliary drainage for transgastrointestinal
deployment of a self-expandable metallic stent. J
Gastroenterol 2008; 43: 637-40.
4. Yamao K, Bhatia V, Mizuno N, Sawaki A, Ishikawa
H, Tajika M, et al. EUS-guided choledochoduo-
denostomy for palliative biliary drainage in patients
with malignant biliary obstruction: results of long-
term follow-up. Endoscopy 2008; 40: 340-2.
5. Lee W, Kim GC, Kim JY, Baik SK, Lee HJ, Kim HJ, et
al. Ultrasound and fluoroscopy guided percuta-
neous transhepatic biliary drainage in patients with
nondilated bile ducts. Abdom Imaging 2008; 33:
6. Khalid K, Shafi M, Dar HM, Durrani KM.
Choledochoduodenostomy: reappraisal in the
laparoscopic era. ANZ J Surg 2008; 78: 495-500.
ปริญญา อัครานุรักษ์กุล, สมเกียรติ วัฒนศิริชัยกุล, เอกกิตติ์ สุรการ
ช่องท้องโดยการส่องกล้องจะมีความยุ่งยากในการทำโดยวิธีนี้ ก่อนปี พ.ศ. 2503 เคยมีผู้ใช้กระเพาะอาหารต่อกับ ทาง
เดินน้ำดีเพื่อใช้ระบายน้ำดี แต่เนื่องจากผลการผ่าตัดพบว่ามีการตีบตันของรอยต่ออันเนื่องจากความตึงของ รอยแผลตัด
ต่อจึงทำให้ไม่เป็นที่ยอมรับในเวลาต่อมา รายงานนี้นำเสนอเทคนิควิธีการผ่าตัดเพื่อระบายน้ำดีโดยการ สร้าง gastric
tube เป็นทางระบายน้ำดีเพื่อให้การผ่าตัดดังกล่าวสามารถทำได้ง่ายขึ้นในการผ่าตัดช่องท้องโดยการ ส่องกล้อง
Fig. 6 Pathologic examination (A) Gross specimen, (B) Cholecystogastrostomy anastomosis.