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 also been described; additional study is needed to determine their appropriate utilization.^{[4, 5, 6, 7, 8, 9, 10, 11]}

Indications

The major indications for hepaticojejunostomy are as follows:

Benign or iatrogenic strictures
Injuries to the biliary system ^{[12, 13, 14, 15, 16]}

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.^[17] 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.^[18]

Roux-en-Y hepaticojejunostomy is sometimes performed for biliary reconstruction in the setting of liver transplantation.^[19]

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.^[20] 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

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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].
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