What are the indications for hepaticojejunostomy?

Indications for Hepaticojejunostomy

Hepaticojejunostomy is indicated for major bile duct injuries (Strasberg E1-E2), bile duct transections, refractory biliary strictures after failed endoscopic or percutaneous treatment, and late-presenting bile duct injuries with stricture formation. 1, 2

Major Bile Duct Injuries

For major bile duct injuries diagnosed within 72 hours post-cholecystectomy, urgent surgical repair with Roux-en-Y hepaticojejunostomy should be performed at a center with hepatopancreatobiliary expertise. 1, 3 This includes:

• Complete transection of the common bile duct or common hepatic duct 2, 4
• Strasberg E1-E2 injuries (major bile duct injuries involving the hepatic duct confluence) 1, 2
• Severe hilar bile duct damage with multiple duct involvement 5, 6

Early aggressive surgical repair within 48 hours guarantees the best outcomes, with superior 5-year results compared to delayed reconstruction. 3

Failed Endoscopic or Percutaneous Management

Hepaticojejunostomy becomes necessary when less invasive approaches fail:

• Approximately 9% of post-transplant patients fail both ERCP and percutaneous transhepatic biliary dilatation and require hepaticojejunostomy 1
• Anastomotic bile leaks and biliary strictures refractory to endoscopic or percutaneous treatment are candidates for surgical revision 1
• Patients with biliary strictures after liver transplantation who do not improve after conservative treatment should undergo hepaticojejunostomy 1

Late-Presenting Bile Duct Injuries

When major bile duct injuries are recognized late after cholecystectomy with clinical manifestations of stricture, Roux-en-Y hepaticojejunostomy should be performed. 1 This applies to:

• Injuries diagnosed more than 3 weeks post-operatively once acute inflammation has resolved 2
• Post-cholecystectomy strictures that develop over time (median 11-30 months) 3, 7
• Symptomatic dominant strictures in primary sclerosing cholangitis when endoscopic therapy fails, though this is controversial 1

Liver Transplant-Related Indications

In the post-transplant setting, specific indications include:

• Nonanastomotic or diffuse biliary strictures from ischemic events, which have a guarded prognosis and often require retransplantation if hepaticojejunostomy fails 1
• Partial graft recipients with bile duct anastomosis stenosis or leakage when interventional radiology fails—approximately 50% eventually require hepaticojejunostomy 1

Critical Technical Requirements

The procedure is only indicated when certain conditions can be met:

• Anastomosis must be performed exclusively on healthy, non-ischemic, non-inflamed, and non-scarred bile duct tissue—failure to adhere to this principle is the primary cause of postoperative failure 2
• Adequate surgical expertise must be available—primary repair attempts by non-expert surgeons have significantly higher failure rates, morbidity, and mortality 3, 2
• The patient's general condition must allow for major surgery with resolution of acute sepsis and inflammation 2

Common Pitfalls to Avoid

• Do not attempt end-to-end bile duct anastomosis when tissue loss is present—this is associated with increased failure rates compared to hepaticojejunostomy 2
• Do not delay referral to tertiary hepatopancreatobiliary centers for major injuries, as early recognition and appropriate referral significantly impacts long-term outcomes 3
• Do not perform hepaticojejunostomy during active inflammation or sepsis (injuries diagnosed between 72 hours and 3 weeks)—delay definitive repair to allow resolution through percutaneous drainage, antibiotics, and nutritional support 2

Expected Outcomes

When performed correctly at the appropriate time, hepaticojejunostomy provides long-term biliary patency of 80-90% 7, 4. However, anastomotic strictures still occur in 10-20% of cases at a median time of 11-30 months postoperatively, necessitating prolonged surveillance. 3, 7