How I Do It

Dig Surg 2002;19:165–167

Bilio-Digestive Double Bypass for

Nonresectable Pancreatic Cancer
J.-M. Heinicke a M.W. Büchler b U.T. Laffer a
a Department of Sugery, Spitalzentrum, Biel, and b Department of Visceral and Transplantation Surgery,

Bern, Switzerland

Key Words use of CT scan, ERCP, endoluminal ultrasonography and

Pancreatic cancer W Palliation W Biliary bypass W
Gastroenterostomy W Surgical technique
Abstract
In spite of extensive preoperative investigation, surgical
exploration is often the only way to determine whether a
pancreatic cancer is curatively resectable. If curative
resection is not possible, palliation of cholestasis and
eventual duodenal obstruction is mandatory. This is best
achieved by construction of a bilio-digestive double by-
pass. Many different techniques have been described
but considerable rates of delayed gastric emptying have
added high morbidity to the procedure. We propose a
retrocolic construction technique combining an omega
loop with a Roux-en-Y reconstruction which to our
knowledge has not been published before.
Copyright © 2002 S. Karger AG, Basel
Introduction
Most patients suffering from pancreatic carcinoma
present themselves only when jaundice and/or gastric
retention appears. Only 20–30% of patients can be cura-
tively operated at the time of diagnosis [1]. Despite the
MRI with image reconstruction of the portal vein, the
mesenteric vessels and the biliary tract, the feasibility of a
curative resection by pancreatoduodenectomy often re-
mains only determinable at explorative laparotomy. In
case of distant metastases or locally advanced cancer of
the pancreatic head with infiltration of the major vessels,
curative R0 resection is no longer possible. Because these
patients have qualified preoperatively for pancreatoduo-
denectomy, surgical palliation by means of a bilio-diges-
tive double bypass should be achieved [2, 3].
Surgical Technique
We perform a bilateral subcostal or midline laparotomy and start
trial dissection if no distant metastases are present. In a nonresecta-
ble situation, a tumor biopsy and cholecystectomy are performed, the
common hepatic duct is transected and closed distally with a running
suture. We then create 2 vertical openings in an avascular region of
the transverse mesocolon both left and right of the middle colic
artery. The jejunum is divided 80 cm distally to the ligament of
Treitz using an intestinal stapler device. The distal part of the jeju-
num is brought up through the right hole in the transverse mesocolon
to the hepatic duct and retrocolic isoperistaltic end-to-side hepatico-
jejunostomy is performed. The anastomosis is usually simple because
of the dilatation of the common hepatic duct due to distal obstruc-
tion of the choledochus.

© 2002 S. Karger AG, Basel J.-M. Heinicke, MD

ABC 0253–4886/02/0193–0165$18.50/0 Department of Surgery
Fax + 41 61 306 12 34 Spitalzentrum
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E-Mail karger@karger.ch Accessible online at: CH–2500 Biel 9 (Switzerland)

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Fig. 1. Combined Roux-en-Y and omega loop bilio-digestive double
bypass. (1) Two openings in the transverse mesocolon, both left and
right of the middle colic artery. (2) Ligament of Treitz. (3) Efferent
loop: retrocolic, isoperistaltic end-to-side hepaticojejunostomy
(40 cm in length). (4) Afferent loop: retrocolic, isoperistaltic side-to-
side gastroenterostomy at the posterior gastric wall. (5) End-to-side
enteroenterostomy.
We then bring the first jejunal loop after the ligament of Treitz up
through the left hole of the transverse mesocolon in an omega loop
way and perform a 6-cm-long, retrocolic, isoperistaltic, side-to-side
gastroenterostomy at the posterior gastric wall.
The two jejunal loops are fixed to the margins of the holes in the
transverse mesocolon to prevent internal hernia formation.
40 cm distal to the bilio-digestive anastomosis, the end-to-side
enteroenterostomy is performed completing the modified Roux-en-Y
construction with the afferent loop being fashioned as an omega loop
(fig. 1).
Postoperative Care
The nasogastric tube is removed within 24 h postoperatively and
oral feeding is started. On the 5th postoperative day the intra-abdom-
inal drainage placed near the bilio-digestive anastomosis is removed,
and the patients normally leave the hospital within 10 days postoper-
atively.
166 Dig Surg 2002;19:165–167
Discussion
The incidence of pancreatic cancer is steadily rising
but unfortunately only 20–30% of all patients can be oper-
ated with a curative intention [1, 4]. If curative resection
is impossible, palliation of cholestasis and the possible
duodenal obstruction can be achieved by constructing a
bilio-digestive double bypass. The operative procedure is
often quite long due to lengthy trial dissection but surgical
palliation has two major advantages. First, the operation
establishes the diagnosis of cancer and confirms its nonre-
sectability, which is often impossible preoperatively in
spite of the use of MRI, ERCP or endosonography. Sec-
ond, surgical palliation achieves long-term relief of jaun-
dice without the need for repeated endoscopy and also
allows palliation of any present or future duodenal ob-
struction.
Thus, interventional palliation by biliary stenting
should only be used if extensive metastases are found in
the preoperative investigation or in poor surgical candi-
dates by reason of age or serious intercurrent disease [2].
A recent study investigating the safety and efficiency of
self-expanding metal stents found considerable proce-
dure-related morbidity and mortality [5]. Prospective
randomized trials comparing endoscopic biliary stenting
and surgical biliary bypass have not been able to show any
considerable advantage for either of the procedures [6].
However, we must take into account that the median sur-
vival of an endoscopic stent has been reported to last only
4–9 months for polyethylene and metal stents [7]. Accord-
ing to a recent study including 56 patients with bilio-
digestive double bypass, 26 stent replacements would
have been necessary in the operated patient group if stent
insertion had been performed instead of the operation [2].
Additionally, the literature indicates that up to 25% of
patients primarily treated with biliary bypass alone will
develop subsequent gastric outlet obstruction and will
need reoperation for gastroenterostomy [3, 6], These
reoperations have much higher morbidity and mortality
than the primary construction of a bilio-digestive double
bypass [8]. Thus, we usually perform a bilio-digestive
double bypass if the patient has been judged fit enough for
surgical exploration, even if clinically significant duode-
nal obstruction has not yet occurred, although the necessi-
ty of prophylactic gastric decompression remains unprov-
en [2, 3].
Bilio-digestive double bypass can be safely achieved
with a low complication rate and must therefore be con-
sidered the gold standard for palliation in operable pa-
tients suffering from nonresectable pancreatic cancer
Heinicke/Büchler/Laffer
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even if we still lack prospective randomized data on this
topic [3, 9–11].
Many different techniques for bilio-digestive double
bypass have been described in the literature. [2, 8, 10–12].
To our knowledge, the specific technique described here
combining a retrocolic omega loop and Roux-en-Y con-
struction has never been published before.
The major postoperative problem – delayed gastric
emptying which occurs in up to 30% – is solved with con-
servative measures. However, it increases morbidity and
prolongs hospital stay in this patient group [2, 3]. Since
1996, we have systematically used this technique and
have observed delayed gastric emptying in 15% of over 60
operated patients [3]. The isoperistaltic gastroenterosto-
my probably helps to prevent disturbances of gastric
emptying and early oral feeding is crucial to maintain the
patency of the broad gastroenterostomy. This specific
construction avoids food reflux into the biliary tree and
bile cannot enter the stomach. The biliary and gastric iso-
peristaltic construction of the bilio-digestive anastomosis
will considerably help to avoid ascending cholangitis.
Jejunal ulcers have almost never occurred in our series
and we therefore do not routinely use H-2 blockers or pro-
ton pump inhibitors.
We thus recommend this construction technique for
bilio-digestive double bypass in the palliation of nonre-
sectable pancreatic cancer.

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