In a patient with a common bile duct >3 cm that cannot be safely reconstructed, what are the indications for performing a Roux‑en‑Y hepaticojejunostomy?

Indications for Hepaticojejunostomy in Very Dilated CBD (>3 cm)

For a common bile duct greater than 3 cm that cannot be safely reconstructed with primary repair, Roux-en-Y hepaticojejunostomy is indicated when the patient has major bile duct injury with tissue loss (Strasberg E), recurrent choledocholithiasis requiring multiple endoscopic interventions, or when the dilated duct is associated with stricture formation that precludes safe end-to-end anastomosis. 1

Major Bile Duct Injuries

The primary indication for hepaticojejunostomy in the setting of a dilated CBD is major bile duct injury (Strasberg E) with tissue loss or complete transection. 1

• For major BDIs associated with tissue loss or when ischemic injury is suspected, Roux-en-Y hepaticojejunostomy is the recommended method of reconstruction rather than attempting primary repair. 1
• End-to-end bile duct anastomosis should be avoided when tissue loss is present, as this approach is associated with significantly higher failure rates compared to hepaticojejunostomy. 1, 2
• The cornerstone of successful reconstruction is performing the anastomosis 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 anastomotic leakage and stricture formation. 3

Recurrent Choledocholithiasis with Marked Ductal Dilation

Intractable choledocholithiasis requiring numerous endoscopic stone removal sessions over a prolonged period is a clear indication for bypass hepaticojejunostomy, particularly when the CBD is markedly dilated (>3 cm). 4, 5

• In a historical series, choledocholithiasis with markedly dilated duct represented 31% (41 of 131 patients) of hepaticojejunostomy indications, with 78.7% of patients remaining symptom-free at 2-13 years follow-up. 4
• Modern case reports demonstrate successful outcomes in patients requiring ERCP more than 9-10 times over 10-14 years, with patients remaining well for at least 2 years post-operatively. 5

Technical Considerations for Very Dilated Ducts

When the CBD is very dilated (>3 cm), the dilation itself facilitates creation of a large-sized, tension-free anastomosis, which is essential for long-term patency. 3, 5

• All scar tissue and devitalized tissue must be removed from the proximal bile duct stump before anastomosis, requiring meticulous dissection to expose healthy bile duct mucosa with adequate caliber. 3
• A tension-free anastomosis is mandatory to prevent ischemia and subsequent stricture formation. 3
• The Roux-en-Y jejunal limb should be 40-60 cm in length to prevent reflux of enteric contents into the biliary tree, though some evidence supports shorter limbs (20 cm) to facilitate future endoscopic access without increased cholangitis risk. 3, 6

Timing and Expertise Requirements

Early aggressive surgical repair within 48-72 hours by an experienced hepatopancreatobiliary (HPB) surgeon yields the best outcomes and prevents sepsis. 1, 3, 2

• Non-expert immediate repair attempts are associated with significantly worse outcomes than expert repair, potentially compromising later revisions. 1
• If local HPB expertise is unavailable, place a drain in the right upper quadrant and transfer the patient to a center with experienced HPB surgeons rather than attempting repair. 1
• Early referral to an HPB center can significantly decrease postoperative complications (OR: 0.24; 95% CI: 0.09-0.68; p = 0.007) and biliary strictures (OR: 0.28; 95% CI: 0.17-0.47; p < 0.001) compared to delayed referral. 1

Critical Pitfalls to Avoid

Never perform anastomosis on ischemic, inflamed, or scarred bile duct tissue, as this guarantees failure. 3

• Avoid attempting primary repair or end-to-end anastomosis when significant tissue loss is present or when the duct cannot be approximated without tension. 1, 2
• Do not delay referral to tertiary HPB centers for major injuries, as primary surgeons without specialized training have significantly higher rates of postoperative failure, morbidity, and mortality. 1, 3, 2
• Any dissection in the hilum may make subsequent reconstruction more difficult or cause further biliary or vascular injury, so conversion to open surgery solely for diagnosis or staging is not recommended. 1

Expected Outcomes

Long-term patency of 80-90% is expected when hepaticojejunostomy is performed correctly by experienced HPB surgeons. 7

• Overall clinical success, defined as absence of incapacitating biliary symptoms, is achieved in 89% of patients with appropriate management. 7, 8
• Post-repair stricture rates reach 10-20% even in high-volume centers, with median time to stricture formation of 11-30 months, necessitating prolonged surveillance. 2, 7
• Bile duct injury-related mortality ranges from 1.8-4.6%, with successful repair preventing long-term complications including recurrent cholangitis (~13%), anastomotic strictures (10-20%), and secondary biliary cirrhosis (2.4-10.9%). 2