Choledochojejunostomy (Roux-en-Y)
What the Examiner Expects
Bilioenteric bypass creating a direct anastomosis between the bile duct (common hepatic or intrahepatic ducts) and a Roux-en-Y jejunal limb. This is the definitive repair for bile duct injuries from cholecystectomy (Strasberg E injuries), and is also used for bypass of unresectable distal CBD obstruction (periampullary cancer, chronic pancreatitis with biliary stricture). The examiner expects you to understand that repair should ideally be performed by an experienced hepatobiliary surgeon, that timing depends on the clinical scenario (immediate repair if recognized intraoperatively; delayed repair 6–12 weeks if recognized postoperatively to allow inflammation to resolve), and that a tension-free, mucosa-to-mucosa anastomosis to well-vascularized, non-inflamed proximal duct is essential for success.
Key Examiner Focus Points
- Definitive repair for major bile duct injuries (Strasberg D and E types)
- Also used for distal CBD obstruction (chronic pancreatitis, unresectable periampullary cancer)
- Roux limb should be 60–70 cm to prevent bile reflux
- Mucosa-to-mucosa anastomosis is critical for long-term patency
- Timing of repair after injury: immediate if recognized, otherwise delay 6–12 weeks for inflammation to resolve
Common Curveballs
Bile duct injury recognized 2 weeks postoperatively with a biloma and sepsis
Manage the acute situation first: percutaneous drainage of the biloma, IV antibiotics, and percutaneous transhepatic biliary drainage (PTC) to control the bile leak and decompress the biliary system. Definitive Roux-en-Y hepaticojejunostomy should be delayed 6–12 weeks until the inflammation resolves and the patient is well-nourished.
Stricture develops at the hepaticojejunostomy 2 years later
Evaluate with MRCP and PTC. Initial management is percutaneous balloon dilation with temporary internal-external biliary drain. If dilation fails, surgical revision of the anastomosis may be needed, ideally by the same hepatobiliary team.
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