Which of the following surgical procedures has the lowest incidence of recurrent jaundice when used in the context of unresectable carcinoma of the head of the pancreas?

d.Choledochojejunostomy

When jaundiced patients undergo exploration in the hopes of resection but unresectable disease is found, biliary bypass should be performed. The jejunum is typically chosen as a conduit in preference to the duodenum because duodenal obstruction may occur as the tumor becomes more advanced. There has been much discussion over the use of the bile duct or the gallbladder for biliary decompression. Operative mortality and mean survival (about 6 months) do not differ between patients with cholecystojejunostomy and choledochojejunostomy. Recurrent jaundice is more common after cholecystojejunostomy. Because recurrent jaundice constitutes a failure of palliation, the use of the common duct for biliary bypass is preferable in most patients. There are circumstances, however, in which it may be more appropriate to use the gallbladder. Such instances include patients with poor performance status, cases in which the tumor is bulky and invades the porta hepatis, or when periductal varices have developed as a result of portal vein thrombosis. The suitability of the gallbladder as a biliary conduit must be proven intraoperatively. If, on aspiration, the gallbladder contains colorless fluid, the cystic duct may be assumed to be obstructed, and the gallbladder should be removed and not used for bypass. If there is green bile in the gallbladder, patency of the cystic duct should be proved by cholangiography before a bypass is performed.