**7.1.2 Endoscopic dilatation during ERCP**

Endoscopic dilatation associated with insertion of biliary prosthesis during ERCP investigation is the most frequently used non-surgical method in the treatment of IBDI. The effectiveness of endoscopic (72%) and surgical (83%) treatment is comparable. Incidence of complications in both methods of treatment is also comparable (35% vs. 26%). The common complications of endoscopic techniques regarding placement of biliary prosthesis include cholangitis, pancreatitis, prosthesis occlusion, migration, dislodgement and perforation of the bile duct.

Recontructive Biliary Surgery in the Treatment of Iatrogenic Bile Duct Injuries 485

number of anastomosis strictures in comparison with Roux-y hepaticojejunostomy (HJ). We recommend EE first, because in some patients, extensive mobilization of the duodenum with the pancreatic head by the Kocher maneuver allows to perform the tension-free anastomosis after the extensive length-loss of the bile duct. Excision of the bile duct stricture, dissection and refreshing of the proximal and distal stumps as far as the tissues are healthy and without inflammation, and the use of non-traumatic, monofilament-interrupted sutures 5-0 allows the achievement of good long-term results. Using of an internal Y tube conducting from the right and left hepatic ducts into the duodenum through EE and the papilla of Vater also allows the proper healing of this anastomosis. This reconstruction can be performed when the bile duct loss is from 0.5 to 4 cm. It allows the achievement of very good long-term results with effectiveness comparable with HJ. It is important that establishing a physiological bile pathway allows proper digestion and absorption, which causes a higher gain weight in patients following EE, which was noted in study performed in our department. Another essential advantage of EE is possibility of of endoscopic control after surgery.The lower number of early complications is observed after EE than HJ, which is associated with opening of the alimentary tract and the higher number of performed anastomoses (biliary-enteric and entero-enteric) in patients with HJ. The disadvantage is the higher incidence of recorded postoperative stenosis at the anastomosis due to poorer blood supply of the operated area. It can't be performed in patients with bile duct loss more than 4 cm. The diameter of both anastomosed ends should be comparable. If there is a difference between a diameter of anastomosed ends, the thinner end should be incised longitudinally in the anterior surface in order to extend it before creation of anastomosis. This repair should not be carried out in bile ducts that are too thin (diameter less than 4 mm). In our opinion a patient, whom we perform first or exceptionally second bile ducts repair, is a candidate for EE. Because of a number of

advantages, EE is recommended as the first method of choice for patients with IBDI.

Roux-Y hepaticojejunostomy (HJ) is the most frequently performed surgical reconstruction of IBDI. In this surgical technique, a proximal common hepatic duct is identified and prepared and the distal common bile duct is sutured. End-to-side or end-to-end HJ is performed in a single layer using interrupted absorbable polydioxanone (PDS 4-0 or 5-0) sutures. Most authors prefer HJ due to the lower number of postoperative anastomosis strictures. According to Terblanche et al, HJ is effective in 90% of cases [50]. However, after this reconstruction, bile flow into the alimentary tract is not physiological, because the duodenum and upper part of the jejunum are excluded from bile passage. Physiological conditions within the proximal gastrointestinal tract are changed as a result of duodenal exclusion from bile passage. An altered bile pathway is a cause of disturbances in the release of gastrointestinal hormones. There is a hypothesis that in patients with HJ, the bile bypass induces gastric hypersecretion leading to a pH change secondary to altered bile synthesis and release of gastrin. A higher number of duodenal ulcers is observed in patients with HJ, which may be associated with a loss of the neutralizing effect of the bile, including bicarbonates and the secondary gastric hypersecretion. Laboratory investigations revealed increased gastrin and glucagon-like immunoreactivity (GLI) plasma levels and decreased triglycerides, gastric inhibitory polypeptide (GIP), and insulin plasma levels in patients with HJ. An altered pathway of bile flow is also a cause of disturbance in fat metabolism in patients undergoing HJ. Moreover, the total surface of absorption in these patients is also decreased due to exclusion of the duodenum and upper jejunum from the food passage. In

*7.2.2.1.2 Roux-Y hepaticojejunostomy* 

Endoscopic treatment is recommended as initial treatment of benign biliary strictures, biliary fistula in the presence and in patients not not qualified to surgical treatment.
