Refractory biliary leaks after liver trauma are often managed selectively in Western countries by nonoperative endoscopic/percutaneous techniques, followed by surgery in case of fail. Conversely, in austere environments, such as low-income countries or during war or internal conflicts, such technologies are rarely accessible, and surgery represents the first-line treatment for chronic posttraumatic biliary fistula. However, expertise in complex reconstructive hepatobiliary surgery might not be available in such settings, making surgical management very challenging. Less-demanding surgical solutions would be quite helpful and more suitable in these circumstances. More than 50 years ago, Galeev, a Russian surgeon, described the anastomosis between the wall of a biliary fistula and the jejunum in a Roux-en-Y fashion as a treatment for chronic refractory fistulas of different causes. This procedure was performed infrequently in Western countries and was later abandoned in favor of operative endoscopy or radiology, or more complex biliary reconstructions. More recently, several reports about fistulojejunostomy in the management of chronic biliary leaks have appeared in the literature from lowand middle-income countries, with satisfactory outcomes. With a review of the literature, we describe the technical details of this operation, according to our experience on a wounded patient during the ongoing conflict in Syria, suggesting that this surgical approach could be a valuable tool in an austere environment, especially for surgeons not trained in reconstructive biliary surgery.
