Overview
Definition:
Hepaticojejunostomy is a surgical procedure that involves creating an anastomosis between the hepatic duct (or common hepatic duct) and the jejunum
It is most commonly performed as part of a Roux-en-Y reconstruction to bypass an obstruction in the biliary tree or to facilitate drainage after liver resections or procedures on the pancreas and duodenum
The Roux-en-Y configuration creates a defunctionalized limb of jejunum, diverting bile and pancreatic secretions away from the stomach and duodenum, thereby reducing the risk of reflux gastritis and peptic ulcer disease.
Indications:
Primary indications include malignant biliary obstruction (e.g., cholangiocarcinoma, pancreatic head cancer), benign biliary strictures (e.g., post-cholecystectomy, post-pancreatitis), primary sclerosing cholangitis, bile duct injuries, and as part of pancreaticoduodenectomy (Whipple procedure)
It may also be used in certain liver transplant scenarios and for management of complex choledochal cysts.
Clinical Significance:
This reconstructive technique is crucial for restoring biliary drainage and relieving obstructive jaundice
Successful hepaticojejunostomy is vital for patient recovery, preventing complications such as cholangitis, liver abscesses, and malnutrition
Its correct performance and post-operative management are key determinants of long-term patient outcomes, especially in oncologic settings where it facilitates palliation or adjuvant therapy delivery.
Indications
Biliary Obstruction:
Malignant obstruction of the common hepatic duct or common bile duct due to tumors (e.g., cholangiocarcinoma, pancreatic adenocarcinoma, ampullary carcinoma) or extrinsic compression
Benign strictures caused by previous surgery, chronic pancreatitis, or primary sclerosing cholangitis.
Liver Resection:
Following extensive hepatic resection where the native common bile duct is compromised or not amenable to direct reconstruction with the duodenum
Often performed as part of reconstruction after hilar resection for tumors.
Pancreaticoduodenectomy:
Integral component of the Whipple procedure to reconstruct the gastrointestinal and biliary tracts after removal of the pancreatic head, duodenum, and distal common bile duct.
Bile Duct Injury:
Repair of iatrogenic or traumatic injuries to the common hepatic duct or proximal common bile duct, especially when primary repair is not feasible or leads to stenosis.
Other Conditions:
Management of choledochal cysts, portoenterostomies in infants (e.g., Kasai procedure for biliary atresia), and rare cases of biliary atresia requiring reconstruction.
Preoperative Preparation
Evaluation:
Thorough assessment of the biliary tree anatomy (MRCP, ERCP), tumor staging (CT, PET-CT), and overall patient health (cardiac, pulmonary, renal function)
Nutritional status assessment and optimization are important, especially for oncologic patients.
Decompression:
If significant obstructive jaundice is present, preoperative biliary decompression via percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde cholangiopancreatography (ERCP) with stent placement may be necessary to improve liver function and reduce operative risk
However, prolonged stenting can sometimes increase the risk of infection.
Antibiotics:
Prophylactic broad-spectrum antibiotics should be administered intravenously preoperatively to reduce the risk of intra-abdominal infection and cholangitis
Anesthesia consult for optimization of co-morbidities.
Bowel Preparation:
Mechanical bowel preparation and oral antibiotics are often administered prior to creating the enteric anastomosis to reduce bacterial load in the jejunum.
Procedure Steps
Approach:
The procedure is typically performed via an open laparotomy or laparoscopy, depending on the surgeon's expertise and patient factors
Laparoscopic approach is favored for minimally invasive surgery, offering faster recovery.
Roux Limb Creation:
A segment of the jejunum is isolated, usually 40-50 cm distal to the duodenojejunal flexure, to create a Roux limb
This limb is then brought up to the porta hepatis or the area of the hepatic duct remnant.
Hepatic Duct Mobilization:
The remnant hepatic duct (common hepatic duct or intrahepatic ducts if necessary) is carefully dissected and mobilized
The plane between the hepatic artery and portal vein is maintained to avoid vascular injury
If the common hepatic duct is not accessible, intrahepatic duct jejunostomy may be performed.
Anastomosis Creation:
A tension-free anastomosis is created between the opened hepatic duct and the antimesenteric border of the Roux limb of the jejunum
Fine sutures (e.g., 5-0 or 6-0 absorbable or non-absorbable sutures) are used
Some surgeons prefer a one-layer anastomosis, while others opt for two layers to enhance security
Stents (e.g., silicone T-tubes or internal stents) may be placed across the anastomosis to maintain patency and facilitate healing, although their routine use is debated.
Enteroenterostomy:
The continuity of the gastrointestinal tract is restored by performing an end-to-side or side-to-side enteroenterostomy between the proximal and distal limbs of the jejunum, typically 40-50 cm distal to the hepaticojejunostomy site, to create the "Y" configuration.
Postoperative Care
Monitoring:
Close monitoring for vital signs, urine output, and signs of complications such as bleeding, infection, or biliary leak
Nasogastric tube decompression is often maintained initially.
Pain Management:
Adequate analgesia, often with patient-controlled analgesia (PCA), is essential
Early mobilization is encouraged.
Fluid Electrolyte Balance:
Intravenous fluids and electrolyte replacement are managed based on urine output and laboratory values
Monitoring for dehydration and electrolyte imbalances is critical.
Nutrition:
Oral intake is gradually advanced as tolerated
In cases of Whipple procedure or extensive resections, parenteral or enteral nutrition may be required
Patients with a Roux-en-Y reconstruction may need lifelong vitamin B12 supplementation due to bypassing the duodenum and jejunum where absorption occurs.
Drain Management:
Surgical drains are typically placed near the anastomosis to monitor for bile leak or bleeding
They are usually removed when the output is serous and minimal
Monitoring of drain fluid for bilirubin levels can detect leaks.
Complications
Early Complications:
Bile leak from the anastomosis (bilioenterostomy leak), cholangitis (infection of the biliary tree), intra-abdominal bleeding, pancreatitis (especially after Whipple), anastomotic leak into the peritoneal cavity, postoperative ileus, wound infection, and gastric stasis (dumping syndrome).
Late Complications:
Biliary stricture at the anastomosis (leading to recurrent jaundice and cholangitis), cholangiocarcinoma in patients with underlying biliary disease (e.g., primary sclerosing cholangitis), afferent loop syndrome (obstruction of the biliopancreatic limb), malnutrition, vitamin deficiencies (especially B12), peptic ulcer disease in the afferent loop, and gallstone formation in the bypassed biliary system.
Prevention Strategies:
Meticulous surgical technique with careful dissection, tension-free anastomosis, appropriate suture material, and judicious use of internal stents can minimize early complications
Careful patient selection, optimization of comorbidities, and early recognition and management of complications are crucial
Long-term follow-up with regular surveillance and prompt treatment of symptoms are important for late complication prevention.
Key Points
Exam Focus:
Understand the indications for Roux-en-Y hepaticojejunostomy, especially in the context of oncologic resections like the Whipple procedure
Be prepared to describe the steps of the anastomosis and the management of potential early and late complications like bile leaks and anastomotic strictures.
Clinical Pearls:
Ensure adequate length of the Roux limb to avoid tension
Meticulous hemostasis is paramount
Consider leaving an internal stent if the ductal anatomy is challenging or if there is concern for leak
Lifelong B12 supplementation is crucial for patients with a Roux-en-Y configuration impacting the duodenum.
Common Mistakes:
Creating an anastomosis under tension, inadequate mobilization of the hepatic duct, misidentification of biliary structures leading to injury of portal vein or hepatic artery, failure to recognize and manage bile leaks promptly, and overlooking the need for B12 supplementation postoperatively.