What are Roux-en-Y (RNY) hepaticojejunostomy and gastrojejunostomy?

From the Guidelines

Hepaticojejunostomy and gastrojejunostomy are critical surgical procedures that can significantly improve morbidity, mortality, and quality of life in patients with bile duct injuries or obstructions, with Roux-en-Y hepaticojejunostomy being the recommended treatment for major bile duct injuries, as stated in the 2020 WSES guidelines 1.

Overview of Hepaticojejunostomy and Gastrojejunostomy

Hepaticojejunostomy and gastrojejunostomy are surgical procedures that create connections between different parts of the digestive system.

• A hepaticojejunostomy connects the hepatic duct (from the liver) to the jejunum (part of the small intestine), bypassing the common bile duct.
• This procedure is typically performed when the bile duct is obstructed or damaged, such as in cases of bile duct cancer, strictures, or injury during gallbladder surgery.
• A gastrojejunostomy creates a connection between the stomach and jejunum, bypassing the duodenum.
• This procedure is commonly performed for gastric outlet obstruction, gastric cancer, or as part of pancreatic surgery.

Importance of Proper Surgical Technique

Both procedures require careful surgical technique to ensure proper anastomosis (connection) and prevent leakage.

• Recovery typically involves a hospital stay of 5-7 days, gradual advancement of diet from clear liquids to solids, pain management with medications like hydrocodone/acetaminophen or tramadol, and follow-up appointments to monitor healing.
• Potential complications include anastomotic leakage, infection, bleeding, and stricture formation at the connection sites.

Recommendations for Bile Duct Injuries

According to the 2020 WSES guidelines, Roux-en-Y hepaticojejunostomy is the recommended treatment for major bile duct injuries, with a weak recommendation and low quality of evidence (GRADE 2C) 1.

• The guidelines also suggest that when major bile duct injuries are recognized late after the index cholecystectomy and there are clinical manifestations of stricture, Roux-en-Y hepaticojejunostomy should be performed 1.
• The treatment of bile duct injuries is generally considered successful, with an overall success rate of 83.3% in the early period, although late postoperative complications such as stricture and cholangitis can occur 1.

From the Research

Hepaticojejunostomy

• Hepaticojejunostomy is a surgical procedure that involves creating a connection between the hepatic duct and the jejunum, a part of the small intestine, to restore bile flow [(2,3,4,5,6)].
• The Roux-en-Y hepaticojejunostomy (RYHJ) is a common technique used for this procedure, which involves creating a loop of jejunum to connect to the hepatic duct [(2,3,4)].
• The RYHJ procedure has undergone evolution over the years, with advancements in technology and techniques, such as the use of intra-anastomotic stents and laparoscopic/robotic approaches 3.

Gastrojejunostomy

• Gastrojejunostomy is a surgical procedure that involves creating a connection between the stomach and the jejunum 2.
• In the context of hepaticojejunostomy, a gastric access loop can be created to facilitate endoscopic access to the hepaticojejunostomy anastomotic site 2.
• The use of a gastric access loop has been shown to enable easy endoscopic access for the management of future hepaticojejunostomy anastomotic strictures 2.

Comparison of Hepaticojejunostomy and Gastrojejunostomy

• Hepaticojejunostomy is considered a more suitable option for biliary reconstruction in certain situations, such as choledochal cyst repair, due to a lower incidence of complications 4.
• Gastrojejunostomy, on the other hand, may be associated with a higher incidence of complications, such as duodenogastric bile reflux 4.
• The choice of procedure depends on the individual patient's condition and the surgeon's expertise [(2,3,4,5,6)].

Outcomes and Complications

• Hepaticojejunostomy has been shown to be a relatively safe procedure, with a low mortality rate and a high success rate in restoring biliary patency [(5,6)].
• However, complications such as anastomotic strictures and leaks can occur, and may require additional treatment, such as percutaneous dilatation or reoperation 5.
• The use of a gastric access loop in hepaticojejunostomy has been shown to facilitate endoscopic access and management of complications 2.