Biliaryenteric Anastomosis

When the bile duct is obstructed, it may be surgically bypassed. When resected, it must be surgically reconstructed. In both cases, the small intestine is anastomosed to the biliary tree. The only variation is which piece of small intestine is used for the anastomosis and how it is brought up to the biliary tree. The names of these procedures are based on these variations and the level of the anastomosis on the biliary tree. For example, a side-to-side choledochoduodenostomy refers to an anastomosis between the common bile duct and the second portion of the duodenum (Fig. 1A). This is one of the simplest biliary bypasses to perform and is occasionally done in an end-to-side fashion (Fig. 1B). Similarly, a hepaticojejunostomy refers to an anastomosis between the hepatic duct (common and above) and jejunum. Although these anastomoses may be done with a loop of jejunum (e.g., cholecystojejunostomy), the workhorse is a Roux-Y limb of jejunum. The principle recommending a Roux limb is that peristalsis remains directed downstream for the limb and the gastrointestinal (GI) tract (Fig. 2). Consequently, no food will be brought to the biliary tree by the gut as a matter of normal function, and better drainage is expected. Again, Roux-en Y anastomoses are named for which part of the biliary tree is anastomosed to the end of divided jejunum; "Choledochojejunostomy" and "Cholehepaticojejunostomy," or just plain "hepaticojejunostomy" if the anastomosis is at or above the bifurcation of the bile ducts. The Roux limb should be 40-70 cm in length and constructed from proximal jejunum. Accidental use of more distal intestine risks diarrhea and malabsorption.

From: Clinical Gastroenterology: An Internist's Illustrated Guide to Gastrointestinal Surgery Edited by: George Y. Wu, Khalid Aziz, and Giles F. Whalen © Humana Press Inc., Totowa, NJ

Choledochoduodenostomy
Fig. 1. Diagrams of choledochoduodenostomies. (A) Side-to side. (B) End-to-side.
Side Side Choledochoduodenostomy

Jejuno-

jejunostomy hi

Fig. 2. Roux-en-Y jejunal limb. Arrow depict the direction of peristaltic movement.

Choledochoduodenostomy
Fig. 3. Bile duct blood supply. Note the rich network of blood vessels from the pancreas and duodenum in the infraduodenal portions, and from the right and left hepatic arteries at the bifurcation. In between, the blood supply is axial.
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  • Remo
    Where is the hepatic bifurcation?
    6 years ago

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