Background
Oskar Sprengel published the first report of a choledochoenterostomy in 1891. [1] He found that in one case, attempting to clear the distal common bile duct of stones would be impossible through standard methods. At this time, he made a choledochotomy in the common bile duct and anastomosed it to the duodenum. Attempts to repeat this operation resulted in multiple deaths, likely from sequelae related to bile leaks. [2, 3] By the early 1900s, two basic principles had been formulated that helped popularize this procedure. These principles were as follows:
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The anastomosis should be made without tension
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Mucosa-to-mucosa contact is needed for appropriate healing
Laparoscopic and robot-asisted approaches to hepaticojejunostomy have also been described; additional study is needed to determine their appropriate utilization. [4, 5, 6]
Indications
The major indications for hepaticojejunostomy are as follows:
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Benign or iatrogenic strictures
Additionally, obstruction from malignancies of the biliary system caused by pancreatic or duct wall tumors may necessitate this operation. Rare indications are trauma and dilated areas occurring in sclerosing cholangitis. In the pediatric population, choledochal cysts are also an indication for reconstruction with hepaticojejunostomy. [11] Because each unsuccessful attempt at repair can cause increased morbidity for the patient, providing long-term functional and anatomic stability is paramount during the reconstruction. [12]
Contraindications
Patients with severe systemic illness (eg, severe cardiac or pulmonary dysfunction) should be cleared preoperatively to confirm that they are able to tolerate this procedure. The presence of proximal obstruction to bile flow in a given patient is also a contraindication for this procedure.
Outcomes
A muli-institutional analysis by Ismael et al used data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to study 30-day outcomes in 293 patients treated with hepaticojejunostomy for repair of complex bile duct injury. [13] The 30-day morbidity was 26.3%, and the mortality was 2%. Factors associated with increased morbidity were as follows:
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Male gender
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Higher American Society of Anesthesiologists (ASA) class
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Poorer preoperative functional status
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Diabetes
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Hypertension
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Long-term steroid use
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Posterior wall of hepaticojejunostomy anastomosis completed, with anterior wall retracted by stay sutures.
