Palliative Double Bypass

(Roux-en-Y Procedure)

This procedure is for patients with tumors in the distal common bile duct which have been deemed inoperable because of metastases, vessel involvement, etc. As seen in Fig. 1 below, in these patients, the flow of bile (green) , food (red) and pancreatic fluid (yellow) are disrupted. In a normal ampulla of Vater, the bile duct and pancreatic duct join before emptying into the duodenum. As a tumor grows, the common bile duct can become blocked, resulting in jaundice. The tumor can also bulge out against the duodenum and block the passage of food, shown by the pink arrow.

Essentially, the goal of the Double By-pass procedure is to re-route the flow of stomach contents and bile around the area where the tumor is blocking the normal flow of the gastrointestinal system. This should alleviate jaundice, nausea and vomiting caused by the blockage.

Figure 2 illustrates how the anatomy is reconfigured during the double bypass procedure. On the left is the normal anatomy. First, the gallbladder is removed. The jejunum is cut and one of the ends is moved up and attached to the hepatic duct. Bile from the liver now flows through the hepatic duct and into the jejunum, bypassing the blocked bile duct and duodenum altogether.

The continuity of the gastrointestinal tract is maintained by joining a loop of the jejunum to the lower portion of the stomach and reattaching the cut end of the jejunum to another another section further down. This creates an open passageway for food to flow from the stomach to the small intestine by avoiding the blocked duodenum.

Often a tumor in this portion of the bile duct will grow large enough to press on nerves running along the spine, causing intense pain. A celiac nerve block will alleviate such pain for several months. This is accomplished by injecting alcohol into the affected nerves to numb the sensation of pain. A celiac nerve block can be performed during a surgical procedure or as a separate procedure.