What is the role of biliary enteric (biliary intestinal) anastomosis in the treatment of choledocholithiasis (gallstones in the bile duct)?

Biliary Enteric Anastomosis for Choledocholithiasis

Biliary enteric anastomosis is NOT a primary treatment for choledocholithiasis and should only be considered in highly selected patients with recurrent stones who have failed multiple endoscopic and percutaneous interventions. 1, 2

Primary Treatment Approach: Stone Clearance is Standard of Care

• ERCP with sphincterotomy and stone extraction achieves 90% success rates and remains the first-line definitive treatment for choledocholithiasis. 2, 3
• Laparoscopic bile duct exploration (LBDE) is an appropriate alternative technique with 95% success rates and 5-18% complication rates, particularly when performed during laparoscopic cholecystectomy. 1, 3
• For large stones (>10-15 mm), mechanical lithotripsy or stone fragmentation techniques achieve 79% success rates and should be added to standard ERCP. 2, 3
• When ERCP fails or is not feasible, percutaneous transhepatic approaches achieve 95-100% success rates in experienced hands. 2, 3
• Open bile duct exploration should be reserved only for the small number of patients in whom endoscopic and percutaneous techniques fail or are not possible. 1

The Limited Role of Biliary Enteric Anastomosis

Biliary enteric anastomosis (choledochoduodenostomy or hepaticojejunostomy) is indicated only for recurrent choledocholithiasis after failure of endoscopic and percutaneous treatments. 4, 5

Specific Indications for Biliary Drainage Procedures:

• Patients with multiple episodes of recurrent bile duct stones despite successful endoscopic clearance 4, 5
• Patients with recurrent stones combined with benign biliary strictures causing obstruction 5, 6
• Patients who have failed repeated ERCP attempts and percutaneous interventions 4
• Selected patients with dilated common bile ducts (>9 mm) to prevent subsequent stricture development 3

Important Distinction from Stenting:

• Temporary biliary stenting is recommended to ensure adequate drainage when stones cannot be completely extracted, but this is NOT the same as biliary enteric anastomosis. 1
• Stenting as sole definitive treatment should be restricted to patients with limited life expectancy or prohibitive surgical risk—this is fundamentally different from surgical biliary-enteric anastomosis. 1

Surgical Technique Options When Anastomosis is Indicated

• Side-to-side choledochoduodenostomy is the preferred biliary-enteric anastomosis technique for recurrent stones, involving exposure of the common bile duct, Kocher maneuver, choledochotomy with choledochoscopy inspection, and anastomosis to the duodenum. 4
• Laparoscopic choledochoduodenostomy can be performed as an acceptable alternative to open surgery in experienced hands, requiring intracorporeal suturing skills and ensuring a tension-free anastomosis with adequate-sized stoma. 5
• Hepaticojejunostomy with Roux-en-Y reconstruction is indicated for more proximal bile duct pathology or when duodenal anastomosis is not feasible. 6
• Choledochojejunostomy represents a middle option between choledochoduodenostomy and hepaticojejunostomy. 6

Complications and Outcomes of Biliary Enteric Anastomosis

• Early complications occur in approximately 49% of patients undergoing biliary enteric anastomosis for benign diseases, with wound infection (23%) and bile leak (10%) being most frequent. 7
• Low serum albumin (odds ratio 16) and higher ASA classification (odds ratio 7) independently predict early complications following biliary enteric anastomosis. 7
• Choledochoduodenostomy carries risks of recurrent cholangitis (10.4%) and sump syndrome (4.2%), though it has no anastomotic leaks or restrictures in reported series. 6
• Hepaticojejunostomy has higher technical complexity with anastomotic leak rates requiring potential reoperation and restricture rates of approximately 7%. 6
• Mortality rates for biliary enteric anastomosis range from 5% for benign diseases to higher rates in emergency settings. 7

Critical Clinical Algorithm

Step 1: Attempt ERCP with sphincterotomy and stone extraction (90% success) 2

Step 2: If large stones present, add mechanical lithotripsy (79% success) 2

Step 3: If ERCP fails, attempt percutaneous transhepatic approach (95-100% success) 2

Step 4: If percutaneous approach fails, perform laparoscopic or open bile duct exploration 1, 3

Step 5: Only after multiple failures of the above approaches AND in the setting of recurrent stones, consider biliary enteric anastomosis 4, 5

Key Pitfalls to Avoid

• Do not perform biliary enteric anastomosis as primary treatment for choledocholithiasis—clearance of bile duct stones is the standard of care. 1
• Do not confuse temporary biliary stenting (appropriate for incomplete stone extraction) with definitive biliary-enteric surgical anastomosis (only for recurrent stones after multiple treatment failures). 1
• Recognize that biliary enteric anastomosis carries substantial morbidity (49% complication rate) and should only be performed when less invasive options have been exhausted. 7
• Ensure adequate nutritional status before surgery, as hypoalbuminemia significantly increases complication risk (16-fold). 7
• Refer patients requiring biliary enteric anastomosis to tertiary centers with hepatopancreatobiliary expertise, as technical skill significantly impacts outcomes. 1