Choledochojejunostomy

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Choledochojejunostomy is a procedure for creating an anastomosis of the common bile duct (CBD) to the jejunum, performed to relieve symptoms of biliary obstruction and restore continuity to the biliary tract. Biliary obstruction can be caused by pathology above, at, or below the level of the cystic duct; it can lead to jaundice and pruritus, as well as predispose patients to infections such as cholangitis.

Choledochojejunostomy refers specifically to an anastomosis at the level of the CBD. Accordingly, it is the procedure of choice for obstruction distal to the junction of the cystic duct and the common hepatic duct (CHD). Depending on the cause of the obstruction, choledochojejunostomy can be either curative or palliative.

Choledochojejunostomy is most often performed to relieve benign or malignant CBD obstruction or to repair benign or iatrogenic biliary strictures. ^[1]  The most common indication is an obstructing periampullary mass, usually of duodenal or pancreatic origin. The procedure is sometimes performed preemptively in combination with gastrojejunostomy in anticipation of future gastric outlet obstruction (the so-called double bypass). ^{[1, 2, 3]}

Choledochojejunostomy also can serve a palliative role as the bypass procedure of choice in unresectable periampullary tumors and in cases of metastatic disease that would otherwise be unresectable.

Patients may have concurrent disease processes related to their primary tumor that preclude the safe performance of choledochojejunostomy, such as the following:

In patients with very poor functional status or short life expectancies, the morbidity of this procedure may be less acceptable. ^[4]  In such cases, other less invasive palliative methods, such as percutaneous biliary decompression or transduodenal stenting via endoscopic retrograde cholangiopancreatography (ERCP), are available.

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Tsujie M, Isono S, Sato K, Kawai K, Ikeda M, Hara J, et al. [Four cases of double bypass surgery involving choledochojejunostomy and gastrojejunostomy for inoperable peripancreatic head cancer]. Gan To Kagaku Ryoho. 2013 Nov. 40 (12):1890-2. [Medline].

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Kadaba RS, Bowers KA, Khorsandi S, Hutchins RR, Abraham AT, Sarker SJ, et al. Complications of biliary-enteric anastomoses. Ann R Coll Surg Engl. 2017 Mar. 99 (3):210-215. [Medline].

Christa N Grant, MD Resident Physician in General Surgery, Georgetown University Hospital

Christa N Grant, MD is a member of the following medical societies: American College of Surgeons, Society of Surgical Oncology, Association of Women Surgeons

Disclosure: Nothing to disclose.

Patrick Jackson, MD, FACS Chief of Gastrointestinal Surgery, Department of Surgery, Georgetown University School of Medicine

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Choledochojejunostomy

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