B35. Bilio-digestive anastomoses

A biliodigestive anastomosis is an anastomosis between the common bile duct and digestive tract, used in the treatment of impaired bile flow. Some of the indications of biliodigestive anastomosis include:

• Tumours of the biliary tract
• Injury to biliary tract
• Biliary tract stenosis
• Pancreatic or periampullary tumours which cause bile duct obstruction

Hepaticojejunostomy with Roux-en-Y anastomosis is considered the modern biliodigestive anastomosis.

The choice of procedure for biliary tumours depends on the localisation of the tumour:

• Distal third bile duct tumours – Whipple operation or PPPD
• Middle third bile duct tumours – resection and hepaticojejunostomy with Roux-en-Y anastomosis
• Proximal third bile duct tumours – resection of liver and bile duct with hepaticojejunostomy

Whipple procedure and PPPD

Conventional pancreaticoduodenectomy, the so-called Whipple procedure, is used for pancreatic head tumours, periampullary tumours, pancreatic or duodenal trauma, and chronic pancreatitis. This involves resection of the pancreatic head, distal stomach, duodenum, gallbladder, and common bile duct. This is a lengthy surgery which lasts on average 5 – 6 hours.

Due to shared blood supply of organs in the proximal GI system, surgically removing the head of the pancreas also necessitates removal of these other structures. The duodenum and proximal jejunum are supplied by the superior and inferior pancreaticoduodenal arteries, which pass through the pancreatic head and must therefore be removed during the procedure.

After this resection, the continuity of the GI tract must be reconstructed. A pancreatojejunostomy is made to join the pancreatic duct to the jejunum, a hepaticojejunostomy is made to join the hepatic duct to the jejunum, and a gastrojejunostomy is made to join the stomach and the jejunum.

Pylorus-preserving pancreaticoduodenectomy (PPPD) is a slightly less radical variation of the Whipple procedure which preserves the stomach. It has similar outcomes and similar complications, but shorter operation time and less blood loss. This procedure is preferred instead of Whipple in cases where it’s feasible.

Double bypass

Double bypass refers to the combination of a biliodigestive anastomosis (hepaticojejunostomy) and a gastrojejunostomy. This is used for palliation of pancreatic, periampullary, and distal bile duct tumours which are incurable but cause bile duct obstruction.