Choledochojejunostomy Periprocedural Care

Updated: May 23, 2017
  • Author: Christa N Grant, MD; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Patient Education and Consent

In the early postoperative period, patients should be educated on the function and importance of the biliary drainage tubes and how to care for and empty the tube upon discharge. Signs and symptoms of recurrent obstruction should also be discussed.

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Preprocedural Planning

The surgeon must have a thorough understanding of the patient's biliary anatomy before proceeding to the operating room. In most instances, imaging will have been performed as part of the workup, but this is not always the case. Preoperative or intraoperative cholangiography with magnetic resonance cholangiopancreatography (MRCP) is useful for identifying aberrant anatomy and determining the extent of injury or obstruction and may prove helpful in operative planning.

In jaundiced patients, drainage can be established simultaneously via an endoscopic stent placed during endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic catheter placement. [1]

In patients with associated liver dysfunction (specifically, coagulation disorders), correction of coagulopathy preoperatively will help prevent postoperative bleeding complications. Antibiotics are given routinely at the time of surgery and postoperatively on the basis of intraoperative bile cultures.

Cholangiography is usually performed via the biliary drainage tube placed during choledochojejunostomy.

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Equipment

Biliary drainage tubes (T-tubes) are often used to stent the anastomosis, particularly in cases of stricture. A cholangiogram is sometimes helpful intraoperatively to better delineate the anatomy and determine the extent of duct injury or stricture.

A closed suction drainage system may be used postoperatively to prevent seroma and hematoma formation and may help identify early postoperative complications.

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Patient Preparation

Anesthesia

General endotracheal anesthesia is administered. In patients who have strict contraindications for general anesthesia, spinal or epidural anesthesia may be considered. Preoperative antibiotics are given prior to skin incision.

Positioning

The patient is placed in a supine position. Reverse Trendelenburg positioning may improve exposure.

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Monitoring & Follow-up

Postoperatively, antibiotics should be tailored to the bile cultures taken intraoperatively. If bile cultures are negative, antibiotics are not necessary after the immediate postoperative period.

When performed for the repair of a stricture, a postoperative cholangiogram is usually obtained before the T-tube or stent is removed. The T-tube is left in place at least 6 weeks postoperatively.

Long-term imaging is not necessary unless return of symptoms or laboratory abnormalities suggest a recurrent stricture. Cancer patients should undergo surveillance imaging in accordance with current guidelines.

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