Anastomotic obstruction with recurrent cholangitis is a well recognised complication after a bilioenteric anastomosis and leads to bile stasis with stone formation.[1] The cause is usually a stricture at the site of the anastomosis and it is also, less commonly, due to obstruction of the Roux loop by volvulus or jejunojejunal intussusceptions.[2,3]

We report here an unusual cause of obstruction of the Roux loop of a hepaticojejunostomy.

Case report

A 57 year old female presented with a one month history of pain in the right hypochondrium, jaundice and a vague lump under the right costal margin. Nine years ago she had had an emergency Roux-en-Y hepaticojejunostomy for a biliary fistula which had followed a laparoscopic cholecystectomy. However, eight months after this procedure she began to get recurrent attacks of cholangitis and investigations revealed a complete stricture at the anastomotic site. For this a self-expanding metallic stent was placed percutaneously and transhepatically across the stricture and she was completely relieved of her symptoms till she began to experience symptoms of cholangitis a month ago.

Physical examination of the patient revealed that she had jaundice with a vague, tender, soft mass in the right hypochondrium. Liver function tests showed elevated bilirubin (1.9 mg/dl), alkaline phosphatase (279 IU/l) and gamma glutamyl transpeptidase (117 IU /l) levels. Computed tomography of the abdomen (Figure 1) and magnetic resonance cholangiography revealed dilatation of the intrahepatic biliary radicles, a patent hepaticojejunostomy site and a Roux loop which was being obstructed by a metallic stent which had migrated past the anastomosis. There was an area of hyperdensity around the stent.

At laparotomy, we found a Roux loop which was obstructed approximately 15 cm below the anastomosis by a hard intraluminal mass. We resected a portion of the unhealthy and nearly perforated jejunal loop containing the mass and performed an end-to-end jejunojejunostomy. On opening the resected bowel we discovered that the hard mass consisted of a stone which had formed around a metallic stent (Figure 2). Her postoperative period was uneventful and the liver function tests gradually returned to normal. She was asymptomatic at one year follow up visit.

Discussion

We described here a case of stent migration causing Roux loop obstruction and bile stasis nine years following a hepaticojejunostomy for a biliary fistula and metallic stent placement for a subsequent anastomotic stricture. Roux-en-Y hepaticojejunostomy has been associated with various complications. Common complications include anastomotic stricture, recurrent calculi and biliary sepsis. Uncommon complications include calculi or stricture of the intrahepatic duct, malformed or twisted jejunum loop, too long or too short proximal jejunum, and adhesion of the intestinal loop.[4]

Patients who have had a hepaticojejunostomy for pancreatic and biliary cancers may occasionally develop Roux loop obstruction due to disease recurrence[5] but stone formation leading to Roux loop obstruction has been rarely reported,[6,7,8] with enterolith formation around a stent in the Roux loop seen only after liver transplantation.[9,10]

References