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Updated: Nov 4, 2025
Laparoscopic Choledochal Cyst Excision and Roux-en-Y Choledochojejunostomy in Adults
Published on: February 28, 2025
Indication and surgical techniques of bypass choledochojejunostomy for intractable choledocholithiasis
Shin Hwang1, Dong-Hwan Jung1, Sung Koo Lee2
1Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Insights
Open Roux-en-Y choledochojejunostomy (RYCJ) offers a surgical solution for intractable common bile duct (CBD) stones. This bypass procedure is effective for patients with recurrent CBD stones unresponsive to endoscopic treatments.
Area of Science:
- Gastroenterology and Hepatobiliary Surgery
- Minimally Invasive and Endoscopic Procedures
- Surgical Techniques for Biliary Tract Disease
Background:
- Choledocholithiasis (common bile duct stones) management has advanced with endoscopic and minimally invasive techniques.
- A subset of patients presents with intractable common bile duct stones requiring more definitive interventions.
- Roux-en-Y choledochojejunostomy (RYCJ) serves as a bypass procedure for complex choledocholithiasis cases.
Purpose of the Study:
- To detail open Roux-en-Y choledochojejunostomy (RYCJ) surgical procedures for intractable choledocholithiasis.
- To present two distinct surgical methods for RYCJ in patients with recurrent common bile duct stones.
- To evaluate the efficacy and outcomes of open RYCJ in managing refractory choledocholithiasis.
Main Methods:
- Description of a side-to-end choledochojejunostomy with distal common bile duct (CBD) intraluminal closure.
- Description of an end-to-end choledochojejunostomy with segmental CBD resection.
- Application of these open RYCJ techniques in two patients with a history of multiple endoscopic retrograde cholangiopancreatography (ERCP) sessions.
Main Results:
- Both patients, one with over 10 ERCPs and another with 9 ERCPs, underwent successful open RYCJ.
- The side-to-end RYCJ involved distal CBD occlusion, while the end-to-end RYCJ included segmental CBD resection.
- Both patients experienced uneventful recovery and remained well for two years post-surgery.
Conclusions:
- Open RYCJ is indicated for intractable choledocholithiasis, particularly in patients with numerous failed endoscopic stone removal attempts.
- Preventing ascending cholangitis via distal CBD occlusion or resection is crucial, especially with a patulous papilla.
- Resection of a dilated intrapancreatic distal CBD, such as in choledochal cysts, is recommended.
Abstract:
Despite development in endoscopic treatment and minimally invasive surgery for choledocholithiasis, there remains a small number of patients who require bypass Roux-en-Y choledochojejunostomy (RYCJ) because of the intractable occurrence of common bile duct (CBD) stones. We herein present the detailed procedures of open RYCJ customized for intractable choledocholithiasis. The first method is a side-to-end choledochojejunostomy with intraluminal closure of the distal CBD. This method was applied to a 79-year-old female patient who underwent endoscopic retrograde cholangiopancreatography (ERCP) more than 10 times in the past 14 years (Case No. 1). The distal CBD was explored through choledochotomy and then the distal CBD lumen was occluded with internal running sutures. A large-sized choledochojejunostomy was performed. The patient recovered uneventfully and has been doing well for the past 2 years. The second method is an end-to-end choledochojejunostomy with segmental CBD resection. It was applied to a 75-year-old male patient who underwent ERCP 9 times in the past 10 years (Case No. 2). The CBD was resected segmentally and a large-sized choledochojejunostomy was performed. The patient also recovered uneventfully and has been doing well for the past 2 years. In conclusion, the primary indication of bypass RYCJ is intractable choledocholithiasis which requires numerous sessions of endoscopic stone removal over a long period. Open RYCJ is the preferred procedure to date. If the papilla is patulous, the distal CBD should be occluded or resected to prevent reflux ascending cholangitis. We recommend to resect the intrapancreatic distal CBD if it is markedly dilated like choledochal cyst.
