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.