The hepatico-jejunostomy end-to-side with a Roux-Y excluded upper jejunal loop represents the gold standard of biliodigestive anastomosis.
The success of hepatobiliary anastomoses is influenced by the diameter of the bile duct and the section to be anastomosed. Also crucial is whether it is a primary or revision procedure, and whether there are accompanying infections of the bile ducts. Accurate preoperative diagnostics of the biliary anatomy are indispensable for complication-free biliary surgery. Regarding the reconstructive procedures, hepatico-jejunostomy has established itself as the standard. Here, the biliodigestive anastomosis is preferably placed above the cystic duct exit and about 2–3 cm below the hepatic bifurcation.
The rationale for this height specification lies in the arterial perfusion of the common bile duct (CBD). Thus, a short stump is better arterially supplied than a long one. Diathermy should be used very cautiously due to tissue necrosis. Bleeding at the CBD should therefore be managed with fine transfixion ligatures.
In the suturing of the biliodigestive anastomosis with single button sutures, a peculiarity is that the knots may partially lie in the lumen. Before completing the anterior wall suture, the patency of the anastomosis should be checked in all cases (e.g., using an Overholt clamp).
With single button sutures, the insufficiency rate appears increased, whereas with continuous sutures, the stenosis rate rises. However, there are no randomized studies on this issue (single button suture or continuous suture?).
The anastomosis should be performed with thin, absorbable, monofilament suture material (PDS of size 5/0 or 6/0).
Simultaneous injuries to the common hepatic duct (CHD) and the right hepatic artery are associated with a significantly higher insufficiency rate after hepatico-jejunostomy.
The creation of a so-called "inspection stoma" in the sense of a modified Roux-en-Y hepaticojejunostomy offers the possibility of performing endoscopic and radiological controls after bile duct resections. Indications for this are complex bile duct injuries, tumor resections with uncertain tumor-free resection margins, as well as recurrent intrahepatic sludge formation or cholelithiasis.
In malignant bile duct stenosis, the biliodigestive anastomosis, due to today's low complication and mortality rates, especially in patients in good general condition and without manifest distant metastasis, represents a highly efficient palliative therapy. The secure prevention of duodenal obstruction through simultaneous creation of a gastroenterostomy and long-term free bile drainage can offer advantages over endoscopic procedures, especially in patients with a survival probability of over six months. However, the decisive factor is the interplay of surgical and endoscopic therapeutic options to achieve the optimal palliative therapy for each individual patient.
Due to the postoperatively altered anatomy (endoscopic access to the biliodigestive anastomosis is only possible via the footpoint anastomosis!), the rate of conventionally endoscopically successfully performed ERCP is comparatively low. Single-balloon enteroscopy presents a promising and low-complication alternative here. With appropriate expertise, the use of SBE-assisted ERCP can avoid more invasive procedures such as PTC or surgical intervention.