Surgical management of patients with post-cholecystectomy benign biliary stricture complicated by atrophy-hypertrophy complex of the liver

Background: Atrophy-hypertrophy complex (AHC) of the liver rarely complicates post-cholecystectomy benign biliary strictures (BBS). This study aimed to analyse the effect of AHC on the surgical management of patients with BBS. Methods: Between 1989 and 2005, 362 patients underwent surgical repair for BBS at a tertiary referral centre in northern India. A total of 36 (10%) patients had AHC. Patients with AHC (n = 36) were compared with those without (n = 336) to define the factors associated with the development of AHC. Results: Overall, 35 patients with AHC underwent Roux-en-Y hepaticojejunostomy; right hepatectomy was performed in one patient. The interval between bile duct injury and stricture repair did not influence the development of AHC (mean 24 months in AHC patients vs. 19 months in non-AHC patients; P = 0.522). Of the 36 patients with AHC, 26 (72%) had hilar strictures (Bismuth's types III, IV, V), as did 163 of the 326 (50%) patients without AHC (P = 0.012). Patients with AHC had more blood loss at surgery (mean blood loss 340 ml in the AHC group vs. 190 ml in the non-AHC group; P = 0.004) and required more blood transfusion (mean blood transfused 300 ml vs. 120 ml; P = 0.001). Surgery was prolonged in AHC patients (mean duration of operation 4.2 hours in the AHC group vs. 2.8 hours in the non-AHC group; P = 0.001). Over a mean follow-up of 43 months (range 6-163 months), three of 36 (8%) AHC patients required re-intervention for recurrent strictures, compared with nine of 326 (3%) non-AHC patients (P = 0.006). Conclusions: Iatrogenic injury at the hepatic hilum predisposes for the development of AHC. Surgery is more difficult and blood transfusion requirements are higher in patients with AHC during surgical repair of BBS. Atrophy-hypertrophy complex is a risk factor for recurrent stricture formation after hepaticojejunostomy.