Management of Pneumobilia After Hepaticojejunostomy

Initial Assessment and Management

The presence of pneumobilia after hepaticojejunostomy is a normal consequence of the surgically created bilioenteric anastomosis, and no intervention is required in asymptomatic patients, according to the American College of Surgeons 1.
For symptomatic patients, immediate assessment includes obtaining liver function tests, such as direct and indirect bilirubin, AST, ALT, alkaline phosphatase, and GGT, to evaluate for cholestasis or anastomotic complications, as recommended by the World Journal of Emergency Surgery 4, 1.
In symptomatic patients, inflammatory markers, including CBC, CRP, and procalcitonin, should be obtained to evaluate the severity of acute inflammation and sepsis, according to the World Journal of Emergency Surgery 4, 1.
Transabdominal ultrasound is recommended as the first-line imaging modality to identify bile duct dilation, fluid collections, and anastomotic strictures, as suggested by the World Journal of Emergency Surgery 4, 1.

In cases of recurrent cholangitis, broad-spectrum antibiotics should be started immediately, and biliary decompression via percutaneous transhepatic cholangiography (PTC) should be performed as the primary treatment modality, according to the American College of Surgeons 1, 3.
For bile leak or biloma formation, immediate broad-spectrum antibiotics should be initiated, and percutaneous drainage of fluid collections should be performed under CT or ultrasound guidance, as recommended by the World Journal of Emergency Surgery 6, 3, 5, 4, 7.
In cases of failed hepaticojejunostomy, immediate referral to a tertiary hepatobiliary center is recommended for multidisciplinary management, according to the American College of Surgeons 1, 2, 3.

Overall clinical success, defined as the absence of incapacitating biliary symptoms, is achieved in 89% of patients with appropriate management, as reported by the American College of Surgeons 1.
Long-term patency of 80-90% is expected when hepaticojejunostomy is performed correctly, according to the American College of Surgeons 1.
Anastomotic strictures develop in 10-20% of cases, typically between 11-30 months postoperatively, as reported by the American College of Surgeons 1, 3.