Future-Proof Biliary Reconstruction: Strategies to Facilitate Endoscopic Access After Hepaticojejunostomy

Background and Aims: Benign hepaticojejunostomy stricture (HJS) remains a challenging long-term complication after major hepatobiliary surgery. Although advanced endoscopic and interventional modalities have improved clinical outcomes, successful management is heavily constrained by anastomotic accessibility, particularly in altered post-hepatectomy anatomy. This review evaluates the clinical burden and anatomical barriers of conventional Roux-en-Y reconstruction and introduces “future-proof” biliary reconstruction strategies aimed at preserving lifelong therapeutic access. Methods: A comprehensive literature review was conducted to synthesize current evidence regarding the epidemiology, risk factors, and clinical consequences of benign HJS. We analyzed the technical limitations of contemporary interventions and critically reviewed the historical evolution of access-oriented surgical modifications, including access loops and modified enteric configurations. This narrative review was conducted through a structured search of PubMed, Scopus, and Web of Science for studies published between January 2000 and March 2026. Search terms included “hepaticojejunostomy”, “benign hepaticojejunostomy stricture”, “Roux-en-Y”, “balloon enteroscopy”, “EUS-guided biliary drainage”, “PTBD”, “access loop”, “jejunoduodenostomy”, and “biliary reconstruction”. Original articles, systematic reviews, meta-analyses, and relevant guideline papers published in English were included. Conference abstracts, editorials, and articles lacking sufficient clinical information were excluded. Results: Anatomical factors—such as excessive Roux limb length ($ > $50–70 cm), dense postoperative adhesions, sharp intestinal angulations, and complex multi-ductal hilar reconstructions—represent the primary drivers of endoscopic failure. Conventional reactive approaches address these barriers only after complications manifest, severely impacting patient quality of life and increasing healthcare utilization. Conversely, access-oriented strategies proactively incorporate long-term accessibility into initial operative planning. Specifically, Future Access Biliary Reconstruction (FABR)—utilizing a side-to-side jejunoduodenostomy between the elevated jejunal limb and the second portion of the duodenum—creates a direct, permanent route to the biliary limb, permitting rapid and reliable intervention via standard upper gastrointestinal endoscopy without compromising the primary hepaticojejunostomy. Conclusions: Future-proof biliary reconstruction represents a pivotal paradigm shift in hepatobiliary surgery, transitioning from purely functional restoration to proactive, lifelong disease management. Incorporating FABR during the index operation may eliminate anatomical barriers before they arise, potentially reducing reliance on invasive percutaneous interventions or high-risk surgical revisions. Prospective multicenter studies are warranted to validate its long-term safety, clinical efficacy, and optimal selection criteria.