What is Choledochojejunostomy
Choledochojejunostomy is a surgical procedure in which the bile duct (common bile duct or hepatic duct) is directly anastomosed to a loop of jejunum, creating a bypass for bile drainage when normal biliary anatomy cannot be preserved. 1
Surgical Technique
The procedure involves creating a Roux-en-Y jejunal limb and anastomosing it to the bile duct using fine suture technique (5-0 or 6-0 sutures) with mucosa-to-mucosa apposition. 1 The anastomosis must be:
- Performed with healthy, non-ischemic, non-inflamed bile duct tissue 2
- Created using single-layer stitching with uniform margins and appropriate density 1
- Tension-free with adequate caliber to prevent stricture formation 1
- Tight enough to prevent bile leakage but not so tight as to compromise blood supply 1
Primary Indications
Major bile duct injuries with complete transection or tissue loss require Roux-en-Y hepaticojejunostomy (or choledochojejunostomy) as the definitive treatment. 3 Specific indications include:
- Bile duct injuries: Strasberg type E injuries (E1-E5) with complete loss of bile duct continuity 3
- Biliary strictures: Benign strictures refractory to endoscopic management (success rate 74-90% but recurrence up to 30% within 2 years) 3
- Liver transplantation: Preferred method for patients with PSC, cholangiocarcinoma, biliary atresia, inadequate bile duct size, or large disparity between donor and recipient ducts 1
- Surgical correction: Used to repair complications from failed duct-to-duct anastomosis 1
- High-grade trauma: Extrahepatic bile duct injuries with complete loss of continuity 3
Advantages Over Alternative Techniques
The procedure is preferred over duct-to-duct anastomosis in specific scenarios because:
- It does not require matching bile duct sizes 1
- It can accommodate tissue loss or damaged bile duct segments 3
- It provides definitive reconstruction when primary repair is not feasible 3
However, this method eliminates the Sphincter of Oddi as a defense against enteric organisms and prevents future endoscopic access to the biliary tree. 1
Clinical Outcomes
When performed by experienced hepatopancreatobiliary surgeons, choledochojejunostomy has a success rate of 80-90%. 4 Key factors affecting outcomes include:
- Timing of repair: Early repair within 48-72 hours by experienced surgeons provides good results and avoids sepsis 3
- Surgical expertise: Repairs performed by surgeons without HPB expertise have higher rates of failure, morbidity, and mortality 3
- Delayed repair: For cases with infection, peritonitis, or vascular injury, definitive repair should be performed 4-6 weeks after controlling inflammation 2
Common Complications
Potential complications include:
- Anastomotic strictures: Can occur at any time after surgery, requiring endoscopic or percutaneous intervention 1
- Cholangitis: Occurs in up to 60% of patients in some series 5
- Bile leaks: Managed with percutaneous drainage and endoscopic stenting (96% success rate) 4
- Bilomas: Treated with percutaneous drainage as first-line therapy 4
Critical Technical Considerations
The key to successful choledochojejunostomy is establishing an adequate caliber of anastomosis using a narrow proximal bile duct with normal mucosa. 1 This requires:
- Complete removal of scar tissue from the bile duct stump after full exposure 1
- For injuries where left and right hepatic ducts are separated, suturing the medial margins together before anastomosing to jejunum 1
- Avoiding placement of non-absorbable sutures in the cavity 1
- Routine biliary drainage is not necessary unless anastomosis is suboptimal, inflammation is present, or intrahepatic stones exist 1