International Journal of Clinical Medicine, 2013, 4, 400-404 Published Online September 2013 (
A New Surgical Technique of Biliary Drainage
Shafiqul Hoque
Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
Received June 17th, 2013; revised July 16th, 2013; accepted August 2nd, 2013
Copyright © 2013 Shafiqul Hoque. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: Roux-en-Y Hepatico-jejunostomy is the standard technique of biliary reconstruction after excision of
choledochal cyst. Here the author describ es a new surgical technique of biliary reconstruction using native gall bladder
as biliary conduit. New Surgical Technique: The choledochal cyst is excised as standard technique but gall bladder
with its neck is kept in situ. The gall bladder neck is anastomosed with the common hepatic duct stump and gall blad-
der fundus is anastomosed with the antero-inferior wall of the first part of distal duodenum. Materials & Methods:
Eleven patients with choledochal cyst have been operated with the new technique from July 2011 to December 2012 in
the city of Dhaka, Bangladesh. Feeding was started from 3rd post-operative day and drain was removed by 7th day unless
complicated and they were released from the hospital between 10 - 15 days. Results: The ages of eleven patients were
from 3 months to 11 years. There were 7 females and 4 males. Lump was felt in 3 patients and jaundice was present in 4
patients. Recurrent abdominal pain was present in all patients. They were diagnosed by ultrasonography and MRCP was
done in 6 patients only. Prothrombin time was elevated by 10% & 15% in 2 patients. Average operation time was 2
hours and 10 minutes. A 9-year girl died suddenly and unexpectedly on the 5th post-operative day from severe convul-
sion of unknown origin. One child suffered from prolonged bile leakage and re-explored to repair anastomotic leak.
Another patient had a collection near the anastomosis which resolved spontaneously. Discussion: Benefits of the new
surgical technique are total absence of Roux-en-Y related intestinal complications. Possible disadvantages are discussed.
It is anatomical and physiological. Small incision and less operation time are other benefits which need to be mentioned.
Possible disadvantages are discussed.
Keywords: Biliary Reconstruction; Bilioenteric Anastomosis; Choledocho-Cholecystostomy;
Cholecysto-Duodenostomy; Choledocho-Cholecysto-Duodenostomy
1. Introduction
Roux-en-Y hep atico-porto-jejunostomy (RYH J) is now a
well-accepted biliary drainage procedure for benign bil-
iary tract diseases such as choledochal cyst and biliary
strictures [1-5]. It involves two anastomoses, namely
jejunojejunostomy and hepatico-porto-jejunostomy with
a long segment (40 cm) of defunctioning jejunum as the
biliary conduit. The anastomoses are quite big and nor-
mal anatomy is distorted. Here, the author describes an
alternate procedure of biliary drainage which is an atomi-
cally as well as physiologically smaller in size and tech-
nically simpler. The technique has been successfully ap-
plied in 11 children with choledochal cyst.
2. New Surgical Technique
The main difference between this new technique and the
original Roux-en-Y hepatico-porto-jejunostomy (RYHJ)
is the preservation of gall bladder, which has been used
as the biliary conduit. The abdomen was explored by
smaller upper right transverse incision mostly dividing
the rectus only. The area of dissection was only the sub
hepatic region. The choledochal cyst was excised in the
classical way (Figure 1). The important point in dissec-
tion is the isolation and preservation of the cystic artery.
In one patient, the cystic artery was accidentally injured
and ligated. But no adverse effect occurred since the gall
bladder is well vascularized with alternate sources from
the liver bed. The cystic duct was excised en-masse with
the choledochal cyst at its junction with the neck of the
gall bladder (Figure 2). The gall bladder fundus and part
of body is mobilized from the liver bed such that the
fundal tip easily comes close to the duodenum without
any tension. The biliary channels in the liver were
cleared of all stones, debris or sludge. Then the gall
bladder neck was brought near the remaining common
Copyright © 2013 SciRes. IJCM
A New Surgical Technique of Biliary Draina ge 401
Figure 1. Choledochal cyst and lines of excision. A, division
of lowest end of terminal common bile duct or choledochal
cyst. B, Division at the site of common hepatic duct just
above the choledochal cyst. C, Division of gall bladder neck.
Figure 2. After the excision of the choledochal cyst.
hepatic duct for anastomosis. Any inequality was ad-
justed by opening the gall bladder neck longitudinally.
Extra Care was taken not to twist the gall bladder neck.
Interrupted water tight su tures with 6/0 polyglycolic acid
(Vicryl) were applied in a single layer. The site for the
anastomosis of the fundal tip with duodenum was se-
lected on the antero-inferior wall of distal first part of the
duodenum. This site was specifically selected for possi-
ble prevention of reflux and subsequent cholangitis. The
size of the anastomosis was kept within 10 mm. The an-
astomosis was completed in two layers with interrupted
stitches of 6/0 p olyglycolic acid (Vicryl). The outer sero-
muscular stiches were taken little away from the margin
such that the stoma invaginates a little into the duodenal
lume n like a papilla to prevent possible reflux (Figure 3).
Figure 3. Anastomosis of gall blader neck with common
hepatic duct and anastomosis of fundus of the gall bladder
with antero-inferior wall of distal first part of duodenum.
The excised choledochal cyst was sent for histological ex-
amination. The cystic duct stump was also examined sepa-
rately in 4 patients. Any leakage was checked. The wound
was closed by giving a drain in the subhepatic pouch.
3. Materials & Methods
This is a prospective study done in BSMMU (Ban-
gabandhu Sheikh Mujib Medical University), DMCH
(Dhaka Medical College Hospital) and private clinics in
the City of Dhaka, Bangladesh during the period from
July 2011 to December 2012. A total of 11 patients di-
agnosed as choledochal cyst were selected for the proce-
dure. The procedure has been explained to the surgical
team for a better assistance. Histological examination of
the resected cyst specimen was done in all patients. His-
tology of the cystic duct stump was performed in 4 pa-
tients only. Oral feeding of liquids was given from the 3rd
post-operative day. The drain was kept usually for 7 days
to observe for any leakage. If leakage is suspected the
drainage tube was kept for prolonged period. Patients
were discharged from the hospital between 10 - 15 days
after the surgery. They were followed up at 6th & 12th
weeks after discharge from the hospital.
4. Results
A total of 11 patients with ages ranging from 3 months to
11 years were included in the study protocol. Seven pa-
tients were female and 4 were male. All the patients were
diagnosed as choledochal cysts. Lumps were felt in 3
patients and jaundice was present in 4 patients. A vari-
able degree of recurrent abdominal pain was present in
all patients. All the patients were diagnosed by ultra-
Copyright © 2013 SciRes. IJCM
A New Surgical Technique of Biliary Draina ge
sonography. MRCP was done in 6 patients only. Early
cirrhosis was found in only 3 patients. Small elevation of
bilirubin level was seen in 4 patients. Prothrombin time
was in- creased by 10% & 15% in 2 patients. Blood
transfusion was not needed in any of the patients. The
average operation time was 2 hour & 10 minutes. Un-
eventful recovery occurred in 8 patients. A 9-year-old
girl was on smooth recovery until 5th post-operative day
midnight when she suffered severe convulsions and died
within a short per iod. Th er e were no abdomin al sign s and
symptoms. The cause of death remains unexplained. One
child suffered for prolonged biliary drainage and re-ex-
plored for anastomotic leakage at the site of porta hepatis
and reconstructed again which resulted in an uneventful
recovery. Another patient, a boy of 8 months old was re-
covering well until 7th post-operative day when there was
moderate abdominal disten sion with incr ease of drain age.
Ultrasonography revealed a 3 cm × 2 cm area of cystic
swelling (collection) near the an astomotic site. The drain
was kept in situ. Food intake was stopped and patient
was kept under close observation. Food intake was re-
started after 6 days and the patient responded well with
resolution of the problem. Ultrasonography revealed ab-
sorption of the collection with no further external drain-
age. Thereafter the drainage tube was taken off. Malig-
nancy was not found in any of the patient. Histology of
the cystic duct stump showed abundance of fibres, scat-
tered muscles with normal lining epithelium in 4 patients.
The longest follow up is 1 5 months, with sh ortest follow
up of 4 months in the last patient. All the 10 patients are
doing well. None of the patients has suffered from at-
tacks of abdominal pain with fever suggesting cholangitis
nor any ulcer symptoms in this short period of fo llow up.
5. Discussion
Roux-en-Y hepatico-porto-jejunostomy (RYHJ) is a stan-
dard and well-practiced procedure for obstructive benign/
malignant biliary tract disease worldwide. It involves a
bigger incision, longer operation time, two bigger anas-
tomoses with greater possibility of intestinal complica-
tions. A long intestinal conduit for biliary drainage is
another aspect. The complications of the original proce-
dure are anastomotic stricture, recurrent calculi, recurrent
cholangitis, malformed or twisted loop, too long or too
short proximal jejunum and adhesions of intestinal loops
The new technique uses native biliary channel for bile
drainage instead of intestinal conduit. Gall blad der is not
usually involved in the process of choledochal cyst for-
mation. So gall bladder has been used as biliary conduit
in place of Roux-en-Y Hepatico-jejunostomy. When the
gall bladder was pulled down to anastomose with duo-
denum it more or less becomes an elongated tube with a
little bigger caliber than normal CBD. It acts as a conduit
for bile instead of a temporary reservoir of bile. But it is
a biliary tract rather than intestinal tract as in Roux-en-Y
hepatico-jejunostomy. In Roux-en-Y hepatico-jejuno sto my
the bile has to travel a long distance of 40 cm to come in
contact with the food in the jejunum, whereas in present
technique by traveling hardly a distance of 8 - 10 cm,
bile comes in contact with the food material in the duo-
denum like normal anatomy. Hence it is more physio-
logical than Roux-en-Y anastomosis.
The advantages of the new technique are:
The new technique maintains a normal anatomy more
than the Roux-en-Y Hepatico-j ejunostomy.
A biliary conduit (gall bladder) has been used in-
place of an intestinal conduit and hence more physio-
Area of dissection is small (only sub-hepatic region)
thus reducing the area of adhesion.
Primary incision is small.
Possibility of reflux is less as the cholecysto-duo-
denostomy size is small (<10 mm) and its placement
is on the anterior wall of the duodenum.
Total operation time is less (130 min average) com-
pared to Roux-en-Y hepaticojejunostomy (161 min to
5.1 hours) [ 2, 8 ].
The possibility of gall stone formation is less as gall
bladder works as a conduit with continuous flow of
bile rather than a normal reservoir.
The new technique logically excludes intestinal com-
plications that may occur from Roux-en-Hepaticoje-
junostomy. The complications are adhesive obstruc-
tion, twisting of jejunal loo p, duodenal ulcer [1-7].
No significant disadvantage or complications has been
observed in the new technique comparing to all other
bilio-enteric anastomoses. However possibility of occur-
ing complications or disadvatages in the new technique
are discussed.
Anastomotic leakage: The anastomosis of dilated
common hepatic duct and gall bladder neck is a weak
one because of their thin walls specially GB neck. In
the present technique it is suggested to give inter-
rupted stic hes wi t h 3 - 5 mm gap by 6 - 0 polyglocoli c
acid (Vicryl) with round body needles. Importance of
proper surgical technique in reducing complications
in biliary reconstruction has been stressed by Satoshi
et al. [9]. Gentle handling is very important. In the
present series 2 patients presented with complication
of bile leakage. Re-exploration and repair of the leak
has been done successfully in one patient and leakage
spontaneously stopped in another. Anastomotic leak-
age is a documented complication in bilio-enteric/
biliary duct-to-duct an astomosis [3,7,10-12].
Anasto motic str i ct u r e : It is another common compli-
cation of biliary tract surgery [3,10,13-17]. In the
present technique d ilated hepatic duct is anastomosed
Copyright © 2013 SciRes. IJCM
A New Surgical Technique of Biliary Draina ge 403
with narrow gall bladder neck where it may be com-
plicated by str icture. Even it happened it can be treated
by a redo-cholecystostomy with wider part of gall blad-
der body or Roux-en-Y choledocho-jejunostomy.
Biliary fistula: An anastomotic leakage if not closed
spontaneously o r not repaired in time it will result in a
biliary fistula. It is not a common complication. Bil-
iary fistula as a complication is found in one report of
Roux-en-Y Hepaticojejunostomy [3].
Reflux and Recurrent cholangitis: It is a common
complication in bilio-enteric/biliary duct-to-duct an-
astomosis [3,5,10,13,14,17]. When the normal anat-
omy of protruding papilla and sphincter of Oddi at
termination of CBD (Common Bile Duct) is replaced
by simple anastomosis there is possibility of reflux of
foods to cause cholangitis. A long isoperistaltic seg-
ment of jejunum (>40 cm) in Ro ux-en-Y anastomosis
or an interposition of reconstructed valve is a good
prevention for reflux. Even then there is reflux to
cause cholangitis [2,3,5,13,14,17]. But in choledo-
choduodenostomy no such mechanism works and
hence incidence of reflux is more [14]. This high in-
cidence of reflux is probably due to the fact that the
short common hepatic duct is anastomosed directly
with the superior surface of duodenum which has
been pulled up making an angulation and easy way
for reflux. Also to add that the anastomosis with duo-
denum is wide because of dilated common hepatic
duct from obstructive effect of the choledochal cyst.
In the present technique a small anastomosis with
some degree of projecting stoma into th e anterior wall
of first part of duodenum is likely to minimise the in-
cidence of reflux.
Gall stones: Gall stone is an uncommon complication
[6,13] which may occur in the present technique as
because native gall bladder is preserved. But in the
new technique, the possibility is less as the gall blad-
der has been used as a conduit where there is conti-
nous flow of bil e instea d of a normal reservoir.
Carcinoma of gall bladder: If cyst wall with the lin-
ing epithelium is retained (as in earlier days) either in
partial excision or cystoduodenostomy there is good
chance of carcinoma formation from the abnormal
cyst epithelium. But in presnt technique the cyst has
been completely removed. So chance of developing
carcinoma from cyst remnant does not arise. But, as
gall bladder is retained the possibility of developing
carcinoma from it is always there like a normal gall
6. Conclusion
The new surgical technique is more anatomical and
physiological than standard Roux-en-Y hepatico-jeju-
nostomy. There was no significant disadvantage or com-
plication within this sh ort period of follow-up. However,
a long term follow-up of patients is needed to look for
future probable complications of stricture, recurrent
cholangitis or any other untoward complications. Even
such complications occur there is scope for a redo-sur-
gery or a Roux-en-Y Hepaticojejunostomy. The tech-
nique can be employed not only for the treatment of
choledochal cyst but also for the treatment of other
causes of Common Bile Duct replacement.
7. Acknowledgements
I would like to acknowledge my wife, Dr. Nasreen
Raushan, for her contributions in editing and proofread-
ing the paper and for her constant support.
[1] Z. Li, N. Cui and L. Chen, “Treatment Experience of
Subsequent Complications after Roux-en-Y Biliojejunos-
tomy,” European Surgical Research, Vol. 43, No. 1, 2009,
pp. 34-38. doi:10.1159/000216521
[2] E. Elhalaby, A. Hashish, M. Elbarbary and M. Elwagih,
“Roux-en-Y Hepaticojejunostomy versus Hepaticoduo-
denostomy for Biliary Reconstruction after Excision of
Choledochal Cysts in Children,” Annals of Pediatric Sur-
gery, Vol. 1, No. 1, 2005, pp. 79-85
[3] P. Stefanini, M. Carboni, N. Patrassi, A. Basoli, G. de
Bernardinis and P. Negro, “Roux-en-Y Hepaticojejunos-
tomy: A Reappraisal of Its Indications and Results,” An-
nals of Surgery, Vol. 181, No. 2, 1975, pp. 213-219.
[4] G. Pappalardo, S. Correnti, S. Mobarhan, P. Trentino, A.
Pietropaolo, F. Frattaroli and G. Castrini, “Long-Term
Results of Roux-en-Y Hepaticojejunostomy and Hepati-
cojejunoduodenostomy,” Annals of Surgery, Vol. 196, No.
2, 1982, pp. 149-152.
[5] A. Shimotakahara, A. Yamataka, T. Yanai, H. Kobayashi,
T. Okazaki, G. J. Lane and T. Miyano, “Roux-en-Y Hepa
tico-Jejunostomy for Biliary Reconstruction during the
Surgical Treatment of Choledochal Cyst: Which Is Bet-
ter?” Pediatric Surgery International, Vol. 21, No. 1,
2005, pp. 5-7. doi:10.1007/s00383-004-1252-1
[6] G. Halff, S. Todo, R. Hall and T. E. Starzl, “Late Compli-
cations with Gall Bladder Conduit Biliary Reconstruction
after Liver Transplantation,” Transplantation, Vol. 48,
No. 3, 1989, pp. 537-539.
[7] K. Congo, M. F. Lopes, P. H. Oliveira, H. Matos, S.
Basso and A. Reis, “Outcomes of Choledochal Cysts with
or without Intrahepatic Involvement in Children after Ex-
trahepatic Cyst Excision and Roux-en-Y Hepaticojeju-
nostomy,” Annals of Hepatology, Vol. 11, No. 4, 2012,
pp. 536-543.
[8] M. T. Santore, B. J. Behar, T. A. Blinman, E. J. Doolin, H.
L. Hedrick, P. Mattei, M. L. Nance, N. S. Adzick and A.
W. Flake, “Hepaticoduodenostmy versus Hepaticojeju-
Copyright © 2013 SciRes. IJCM
A New Surgical Technique of Biliary Draina ge
Copyright © 2013 SciRes. IJCM
nostomy for Reconstruction after Resection of Choledo-
chal Cyst,” Journal of Pediatric Surgery, Vol. 46, No. 1,
2011, pp. 209-213. doi:10.1016/j.jpedsurg.2010.09.092
[9] S. Hirano, E. Tanaka, T. Tsuchikawa, J. Matsumoto, T.
Shichinohe and K. Kato, “Technique of Biliary Recon-
struction Following Bile Duct Resection,” Journal of
Hepatobiliary-Pancreatic Sciences, Vol. 19, No. 3, 2012,
pp. 203-209. doi:10.1007/s00534-011-0475-5
[10] N. Akamatsu, Y. Sugawara and D. Hashimoto, “Biliary
Reconstruction, Its Complications and Management of
Biliary Complications after Adult Liver Transplantation:
A Systematic Review of the Incidence, Risk Factors and
Outcome,” Transplant International, Vol. 24, No. 4, 2011,
pp. 379-392. doi:10.1111/j.1432-2277.2010.01202.x
[11] F. Cianci, F. Al Oraifi, F. Tareen and M. Corbally, “Cho-
ledochal Cyst: Our Ten Year Experience,” Irish Medical
Journal, Vol. 105, No. 4, 2012, pp. 110-113.
[12] S. S. Saluja, M. Nayee m, B. C. Sharma, G. Bora and P. K.
Mishra, “Management of Choledochal Cysts and Their
Complications,” American Surgeons, Vol. 78, No. 3,
2012, pp. 284-290.
[13] A. J. Oishi, M. G. Sarr, D. M. Nagomey, M. D. Traynor
and P. Mucha Jr., “Long-Term Outcome of Cholecysto-
enterostomy as a Definitive Biliary Drainage Procedure
for Benign Disease,” World Journal of Surgery, Vol. 19,
No. 4, 1995, pp. 616-619. doi:10.1007/BF00294736
[14] D. P Vogt and R. E Hermann, “Choledochoduodenos-
tomy, Choledochojejunostomy or Sphincteroplasty for
Biliary and Pancreatic Disease,” Annals of Surgery, Vol.
190, No. 2, 1981, pp. 161-168.
[15] R. M. Walsh, J. M. Henderson, D. P. Vogt and N. Brown,
“Long-Term Outcome of Biliary Reconstruction for Bile
Duct Injuries from Laparoscopic Cholecystectomies,”
Surgery, Vol. 142, No. 4, 2007, pp. 450-456.
[16] R. F. Saidi, N. Ilias, D. Sc Ko, T. Kawai, J. Markmann, A.
B. Cosimi and M. Hartl, “Biliary Reconstruction and
Complications after Living-Donor Liver Transplantation,”
HPB (Oxford), Vol. 11, No. 6, 2009, pp. 505-509.
[17] B. Mukhopadhyay, R. M. Shukla, M. Mukhopadhyay, K.
C. Mandal, P. P. Mukharjee, D. Roy, S. K. Biswas and K.
S. Basu, “Choledochal Cyst: A Review of 79 Cases and
the Role of Hepaticodochoduodenostomy,” Journal of
Indian Association of Pediatric Surgeons, Vol. 16, No. 2,
2011, pp. 54-57. doi:10.4103/0971-9261.78131