Why Perform a Braun's Jejunojejunostomy During Cholecystoenterotomy?
A Braun's jejunojejunostomy is performed during cholecystoenterotomy to prevent bile reflux into the stomach and reduce the risk of marginal ulceration, cholangitis, and "sump syndrome" by creating a side-to-side anastomosis between the afferent and efferent jejunal limbs.
Primary Rationale for Braun's Anastomosis
The Braun's jejunojejunostomy serves as a critical protective measure when performing cholecystoenterotomy (cholecystojejunostomy) for biliary bypass:
Prevents bile reflux gastritis: When bile drains directly into a jejunal loop without a Braun's anastomosis, intestinal contents and bile can reflux proximally through the afferent limb into the stomach, causing severe alkaline gastritis 1
Reduces marginal ulceration risk: The side-to-side jejunojejunal anastomosis allows intestinal contents to bypass the biliary anastomosis, minimizing exposure of the gastrojejunal anastomosis to bile acids that can cause ulceration 1
Prevents "sump syndrome": Without a Braun's anastomosis, the blind afferent limb can accumulate food debris, bacteria, and bile, leading to bacterial overgrowth, cholangitis, and recurrent hepatic abscesses—complications well-documented after cholecystojejunostomy 2
Technical Considerations
When performing combined biliary and gastric bypass procedures:
Use a common jejunal loop: The cholecystojejunostomy and gastrojejunostomy can share a single jejunal loop, with the Braun's anastomosis placed 10-15 cm distal to both anastomoses to provide decompression 1
Stapling technique simplifies construction: Modern gastrointestinal staplers allow rapid creation of the side-to-side Braun's anastomosis, typically adding only 10-15 minutes to operative time 3, 1
Position matters: The Braun's anastomosis should be placed on the efferent limb approximately 10-15 cm downstream from the gastrojejunostomy to effectively decompress the afferent limb 1
Evidence from Palliative Procedures
The rationale for Braun's anastomosis is best understood from experience with combined biliary and gastric bypass:
Comparable outcomes with added protection: Cholecystoenterostomy has comparable 30-day mortality (6.3-8.8%) and survival (7.8-8.9 months) to choledochoenterostomy, but the addition of Braun's anastomosis reduces late complications 4
Failure rates without proper drainage: Cholecystojejunostomy without adequate afferent limb decompression has a 10.9% failure rate due to recurrent jaundice and cholangitis 4
Chronic complications are preventable: Long-term complications including chronic cholecystitis, gastrointestinal bleeding, recurrent hepatic and brain abscesses, and anastomotic varices have been reported after cholecystojejunostomy without Braun's anastomosis 2
Common Pitfalls and How to Avoid Them
Never omit the Braun's when performing gastrojejunostomy concurrently: If both biliary and gastric bypass are needed, the Braun's anastomosis is mandatory to prevent afferent limb syndrome 1
Ensure adequate limb length: The afferent limb between the biliary anastomosis and Braun's should be at least 10-15 cm to prevent tension and allow proper drainage 1
Consider even for cholecystojejunostomy alone: While traditionally described for combined procedures, a Braun's anastomosis may benefit isolated cholecystojejunostomy by preventing bacterial overgrowth in the afferent limb 2
Monitor for late complications: Even with proper technique, patients require long-term surveillance for cholangitis, hepatic abscesses, and anastomotic complications 2