Background
Choledochojejunostomy is a procedure for creating an anastomosis of the common bile duct (CBD) to the jejunum, performed to relieve symptoms of biliary obstruction and restore continuity to the biliary tract. [1] Biliary obstruction can be caused by pathology above, at, or below the level of the cystic duct; it can lead to jaundice and pruritus, as well as predispose patients to infections such as cholangitis.
Choledochojejunostomy refers specifically to an anastomosis at the level of the CBD. Accordingly, it is the procedure of choice for obstruction distal to the junction of the cystic duct and the common hepatic duct (CHD). Depending on the cause of the obstruction, choledochojejunostomy can be either curative or palliative. [2] Laparoscopic approaches to the procedure have been described that appear to be comparable in terms of feasibility and safety. [3]
Indications
Choledochojejunostomy is most often performed to relieve benign or malignant CBD obstruction or to repair benign or iatrogenic biliary strictures. [1] The most common indication is an obstructing periampullary mass, usually of duodenal or pancreatic origin. The procedure is sometimes performed preemptively in combination with gastrojejunostomy in anticipation of future gastric outlet obstruction (the so-called double bypass). [1, 4, 5]
Choledochojejunostomy is a treatment option for recurrent CBD stones. Park et al compared choledochojejunostomy with choledochoduodenostomy for the management of recurrent CBD stones after surgical treatment and found a lower rate of stone recurrence after choledochojejunostomy (14.3% vs 66.7%). [6]
Choledochojejunostomy also can serve a palliative role as the bypass procedure of choice in unresectable periampullary tumors and in cases of metastatic disease that would otherwise be unresectable.
Contraindications
Patients may have concurrent disease processes related to their primary tumor that preclude the safe performance of choledochojejunostomy, such as the following:
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Coagulation disorders not corrected sufficiently with vitamin K
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Infections such as cholangitis
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Poor hepatic function leading to cirrhosis and ascites
In patients with very poor functional status or short life expectancies, the morbidity of this procedure may be less acceptable. [7] In such cases, other palliative methods that are less invasive, such as percutaneous biliary decompression or transduodenal stenting via endoscopic retrograde cholangiopancreatography (ERCP), are available.
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Replaced right hepatic artery.
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Common bile duct blood supply.
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End-to-end choledochojejunostomy.
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Retrograde stenting of choledochojejunostomy through an opening in the jejunum.
