What are the details of the Hepaticojejunostomy procedure?

Hepaticojejunostomy: Technical Details and Surgical Principles

Hepaticojejunostomy is a biliary-enteric anastomosis procedure that creates a tension-free, mucosa-to-mucosa connection between healthy bile duct tissue and a Roux-en-Y jejunal limb, primarily used for major bile duct injuries and benign biliary strictures. 1

Fundamental Surgical Principle

The cornerstone of successful hepaticojejunostomy is anastomosis performed exclusively on healthy, non-ischemic, non-inflamed, and non-scarred bile duct tissue. 2, 1 Failure to adhere to this principle is the primary cause of postoperative anastomotic leakage and stricture formation. 1

Preoperative Preparation and Timing

Optimal Timing for Repair

• For injuries detected intraoperatively or within 72 hours: Early repair by an experienced hepatopancreatobiliary (HPB) surgeon can be performed if appropriate expertise is available. 2, 1

• For injuries detected between 72 hours and 3 weeks: Delay definitive repair to allow resolution of inflammation and infection through percutaneous drainage, targeted antibiotics, and nutritional support. 2

• For late-diagnosed injuries (>3 weeks): Proceed with hepaticojejunostomy once the patient's general condition allows and acute inflammation has resolved. 2

Critical Caveat on Timing

Thermal injury boundaries are often unclear at the early stage, making accurate determination of ischemic and devitalized bile duct planes difficult. 2 Surgery erroneously performed on ischemic bile ducts guarantees failure. 1

Technical Specifications

Bile Duct Preparation

• Remove all scar tissue and devitalized tissue from the proximal bile duct stump before anastomosis. 1 This requires meticulous dissection to expose healthy bile duct mucosa with adequate caliber and normal mucosal characteristics. 1

• Preserve blood supply to the bile duct during dissection, as vascularized ducts are essential for successful reconstruction. 1 Associated hepatic artery injury significantly worsens outcomes, increasing rates of anastomotic strictures and biliary cirrhosis. 1

Anastomotic Technique

• Use fine suture technique with 5-0 or 6-0 sutures, selecting size according to bile duct wall thickness. 1 Either absorbable or non-absorbable materials are acceptable. 1

• Ensure meticulous mucosa-to-mucosa apposition between bile duct and jejunal mucosa, as this is essential for long-term patency. 1

• Create a tension-free anastomosis to prevent ischemia and subsequent stricture formation. 2

Roux-en-Y Limb Construction

• Create a Roux-en-Y jejunal limb of 40-60 cm length to prevent reflux of enteric contents into the biliary tree. 1

• Perform end-to-side hepaticojejunostomy as the standard approach. 3 For high strictures and recurrences, the Hepp-Couinaud approach (accessing the left hepatic duct at the base of segment IV) should be utilized. 3

Optional Technical Adjuncts

• Gastric access loops can be created during hepaticojejunostomy to facilitate future endoscopic access for management of anastomotic strictures, reducing the need for revision surgery. 4 This technique is particularly useful in settings with limited facilities for radiological interventions. 4

• Intra-anastomotic stenting remains debated, though some centers routinely employ this technique. 5

Indications for Hepaticojejunostomy

Major Bile Duct Injuries (Strasberg Classification)

• Type I injuries (severe): Transection of common bile duct requires choledochojejunostomy. 2

• Types II1 and II2 injuries with large tissue defect or serious damage: Choledochojejunostomy is the procedure of choice. 2

• Type II3 injuries (first branches of hepatic duct) with large tissue defect: Choledochojejunostomy should be performed. 2

• Type II4 injuries (secondary branches) with insufficient functional remnant liver: Choose duct-to-duct anastomosis or choledochojejunostomy. 2

• Strasberg E1-E2 injuries (major BDI): Hepaticojejunostomy is the treatment of choice. 2

Other Indications

• Chronic pancreatitis with biliary obstruction 3
• Anastomotic strictures following liver transplantation (when endoscopic treatment fails) 2
• Late-stage Type II3 injuries with chronic liver abscess or secondary hepatolithiasis 2

Expected Outcomes and Complications

Success Rates

• Long-term biliary patency of 80-90% when performed correctly. 6

• Anastomotic stricture rates range from 4.1% to 69%, with most studies reporting 10-20%, occurring at a median time of 11-30 months postoperatively. 1

Early Complications

• Postoperative complications occur in approximately 33% of patients. 3
• Mortality rate is approximately 2% in experienced centers. 3
• Hospital stay averages 24 days (range 8-90 days). 3

Late Complications

• Late complications develop in approximately 25% of patients, occurring 2 months to 6 years after operation. 3
• Stenosis and cholangitis necessitate reoperation in approximately 6% of cases. 3
• When successful, 89% of patients report good or very good condition at long-term follow-up. 3

Critical Pitfalls to Avoid

• Never perform anastomosis on ischemic, inflamed, or scarred bile duct tissue—this guarantees failure. 1

• Avoid end-to-end bile duct anastomosis when tissue loss is present, as this is associated with increased failure rates compared to hepaticojejunostomy. 1

• Do not attempt complex vasculobiliary injuries intraoperatively, even by expert HPB surgeons, without proper preparation and planning. 2

• Ensure referral to a tertiary HPB center if local expertise is unavailable, as primary repair attempts by non-expert surgeons have significantly higher failure rates, morbidity, and mortality. 2, 1

Surgical Expertise Requirements

Hepaticojejunostomy should only be performed by experienced HPB surgeons. 2, 1, 6 The procedure requires appropriate multidisciplinary approach and expert high-quality surgical technique, as complications and failure can be extremely difficult to manage. 6