Choledochojejunostomy and Cholecystojejunostomy
Executive Summary
Surgical biliary bypass procedures, specifically choledochojejunostomy and cholecystojejunostomy, serve as critical palliative and therapeutic interventions for patients with biliary obstruction. While endoscopic and percutaneous radiological approaches often manage acute emergencies, surgical bypass is preferred for patients with a life expectancy exceeding six months or those suffering from chronic issues like recurrent jaundice and ascending cholangitis due to stent failure.
The primary objective of these procedures is to provide durable relief from jaundice and infection. Choledochojejunostomy is the more common approach, often performed as an end-to-side or side-to-side anastomosis using a Roux-en-Y limb of the jejunum. Cholecystojejunostomy is reserved for highly specific cases involving frail patients where ductal dissection is too risky. Success depends on meticulous preoperative preparation—including the correction of coagulopathy and management of infection—and precise surgical technique to ensure a tension-free, mucosa-to-mucosa anastomosis.
Indications and Patient Selection
Clinical Indications
Surgical intervention is indicated for both malignant and benign conditions where radiological stenting is inadequate or unlikely to provide long-term patency.
Contraindications and Considerations
There are no absolute contraindications, but several factors must be assessed to balance morbidity against life expectancy:
Coagulation Disorders: Severe disorders must be corrected via Vitamin K or clotting factors.
Local Infection: Cholangitis or abscesses require preoperative correction with antibiotics and drainage.
Anatomical Quality: Portal hypertension, sclerosing cholangitis, or short bowel syndrome may complicate the surgery.
Comorbidities: Conditions such as Child-Pugh C liver cirrhosis significantly increase risk.
Investigation and Preoperative Preparation
Preoperative Investigations
A thorough diagnostic workup is essential to define the extent of the obstruction and the patient's physiological state.
Clinical Assessment: Monitoring for right upper quadrant pain, weight loss, icterus (jaundice), pruritus, coagulopathy, hepatorenal dysfunction, and cholangitis.
Laboratory Testing: Full blood count, urea and electrolytes, C-reactive protein (CRP), liver function tests (bilirubin and enzymes), and prothrombin time.
Radiology:
Ultrasound: To determine the origin and type of obstruction and the width of biliary ducts.
Three-phase CT scan: To assess local resectability and the relationship of the tumor to major structures like the portal vein and common hepatic artery.
MRI with MRCP: To further define tumor extent and biliary anatomy.
Preparation Prior to Surgery
Correction of Coagulopathy: Administration of Vitamin K (or clotting factors for urgent cases).
Preoperative Drainage: Recommended if significant jaundice or cholangitis is present and unresponsive to antibiotics, despite the risk of increased morbidity from biliary infections.
Antibiotic Prophylaxis: Standard requirement for preventing infection.
Stent Management: Plastic stents can remain until surgery; however, metal stents should be avoided if surgery is planned, as they are difficult to remove.
Surgical Procedures
Choledochojejunostomy
This is the preferred surgical method for biliary bypass. Modern practice favors an end-to-side anastomosis to a Roux-en-Y limb of the jejunum.
1. Access and Exposure
Incision: Right upper quadrant transverse, subcostal, or upper midline incision.
Laparoscopic Approach: Increasing expertise allows these techniques to be performed laparoscopically with specific port placement for triangulation.
Exposure: Adhesiolysis is performed in redo operations. In first-access cases, mobilization of the duodenum (Kocher’s manoeuvre) is rarely necessary but can facilitate exposure.
2. Technical Execution (Side-to-Side vs. End-to-Side)
Side-to-Side: Used in some centers but lacks clear advantages over end-to-side. It involves a longitudinal opening of the common hepatic duct.
End-to-Side (Standard): The common hepatic duct is transected, the duodenal side is closed, and an anastomosis is created between the duct and a 40–60 cm Roux-en-Y jejunal limb.
Suturing Technique: Uses 3-0, 4-0, or 5-0 Vicryl, PDS, or Prolene. A "parachute" technique with interrupted or continuous sutures is often employed to ensure a secure, tension-free mucosa-to-mucosa contact.
3. Segment 3 Bypass
In cases where tumor prevents access to the common hepatic duct or confluence, a bypass to the segment 3 hepatic duct may be the only surgical option.
Cholecystojejunostomy
This procedure is rarely performed today due to limited applicability.
Application: Specifically for very frail patients who cannot tolerate prolonged common hepatic duct dissection.
Requirements: Requires a high insertion of the cystic duct into the common bile duct and a low obstruction with no risk of impending cystic duct blockage.
Postoperative Management and Complications
Postoperative Care and Testing
Clinical Monitoring: Daily checks for signs of biliary obstruction (fever, jaundice, pain). Note that edema may cause temporary obstruction in the first few days.
Drainage: A silicone closed-system drain is typically left behind the anastomosis. If an enterohepatic drain is present, a cholangiography is performed on day 5 to check for leaks.
Drain Removal: If no leak is identified, the drain is removed after day 5. If a leak exists, it may remain for at least 6 weeks.
Potential Complications
Bleeding: Rare; requires immediate re-exploration if it occurs within 24 hours.
Bile Leakage: Common; usually managed with abdominal drainage. If drainage fails, percutaneous drainage under ultrasound/CT is required.
Cholangitis: Typically occurs in the first few days; treated with antibiotics.
Restenosis: Evident via recurrent jaundice. Reoperation is difficult; percutaneous dilation or metal stents are preferred for malignant cases.
Enterocutaneous Fistula: Rare; usually treated conservatively.
Delayed Gastric Emptying/Ileus: Should be investigated via CT scan if persistent.
Senior Surgeon’s Clinical Pearls
Localization: Preoperative stenting (ERCP or PTC) helps the surgeon locate the hepatic duct during surgery.
Anastomosis Sizing: In end-to-side procedures, the hole in the jejunum should be smaller than the diameter of the duct, as the ductal opening often ends up larger than anticipated.
Clearing the Duct: Choledochoscopy is useful for clearing biliary sludge and stones and assessing the level of stricturing.
