Biliary bypass

Salient facts about Choledochoduodenostomy
•Requires a CBD of at least 15mm diameter.
•Must Kocherize the duodenum to have a tension free anastomosis.
•Patients can get a sump syndrome that is managed by converting the side to side choledochoduodenostomy into an end to side or a roux en Y.


Roux-en-Y hepaticojejunostomy
1.Depending on the scenario, the incision may be a right subcostal or midline.
2.In the setting of pancreatic cancer, the root of the mesentery may be involved in which case a cholecystojejunostomy may be a better option.
3.If proceeding with a roux limb, inspect the jejunal mesentery looking for the second jejunal branch from the SMA. The marginal arcade can be clearly seen beyond this level.
4.Divide the jejunum with a linear stapler beyond this second branch and continue the incision distally down to but not necessarily including the fourth branch, ligating these branches but not the arcade.
5.This should provide a loop long enough to reach the hepatic ducts (75cm).
6.Create a window in the transverse mesocolon to the right of the middle colic vessels (retrocolic loop).
7.Depending on the situation, you can then perform an end to side (preferred if hepaticojejunostomy) or side to end. Perform the anastomosis using a single layer 5/0 PDS.
8.In the setting of pancreatic cancer, perform a gastrojejunostomy (60cm from the hepaticojejunostomy) with 3/0 PDS.
9.Perform the entero-enterostomy with 4/0 PDS.
10.Lavage and close in layers.