Background

A hepaticojejunostomy is the surgical creation of a communication between the hepatic duct and the jejunum; a choledochojejunostomy is the surgical creation of a communication between the common bile duct (CBD) and the jejunum.

Oskar Sprengel published the first report of a choledochoenterostomy in 1891.^[1]He found that in one case, attempting to clear the distal CBD of stones would be impossible through standard methods. At this time, he made a choledochotomy in the CBD 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:

The anastomosis should be made without tension
Mucosa-to-mucosa contact is needed for appropriate healing

Laparoscopic and robot-asisted approaches to hepaticojejunostomy have been described; additional study is needed to determine their appropriate utilization.^{[4, 5, 6, 7, 8, 9, 10, 11, 12]} Endoscopic ultrasonography (EUS)-guided approaches have been employed for instances of malignant biliary obstruction in patients with with surgically altered anatomy.^[13]

Indications

The major indications for hepaticojejunostomy are as follows:

Benign or iatrogenic strictures
Injuries to the biliary system ^{[14, 15, 16, 17, 18]}

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.^[19] Because each unsuccessful attempt at repair can cause increased morbidity for the patient, provision of long-term functional and anatomic stability is paramount during the reconstruction.^[20]

Roux-en-Y hepaticojejunostomy is sometimes performed for biliary reconstruction in the setting of liver transplantation.^[21]

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 (ACS) National Surgical Quality Improvement Program (NSQIP) to study 30-day outcomes in 293 patients treated with hepaticojejunostomy for repair of complex bile duct injury.^[22] The 30-day morbidity was 26.3%, and the mortality was 2%. Factors associated with increased morbidity were as follows:

Male gender
Higher American Society of Anesthesiologists (ASA) class
Poorer preoperative functional status
Diabetes
Hypertension
Long-term steroid use

Periprocedure

Sprengel O. Uber eienen fall von exstirpation der gallenblase mit anlegung einer kommunikation zwischen duodenum und ductus choledochus. Zentralbl Chir. 1891. 18:121-122.
Sasse F. Uber choledochoduodenostomie. Zentralbl Chir. 1913. 40:942-943.
Santore MT, Behar BJ, Blinman TA, Doolin EJ, Hedrick HL, Mattei P, et al. Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst. J Pediatr Surg. 2011 Jan. 46 (1):209-13. [QxMD MEDLINE Link].
Zhang R, Liu S, Li T, Zhan J. Efficacy of robot-assisted hepaticojejunostomy and laparoscopic-assisted hepaticojejunostomy in pediatric congenital choledochal dilatation: a system review and meta-analysis. Pediatr Surg Int. 2022 Dec 11. 39 (1):46. [QxMD MEDLINE Link].
Cuendis-Velázquez A, Morales-Chávez C, Aguirre-Olmedo I, Torres-Ruiz F, Rojano-Rodríguez M, Fernández-Álvarez L, et al. Laparoscopic hepaticojejunostomy after bile duct injury. Surg Endosc. 2016 Mar. 30 (3):876-82. [QxMD MEDLINE Link].
Lai EC, Tang CN. Robot-assisted laparoscopic hepaticojejunostomy for advanced malignant biliary obstruction. Asian J Surg. 2015 Oct. 38 (4):210-3. [QxMD MEDLINE Link].
Prasad A, De S, Mishra P, Tiwari A. Robotic assisted Roux-en-Y hepaticojejunostomy in a post-cholecystectomy type E2 bile duct injury. World J Gastroenterol. 2015 Feb 14. 21 (6):1703-6. [QxMD MEDLINE Link].
Miyano G, Koyama M, Miyake H, Kaneshiro M, Morita K, Nakajima H, et al. Comparison of laparoscopic hepaticojejunostomy and open hepaticojejunostomy. Can stenosis of the hilar hepatic duct affect postoperative outcome?. Asian J Endosc Surg. 2017 Aug. 10 (3):295-300. [QxMD MEDLINE Link].
Guerra F, Di Marino M, Coratti A. Robotic Surgery of the Liver and Biliary Tract. J Laparoendosc Adv Surg Tech A. 2019 Feb. 29 (2):141-146. [QxMD MEDLINE Link].
Diao M, Li L, Cheng W. Laparoscopic management for aberrant hepatic duct in children with choledochal cysts. Surg Endosc. 2019 Jul. 33 (7):2376-2380. [QxMD MEDLINE Link].
Liu F, Xu X, Lan M, Tao B, Li L, Wu Q, et al. Total versus conventional laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in children with choledochal cysts: a case-control study. BMC Surg. 2020 Oct 17. 20 (1):243. [QxMD MEDLINE Link]. [Full Text].
Goméz D, Cabrera LF, Pedraza-Ciro M, Mendoza A, Pulido J. Laparoscopic Roux-en-Y hepaticojejunostomy reconstruction after iatrogenic bile duct injury: case series report. Cir Cir. 2020. 88 (5):608-616. [QxMD MEDLINE Link].
Ogura T, Okuda A, Ueno S, Nishioka N, Higuchi K. EUS-guided hepaticojejunostomy using a 22G needle and novel 0.018-inch guidewire (with video). Endosc Ultrasound. 2022 Nov-Dec. 11 (6):513-514. [QxMD MEDLINE Link]. [Full Text].
Seeras K, Qasawa RN, Kashyap S, Kalani AD. Bile Duct Repair. Treasure Island, FL: StatPearls; 2022. [Full Text].
Lubikowski J, Post M, Białek A, Kordowski J, Milkiewicz P, Wójcicki M. Surgical management and outcome of bile duct injuries following cholecystectomy: a single-center experience. Langenbecks Arch Surg. 2011 Jun. 396 (5):699-707. [QxMD MEDLINE Link].
Schmidt SC, Fikatas P, Denecke T, Schmaucher G, et al. Hepatic resection for patients with cholecystectomy related complex bile duct injury. Eur Surg. 2010. 42:77-82.
Mathisen O, Søreide O, Bergan A. Laparoscopic cholecystectomy: bile duct and vascular injuries: management and outcome. Scand J Gastroenterol. 2002 Apr. 37 (4):476-81. [QxMD MEDLINE Link].
Schmidt SC, Settmacher U, Langrehr JM, Neuhaus P. Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery. 2004 Jun. 135 (6):613-8. [QxMD MEDLINE Link].
Hung MH, Lin LH, Chen DF, Huang CS. Choledochal cysts in infants and children: experiences over a 20-year period at a single institution. Eur J Pediatr. 2011 Sep. 170 (9):1179-85. [QxMD MEDLINE Link].
Toumi Z, Aljarabah M, Ammori BJ. Role of the laparoscopic approach to biliary bypass for benign and malignant biliary diseases: a systematic review. Surg Endosc. 2011 Jul. 25 (7):2105-16. [QxMD MEDLINE Link].
Prieto M, Valdivieso A, Gastaca M, Pijoan JI, Ruiz P, Ventoso A, et al. Hepaticojejunostomy in Orthotopic Liver Transplant: A Retrospective Case Control Study. Transplant Proc. 2019 Jan - Feb. 51 (1):58-61. [QxMD MEDLINE Link].
Ismael HN, Cox S, Cooper A, Narula N, Aloia T. The morbidity and mortality of hepaticojejunostomies for complex bile duct injuries: a multi-institutional analysis of risk factors and outcomes using NSQIP. HPB (Oxford). 2017 Apr. 19 (4):352-358. [QxMD MEDLINE Link].
Koops A, Wojciechowski B, Broering DC, Adam G, Krupski-Berdien G. Anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies. Surg Radiol Anat. 2004 Jun. 26 (3):239-44. [QxMD MEDLINE Link].
Northover JM, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg. 1979 Jun. 66 (6):379-84. [QxMD MEDLINE Link].
Felder SI, Menon VG, Nissen NN, Margulies DR, Lo S, Colquhoun SD. Hepaticojejunostomy using short-limb Roux-en-Y reconstruction. JAMA Surg. 2013 Mar. 148 (3):253-7; discussion 257-8. [QxMD MEDLINE Link].
Diao M, Li L, Li Q, Ye M, Cheng W. Single-incision versus conventional laparoscopic cyst excision and Roux-Y hepaticojejunostomy for children with choledochal cysts: a case-control study. World J Surg. 2013 Jul. 37 (7):1707-13. [QxMD MEDLINE Link].
Fabbri N, Ferro S, Bagolini F, Romeo L, Carcoforo P, Giorgio C, et al. Mechanical hepaticojejunostomy: can we use a circular stapler as a viable and safe alternative? -a retrospective study of a single center. Gland Surg. 2020 Oct. 9 (5):1298-1304. [QxMD MEDLINE Link]. [Full Text].
Abdullah SS, Mabrut JY, Garbit V, De La Roche E, Olagne E, Rode A, et al. Anatomical variations of the hepatic artery: study of 932 cases in liver transplantation. Surg Radiol Anat. 2006 Oct. 28 (5):468-73. [QxMD MEDLINE Link].
Gupta N, Solomon H, Fairchild R, Kaminski DL. Management and outcome of patients with combined bile duct and hepatic artery injuries. Arch Surg. 1998 Feb. 133 (2):176-81. [QxMD MEDLINE Link].
Dawson DL, Johansen KH, Jurkovich GJ. Injuries to the portal triad. Am J Surg. 1991 May. 161 (5):545-51. [QxMD MEDLINE Link].
Katsinelos P, Paroutoglou G, Beltsis A, Tsolkas P, Arvaniti M, Katsiba D, et al. Endobiliary endoprosthesis without sphincterotomy for the treatment of biliary leakage. Surg Endosc. 2004 Jan. 18 (1):165-6. [QxMD MEDLINE Link].
Jester AL, Chung CW, Becerra DC, Molly Kilbane E, House MG, Zyromski NJ, et al. The Impact of Hepaticojejunostomy Leaks After Pancreatoduodenectomy: a Devastating Source of Morbidity and Mortality. J Gastrointest Surg. 2017 Jun. 21 (6):1017-1024. [QxMD MEDLINE Link].
Moghadamyeghaneh Z, Krosser AF, Rubinshteyn V, Dresner L. Outcome of bile leakage following liver resection with hepaticojejunostomy for liver cancer. Updates Surg. 2021 Apr. 73 (2):411-417. [QxMD MEDLINE Link].
Michelassi F, Ranson JH. Bile duct disruption by blunt trauma. J Trauma. 1985 May. 25 (5):454-7. [QxMD MEDLINE Link].
Sawaya DE Jr, Johnson LW, Sittig K, McDonald JC, Zibari GB. Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review. Am Surg. 2001 May. 67 (5):473-7. [QxMD MEDLINE Link].
Dimou FM, Adhikari D, Mehta HB, Olino K, Riall TS, Brown KM. Incidence of hepaticojejunostomy stricture after hepaticojejunostomy. Surgery. 2016 Sep. 160 (3):691-8. [QxMD MEDLINE Link]. [Full Text].
Choi KKH, Bonnichsen M, Liu K, Massey S, Staudenmann D, Saxena P, et al. Outcomes of patients with hepaticojejunostomy anastomotic strictures undergoing endoscopic and percutaneous treatment. Endosc Int Open. 2023 Jan. 11 (1):E24-E31. [QxMD MEDLINE Link]. [Full Text].
AbdelRafee A, El-Shobari M, Askar W, Sultan AM, El Nakeeb A. Long-term follow-up of 120 patients after hepaticojejunostomy for treatment of post-cholecystectomy bile duct injuries: A retrospective cohort study. Int J Surg. 2015 Jun. 18:205-10. [QxMD MEDLINE Link].
Sharma A, Hammond JS, Psaltis E, Dunn WK, Lobo DN. Portoenterostomy as a Salvage Procedure for Major Biliary Complications Following Hepaticojejunostomy. J Gastrointest Surg. 2017 Jun. 21 (6):1086-1092. [QxMD MEDLINE Link].