2. Introduction
• Hepaticojejunostomy is a surgical procedure used to restore bile flow
in patients with obstructed or damaged bile ducts. It involves
connecting the bile ducts to the small intestine (jejunum) to bypass
the obstruction or damage.
• The most common indication is an obstructing periampullary mass
• The success rate of hepaticojejunostomy is high, with over 90% of
patients experiencing long-term relief of symptoms.
• Medscape Updated: Feb 16, 2023
3.
4. Indications for Hepaticojejunostomy
• Benign or iatrogenic strictures.
• Injuries to the biliary system.
• Relieve benign or malignant CBD obstruction
• Palliative role in unresectable periampullary tumors.
•Choledochal cysts (pediatric)
•Primary sclerosing cholangitis (rare)
•Part of liver transplantation.
Moghul F, Kashyap S. StatPearls [Internet]. StatPearls
Publishing; Treasure Island (FL): Aug 1, 2022. Bile Duct Injury.
Seeras K, Qasawa RN, Kashyap S, et al. Bile Duct Repair.
5.
6. Contraindications
• Coagulation disorders not corrected sufficiently with vitamin K.
• Infections such as cholangitis.
• Poor hepatic function leading to cirrhosis and ascites.
• Patients unfit for anesthesia.
Operative Techniques in General Surgery, Vol 2, No 4
(December), 2000: pp 295-303
7. Types of Hepaticojejunostomy
There are two types of hepaticojejunostomy:
•Roux-en-Y hepaticojejunostomy:
It involves creating a loop of jejunum
and connecting it to the bile ducts.
This creates a "Y" shaped anastomosis.
•Loop hepaticojejunostomy :
involves creating a simple
anastomosis between the bile ducts
and the jejunum.
8. Advantages and disadvantages
of Roux-en-Y Hepaticojejunostomy
The advantages:
•Better drainage of bile.
•Reduced risk of bile leak.
•Lower risk of anastomotic stricture.
•Reduces risk of ascending cholangitis.
The disadvantages:
•Longer operative time.
•More complex procedure.
•Greater risk of anastomotic leak.
9. Technique of Roux-en-Y
Hepaticojejunostomy
The technique of Roux-en-Y hepaticojejunostomy involves the
following steps:
•Mobilization of the jejunum.
•Identification and dissection of the bile ducts.
•Creation of a loop of jejunum.
•Anastomosis of the bile ducts to the jejunum.
Farquharson’s textbook of operative general surgery Ninth
edition 2005.
Gastrointestinal Surgery Pathophysiology and Management
10.
11. Complications of Roux-en-Y
Hepaticojejunostomy
The complications of Roux-en-Y hepaticojejunostomy are:
•Anastomotic leak.
•Anastomotic stricture.
•Bile reflux.
•Small bowel obstruction.
•Recurrent ascending cholangitis.
• Wound infection.
Int. J. Environ. Res. Public Health 2023, 20, 781
12. Advances in Roux-en-Y
Hepaticojejunostomy
• Refinement of the technique as
o Suture material used
o Mucosal fixation
o Access loop
•Use of laparoscopic or robotic techniques.
•Better preoperative planning using imaging techniques, intervention
radiology and endoscopy. (Multidisciplinary team work).
•The new horizon will be:
The use of biomaterials.
The use of tissue-engineered bile ducts.
Regenerative medicine techniques such as stem cell therapy and gene therapy.
Int J Surg. 2014;12(9):886-92. doi: 10.1016/j.ijsu.2014.07.264.
Epub 2014 Jul 28.
Turk J Gastroenterol. 2020 Apr;31(4):318-323. doi:
10.5152/tjg.2020.19229.
14. Robotic and Laparoscopic Roux-en-Y
Hepaticojejunostomy
Robotic
• A minimally invasive.
• Reduces postoperative pain.
• Reduces length of hospital stay
and recovery time.
• Less blood loss
• greater precision.
• Improved visualization.
• But needs more training and
finances.
Laparoscopic
• A minimally invasive.
• Reduces postoperative pain.
• Reduces length of hospital stay
and recovery time.
• new articulating laparoscopic
instrument
• But still used for selected
patients
2023 Feb 26;39(1):139. doi: 10.1007/s00383-023-05414-0. J Minim Access Surg. 2022 Jan-Mar; 18(1): 20–24.
Ann Hepatobiliary Pancreat Surg. 2018 Nov;22(4):359-366. Ann Med Surg (Lond). 2022 Feb 26;75:103412. Mar.
Pinsak et al. Mini-invasive Surg 2022;6:47 J Minim Invasive Surg 2022;25(4):161-164
15. Imaging and Intervention Radiology
• Identify the location and extent of the bile duct obstruction or
damage, and can aid in surgical planning.
• Intraoperative, such as intraoperative cholangiography, can help
confirm the anatomy of the bile ducts and ensure proper placement
of the anastomosis
• Biliary Stenting to maintain patency and facilitate healing after
hepaticojejunostomy. It can also be used to treat bile leaks or
strictures.
In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan.
18. Promising research areas
• The use of biomaterials
has shown promise in reducing the risk of bile leakage and other
complications.
Biomaterials such as collagen sponges and fibrin glue can be used to
reinforce the anastomosis and improve healing.
• The use of tissue-engineered bile ducts is a promising area of
research that could potentially eliminate the need for
hepaticojejunostomy in some cases.
• Tissue-engineered bile ducts are created using a patient's own cells and can
be used to repair or replace damaged bile ducts.
• The use of regenerative medicine techniques such as stem cell
therapy and gene therapy may also hold promise.
Cardiovasc Intervent Radiol. 2019 Mar;42(3):466-470
Scand J Gastroenterol. 2018 Oct-Nov;53(10-11):1376-1380.
19. Conclusions
• By multidiscipline approach (MDT) we can safely diagnose, prepare,
manage and decrease the complications in patients indicated for
hepaticojejunostomy.
• Refining the technique decreases the risk of leak and stricture.
• Laparoscopy and robotic surgery have promising role with less trauma
and more precision. But they need more research.
• More research and efforts are needed in stem cell and bioengineered
bile duct.
