Surgical biliary drainage in primary sclerosing cholangitis. The role of the Hepp-Couinaud approach

J. A. Myburgh
Department of Surgery, University of the Witwatersrand, South Africa.

OBJECTIVE: To assess the value of bilioenteric bypass, particularly by the Hepp-Couinaud technique, in patients with primary sclerosing cholangitis and dominant strictures in the extrahepatic biliary tract. DESIGN: Prospective study and analysis of a personal series. SETTING: Academic hospital. PATIENTS: Twenty-four of 69 patients with primary sclerosing cholangitis were selected for operative intervention. In all patients both intrahepatic and extrahepatic ducts had multiple strictures. In 22 patients the major proximal extrahepatic site of stricturing was at the confluence of the right, left, and common hepatic ducts. All patients were jaundiced at some stage before operation and 19 had persistent jaundice. Five patients were cirrhotic at presentation. INTERVENTIONS: Twenty Hepp procedures were performed in 19 patients, involving a side-to-side anastomosis 2.5 to 3.5 cm wide between a Roux-en-Y loop and the right and left hepatic ducts at their confluence. No transanastomotic stents were used. MAIN OUTCOME MEASURES: Survival and relief of jaundice. RESULTS: Follow-up ranged from 20 months to 11 years; median, 6.5 years. At the time of this report, three of the five cirrhotic patients had died, and the two surviving patients had progressive liver disease. In the 16 noncirrhotic patients who underwent bypass, actuarial survival was 100% up to 8 years. Four of these patients were mildly icteric but stable 2.3 and 7 years after bypass. Eleven patients remained free of jaundice for 2.3 to 9 years after bypass. One patient died of hepatic failure 8.5 years after bypass. CONCLUSIONS: In noncirrhotic patients with primary sclerosing cholangitis and dominant extrahepatic biliary strictures, bilioenteric bypass with the Hepp technique and without transanastomotic stenting relieves jaundice durably, safely, and effectively and is associated with freedom from recurrent bouts of cholangitis. This may attenuate or halt the development of secondary biliary cirrhosis. Patients with cirrhosis derive minimal benefit from biliary bypass and should undergo liver transplantation.