BACKGROUND: Biliary-enteric anastomosis especially Roux-en Y hepaticojejunostomy is frequently used for biliary diversion in benign biliary strictures. In this study, we present the results of hepaticojejunostomy with external metallic circle. METHODS: Hepaticojejunostomy with external metallic circle were performed in eight male Sprague-Dawley rats. At the end of the third month, anastomoses were analysed for patency and stability of external circles. RESULTS: Relaparotomy revealed that all the anastomoses were patent and circles were in original places. CONCLUSION: To provide the patency of narrow hepaticojejunostomy anastomoses, external metallic circle can be a good alternative to use of internal stents in suitable cases

Göçmen, Erdal

Karamürsel, Sebat

Keskek, Mehmet

Kılıç, Mehmet

Koç, Mahmut

Tez, Mesut

English

PubMed

Abstract Background Biliary-enteric anastomosis especially Roux-en Y hepaticojejunostomy is frequently used for biliary diversion in benign biliary strictures. In this study, we present the results of hepaticojejunostomy with external metallic circle. Methods Hepaticojejunostomy with external metallic circle were performed in eight male Sprague-Dawley rats. At the end of the third month, anastomoses were analysed for patency and stability of external circles. Results Relaparotomy revealed that all the anastomoses were patent and circles were in original places. Conclusion To provide the patency of narrow hepaticojejunostomy anastomoses, external metallic circle can be a good alternative to use of internal stents in suitable cases.</p

Koç Mahmut

Karamürsel Sebat

Tez Mesut

Keskek Mehmet

Göçmen Erdal

Kılıç Mehmet

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BMC Surgery

External metallic circle in hepaticojejunostomy

Erdal Göçmen

Mehmet Keskek

Mesut Tez

Sebat Karamürsel

Mahmut Koç

Mehmet Kılıç

Springer - Publisher Connector

BioMed CentralBMC Surgery
ssOpen AcceTechnical advance
External metallic circle in hepaticojejunostomy
Erdal Göçmen1, Mehmet Keskek1, Mesut Tez*1, Sebat Karamürsel2, 
Mahmut Koç1 and Mehmet Kılıç1
Address: 1Department of 5th Surgery, Numune Training and Research Hospital, Sıhhiye, Ankara, Turkey and 2Department of Plastic and 
Reconstructive Surgery, Social Insurances Foundation Hospital, Ankara, Turkey
Email: Erdal Göçmen - erdalgocmen@yahoo.com; Mehmet Keskek - keskekm@yahoo.com; Mesut Tez* - mesuttez@yahoo.com; 
Sebat Karamürsel - sebatmursel@hotmail.com; Mahmut Koç - mahmutkoc55@yahoo.com; Mehmet Kılıç - mkilic69@yahoo.com
* Corresponding author    
Abstract
Background: Biliary-enteric anastomosis especially Roux-en Y hepaticojejunostomy is frequently
used for biliary diversion in benign biliary strictures. In this study, we present the results of
hepaticojejunostomy with external metallic circle.
Methods: Hepaticojejunostomy with external metallic circle were performed in eight male
Sprague-Dawley rats. At the end of the third month, anastomoses were analysed for patency and
stability of external circles.
Results: Relaparotomy revealed that all the anastomoses were patent and circles were in original
places.
Conclusion: To provide the patency of narrow hepaticojejunostomy anastomoses, external
metallic circle can be a good alternative to use of internal stents in suitable cases.
Background
Although the risk of late bile duct cancer complicating bil-
iary-enteric anastomosis has been well documented [1,2],
biliary-enteric anastomosis especially, Roux-en Y hepati-
cojejunostomy is frequently used for high biliary injuries
and for biliary diversion in benign biliary strictures [3].
Among the surgical techniques hepaticojejunostomy
yields the most favaroble results [4].
External metallic circle had been used for the end to end
choledochocholedocostomy in rats by Tez et al [5]. The
patency of anastomosis was higher than conventional pri-
mary anastomosis with this device.
The aim of this study was to examine applicability of
external metallic circle in hepaticojejunostomy.
Methods
Eight male Sprague-Dawley rats (Laboratory of Experi-
mental Animals, Hacettepe University Faculty of Medi-
cine, Ankara, Turkey) weighing 250 to 300 g were used.
The animals housed under environmentally controlled
conditions at 21 ± 2°C and 30% to 70% relative humidity
with a 12-hour dark and 12-hour light cycle. Free access to
water and standard laboratory food was provided. Before
the operations, the rats were fasted overnight and were
only allowed free access to water. Guiding Principles in
the Care and Use of Laboratory Animals was strictly
Published: 06 October 2004
BMC Surgery 2004, 4:14 doi:10.1186/1471-2482-4-14
Received: 15 April 2004
Accepted: 06 October 2004
This article is available from: http://www.biomedcentral.com/1471-2482/4/14
© 2004 Göçmen et al; licensee BioMed Central Ltd. 
This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
BMC Surgery 2004, 4:14 http://www.biomedcentral.com/1471-2482/4/14adhered to at all times together with the recommenda-
tions from the Declaration of Helsinki.
Technique
A surgical microscope (Zeiss, Opmi99, Germany), Cod-
man microsurgical instruments, jeweler's forceps, and 10-
0 Ethilon suture were used. Rats were anaesthesized with
intramuscular injection of ketamine hydrochloride 100
mg/kg and xylazine 10 mg/kg. Under sterile conditions, a
midline abdominal incision was made, and the peritoneal
cavity was opened. After the traction of duodenum
towards the left, the common bile duct was identified and
a complete transection midway between the portal hilus
and the duodenum was performed by means of sharp dis-
section. Proximal end was used for hepaticojejunostomy
and distal end was closed by a tie. An opening was made
on the wall of the jejunum, wide enough to match the size
of the duct at a distance of 4–5 cm from the pylorus.
Hepaticojejunostomy was performed by the help of surgi-
cal microscope with a silver made external metallic circle.
All anastomoses were performed by the same investigator
(S.K.). The principle of the technique was to tie the sutures
over an external metallic circle 20 to 50 percent greater
than the original outer diameter of the bile duct. The circle
was handmade from a round-bodied silver wire 0.1 to 0.2
mm thick and 1.0 to 1.2 mm in diameter. The external
metallic circle was incorporated at the anastomotic line
without any effort to slip it over the cut end of the bile
duct. The first suture was placed passing inside the circle
and tied over the circle, passing through all layers of duct
wall and intestinal wall. The remaining sutures were
placed and tied according to the same principles. After
completion of sutures, the circle was automatically exteri-
orised (Figure 1). In a preliminary work, we have per-
formed relaparotomy at the end of third month.
Eventhough all the anastomosis were patent, interest-
ingly, we were not able to find any metallic circle around
the anastomosis or anywhere else inside the abdomen.
Therefore, we modified our technique in this study and
placed 2–3 supporting sutures between the circle and jeju-
nal serosa following hepaticojejunostomy anastomosis.
These supporting sutures were passing only through the
inside of circle and jejunal serosa 4 to 5 mm distant to
anastomotic line. At the end of the third month, the rats
underwent relaparotomy to investigate the patency of
hepaticojejunostomy and stability of circles.
Results
All anastomoses were completed with five or six sutures.
Mean operation time was 30 minutes.
One rat died in the postoperative fourth day. In necropsy,
there was anastomotic disruption on the anterior surface
of anastomosis and external circle was on the original
place.
At the end of third month, relaparotomy was performed
on the remaining seven rats. There were no anastomotic
dehiscense or biliary leakage. In all animals, there was a
good connective tissue mass between the bile duct and
jejunum. Dissection of the anastomosis region revealed
that all the anastomosis were patent and all the circles
were staying in original places.
Discussion
For the past 10 to 15 years, hepaticojejunostomy has been
the method of choice for the treatment of benign biliary
stricrures [6,7]. In this study, our aim was to examine the
applicability of external circle in hepaticojejunostomy,
not comparing the hepaticojejunostomy with or without
external metallic circle. Since the first description of
injured bile duct repair, many stenting techniques have
been used [8]. In clinical practice, there is arguement
View of hepaticojejunostomyF gure 1
View of hepaticojejunostomy. (Arrows indicates External 
Metallic Circle)Page 2 of 3
(page number not for citation purposes)
BMC Surgery 2004, 4:14 http://www.biomedcentral.com/1471-2482/4/14about the use of internal stents in hepaticojejunostomy.
Some authors recommend internal stents when unhealty
(ie, ischemic, scarred) and small bile ducts (<4 mm) are
found [9]. Braasch [10], Saypol [11] and Cameron [12]
have reported high long-term results. when biliary-enteric
anastomosis was complimented with internal stent; 80%,
80% and 88% success rates respectively. On the other
hand, some authors suggest that biliaryenteric anastomo-
sis can be performed without anastomotic stents. Aust
[13], Bismuth [14] and Innes [15] have reported 84%,
86%, 95% success rates respectively when biliary-enteric
anastomosis was performed without using any stents and
they suggest that a stent may promote fibrosis of the anas-
tomosis due to constant irritation of ductal mucosa. Thus,
transanastomotic stents appear to have little impact on
outcome and probably should not be used routinely.
However, stents still may be useful in selected cases in
which poor outcome is considered preoperatively or
intraoperatively.
In a previous study of us [5], we showed that end to end
biliary anastomosis with an external metallic circle had
the advantage of shorter operating time and lower bile
leakage rate compared to primary microsurgical anasto-
mosis. And alkaline phosphatase levels were also found to
be significantly lower for end to end biliary anastomosis
with external metallic circle. This results directed us to
search the applicability of external metallic circle in nar-
row hepaticojejunostomy anastomoses. Therefore, we
designed a study to perform end to side hepaticojejunos-
tomy with external metallic circle. During the relaparot-
omy performed at the end of third month, we found all
the anastomosis were patent but we were not able to find
circles in original places except in one rat. Later on, in this
study, we modified our technique and added 2–3 sup-
porting sutures between the circle and jejunal serosa.
Relaparotomy revelad all the anastomosis were patent
and circles were still in place.
Conclusion
We think that external metallic circles are also applicable
to end to side hepaticojejunostomy anastomosis, should
the extra sutures were placed between the circle and jeju-
nal serosa neighbouring the anastomotic line following
the completion of anastomosis. To provide the patency of
narrow hepaticojejunostomy anastomoses, external
metallic circle can be an alternative to use of internal
stents in suitable cases.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
EG designed the study, performed the operations and pre-
pared the manuscript. MK, MT, and MKı participated in
performing the operations. MKo participated in the
design of study and coordination. SK performed the
microsurgical anastomosis. All authors read and approved
the final manuscript.
Acknowledgments
Authors thank to Selim Celebioglu from Department of Plastic and Recon-
structive Surgery, Social Insurances Foundation Hospital, Ankara for his 
assistance during the research.
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Pre-publication history
The pre-publication history for this paper can be accessed
here:
http://www.biomedcentral.com/1471-2482/4/14/prepubPage 3 of 3
(page number not for citation purposes)


External metallic circle in microsurgical anastomosis of common bile duct.

G: A technique of repair of stricture of the bile duct. Surg Gynecol Obstet

GD: The use of Silastic transhepatic stents in benign and malignant biliary strictures. Ann Surg

Hilar and intrahepatic biliary enteric anastomosis. Surg Clin North Am

JL: Benign postoperative biliary strictures. Operate or dilate? Ann Surg

JL: Current management of benign biliary strictures. Adv Surg

Late bile duct cancer complicating bilary-enteric anastomosis for benign disease.

Late development of bile duct cancer in patients who had biliaryenteric drainage for benign disease: a follow-up study of more than 1,000 patients. Ann Surg

LC: Biliary reconstruction without transanastomotic stent. Am Surg

LM: Survival and quality of life after bile duct reconstruction. HPB Surg

Long term results of Roux-en-Y hepaticojejunostomy. Surg Gynecol Obstet

RL: A technique of biliary tract reconstruction with complete follow-up in 44 consecutive cases. Ann Surg

RL: Intubation techniques in biliary tract surgery. Surg Clin North Am

Samaniego-Arvizu G: To stent or not to stent bilioenteric anastomosis after iatrogenic injury: a dilemma not answered? Arch Surg

Varco RL: Biliary stricture. Surgery

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External metallic circle in hepaticojejunostomy

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