Hepaticojejunostomy to Treat Medically Refractory Bile Reflux After Esophagectomy With Gastric Pull-Up

Gastroesophageal biliary reflux is a common complication after esophagectomy with gastric pull-up. Symptomatic relief focuses on dietary/lifestyle modifications and acid suppression, and possibly bile-binding medications. Rarely, patients with medically refractory bile reflux may need a surgical intervention. Reoperation in these patients is challenging as injury to the gastroduodenal artery could lead to graft ischemia. To avoid vascular injury, we treated three patients with refractory biliary reflux using a retro-colic Roux-en-Y hepaticojejunostomy. Two patients reported complete resolution of bile reflux symptoms, and the third reported minimal bile reflux after biliary diversion. Follow-up endoscopy in two patients showed improvement of esophagitis, no bile in their grafts, and no recurrent Barrett's esophagus. The Roux-en-Y hepaticojejunostomy, a common and safe operation for biliary diversion, provides the advantage of reducing the risk of conduit vascular injury by avoiding a previous operative field. This surgical strategy provides symptomatic relief and endoscopically confirmed improvement of esophagitis.