Reconstruction of small and fragile bile ducts without mucosa-to-mucosa anastomosis

We describe a simple and easy technique for performing choledochojejunostomy without the need to suture the full thickness of the ductal and intestinal walls for patients in whom standard choledochojejunostomy is difficult because the stumps of the residual bile ducts are small and fragile. This technique is useful in partial liver transplantation or after hepatectomy that includes removal of the extrahepatic bile ducts. The procedure involves the placing of external biliary drainage tubes through a Roux-en-Y jejunal loop, positioned transanastomotically, and the use of an external jejunostomy to decompress the loop. The tubes are fixed to the jejunal loop by a purse-string suture and to the duct by simple ligation or a purse-string suture. Anastomosis is performed by suturing the connective tissue and liver parenchyma around the ductal stump to the seromuscular layer of the intestine. Choledochojejunostomy according to this method was performed in 5 cases; the biliary drainage tubes were removed 1 to 4 months after surgery. The only complications were cerebellar infarction and cholangitis, both of which resolved with conservative treatment. We consider that this technique will be helpful as a last-ditch measure when standard choledochojejunostomy, with suturing of the full thickness of the walls of the duct and intestine to secure mucosa-to-mucosa apposition, is impossible because of small and fragile bile ducts.