Updated: Mar 24, 2021
Author: Christa N Grant, MD; Chief Editor: Kurt E Roberts, MD 



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. Laparoscopic approaches to the procedure have been described that appear to be comparable in terms of feasibility and safety.[2]


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, 3, 4]

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%).[5]

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.


Patients may have concurrent disease processes related to their primary tumor that preclude the safe performance of choledochojejunostomy, such as the following:

  • Coagulation disorders not corrected sufficiently with vitamin K
  • Infections such as cholangitis
  • 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.[6]  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.


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.

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.


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.

Patient Preparation


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.


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

Monitoring & Follow-up

Postoperatively, antibiotic regimens 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.



Creation of Biliary-Duodenal Anastomosis

A right subcostal, upper midline, right paramedian, or bilateral subcostal “bucket-handle”[1] incision may be used. The last of these is preferred in patients with unfavorable body habitus, particularly when exposure remains poor after a right subcostal approach is attempted.[6] A self-retaining retractor is placed if needed.

Creation of the biliary-enteric anastomosis itself involves the following three main steps[7] :

  • Exposure
  • Dissection
  • Establishment of biliary continuity

Depending on the underlying pathology, lysis of adhesions may be mandatory upon entry into the abdomen and dissection toward the area of the hepatoduodenal ligament. Blunt dissection is used to free the edge and undersurface of the liver. After the peritoneal attachments lateral to the duodenum are divided, the Kocher maneuver is used to mobilize the duodenum medially, further exposing the foramen of Winslow and the portal triad.[8]

After careful dissection of the plane between the underside of the the right hemiliver and the duodenum, the portal triad comes into view. Although in the majority of people, the hepatic artery lies to the left of the common bile duct (CBD), there are numerous potential anatomic variations in this area that must be kept in mind. Most notably, a replaced right hepatic artery (see the image below) may arise from the superior mesenteric artery and course to the right of the portal vein, the common hepatic duct (CHD), and the CBD.

Replaced right hepatic artery. Replaced right hepatic artery.

In some instances, aspiration with a 25-gauge needle may help identify the CBD.[1]

Once isolated, the CBD is encircled and transected above the level of obstruction. The distal CBD is then doubly ligated. Bile cultures are taken at this time, and if appropriate, the duct is irrigated or explored for stone or debris. The proximal end is then inspected and trimmed to healthy, even edges as needed.

The CHD and CBD receive their blood supply from axial arteries just lateral and medial to the duct (see the image below). These arteries originate from the intrahepatic arterial collaterals feeding the biliary tree superiorly and from the gastroduodenal artery inferiorly. With this in mind, skeletonization of the CBD should be avoided because it can compromise the blood supply and lead to ischemic stricturing.

Common bile duct blood supply. Common bile duct blood supply.

The ligament of Treitz is then identified, and a proximal loop of jejunum that comfortably reaches the subhepatic space is identified. After the jejunal arcades are assessed for adequacy of blood supply, this loop is transected with a gastrointestinal anastomosis (GIA) stapler. Alternatively, if the jejunum is divided between bowel clamps, the distal end is closed with two layers of interrupted silk suture.[8]

The distal jejunum is rotated through the avascular space just to the right of the middle colic artery up into the porta hepatis. The proximal (afferent) divided end of the jejunum is then sutured to the distal end of the jejunum 45 cm aborally from the divided end where the choledochojejunostomy will be created. After the choledochojejunostomy is complete, the defect in the transverse mesocolon is closed, and several interrupted absorbable sutures are used to anchor the afferent limb to the mesocolon.[1]

In the case of a very dilated CBD, the choledochojejunostomy may be performed in an end-to-end fashion (see the image below).

End-to-end choledochojejunostomy. End-to-end choledochojejunostomy.

The author prefers a single-layer closure with 3-0 absorbable suture. Two “stay” sutures are placed at the corners, dividing the anterior and posterior halves. The posterior wall of the anastomosis is fashioned first, starting with a single suture placed midway and followed by a meticulously placed row of interrupted sutures, each with the knot tied intraluminally and the suture held on slight tension to assist in placement of the subsequent stitch.

Starting at each corner, alternating interrupted sutures are then placed and tied to approximate the anterior wall of the anastomosis. These sutures are placed in an inside-outside-outside-inside fashion so that the knot lies within the lumen. The final few stitches at the center of the anterior wall of the anastomosis are tied on the outside. The most important principle in fashioning this anastomosis is taking full-thickness bites of the duct and the jejunum with the placement of each suture.[1]

More commonly, given the size mismatch between the CBD and the jejunum, an end-to-side mucosa-to-mucosa choledochojejunostomy is performed. The stump of the jejunal limb, previously divided by a GIA stapler, is oversewn with a layer of interrupted absorbable sutures. An electrocautery device is then used to the divide the jejunum longitudinally on the antimesenteric border approximately 5 cm distal to this closure. The size of this jejunostomy is determined by the size of the transected end of the CBD. The anastomosis is then carried out in a single layer, mucosa to mucosa, using the Blumgart technique.[1]

Interrupted absorbable monofilament 4-0 or 5-0 sutures are placed on the anterior wall of the proximal bile duct inside out and clamped with rubber shods. Lifting of this row of sutures then increases the visibility for placement of the posterior-layer sutures in a similar fashion. These are placed through the full thickness of the tissue in an inside-out-outside-in manner from bile duct to jejunum and tied, with knots woven intraluminally so as to afford exact mucosal apposition.

The anterior wall is then completed by using the needles previously passed through the bile duct wall. Starting at each corner, the needle is passed from outside in, tied, and cut, again with the knot facing the lumen. The final few stitches at the center of the anterior wall are placed so that the knot lies on the outside. The key to a successful choledochojejunostomy is creating a tension-free anastomosis with direct mucosa-to-mucosa apposition at this stage. A few anchoring stitches may be placed between the jejunum and surrounding structures of the hepatoduodenal ligament.

If internal stenting is desired, it is placed through a separate opening in the bile duct or in a retrograde manner through an opening in the duodenum (see the image below).

Retrograde stenting of choledochojejunostomy throu Retrograde stenting of choledochojejunostomy through an opening in the jejunum.

The stent is then brought out through the abdominal wall at the conclusion of the operation. An alternate maneuver is to pass a Silastic tube with multiple holes through the liver parenchyma, into the biliary tree, and across the anastomosis before completion. The decision to leave an internal stent varies with physician preference. The author finds stenting most successful when used for management of biliary reconstructions after iatrogenic bile duct injury.


Intraoperative/postoperative bleeding

Careful attention must be paid to identifying the arteries related to the biliary system at the time of initial dissection. The surgeon's familiarity with biliary anatomy and the most common aberrations is crucial. If the arteries to the bile duct are not identified early and preserved, intraoperative bleeding may further obscure a challenging operative field, making it difficult to identify key structures and avoid inadvertent injury. If injury to these arteries is not identified early, postoperative anastomotic bleeding may also occur.

Less common, but equally consequential, are iatrogenic portal vein injuries, hepatic artery injuries, and right hepatic artery ligation. These injuries can be prevented by meticulous dissection early during exposure in order to properly identify all major vessels prior to any transection.


Injury to the arteries feeding the bile duct, caused either by direct division or by heat injury from extensive electrocautery use, can lead to duct ischemia. Such an injury could manifest early as a bile leak or late as a bile duct or anastomotic stricture. Younger patients may be at higher risk for postoperative stricture.[9]

Sano et al retrospectively assessed long-term outcomes after therapeutic ERCP using balloon-assisted enteroscopy (BAE) to manage anastomotic stenosis in choledochojejunostomy or pancreaticojejunostomy.[10] ​ They found the outcomes of BAE-ERCP to be comparable to those of percutaneous transhepatic treatment or surgical reanastomosis.

Biliary drainage tube dislodgment

Care should be taken to allow enough laxity of the T-tube intra-abdominally and to anchor the tube to the skin adequately so as to prevent inadvertent dislodgment of the tube, which, in addition to causing a bile leak or enterostomy, may cause a narrowing of the anastomosis in cases where stenting was used across a narrow or difficult anastomosis.

Anastomotic leakage

Leaks of the anastomosis present most commonly as bilomas or peritonitis from a noncontained leak of bile or enteric content. The key to prevention of this complication is performing a tension-free anastomosis. This is achieved by preparing a long enough jejunal loop that is well vascularized, passed in a retrocolic fashion, and anchored to surrounding tissue after anastomosis. Attention to direct mucosa-mucosa apposition during anastomosis will also improve healing and help prevent postoperative leakage.

Significant risk factors for postoperative anastomotic leakage include biliary reconstruction following injury and a high anastomosis (above the confluence).[9]

Distal common bile duct stump leak

Failure to ligate the distal CBD stump or poor ligature placement may lead to leakage of enteric contents from the duodenum. This complication can be severe, leading to peritonitis or abscess and the need for reexploration. Leakage of gastric content in this area also threatens the anastomosis.

This complication can be avoided by careful dissection and ligation of the distal CBD. Intimate knowledge of aberrant ductal anatomy, such as an accessory bile duct running in parallel to the CBD, may decrease the incidence of stump leaks.