In the era of prevailing minimally invasive surgeries with laparoscopic or robotic approaches, open RYCJ is not a matter of concern.^12-16 Moreover, recent development in ERCP with endoscopic therapeutic intervention has led choledocholithiasis to be placed beyond the territory of surgical indication.^1-9 On the contrary, we should not forget that there remains a small number of patients who still require open RYCJ because of the intractable occurrence of CBD stones. Since such a surgical procedure has been rarely performed, many young surgeons majoring in hepatobiliary surgery do not have enough experience on the indications and surgical techniques for open RYCJ in the cases of patients with intractable choledocholithiasis.

The principles for surgical techniques toward achieving complication-free RYCJ include avoidance of unnecessary dissection of the CBD, making a large-sized biliary-enteric anastomosis according to the fluid dynamics, and prevention of reflux ascending cholangitis. To avoid unnecessary dissection of the CBD, the luminal occlusion technique was used instead of segmental bile duct resection in Case No. 1. As the wall of the dilated CBD is usually thickened over 2 mm, the elliptical side-wall excision should be performed to make a large opening since a simple longitudinal incision can be eventually narrowed due to the slit closing effect.

Unlike the abovementioned two points, some background knowledge is necessary to understand why reflux ascending cholangitis should be prevented. If RYCJ is performed without interruption of distal CBD lumen, food materials would pass in a retrograde manner through the patulous papilla, which can be a source of frequent ascending cholangitis and CBD stone formation. Based on our experience with 8 cases of conventional side-to-end RYCJ without distal CBD interruption, episodes of reflux ascending cholangitis occurred repeatedly in at least 2 patients. A prospective study to determine the incidence of duodenobiliary reflux and acute cholangitis after placement of self-expanding metal stent across the main duodenal papilla revealed that reflux of duodenal contents is a universal phenomenon.¹⁷ A patulous papilla following multiple sessions of ERCP is vulnerable to reflux similar to the papilla state with a self-expanding metal stent. On the contrary, distal CBD interruption is not necessary for patients with distal CBD stenosis from benign or malignant diseases.

In the cases of usual patients with intractable choledocholithiasis, segmental bile duct resection is theoretically not necessary. However, if the CBD is markedly enlarged, leaving a large lumen within the distal CBD can make a blind-ended pool inducing infection or stone formation by food material regurgitation through the patulous ampulla. Thus, it is reasonable to resect the excessively dilated portion of the distal CBD, as demonstrated in Case No. 2.

We had used a refined technique of clustered biliary-enteric anastomosis when the bile duct opening was greater than 2 cm in diameter. Routine Roux-en-Y jejunal limb was prepared and pulled up through the retrocolic tunnel. A longitudinal incision was made at the antemesenteric border of the jejunal limb and the posterior wall anastomosis was performed with 2 or 3 segmented continuous running sutures with 5-0 Prolene. Anterior wall anastomosis was performed through multiple interrupted sutures.¹⁸ With the application of such customized techniques for intractable choledocholithiasis, until date, we did not experience any noticeable surgical complications yet 15 patients with age of 63-82 years.

In conclusion, we contemplate that the primary indication of bypass RYCJ is intractable choledocholithiasis which requires numerous sessions of ERCP over a long period. So far, open RYCJ has been the preferred procedure as it is much more reliable than the minimally invasive procedures regarding patient safety. If the papilla is patulous, 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 a choledochal cyst because food material can regurgitate through the patulous ampulla.