The gold standard in biliodigestive anastomosis is end-to-side Roux-en-Y hepaticojejunostomy with a segment of the proximal jejunum.
The successful outcome of hepatobiliary anastomosis is determined by the diameter of the bile duct and the section undergoing anastomosis. Another decisive factor is the fact if this is the first such procedure or revision surgery and if there is concomitant bile duct infection.
In surgery of the biliary tract exact preoperative diagnostic work-up of the biliary tract anatomy is mandatory for low complication rates. In terms of afferent reconstruction techniques, hepaticojejunostomy has become the gold standard. Here, the preferred bilioenteric anastomosis is established proximal to the cystic duct origin and about 2– 3 cm distal to the union of the hepatic ducts.
The rationale for this level lies in the arterial perfusion of the CHD. A short ductal stump has better arterial perfusion than a long remnant. Due to tissue necrosis electrocautery should be used rather sparingly. Bleeding at the cystic duct/CHD should be controlled with thin suture-ligatures.
When fashioning the bilioenteric anastomosis with interrupted sutures some of the knots will be located within the lumen of the duct. Before completing the anterior wall, the patency of the anastomosis should always be verified (e.g., with Overholt forceps).
Interrupted sutures seem to result in higher failure rates, while in running sutures the rate of stenosis is higher. However, there are no randomized trials studying this issue (interrupted or running sutures?).
The anastomosis should be performed with thin absorbable monofilament sutures (PDS 5/0 or 6/0).
Simultaneous injury of the CHD and the proper hepatic artery result in significantly higher failure rates of the hepaticojejunostomy.
Creation of a so-called “inspection stoma” as a modified Roux-en-Y hepaticojejunostomy offers the opportunity for endoscopic and radiological follow-up after bile duct resection. This is indicated in complex bile duct injuries, tumor resections where the resection margin has not been confirmed clear of tumor, and recurrent intrahepatic sludge formation or cholelithiasis.
Due to its present low complication rate and mortality, bilioenteric anastomosis in malignant bile duct obstruction offers highly effective palliation primarily in those patients who are in good general condition and without manifest distant metastasis. Compared with endoscopic procedures, the safe prevention of duodenal obstruction by combined gastroenterostomy and long-term bile drainage benefits particularly those patients with an expected survival longer than six months. However, the deciding factor for optimized palliation in each patient is the cooperative application of surgical and endoscopic techniques.
Due to the change in postoperative anatomy (endoscopy of the biliodigestive anastomosis possible only via jejunojejunostomy!), the rate of successful standard ERCPs is rather low. Single balloon enteroscopy is a promising alternative with few complications. For most of these cases, in the hands of experienced interventionists ERCP with SBE-enhancement can help avoid more invasive procedures, such as PTC or surgery.