What are the indications for hepaticojejunostomy?

Indications for Hepaticojejunostomy

Hepaticojejunostomy is indicated for major bile duct injuries with complete transection or tissue loss, benign biliary strictures refractory to endoscopic management, high-grade extrahepatic bile duct trauma, and complex biliary reconstructions following pancreaticoduodenectomy or liver transplantation. 1, 2

Traumatic Bile Duct Injuries

For extrahepatic bile duct injuries with complete loss of continuity, distal ligation and reconstruction with Roux-en-Y hepaticojejunostomy is the recommended treatment. 1 This applies to:

• WSES class II and III injuries (AAST-OIS grade IV-V) requiring operative management or after failed non-operative management 1
• Choledochojejunostomy may be used for distal common bile duct injuries only when there is no associated vascular injury that could compromise blood supply to the anastomosis 1
• Primary repair over a T-tube can be attempted for WSES class II injuries but carries risk of stricture formation and may require future reconstructive surgery 1

Iatrogenic Bile Duct Injuries

Major bile duct injuries (Strasberg E1-E5) with complete loss of common and/or hepatic bile duct continuity require Roux-en-Y hepaticojejunostomy as definitive treatment. 1, 3 Specific indications include:

• Complete transection of the hepatic or common bile duct with clips on proximal and distal segments 3, 4
• Bile duct injuries with tissue loss where primary repair or end-to-end anastomosis is not technically feasible 1, 3
• Bismuth type 4 injuries involving the first branches of the hepatic duct at the hilar plate level 5
• High-grade bile leaks refractory to endoscopic management with stenting 1, 3

End-to-end anastomosis should be avoided as it is associated with increased failure rates compared to hepaticojejunostomy, particularly when tissue loss is present or clips have been placed on the ducts. 1, 3

Complex Pancreaticoduodenal Injuries

Hepaticojejunostomy is required for reconstruction following pancreaticoduodenectomy (Whipple procedure) in trauma patients with:

• WSES class III pancreatic injuries (AAST-OIS grade IV-V) with complete destruction or devascularization of the pancreatic head and pancreatico-duodenal complex 1
• Duodenal injuries involving the ampulla or distal common bile duct when re-implantation into adjacent duodenum is not possible 1

Post-Liver Transplantation Complications

Hepaticojejunostomy is indicated for liver transplant recipients with:

• Anastomotic biliary strictures refractory to endoscopic or percutaneous treatment 1
• Bile leaks at hepaticojejunostomy anastomosis where endoscopic approach has failed, requiring transhepatic drain placement and potential surgical revision 1
• Nonanastomotic or diffuse biliary strictures with poor prognosis from ischemic events, though these patients often ultimately require retransplantation 1

Benign Biliary Strictures

Hepaticojejunostomy is indicated for benign biliary strictures when:

• Endoscopic management with multiple plastic stents fails after long-term placement (success rate 74-90% but recurrence up to 30% within 2 years) 1
• Chronic pancreatitis causes biliary obstruction requiring long-term biliary bypass 6
• Post-cholecystectomy strictures located >2 cm from the main hepatic confluence fail endoscopic therapy 1

Technical Considerations and Outcomes

The success of hepaticojejunostomy depends on several critical factors:

• Timing of repair: Early repair within 48-72 hours by experienced HPB surgeons provides good results and avoids sepsis 1. However, when inflammation, infection, or vascular injury is present, delayed repair at 4-6 weeks after controlling bile leakage and infection is preferred 4, 5
• Surgical expertise: Repairs performed by surgeons without HPB expertise have higher rates of postoperative failure, morbidity, and mortality 1. Immediate referral to tertiary care centers is essential 1
• Anastomotic technique: Tension-free bilioenteric anastomosis with good mucosal apposition using healthy, non-ischemic, non-inflamed, and non-scarred bile duct is mandatory 1, 4, 5
• Long-term patency: When performed correctly, hepaticojejunostomy provides biliary patency restoration in 80-90% of patients long-term 2, 7

Common pitfalls to avoid:

• Using scarred or ischemic bile duct tissue for reconstruction inevitably leads to surgical failure 4, 5
• Attempting immediate repair without HPB expertise results in higher complication rates 1
• Performing intermediate repair (14-90 days post-injury) has higher stricture rates compared to repair >90 days after injury 8