Bile duct injury following laparoscopic cholecystectomy: referral pattern and management

BACKGROUND: Laparoscopic cholecystectomy is associated with a higher incidence of bile duct injury than open cholecystectomy. This study reviews the management of bile duct injury in a tertiary hepatobiliary unit. METHODS: From 1991 to 1995, 27 patients (18 women) of median age 49 (range 25-67) years were referred to this unit with bile duct injury following elective laparoscopic cholecystectomy. Laparoscopic cholecystectomy was described as 'uneventful' in 14 and 'difficult' in 13 patients; six injuries were recognized at operation. RESULTS: Patients were transferred a median of 26 (range 0-990) days after laparoscopic cholecystectomy, although initial symptoms were recorded a median of 3 (range 0-700) days after cholecystectomy. Fifteen patients underwent additional surgery before referral. Management before referral included surgical exploration (15 patients), endoscopic cholangiography (ERC) and stent insertion (three), external drainage of bile collections (five), and conservative management (five). Management after referral included surgical reconstruction (19 patients), laparotomy with drainage (one), percutaneous drainage (two), ERC and stent insertion (two), percutaneous cholangiography with dilatation and stent placement (three), and conservative management (two). One patient died and the median inpatient stay following referral was 14 (range 7-78) days. Ten of 15 patients who had surgery before referral required a further biliary reconstruction. After median follow-up of 30 (range 3-60) months, four of nine patients with complex high injuries continue to have episodes of cholangitis and one patient has developed secondary biliary cirrhosis. CONCLUSION: Bile duct injury following laparoscopic cholecystectomy is a complex management problem and results in significant postoperative morbidity. Most patients referred after attempted repair require further reconstructive surgery, and patients with complex high injuries have a risk of long-term morbidity.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Fibrotic stricture of the extrapancreatic biliary tract: a new complication of acute pancreatitis. Two cases

Two cases of fibrotic stricture of the extrapancreatic common bile duct were observed 3 and 5.5 months after severe acute alcoholic pancreatitis. The diagnosis was made by endoscopic retrograde cholangiography in both cases. Although colonic or ureteric stenosis have been reported after acute pancreatitis, this is the first report of extrapancreatic biliary stricture occurring after acute pancreatitis. The strictures could have arisen by either an enzymatic or ischemic mechanism. Outcome was favorable after surgical hepaticojejunostomy.     

Complications of laparoscopic cholecystectomy in Switzerland. A prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery

BACKGROUND: We set out to analyze the technical aspects, intraoperative complications, morbidity, and mortality of laparoscopic cholecystectomy in a multi-institutional study representative of Switzerland. METHODS: Data were collected from 10,174 patients from 82 surgical services. A total of 353 different parameters per patient were included. RESULTS: We found intraoperative complications in 34.4% of patients and had a conversion rate of 8.2%. This rate was significantly increased in patients with complicated cholelithiasis and in those with previous upper-but not lower-abdominal surgery. In most cases, conversions to open procedures were required because of technical difficulties due to inflammatory changes and/or unclear anatomical findings at the time of operation. Bleeding was a common intraoperative complication, that significantly increased the risk of conversion. Patients with loss of gallstones in the peritoneal cavity had increased rates of abscesses. The rate of common bile duct injuries was 0.31%, but it decreased significantly as the laparoscopic experience of the surgeon increased. The rate of common bile duct injuries was not increased in patients with acute cholecystitis or in the 1.32% of patients undergoing laparoscopic common bile duct exploration. Intraoperative cholangiography did not reduce the risk of common bile duct injuries, but it allowed them to be diagnosed intraoperatively in 75% of patients. Local complications were recorded in 4.79% of patients, and systemic complications were seen in 5.59%. The mortality rate was 0.2%. CONCLUSIONS: Although laparoscopic cholecystectomy is a safe procedure, the rate of conversion to open cholecystectomy is still substantial. The conversion rate depends both on the indication and intraoperative complications. There is still a 10.38% morbidity associated with the procedure; however, the incidence of common bile duct injuries, which decreases with growing laparoscopic experience, was relatively low.     

Control of the temporal aspect when considering risk factors for acute otitis media

Laparoscopic cholecystectomy, initially performed in France in 1987, has rapidly spread to other European countries, the United States, and elsewhere. Of the techniques that have evolved, the "French" technique, in which the surgeon stands between the patient's legs, and the "American" technique, in which the surgeon stands on the patient's left side, are the most commonly used. In the former technique, the liver is retracted via the mid-clavicular cannula and the infundibulum of the gallbladder via the anterior axillary port. In the latter technique, the liver is retracted by axial traction on the gallbladder through the anterior axillary cannula and the infundibulum through the mid-clavicular cannula. This position may increase the risk of bile duct injury. The technique selected for operative cholangiography should be adapted to the problem at hand. Cystic duct cholangiography shows ductal calculi more reliably due to better filling of the common bile duct; direct puncture of the gallbladder is safer when the biliary anatomy is unclear. A number of European studies confirm the safety of laparoscopic cholecystectomy. Mortality rates vary between 0% and 0.1%, and duct injury rates range between 0.2% and 0.6%. Conversion, which is done in 3% to 8% of cases, may be necessary in the case of uncontrollable hemorrhage, bile duct injury unsuitable for laparoscopic repair, or if the gallbladder is densely scarred (scleroatrophic). It can also be done for safety reasons, when the anatomy is unclear. Complications include bile collections due to accessory duct or cystic duct stump leaks or less commonly to common duct injury. The average postoperative stay is longer in Europe (3.2 days) than in the United States. A decision tree is presented for the management of common bile duct stones. In general, preoperatively identified ductal stones are removed by endoscopic sphincterotomy, which is then followed by laparoscopic cholecystectomy to remove the source of the calculi. The techniques of laparoscopic choledochotomy and transcystic exploration for the removal of stones in the common bile duct are only beginning to be used, but they may well prove to be the most popular procedures. Results with these procedures will need to be evaluated against those obtained with endoscopic sphincterotomy.     

Value of intraoperative cholangiography in laparoscopic cholecystectomy

By introduction of laparoscopic cholecystectomy, an increase of accidental common bile duct injuries up to 1.2% has been reported. In the present study of 325 cholecystectomies we evaluated whether mandatory intraoperative cholangiography (IOC) can reduce the rate of accidental bile duct injuries or, at least, identify them early in order to make an adequate repair possible. In addition 163 patients underwent preoperative intravenous cholangiography (IVC). Both imaging techniques were compared with regard to their sensitivity in the detection of anatomic variations and stones of the extrahepatic bile duct system. Our results demonstrated a great advantage of the IOC. The IOC was feasible in 98.1% of the cases and presented a complete depiction of the extrahepatic bile duct system in 99.3%. IVCs showed the biliary system in 91.4% of the cases but without visualization of the cystic duct in 51.5% and the hepatic confluence in 16%. Anatomic variations of the bile duct system which consecutively influenced the operative management were found in additional 27.6% exclusively by IOC. 71.4% of bile duct stones were not detected by IVC. The intraoperative time consumption of IOC was unimportant. The x-ray-load was clearly lower by a factor of 3.5. There was no complication after IOC. In comparison, 6.1% of patients demonstrated an anaphylactic reaction by IVC. One common duct injury (0.3%) was detected intraoperatively by IOC and at the same operation treated without postoperative complications. In conclusion, we recommend an IOC in addition to a thorough preoperative ultrasound-examination. By this technique intraoperatively identified stones of the common bile duct can be sufficiently treated by postoperative endoscopic extraction and anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.     

Laparoscopic cholecystectomy in The Netherlands

Laparoscopic cholecystectomy was introduced into the Netherlands in the Spring of 1990. The aim of this study was to evaluate the results of the procedure in Dutch hospitals over the first 2 years to obtain some insight into its safety and efficacy in general surgical practice. A written questionnaire was sent to all 138 Dutch surgical institutions enquiring about conversion rate, complications (with emphasis on mortality rate and common bile duct injuries), operating time and hospital stay. The surgeons' opinions were also sought on possible contraindications such as previous operation, bile duct stones and cholecystitis, as were their estimations of the percentage of patients in their practice eligible for laparoscopic cholecystectomy. Data were obtained for 6076 laparoscopic cholecystectomies; the response rate was 100 per cent. Conversion to open cholecystectomy was necessary in 413 patients (6.8 per cent), mostly because of adhesions, cholecystitis, haemorrhage and unclear anatomy. Postoperative complications were reported in 260 patients (4.3 per cent). There were seven deaths (0.12 per cent) and 52 (0.86 per cent) bile duct injuries, of which 20 were recognized during laparoscopy. The mean operating time for the ten most recent patients in each institute was 70 (range 30-180) min and the mean hospital stay 4.5 (range 2-8) days. Previous lower abdominal operations were not considered to be a contraindication by 96 per cent of surgeons, whereas previous upper abdominal procedures were regarded as a contraindication by 66 per cent. After successful clearance of the bile duct at endoscopic retrograde cholangiopancreatography, only 12 per cent would perform an open procedure. Moderate cholecystitis was not considered a contraindication to laparoscopic cholecystectomy by 71 per cent of surgeons, but severe cholecystitis was a reason for open cholecystectomy for 83 per cent. In most surgical practices 70-80 per cent of patients were considered to be eligible for the laparoscopic procedure. In conclusion, laparoscopic cholecystectomy has gained rapid acceptance in the Netherlands. Although the number of bile duct injuries is high, the findings of this general survey are similar to those from highly specialized centres and match the overall results of conventional cholecystectomy.     

The role of endoscopic therapy in chronic pancreatitis-induced common bile duct strictures

During endoscopic retrograde cholangiography, common bile duct strictures are encountered in up to 30% of patients with chronic pancreatitis. The indications for treatment of these strictures are discussed. A surgical biliodigestive anastomosis has always been the traditional treatment modality. Not all patients need treatment, however, and endoscopic biliary drainage is the treatment of choice for certain subgroups of patients.     

Cardiac transplantation in patients aged 60 years or older

The indications and best technique for peroperative cholangiography during laparoscopic cholecystectomy remain unclear, but the operation has been associated with an increased use of preoperative endoscopic retrograde cholangiography. Cystic duct cholangiography, particularly in the hands of the trainee, can be time consuming, and bile duct injury may be caused by attempts to cannulate the cystic duct. This study analyses 113 consecutive patients undergoing peroperative cholangiography through the gallbladder, or cholecystocholangiography. It was successful in 92 (81.4%) patients, the procedure adding less than 10 min to the operating time. There were no cholangiogram-related complications. Common anatomical variations included both short and particularly wide cystic ducts. This information helps to minimize the risk of damage to the common bile duct. This study demonstrates that cholecystocholangiography is a safe, simple, and effective alternative to cystic duct cholangiography with virtually no "learning curve." It provides a "road-map" of biliary anatomy and identifies common bile duct stones prior to the commencement of dissection. Unsuccessful cholecystocholangiography does not preclude the use of cystic duct cholangiography later in the operation. Difficult anatomy is demonstrated prior to dissection. When unsuspected bile duct calculi necessitate open exploration, further laparoscopic dissection is avoided.     

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.     

In vitro activity and clinical evaluation of cefixime in urinary tract infection

BACKGROUND: The management of common bile duct stones (CBDS) in the era of operative laparoscopy is evolving. Several minimally invasive techniques to remove CBDS have been described, including preoperative endoscopic retrograde cholangiopancreatography (ERCP), postoperative ERCP, lithotripsy, laparoscopic transcystic common bile duct exploration, and laparoscopic choledochotomy with common bile duct exploration (CBDE). Because of the risks and limitations of these procedures, we utilize laparoscopically placed endobiliary stents as an adjunct to CBDE. METHODS: Sixteen patients underwent laparoscopic common bile duct exploration (LCBDE) by either choledochotomy or the transcystic technique with placement of endobiliary stents. These patients were identified during laparoscopic cholecystectomy as having occult choledocholithiasis, using routine dynamic intraoperative cholangiography. RESULTS: CBDS were successfully removed in all patients as demonstrated by completion cholangiography and intraoperative choledochoscopy. Eighty percent of patients were discharged the following day; the first three patients in this series were observed for 48 h prior to discharge. No patient required T-tube placement and closed suction drains were removed the morning after surgery. Stents were removed endoscopically at 1 month. Six- to 30-month follow-up demonstrates no complications to date. CONCLUSIONS: Laparoscopic endobiliary stenting reduces operative morbidity, eliminates the complications of T-tubes, and allows patients to return to unrestricted activity quickly. We recommend laparoscopically placed endobiliary stents in patients undergoing LCBDE.     

Bile duct lesions in laparoscopic cholecystectomy--methods of reconstruction and results

From 1/1991 to 1/1997 a total of 18 patients with major biliary lesions after laparoscopic cholecystectomy were treated. Besides 4 biliary strictures (Bismuth III, Siewert II), which were found between 20 and 180 days after laparoscopic cholecystectomy, large defects (Siewert III, IV) of the proximal parts of the hepatic duct (Bismuth III, IV) occurred in the majority of cases (n = 14). Except for 3 intraoperatively realized lesions, diagnosis was made during the first 3 weeks. Subsequent reinterventions resulted in a high morbidity rate and the need of further procedures to establish definitive biliary reconstruction. Selection criteria of the technique used for repair were the extension of the biliary lesion and the exposure of the distal stump of the common bile duct. A small defect was treated by direct suturing protected by a t-tube (n = 1). Large defects and biliary strictures were reconstructed using either a Roux-en-Y bilio-digestive anastomosis (n = 7) or jejunal interposition (n = 10). The results suggest, that early repair of biliary lesions after laparoscopic cholecystectomy should be achieved. Besides the standard procedure of bilio-digestive anastomosis, reconstruction of major biliary lesions should be performed by jejunal interposition in selected cases.     

Choledocholithiasis at the hepatic confluence mimicking a hilar cholangiocarcinoma

Adenocarcinomas of the bifurcation of the hepatic ducts (Klatskin tumors) are a relatively rare cause of obstructive jaundice. Differential diagnosis includes other neoplastic lesions, sclerosing cholangitis, Mirizzi's syndrome and benign strictures. We present a 46 year-old white female with a 2 month history of epigastric pain and progressive jaundice. Endoscopic retrograde cholangiopancreaticography (ERCP) revealed a filiform stenosis of the right hepatic duct and an obstructed left hepatic duct, an image strongly suggestive of a Klatskin tumor. The correct diagnosis was achieved, however, by percutaneous transhepatic cholangiography (PTC), which disclosed a gallstone at the common hepatic duct bifurcation and multiple small concrements in the left hepatic duct. After endoscopic removal of the gallstones in the biliary tree and laparoscopic cholecystectomy, the patient was discharged on the third post-operative day. Protuberant tumors and round biliary stones may be confused at ERCP.     

Persistent obstructive jaundice, cholangitis, and biliary cirrhosis due to common bile duct stenosis in chronic pancreatitis

Long strictures of the intrapancreatic portion of the common bile duct were found in 6 patients with chronic pancreatitis. These strictures were responsible for painless obstructive jaundice, recurrent cholangitis, secondary biliary cirrhosis, and chronic abdominal pain difficult to distinguish from that caused by pancreatitis. Endoscopic retrograde cholangiopancreatography and intraoperative cholangiography were invaluable in making the diagnosis and in planning surgical correction. Decompression of the biliary tree by anastomosis of the gallbladder or common duct to the small intestine completely relieved symptoms and allowed liver function to improve significantly. Common duct stricture as a complication of chronic pancreatitis should be considered in the differential diagnosis of extrahepatic biliary obstruction and whenever surgical treatment of chronic pancreatitis is contemplated.     

Preoperative diagnosis of laparoscopic cholecystectomy. Is there an indication for routine intravenous cholangiography?

In a retrospective study including 163 patients we investigated the necessity of i.v. cholangiography in preoperative routine diagnostic workup prior to laparoscopic cholecystectomy. We evaluated the evidence of i.v. cholangiography concerning the anatomy of the biliary system, the evidence of common bile duct or cystic duct stones and the influence on the further therapeutic procedure. While the common bile duct could be demonstrated in 96.3%, the cystic duct could be visualized in only 54.6%. One out of two patients with a short cystic duct was identified. Stones in the gallbladder were recognized in 72.4% of cases, while only two out of three patients with common bile duct stones were diagnosed. In nine cases a deep junction of the cystic duct was found, but there was no influence on further operative procedure. Thus we found no improvement after routine use of i.v. cholangiography concerning the evidence of common bile duct stones or avoidance of intraoperative lesions of the common bile duct. The routine use of i.v. cholangiography prior to laparoscopic cholecystectomy is therefore not justified.     

Management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy

The development of laparoscopic cholecystectomy has rekindled the issue of management of choledocholithiasis. A number of options exist including pre or postoperative endoscopic sphincterotomy (ERCP-ES), laparoscopic common duct exploration or open common duct exploration. We present here our experience with the management of choledocholithiasis in patients treated with laparoscopic cholecystectomy. From January 1991 to January 1995, 900 patients underwent laparoscopic cholecystectomy. 71 ERCP were carried out in 71 patients with suspicion or evidence of choledocholithiasis. Common duct stones were detected in 44 patients. Preoperative ERCP was done in 56 patients, with suspicion of choledocholithiasis, based on clinical, laboratory or ultrasonographic findings. 29 of these patients (51.7%) had common duct stones, that were successfully removed by endoscopic sphincterotomy. One patient suffered mild pancreatitis and a second one had transient hyperamylasemia. Postoperative ERCP was performed in 15 patients. Indications for ERCP were the evidence of common duct stones in intraoperative cholangiography in 7 cases, and clinical or laboratory suspicion of choledocholithiasis, 3 months to 3 years after laparoscopic cholecystectomy. Stones were detected in 100% of the patients. In 11 patients (73.3%), the stones were extracted by endoscopic sphincterotomy and 4 patients underwent open common duct exploration. Two patients had transient hyperamylasemia. ERCP is a safe and effective method for detection and treatment of common duct stones. ERCP prior to laparoscopic cholecystectomy in patients suspected of having choledocholithiasis, is safe and offers with good results. Rutinary intraoperative cholangiography is recommended, for the detection of unsuspected choledocholithiasis and as an effective treatment (postoperative-ERCP, open or laparoscopic common duct exploration) can be chosen depending on surgeon's skills and patient's characteristics.     

The pharmacodynamics of lansoprazole administered via gastrostomy as intact, non-encapsulated granules

Among the techniques for dealing with common bile stones, choledochoduodenostomy (CDS) represents a useful alternative. This operation is indicated mainly in patients with recurrent stones, giant stones, or concomitant common bile stricture and duct stones. At the present time most of the patients undergoing CDS have been already undergone endoscopic retrograde cholangiography or ultrasonography to study the common bile duct and the cause of symptoms. The common bile duct diameter is of paramount importance when determining the feasibility of performing a CDS, the critical size being 1.2 cm. The most common operation is a side-to-side anastomosis employing absorbable sutures. Stomal patency is the most important factor for preventing classic complications such as cholangitis and sump syndrome. These complications are rare, being observed in only 5% of the patients. Long-term results of the operation show that it is a safe procedure that should be considered a good option in selected patients with choledocholithiasis.     

Drug efflux as a mechanism of resistance

The rate of iatrogenic bile duct lesions has raised up to 3.5% after the introduction of laparoscopic cholecystectomy. Lesions that can not be managed endoscopically require surgical intervention. In this study 12 patients that presented with iatrogenic bile duct lesions following laparoscopic cholecystectomy and underwent reconstructive surgery at our institution are included. In nine patients a hepaticojejunostomy was performed, whereas two patients underwent end-to-end anastomosis. In one patient the lesion was oversewn. There were no complications postoperatively. After a median follow-up of 24,5 months (SD +/- 8 months) all patients are without symptoms. However, in two patients a postoperative endoscopic stenting for 4 months was necessary for bouginage. Reconstructive surgery, mainly hepaticojejunostomy in bile duct lesions is a safe and efficacious treatment of endoscopic treatment failure.     

Surgical treatment of cicatricial biliary strictures

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.