What are the advantages, disadvantages, and complications of choledochoduodenostomy (surgical creation of a connection between the common bile duct (CBD) and the duodenum) vs choledochojejunostomy (surgical creation of a connection between the CBD and the jejunum) vs hepaticojejunostomy (surgical creation of a connection between the hepatic duct and the jejunum) for treating large common bile duct (CBD) stones?

Surgical Bypass for Large CBD Stones: Comparative Analysis

Primary Recommendation

Biliary-enteric anastomosis should only be performed for large CBD stones after all endoscopic and laparoscopic extraction methods have failed, as surgical bypass is not recommended as first-line treatment for stone disease. 1

Critical Context: When Bypass Surgery Is Appropriate

The 2017 British Society of Gastroenterology guidelines explicitly do not recommend bypass surgery as a primary treatment option for large CBD stones. 1 Biliary-enteric anastomosis is primarily indicated for bile duct injuries, not for stone disease alone. 1

Bypass surgery should only be considered when:

• All endoscopic extraction methods (EPLBD, mechanical lithotripsy, cholangioscopy-guided lithotripsy) have failed 1
• Laparoscopic bile duct exploration is not feasible or has failed 1
• The patient has intractable recurrent stones despite repeated interventions over years 2

Comparative Analysis of Bypass Procedures

Choledochoduodenostomy (CDD)

Advantages:

• Technically simpler and faster procedure with shorter operative time 3, 4
• Direct anastomosis without need for Roux-en-Y limb construction 4
• Excellent long-term results with 78-89% of patients symptom-free 3, 5
• No increased risk of duodenal fistula or anastomotic leak when properly performed 4
• Maintains physiologic bile flow into duodenum 5

Disadvantages:

• Requires CBD diameter ≥12mm for technical feasibility 3
• Risk of "sump syndrome" (reflux of duodenal contents causing recurrent cholangitis), though this occurs in only 5% of patients with proper technique 3
• Cannot be used for high bile duct strictures or injuries 6
• Theoretical concern for reflux cholangitis if anastomosis is not sufficiently wide 5

Complications:

• Cholangitis: 5% when stomal patency is maintained 3
• Anastomotic stricture: rare with wide anastomosis (>20mm) 5
• No increased peptic ulcer disease 6
• Operative mortality: 1.6% 5

Choledochojejunostomy (Roux-en-Y)

Advantages:

• Eliminates reflux of enteric contents into biliary tree 6
• Avoids "sump syndrome" concerns 6
• Can accommodate various CBD diameters 2
• Allows for distal CBD occlusion or resection to prevent ascending cholangitis when papilla is patulous 2
• Suitable for intractable recurrent stones requiring numerous endoscopic interventions 2

Disadvantages:

• More complex procedure requiring Roux-en-Y limb construction (typically 40-60cm) 2
• Longer operative time compared to CDD 6
• Requires two anastomoses (biliary-enteric and jejuno-jejunal) 2
• More technically demanding 6

Complications:

• Anastomotic stricture: 10-20% (range 4.1-69% in some series) 7
• Median time to stricture formation: 11-30 months 7
• Recurrent cholangitis: 10% requiring endoscopic stenting 7
• Biliary cirrhosis: 2.4-10.9% long-term 7
• Operative mortality: 4% 6
• Brief episodes of cholangitis: 10% responsive to antibiotics 6

Hepaticojejunostomy (Roux-en-Y)

Advantages:

• Preferred for high bile duct strictures or injuries 7
• Superior outcomes at 5 years when performed early for bile duct injuries 7
• Avoids diseased or damaged distal CBD 6
• Can be performed as left hepatic duct anastomosis for very high strictures 6

Disadvantages:

• Most technically demanding of the three procedures 7
• Requires expertise of HPB surgeon in tertiary care setting 7
• Longer operative time 6
• Not necessary for distal CBD stone disease 6

Complications:

• Similar complication profile to choledochojejunostomy 6
• Anastomotic stricture: 10-20% 7
• Recurrent cholangitis requiring reoperation: 11% 6
• Biliary cirrhosis: 2.4-10.9% 7
• Mortality: 1.8-4.6% 7
• Associated vascular injury, sepsis, or peritonitis worsens outcomes 7

Algorithmic Approach to Procedure Selection

For distal CBD stones with failed endoscopic/laparoscopic extraction:

1. If CBD diameter ≥12mm and stone disease is distal: Consider choledochoduodenostomy as first choice 3, 4

   • Simpler, faster, excellent long-term results 4, 5
   • Ensure wide anastomosis (≥20mm) to prevent sump syndrome 5

2. If papilla is patulous or patient has recurrent stones over many years: Consider Roux-en-Y choledochojejunostomy with distal CBD occlusion or resection 2

   • Prevents reflux ascending cholangitis 2, 6
   • Particularly indicated after 9-10+ endoscopic procedures over years 2

3. If CBD diameter <12mm or high bile duct involvement: Hepaticojejunostomy is required 6

   • Refer to HPB surgeon in tertiary center 7

Critical Pitfalls to Avoid

• Never proceed directly to bypass surgery without attempting advanced endoscopic techniques including cholangioscopy-guided electrohydraulic or laser lithotripsy (73-97% stone clearance rates) 1
• Do not perform choledochoduodenostomy with CBD diameter <12mm as this increases stricture risk 3
• Ensure anastomotic width ≥20mm for CDD to prevent sump syndrome 5
• For Roux-en-Y procedures, create tension-free anastomosis with good mucosal apposition as this is the mainstay of preventing complications 7
• If papilla is patulous during choledochojejunostomy, occlude or resect distal CBD to prevent reflux cholangitis 2
• Avoid end-to-end anastomosis when possible as it is associated with increased failure rates 7

Outcomes Summary

Long-term success rates (symptom-free):

• Choledochoduodenostomy: 78-89% 3, 5
• Choledochojejunostomy: 78.7% 6
• Hepaticojejunostomy: 78.7% 6

The key determinant of success is not the procedure type but rather the technical execution: wide, tension-free anastomosis with good mucosal apposition and vascularized ducts. 7, 5