Surgical Management of Occluded Biliary Expandable Metallic Stent for Benign Stricture of Bilioenteric Anastomosis: Usefulness of Anterior Transhepatic Procedure

The occluded biliary expandable metallic stent (EMS) placed for postoperative stricture of bihoentero-anastomosis can be treated with percutaneous interventional procedures, but most EMSs eventually re-occlude after a certain period of time with sludge/stone or epithelial hyperplasia. The complete removal of EMS is, therefore required for a good long-term outcome. Surgical procedures with EMS removal, and re-bihoenteric anastomosis after resection of damaged bile ducts, are usually complex and difficult, especially when the proximal end of the EMS is located at the second or more proximal biliary branch. In such cases, we have devised a new technique for complete EMS removal and more proximal hepatic duct resection by separating the liver parenchyma along the interlobar plane (anterior transhepatic hepatic approach). Liver transection is performed along the left side of the middle hepatic vein until good exposure of the hilar plate is obtained. The EMS is then extracted, together with resection of the dense/damaged intrahepatic ducts for re-biliary reconstruction. The anterior transhepatic approach may be a very useful procedure for approach to the second or more proximal biliary ducts without hepatic resection.