End-to-end biliary anastomosis combined with hepaticojejunostomy for the management of high bile duct injuries: a technical case series

High bile duct injuries are rare but severe complications of hepatobiliary surgery, often requiring complex biliary reconstruction. The optimal surgical strategy for managing such injuries remains debated. We assessed the feasibility and safety of end-to-end biliary anastomosis combined with hepaticojejunostomy, with exploratory comparison to conventional Roux-en-Y hepaticojejunostomy, in patients with high bile duct injury. In this retrospective cohort study, 46 patients with Strasberg–Bismuth type E2–E4 injuries were treated between 2003 and 2023. Of these, 15 underwent combined end-to-end anastomosis plus hepaticojejunostomy (combined group) and 26 underwent conventional Roux-en-Y hepaticojejunostomy (control group). The primary outcome was treatment success (McDonald grade A/B). Multivariable logistic regression and LASSO validation identified factors associated with success. The combined group had shorter hospital stay (16.3 vs. 21.2 days; P = 0.02), fewer early complications (20.0% vs. 61.5%; P = 0.03), and less bile leakage (0% vs. 23.1%; P = 0.04). Treatment success rates were 86.7% vs. 69.2% ( P = 0.21). On multivariable analysis, combined repair (OR, 5.36; 95% CI, 1.10–26.12; P = 0.038) and higher preoperative albumin (OR per 1 g/L, 1.21; 95% CI, 1.01–1.44; P = 0.035) independently predicted success; E4 injury (OR, 0.23; 95% CI, 0.05–0.98; P = 0.047) and higher neutrophil percentage (OR per 1%, 0.90; 95% CI, 0.81–0.99; P = 0.028) were risk factors. LASSO identified these four factors as potential predictors in exploratory analysis. Combined end-to-end anastomosis with hepaticojejunostomy showed encouraging outcomes, including shorter hospitalization, fewer complications, and less bile leakage than conventional Roux-en-Y reconstruction, without increased operative risk. This approach appears to be a safe alternative for selected patients with high bile duct injury, although further validation in larger studies is warranted.