The hepaticojejunostomy end-to-side with an upper jejunal loop disconnected from the passage according to Roux-Y represents the gold standard of the biliodigestive anastomosis.
The success of hepatobiliary anastomoses is influenced by the diameter of the bile duct and the section to be anastomosed. Also decisive is the circumstance of whether it is a primary or revision procedure, and whether there is an accompanying infection of the bile ducts.
The exact preoperative diagnosis of the bile duct anatomy is indispensable for complication-free bile duct surgery. With regard to the derivative reconstructive procedures, the hepaticojejunostomy has established itself as the standard overall. Here, the biliodigestive anastomosis is preferably created above the cystic duct origin and approx. 2–3 cm below the hepatic bifurcation.
The rationale for this height specification lies in the arterial perfusion of the DHC. Thus, a short stump is better arterially supplied than a long one. Diathermy should be used only with extreme caution due to tissue necrosis. Bleedings at the DC/DHC should therefore be managed with thin transfixion ligatures.
In the suture of the biliodigestive anastomosis with single button sutures, the knots partially lie in the lumen as a special feature. Before the anterior wall suture is completed, the patency of the anastomosis should be checked in all cases (e.g., using an Overholt clamp).
With single button sutures, the insufficiency rate seems increased, whereas with continuous suture the stenosis rate increases. However, there are no randomized studies on this question (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 of the common hepatic duct (DHC) and the right hepatic artery are associated with a significantly higher insufficiency rate after hepaticojejunostomy.
The creation of a so-called "inspection stoma" in the sense of a modified Roux-en-Y
hepaticojejunostomy offers the possibility to perform endoscopic and radiological controls after bile duct resections. Indications for this are complex bile duct injuries, tumor resections with not securely tumor-free resection margin as well as recurrent intrahepatic sludge formation or cholelithiasis.
In malignant bile duct stenosis, the biliodigestive anastomosis represents an extremely efficient palliative therapy due to the currently low complication and lethality rates, especially in patients in good general condition and without manifest distant metastasis. The reliable prevention of duodenal obstruction through simultaneous creation of a gastrojejunostomy and the longer-term free bile drainage can bring advantages over endoscopic procedures, especially in patients with a survival probability of over six months. However, the interplay of operative with endoscopic therapy options is decisive in order to achieve the optimal palliative therapy for each individual patient.
Due to the postoperatively altered anatomy (endoscopic access to the biliodigestive anastomosis only possible via loop anastomosis!), the rate of conventionally endoscopically successfully performed ERCP is comparatively low. Single-balloon enteroscopy represents a promising and low-complication alternative here. With appropriate expertise, more invasive procedures such as PTC or a surgical approach can be avoided through the use of SBE-assisted ERCP.