Long-term results of choledochoduodenostomy in the treatment of choledocholithiasis: assessment of 225 cases

Long-term postoperative outcomes of Roux-en-Y cholangiojejunostomy in patients with benign biliary stricture

Background

Although there are common postoperative complications, Roux-en-Y cholangiojejunostomy is still broadly used as a standard surgical procedure for patients with biliary stricture. This study aimed to explore long-term risk factors of cholangiojejunostomy in patients with biliary stricture who underwent revisional cholangiojejunostomy.

Methods

Clinical data of 61 patients with biliary stricture undergoing revisional cholangiojejunostomy were retrospectively analyzed. These patients were classified into two groups (patients with traumatic biliary stricture and non-traumatic biliary stricture). Postoperative complications and survival time were successfully followed up.

Results

Among the patients, 34 underwent revisional cholangiojejunostomy due to traumatic biliary stricture, and 27 underwent revisional cholangiojejunostomy due to non-traumatic biliary surgery. Although there was no statistical difference in most clinical data between two groups, biliary dilation or not during the first surgery, cholelithiasis or not during the first surgery, long-term complications after first surgery, cholelithiasis or not during the second surgery, identifying abnormalities during the second surgery and long-term complications after second surgery were significantly different. All patients were successfully followed up and average follow-up time for patients with traumatic and non-traumatic biliary stricture was (88.44 ± 35.67) months and (69.48 ± 36.61) months respectively. Survival analysis indicated that there was no statistical difference in overall survival between two groups. Additionally, cox proportional hazard analysis demonstrated that first preoperative bilirubin level, short-term complication after first surgery and identifying abnormalities during the second surgery were independent risk factors that may have significant effects on patients' overall survival and long-term prognosis after cholangiojejunostomy. Among the intraoperative abnormal findings, residual lesions after the first operation had significant effects on the patients overall survival in the earlier stage. Relatively, anastomotic stoma stricture and biliary output loop problems had obvious effects on patients' overall survival at later stages.

Conclusion

First preoperative bilirubin level, short-term complication after first surgery and abnormal findings during the second surgery were independent risk factors of revisional cholangiojejunostomy, which may affect patients' long-term survival. Therefore, surgeons should minimize incidence of postoperative complications through fully evaluating optimal operative time and standardizing surgical procedures.

Risk factors and management of primary choledocholithiasis: a systematic review

BACKGROUND

Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy.

METHODS

Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed.

RESULTS

A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches.

CONCLUSION

Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for young patients or those in good conditions.

Choledochoduodenostomy as the Biliary–Enteric Bypass of Choice for Benign and Malignant Distal Common Bile Duct Strictures

Choledochoduodenostomy (including hepaticoduodenostomy) for common bile duct (CBD) strictures has been underused because of concerns regarding postoperative duodenal fistula and cholangitis attending the so-called “sump syndrome.” An institutional retrospective review of 55 consecutive choledochoduodenostomy procedures for CBD strictures from 1995 to 2011 was performed to examine its suitability as the biliary–enteric bypass procedure of choice. There were 30 male (55%) and 25 female (45%) patients with a mean age of 49 years (range, 13 to 73 years). Thirty-seven (67%) patients had benign CBD strictures and 18 (33%) had unresectable periampullary adenocarcinomas. Forty-nine (89%) underwent choledochoduodenostomy and six (11%) underwent hepaticoduodenostomy. There were no 30-day postoperative deaths, anastomotic leaks, or intra-abdominal abscesses. Five patients (9%) sustained Clavien Grade III or IV complications. Over a mean long-term follow-up of 29 months (range, 1 to 162 months), there was one anastomotic stricture successfully managed by endoscopic dilation and temporary stenting. Liver function tests in all other patients returned to and remained within normal limits. We conclude that choledochoduodenostomy is the preferred biliary–enteric bypass for both benign and malignant distal CBD strictures because of its ease, safety, and durability. Persistent fears of duodenal fistula and the “sump syndrome” are not warranted by the empiric data and should be abandoned.

Acute Cholangitis After Bilioenteric Anastomosis for Bile Duct Injuries

BACKGROUND/PURPOSE

The study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis (AC) after bilioenteric anastomosis (BEA) for biliary duct injury (BDI). Additionally, we assessed the performance of the Tokyo Guidelines 2013 (TG13) recommendations in these patients.

METHODS

We conducted a case-control study of 524 adults with a history of BEA for BDI from January 2000 to January 2014. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure.

RESULTS

We identified 117 episodes of AC in 70 patients; 51.3% were definitive AC according to the TG13 diagnostic criteria, and 39.3% did not fulfill the imaging criteria of AC. A history of post-operative biliary complications (OR 2.55, 95% CI 1.38-4.70) and the bile duct confluence preservation (OR 0.46, 95% CI 0.24-0.87) were associated with AC. Eighty-nine percent of the microorganisms were Enterobacteriaceae; of them, 28% were extended spectrum β-lactamase (ESBL) producers.

CONCLUSIONS

AC is a common complication after BEA and must be suspected even in the absence of imaging findings, particulary in patients with a history of post-operative biliary complications, and/or without bile duct confluence preserved. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance.

Current assessment of choledochoduodenostomy: 130 consecutive series

Introduction Cholelithiasis usually can be managed successfully by endoscopic sphincterotomy. Choledochoduodenostomy (CDD) is one of the surgical treatment options but its acceptance remains debated because of the risk of reflux cholangitis and sump syndrome. The aim of this study was to assess the current features and outcomes of patient undergoing CDD. Patients and methods We retrospectively analysed the surgical results of consecutive 130 patients treated by CDD between 1991 and 2013 and excluded five cases with a malignant disorder. Indications for surgery included endoscopic management where stones were difficult or failed to pass and primary common bile duct stones with choledochal dilatation. Incidences of reflux cholangitis, stone recurrence, pancreatitis or sump syndrome were investigated and the data between end-to-side and side-to-side CDD were compared. Results Reflux cholangitis and stone recurrence was 1.6% (2/125) and 0% (0/125) of cases by CDD. There is no therapeutic-related pancreatitis in CDD. Sump syndrome was not also observed in side-to-side CDD. Conclusions This study is a first comparative study between end-to-side and side-to-side CDD. The surgical outcomes for CDD treatment of choledocholithiasis were acceptable. The incidence of reflux cholangitis, stone recurrence, pancreatitis and sump syndrome was very low.

Hepatectomy with primary closure of common bile duct for hepatolithiasis combined with choledocholithiasis

AIM: To evaluate the feasibility of hepatectomy and primary closure of common bile duct for intrahepatic and extrahepatic calculi.

METHODS: From January 2008 to May 2013, anatomic hepatectomy followed by biliary tract exploration without biliary drainage (non-drainage group) was performed in 43 patients with intrahepatic and extrahepatic calculi. After hepatectomy, flexible choledochoscopy was used to extract residual stones and observe the intrahepatic bile duct and common bile duct (CBD) for determination of biliary stricture and dilatation. Function of the sphincter of Oddi was determined by manometry of the CBD. Primary closure of the CBD without T-tube drainage or bilioenteric anastomosis was performed when there was no biliary stricture or sphincter of Oddi dysfunction. Dexamethasone and anisodamine were intravenously injected 2-3 d after surgery to prevent postoperative retrograde infection due to intraoperative bile duct irrigation, and to maintain relaxation of the sphincter of Oddi, respectively. During the same period, anatomic hepatectomy followed by biliary tract exploration with biliary drainage (drainage group) was performed in 48 patients as the control group. Postoperative complications and hospital stay were compared between the two groups.

RESULTS: There was no operative mortality in either group of patients. Compared to intrahepatic and extrabiliary drainage, hepatectomy with primary closure of the CBD (non-drainage) did not increase the incidence of complications, including residual stones, bile leakage, pancreatitis and cholangitis (P > 0.05). Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage group than in the drainage group. The median postoperative hospital stay was shorter in the non-drainage group than in the drainage group (11.2 ± 2.8 d vs 15.4 ± 2.1 d, P = 0.000). The average postoperative cost of treatment was lower in the non-drainage group than in the drainage group (29325.6 ± 5668.2 yuan vs 32933.3 ± 6235.1 yuan, P = 0.005).

CONCLUSION: Hepatectomy followed by choledochoendoscopic stone extraction without biliary drainage is a safe and effective treatment of hepatolithiasis combined with choledocholithiasis.

Pyogenic hepatic abscess presenting years after a choledochojejunostomy: a rare clinical occurrence

A 69-year-old Caucasian man presented with fever, chills/rigors and night sweats since 6 days. Blood cultures (4/4) initially reported Gram negative lactose-fermenting rods. Physical examination was fairly benign which included a normal abdominal examination. Laboratory tests were significant for an elevated white cell count, erythrocyte sedimentation rate and C reactive protein . Empirically, he was treated with piperacillin tazobactam. A chart review showed that he had undergone a choledochojejunostomy for a pancreatic head tumour 7 years before. We found a few reported cases of hepatic abscesses after choledochojejunostomy presenting years after the procedure. An abdominal CT scan confirmed our suspicion. Percutaneous drainage was performed and his antibiotics were switched to ciprofloxacin and metronidazole, based on the sensitivity report. The patient's clinical condition steadily improved.

Operative management of recurrent choledocholithiasis

INTRODUCTION

With the advent of endoscopic and image-directed percutaneous approaches, it is increasingly uncommon to require a surgical approach for recurrent bile duct stones.

TECHNIQUE

We describe open side-to-side choledochoduodenostomy as one of the surgical options for recurrent bile duct stones. This procedure includes the following elements: exposure of the common bile duct, mobilization of the duodenum (Kocher maneuver), choledochotomy, inspection of the bile duct with a choledochoscopy, and anastomosis of the bile duct with the duodenum. Other options for operative management are discussed.

CONCLUSION

Surgical drainage procedures for recurrent bile duct stones can be performed for patients who fail to respond to endoscopic and nonoperative interventional treatments with good long-term outcomes.

Outcomes following laparoscopic choledochoduodenostomy in the management of benign biliary obstruction

INTRODUCTION

With the advent of endoscopic retrograde choledochoduodenostomy, the need for choledochoduodenostomy to treat common bile duct obstruction is less common, but occasionally required.

METHODS

Patients considered for laparoscopic choledochoduodenostomy secondary to benign conditions between 1999 and 2009 at a single institution were included. Charts were retrospectively reviewed for preoperative, operative, and long-term outcomes data.

RESULTS

Twenty patients were identified; 15 with chronic choledocholithiasis causing benign biliary obstruction or chronic recurrent cholangitis, 3 with chronic relapsing pancreatitis, and 2 with distal common bile duct strictures. Mean operative time was 270 min. No major operative complications were reported. Five patients with severe adhesions or portal hypertension required conversion to laparotomy. Median hospital stay was 6 days (range, 2-32). Postoperatively, three (20%) patients completed laparoscopically and three (66.7%) patients converted to laparotomy had complications. In addition, one death due to myocardial infarction was reported 4 weeks after hospital discharge. With an average follow-up of 21 months, only one patient (5%) developed recurrent symptoms.

CONCLUSION

Laparoscopic choledochoduodenostomy is a useful technique in patients with benign, refractory common bile duct obstruction. This technically demanding procedure is feasible; however, the associated comorbidities in this complex group of patients result in a relatively high complication rate.

Approach to manage the complications of choledochoduodenostomy: robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy

PURPOSE

To evaluate the technical feasibility and safety of robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy, using the robotic surgical system.

METHODS

This is a report of the use of robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy on 2 patients with recurrent pyogenic cholangitis. Both had past history of side-to-side choledochoduodenostomy with complications of Sump syndrome and benign biliary stricture, respectively.

RESULTS

Robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy was completed successfully in these 2 patients. Both patients recovered from the operation, except for 1 patient who had minor bile leakage over the anastomosis 4 days after operation, which subsided after conservative treatment. The mean operating time was 300 minutes and 400 minutes, respectively. The blood loss was 20 mL and 10 mL, respectively. They were able to tolerate liquids on the second postoperative day. They were discharged 6 and 11 days after the operation, respectively.

CONCLUSIONS

Robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy is a feasible and safe procedure. However, more large-scale studies with long-term follow-up results are needed.

Early complications after biliary enteric anastomosis for benign diseases: a retrospective analysis

Background

Biliary-enteric anastomosis (BEA) is a common surgical procedure performed for the management of biliary obstruction or leakage that results from a variety of benign and malignant diseases. Complications following BEA are not rare. We aimed to determine the incidence and the factors associated with early complications occurring after BEA for benign diseases.

Methods

We reviewed the medical records of all patients who underwent BEA for benign diseases at our institution between January 1988 and December 2009. The primary outcome was early post operative complication. Logistic regression analysis was done to identify factors predicting the occurrence of complications.

Results

Records of 79 patients were reviewed. There were 34 (43%) males and 45 (57% females). Majority (53%) had choledocholithiasis with impacted stone or distal stricture, followed by traumatic injury to the biliary system (33%). Thirty-four patients (43%) underwent a hepaticojejunostomy, 19 patients (24%) underwent a choledochojejunostomy, and choledochoduodenostomy was performed in 26 patients (33%). Early complications occurred in 39 (49%) patients - 41% had local complications and 25% had systemic complications. Most frequent complications were wound infection (23%) and bile leak (10%). Four (5%) patients died. On multivariate analysis, low serum albumin level (odds ratio = 16, 95% CI = 1.14-234.6) and higher ASA levels (odds ratio = 7, 95% CI: 1.22-33.34) were the independent factors predicting the early complications following BEA.

Conclusions

Half of the patients who underwent BEA for benign diseases had complications in our population. This high incidence may be explained by the high incidence of hypoalbuminemia and the high-risk group who underwent operation.

Long-term prognosis of patients after endoscopic sphincterotomy for choledocholithiasis

INTRODUCTION

The aims of the present study were to clarify the long-term prognosis of endoscopic sphincterotomy (EST) for choledocholithiasis and to evaluate the need for cholecystectomy after EST.

METHODS

Between 1993 and 2007, 262 patients who underwent successful EST for choledocholithiasis were followed up for more than 6 months). Eighteen patients had previously undergone cholecystectomy (Group A), 129 had a calculous gallbladder (GB) and underwent cholecystectomy after EST (Group B), 46 had a calculous GB in situ (Group C), and 69 had an acalculous GB in situ (Group D). Late complications, including recurrence of choledocholithiasis, acute cholecystitis and biliary carcinoma, were evaluated.

RESULTS

Of the 262 patients, late complications occurred in 34 patients (13.0%) and recurrence of choledocholithiasis occurred in 29 patients (11.1%). The rate of late complications was higher in Group C (23.9%) than in Group B (7.8%) (P < 0.001). The rate of recurrent choledocholithiasis was higher in Group C (17.4%) than in Group B (7.8%) (P < 0.05). Univariate analysis indicated that pneumobilia after EST was associated with the recurrence of choledocholithiasis (P < 0.001). Acute cholecystitis occurred in eight (7.0%) of 115 patients with intact GB. A gallbladder carcinoma was found after EST. Late complications were not serious and endoscopically or surgically manageable.

CONCLUSIONS

EST for choledocholithiasis is safe and effective. Cholecystectomy after EST is recommended in patients with calculous GB, but is not necessary in patients with acalculous GB. Pneumobilia was associated with the recurrence of choledocholithiasis.

Hepaticojejunostomy for hepatolithiasis: A critical appraisal

AIM: To evaluate the long-term outcome and surgical indications of hepaticojejunostomy (HJ) for the treatment of hepatolithiasis.

METHODS: Three hundred and fourteen elective cases with hepatolithiasis but without biliary stricture or cystic dilatation treated in the past 10 years were reviewed retrospectively. The patients were divided into HJ group and T tube drainage group according to biliary drainage procedure. Furthermore, four subgroups were subdivided by hepatectomy as a balance factor, group A₁: hepatectomy+HJ; group A₂: choledochoctomy+HJ; group B₁: hepatectomy + choledochoctomy T tube drainage; group B₂: choledochoctomy + T tube drainage. The stone residual rate, surgical efficacy and long-term outcome were compared among different procedures.

RESULTS: There was no surgical mortality among all patients. The total hospital mortality was 1.6%. The overall stone residual rate after surgical clearance was 25.9%. There was no statistical difference between HJ group and T tube drainage group in terms of stone residual rate after surgical clearance, however, after postoperative choledochoscopic lithotripsy, the total stone residual rate of T tube drainage group was significantly lower than that of HJ group (0.5% vs 16.7%, P < 0.01). Hepatectomy + choledochoctomy tube drainage achieved the optimal therapeutic effect, only 8.2% patients suffered from an attack of cholangitis postoperatively, which was significantly lower than that of hepatectomy + HJ (8.2% vs 22.0%, P = 0.034). The major reason for postoperative cholangitis was stone residual in the HJ group (16/23, 70.0%), and stone recurrence in the T tube drainage group (34/35, 97.1%). The operative times were significantly prolonged in those undergoing HJ, and the operative morbidity of HJ was higher than those of T tube drainage.

CONCLUSION: The treatment result of HJ for hepatolithiasis is not satisfactory in this retrospective study due to high rate of stone residual and postoperative cholangitis. HJ could not drain residual stone effectively. HJ may hinder post-operative choledochoscopic lithotripsy, which is the optimal management for postoperative residual stone. The indications of HJ for hepatolithiasis should be strictly selected.

Surgical complications and long-term outcome of different biliary reconstructions in liver transplantation for primary sclerosing cholangitis-choledochoduodenostomy versus choledochojejunostomy

Choledochojejunostomy (CJS) is commonly used for biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC). We alternatively performed choledochoduodenostomy (CDS) and side-to-side choledochodocholedochstomy in a large cohort of patients. Fifty-one patients with PSC, transplanted between 1988 and 2000, were analyzed retrospectively. Biliary reconstruction was CDS in 25 (49%), CJS in 20 (39%) and CC in 6 transplantations (12%). Biliary leaks occurred in the early follow-up (< or =41 days) only in CDS patients (20%). However, in the late follow-up (>4 months), stricturing of anastomosis was found once in CDS (4%) and CJS (5%). Later (>9 months), intrahepatic bile duct strictures were diagnosed in four CDS (16%), one CJS (5%) and one CC (17%) patient(s). In 48% of CDS (12/25), 60% of CJS (12/20) and 17% of CC (1/6) at least one incidence of cholangitis was observed. Overall, biliary complication rates were significantly higher in CDS (40%) than CJS (10%) and CC (17%); of those none in CC and 12% in CDS were anastomosis-related. Graft/patient survival showed no significant differences among groups. Based on our results we consider CJS the standard method for biliary reconstruction in PSC; however, in selected cases where CJS is difficult to accomplish because of previous surgery or for retransplantation, CDS may present an alternative technique.

Laparoscopic treatment of recurrent pyogenic cholangitis

BACKGROUND/PURPOSE

We reviewed the selective use of hand-assisted laparoscopic segmentectomy (HALS) and laparoscopic choledochoduodenostomy (LCD) in the management of recurrent pyogenic cholangitis (RPC).

METHODS

We carried out a retrospective review of a prospectively maintained database of laparoscopic treatment of RPC during the period 1995 to 2004. The perioperative data were analyzed.

RESULTS

There were 33 laparoscopic procedures performed in 30 patients with RPC during the period 1995--2004. There were 23 female and 7 male patients, with a mean age of 63.2+/-14.9 years (range, 29--92 years). All these patients had a history of repeated attacks of cholangitis, and multiple sessions of endoscopic lithotripsy or operative retrieval had previously been attempted. Of these 33 procedures, there were 23 LCDs and 10 HALS. Three patients underwent simultaneous LCD and HALS in the same operation. The mean operative time was 172+/-63.5 min (range, 75--290 min) and there were three open conversions (10%), due to (1) intraoperative bleeding from the left hepatic vein, (2) lost broken tip of ultrasonic dissector, and (3) significant bleeding during choledochotomy, respectively. Average hospital stay was 11.4+/-11.1 days (range, 5--60 days). Eight complications (26.6%) were encountered, which included four bile leaks, three wound infections, and one intraabdominal collection. Complete stone clearance was achieved in all but 1 patient (rate, 96.6%), in whom the residual stones were extracted through a postoperative combined endoscopic and percutaneous approach. Long-term results were satisfactory, and only one stone recurrence was detected, upon a mean follow-up of 34.7 months (range, 1--107 months).

CONCLUSIONS

Both LCD and HALS are safe, feasible, and effective treatments for patients with RPC.

[One layer end to side choledochusduodenal anastomosis with evertion of the choledochus wall in swines]

PURPOSE

This article aims to study the one layer end to side choledochusduodenal anastomosis creating a "neopapila" which, because of the mucosa recovering it, would prevent stenosis.

METHODS

Thirty male pigs were distributed within 3 equal groups = Group I (control)--conventional choledochusduodenal anastomosis. Group II (experiment)--one layer end to side anastomosis with evertion of the choledochus wall (neopapila). Group III (sham)--isolation and mobilization of the biliar tract with no choledocotomy. We got the biliar flow and pressure (pre and postoperative) monitorized on the 15 PO day the animals went trough an endoscopy and on the 30 PO day they were operated and the tissues were analysed under macro and microscopic view.

RESULTS

Regarding to biliar flow and manometry there were differences between all groups but the III. Animals in groups I and II showed intestinal metaplasia and diminished elastic fibers in the choledochus. All animals showed choledoco dilation.

CONCLUSION

The proposed technique allowed the same results as the standard technique.

Laparoscopic choledochoduodenostomy: an effective drainage procedure for recurrent pyogenic cholangitis

BACKGROUND

This article reports the technical aspects of laparoscopic choledochoduodenostomy (LCD) in patients with recurrent pyogenic cholangitis (RPC) and the perioperative results are also evaluated. This is a retrospective review of a prospectively maintained database.

METHODS

Twelve patients diagnosed to have RPC with the absence of intrahepatic stricture were selected for LCD during the period from 1995 to 2002. The majority of our patients had repeated attacks of cholangitis and had already undergone multiple sessions of endoscopic and operative lithotripsy. The LCD was performed using a five-port approach with the patient lying in the supine position. The stones were first cleared through the longitudinal supraduodenal choledochotomy followed by construction of a side-to-side diamond-shaped anastomosis of at least 15 mm between the bile duct and the first part of the duodenum using 2/0 monocryl in the single-layer method.

RESULTS

During the period from 1995 to 2002, 12 patients with RPC underwent LCD. There were 3 male and 9 female patients with a mean age of 62 (40-77). The median operation time was 137.5 min (90-270) and the median postoperative stay was 7.5 days (5-20). All cases were successful using the laparoscopic approach. Average analgesic requirement post operation was 126 mg (50-200 mg) intramuscular pethidine. There was one postoperative bile leak, and this complication was settled by conservative measures. Upon a mean follow-up of 37.6 months (6-91), there was no recurrent attack of cholangitis or any evidence of sump syndrome in this group of patients.

CONCLUSION

LCD is a safe and effective drainage procedure for patients with RPC. Complications are uncommon and postoperative results are promising.

Long-term prognosis after treatment of patients with choledocholithiasis

OBJECTIVE

This study was conducted to examine the long-term prognosis of after treatment of patients with choledocholithiasis, including the recurrence of lithiasis, and to thereby determine the best treatment modality for choledocholithiasis based on its pathological entity.

SUMMARY BACKGROUND DATA

Choledocholithiasis can be caused by either primary bile duct stones that originate in the bile duct or by secondary bile duct stones that have fallen out of the gallbladder. The recurrence rates vary depending on the type of choledocholithiasis.

METHODS

Two-hundred thirteen outpatients who were treated for choledocholithiasis from 1982 to 1996 were selected as subjects and monitored for a period ranging from 5 to 19 years (mean, 9.6 years). The 213 patients were divided into 3 groups: 87 patients who had undergone choledocholithotomy and T-tube drainage (including the use of the laparoscopic method), 44 patients who had undergone choledochoduodenostomy, and 82 patients whose stones were removed by endoscopic sphincterotomy (EST). Recurrence of lithiasis was examined for each type of treatment modality.

RESULTS

Choledochoduodenostomy was performed in 44 cases for the purpose of preventing any recurrence. The recurrent rate was analyzed in 169 cases. Choledocholithiasis recurred in 17 of the 169 cases (10.1%). The remaining 152 patients that showed no recurrence of lithiasis were examined and compared. The diameter of the common bile duct measured during the initial treatment was more dilated in patients with recurrent lithiasis (16.6 +/- 5.9 mm) than in patients without any recurrence (9.8 +/- 4.9 mm; P < 0.05). Peripapillary diverticula were observed in 10 of the 17 patients with recurrent lithiasis (58.8%), and in 34 of the 152 nonrecurrent patients (22.3%), showing that diverticula were more common in recurrent cases (P < 0.05). Furthermore, while primary bile duct stones were found in 11 of the 17 cases with recurrent lithiasis (64.7%), primary stones were found in only 37 of the 152 nonrecurrent patients (24.3%), showing primary bile duct stones were also more common in recurrent patients (P < 0.05). The recurrent patients were examined by surgical procedure. Nine patients with choledocholithotomy and T-tube drainage had a recurrence (10.3%), and 8 patients in the EST group had a recurrence (9.8%). The recurrence rates for these procedures were higher than for cases with choledochoduodenostomy (recurrence rate: 0%, P < 0.05). In particular, lithiasis recurred in 5 of the 12 patients with T-tube drainage for primary bile duct stones (41.7%).

CONCLUSION

Although choledocholithotomy and T-tube drainage, including open and laparoscopic surgery, is presently a common procedure for choledocholithiasis, this procedure will not necessarily prevent a recurrence of the disease. For older patients with primary bile duct stones, choledochoduodenostomy or EST is recommended.

Recurrent bile duct stones after transduodenal sphincteroplasty

BACKGROUND

Transduodenal sphincteroplasty (TDS) offers permanent prophylaxis against further stones in the common bile duct (CBD) by allowing continuous free efflux of bile from the papilla.

PATIENTS AND RESULTS

In a personal series of 267 consecutive operations, four patients underwent further treatment for recurrent CBD stones during a median follow-up of 12 years. Three of them received Roux-en-Y biliary diversion and had no further symptoms; the fourth patient remains well four years after endoscopic extraction of stones.

DISCUSSION

Recurrent stone formation is rare after an adequate TDS and probably reflects retained food debris within the CBD. Initial treatment may be endoscopic, but biliary diversion is needed for those with recurrent symptoms.

Sump syndrome: endoscopic treatment and late recurrence

OBJECTIVE

Biliary sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by food, stones, or debris after choledochoenterostomy. Endoscopic sphincterotomy has been recommended as the primary and definitive treatment modality. The aim of our study was to confirm the short and long term therapeutic efficacy of endoscopic treatment in a long follow-up period.

METHODS

The series include 31 patients with characteristic clinical illness after choledochoduodenostomy. All of them were successfully treated by endoscopic sphincterotomy and bile duct clearance with a balloon catheter or basket. The follow-up period ranged from 18 to 84 months (median: 51 months).

RESULTS

Clinical improvement was immediate in all patients. No complications were recorded. Recurrence of the syndrome, with restenosis of the sphincterotomy opening, was observed in six patients (19%) and was treated successfully and safely with a new papillotomy. Sump syndrome recurrence occurred 31-72 months (median: 58.5 months) after the initial treatment.

CONCLUSIONS

We report a considerably high recurrence rate of sump syndrome after initially successful endoscopic management and its effective endoscopic treatment with a new papillotomy. We still believe that the primary therapeutic approach in patients with sump syndrome should be endoscopic.

Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms

BACKGROUND

The long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms.

METHODS

Between 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients' relatives and general practitioners.

RESULTS

The procedure was successful in 217 of 223 cases (97%), of which 203 were followed-up; 2 patients died in the first month after treatment (0.89%). Mean follow-up for the 201 patients was 6.2 years, during which 31 relapsed (15%). Three significant prognostic factors for late complications were identified in a multivariate analysis. The recurrence rate of biliary symptoms in patients who were left with an in situ gallbladder was 20.2%, and 11% for those whose gallbladder was removed (p = 0.04). Patients with a bile duct 15 mm or greater in diameter were more prone to recurrence of symptoms than those with a bile duct 10 mm or less in diameter (41% vs. 10%, p = 0.025) and were especially at higher risk to develop recurrent stones (19.5% vs. 4.9%, p = 0.019). Stone recurrence, but not biliary symptoms as a whole, was more frequent in patients with a peripapillary diverticulum (p = 0.035).

CONCLUSIONS

The long-term results of endoscopic papillotomy are comparable with those of surgical techniques. The prognostic factors associated with relapse of biliary symptoms as a whole are gallbladder left in situ and choledochal diameter. Bile duct size and peripapillary diverticula are associated with recurrent bile duct stones.

Duodenogastric reflux after choledochoduodenostomy

Duodenogastric reflux (DGR) has been implicated in several disease processes. The present study was carried out to document the incidence and evaluate the clinical significance of DGR after choledochoduodenostomy (CDD). A total of 13 patients who had undergone cholecystectomy with a standard side-to-side CDD for choledocholithiasis or chronic pancreatitis were studied by symptom evaluation, scintigraphy, endoscopy, and gastric mucosal histology at least 6 months after surgery. The scintigraphic findings were then compared with those of 10 patients who had undergone cholecystectomy alone. Only two patients (15%) had mild dyspeptic symptoms. The incidence of DGR after CDD was 69% compared to 20% in the cholecystectomy alone group (P < 0.05). In the majority of patients the DGR was only mild to moderate and the severity correlated well with the degree of endoscopic gastritis, but not with the clinical symptoms or histological findings. These results indicate that while CDD is associated with a high incidence of DGR, its occurrence does not produce significant clinical symptoms.

Sump syndrome complicating Roux-en-Y hepaticojejunostomy: case report and review of the literature

Sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by gastrointestinal debris after choledochoduodenostomy, resulting in cholangitis or, less commonly pancreatitis. Obstruction of the biliary tree by gastrointestinal contents after Roux-en-Y choledochojejunostomy or hepaticojejunostomy has not been described in the English-language literature. This report details the diagnostic and operative management of the first patient with sump syndrome after hepaticojejunostomy. The presumed pathophysiology was reflux of vegetable matter up the efferent limb, resulting in hepatic duct obstruction and cholangitis. The patient ultimately required complex choledochoscopic drainage of the intrahepatic biliary tree and revision of the previous Roux-en-Y hepaticojejunostomy.

Recent advances in the management of gallstones

Demands for less invasive, more cost-effective therapy have revolutionized the management of gallstones over the past 10 years. There are no reliable methods of permanently reversing the pathophysiologic defects that cause gallstones. Open cholecystectomy (OC), the gold standard for managing symptomatic cholelithiasis, has been largely replaced by laparoscopic cholecystectomy (LC), which has the advantages of a minimal hospital stay and quicker return to work. Other adjunctive therapies, limited in applicability to selected patients, include oral bile acid therapy (BAT), dissolutional agents, and extracorporeal shock wave lithotripsy. Choledocholithiasis (CDL), formerly managed exclusively with surgical common duct exploration, is increasingly treated with therapeutic biliary endoscopy. Methods of laparoscopic common bile duct exploration are being developed. Optimal algorithms for applying these techniques to patients undergoing LC are evolving. In a sense, the solution to all, or certainly most, gallstones now can be seen through a scope.

Choledochoduodenostomy and sphincterotomy in the treatment of choledocholithiasis

Over a 10-year period, 2610 patients underwent operation for biliary lithiasis. Exploratory choledochotomy was indicated in 591 patients (22.6 per cent). This was followed by simple choledochorrhaphy over a T tube in 240 patients (40.6 per cent), transduodenal sphincterotomy and choledochorrhaphy over a T tube in 126 (21.3 per cent), supraduodenal choledochoduodenostomy in 216 (36.5 per cent), and choledochoduodenostomy and transduodenal sphincterotomy in nine (1.5 per cent). Choledochoduodenostomy was performed if the bile duct was more than 12 mm in diameter. The indication for transduodenal sphincterotomy was the presence of a stone impacted in the papilla and/or papillary stenosis. Six patients developed abdominal abscess and three an external biliary fistula following choledochoduodenostomy. There were four abscesses and two episodes of acute pancreatitis in patients undergoing sphincterotomy. There was no difference in mortality rate between the two groups. After a mean follow-up of 5.6 years, 71.5 per cent of patients who underwent choledochoduodenostomy and 75.2 per cent of those who received transduodenal sphincterotomy were asymptomatic. The remainder suffered from dyspepsia, colicky pain or episodes of cholangitis. Nine patients underwent reoperation for residual calculi (six choledochoduodenostomies, three sphincterotomies).

Reoperation for biliary tract complications following orthotopic liver transplantation

Biliary tract complications were analysed after 54 orthotopic liver transplantations performed in 49 patients over a 2-year period. Reconstruction of the bile duct consisted of end-to-end choledochocholedochostomy over a T tube in 47 cases and Roux-en-Y choledochojejunostomy in seven (two for sclerosing cholangitis, one for secondary biliary cirrhosis, four retransplants). The T tube was withdrawn 12-16 weeks after operation in all but two patients (2-3 weeks). There was no intraoperative mortality. Eight patients (16 per cent) died during the first month and the 1-year actuarial survival rate was 75 per cent. Early biliary complications (up to 3 months after operation) consisted of five bilomas, for which ultrasonographically guided drainage was effective in three and surgical drainage necessary in two. Late biliary complications (3 months onwards) consisted of biliary peritonitis following T tube removal (four patients; reoperation was required in all four) and necrosis of the bile duct secondary to a late arterial thrombosis (one). The incidence of reoperation as a result of early biliary complications was low (two patients), but higher for biliary peritonitis following T tube removal.