Hepatico-Jejunostomy or Hepatico-duodenostomy after resection of a choledochal cyst?

Cholangitis!!!... is that not the main concern when food is passing right next to the hepatic ducts after a hepatico-duodenostomy (HD), with no interposed common bile  duct or sphincter of Oddi?  That was what I thought until I was told otherwise, and confirmed with the limited available evidence.

When a Kocherized (salute to the verb-nouns) duodenum can reach the hepatic ducts for reestablishing continuity after choledochal cyst resection, the laparoscopic operation becomes simpler, more physiologic, and avoids potential complications related to the roux-en-y reconstructions.  Additionally, it allows for future endoscopic access to the anastomosis in case an anastomotic stricture or intrahepatic stones develop. No much controversy there.

But what about cholangitis, how can it be OK for food to pass right by the hepatic ducts and not cause an infection.

In a paper by Santore et al out of CHOP, the authors retrospectively reviewed charts of 59 patients who underwent open resection by the same surgeon with reconstruction using either HD (66%) or HJ (34%). After a mean of 2.3 years follow up for HD and 3.5 years follow up for HJ, only one patient in the HJ developed cholangitis.  Additionally, there was no significant difference in the rate of postoperative leaks or strictures.

Another argument against reconstruction with a HD relates to the risk of bile gastritis.  A meta-analysis of several papers with a total of 679 patients (60% of whom underwent reconstruction with a HD) suggested that patients who are reconstructed using a HD are at increased risk of bile gastritis (5.9% for HD vs. 0% for HJ).  It is clear how reconstruction with a HJ completely diverts bile away from the stomach and thus prevents any bile gastritis.  It is unclear to me, however, how placing the anastomosis in the duodenum, and downstream of a perfectly healthy pylorus, is any different from the normal physiologic drainage of bile, and why that would cause gastritis.

At this point, it seems reasonable to me to chose a HD over a HJ if technically feasible.

Hypophosphatemia after major liver resection

A conversation about hypophosphatemia after a recent liver resection elicited a literature search on the subject.  A paucity of material in the pediatric surgical literature (a quick search yielded only one case report) prompted a move to the adult literature (yes, I know, they are not just small adults!).

A retrospective study by Salem et al looked at post operative phosphate levels in 20 patients who underwent major liver resection.  The authors confirmed the known association between hypophosphatemia and major liver resection with a drop in phosphate levels of an average of 1.1 mg/dl and a nadir at post operative day 2.

They discussed several potential explanations, including the common assumption that the drop in phosphate levels is due to the consumption of phosphate ions by the aggressively regenerating liver, but noted that these patients also experience hyperphosphaturea.  This finding contradicted what would be expected in the setting of phosphate ion depletion by the liver.

Their alternate explanation involved some form of messenger molecule controlled by the liver, and depleted with a major liver resection.  They described this as a disruption in normal hepatorenal messaging that results in phosphate ion wasting by the kidney.  This starts immediately postoperatively, peaks at 2 days post operatively, and usually resolves by post op day 5.