Choledochoduodenostomy: an unjustly maligned surgical procedure?

Outcome of Biliary-enteric Reconstruction with Hepaticoduodenostomy Following Choledochal Cyst Resection: A Prospective Study

BACKGROUND

The two most commonly performed methods of biliary-enteric reconstruction following choledochal cyst resection are Roux-en-Y hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD). There is a lack of consensus regarding the better technique between them. This study aimed to evaluate the outcomes, efficacy and early complications of HD as a mode of biliary reconstruction after surgical resection of a choledochal cyst.

MATERIALS AND METHODS

This was a multi-institutional prospective study carried out in high-volume tertiary care teaching institutes from January 2010 to December 2022. All children managed with HD following choledochal cyst resection were analysed for their early complications and outcomes.

RESULTS

A total of 74 patients were included in this study. There were 59 (79.73%) females and 15 (20.27%) males. Thirty-nine (52.70%) patients had jaundice at the time of presentation. Magnetic resonance cholangiopancreatography was performed in 57 (77.03%) patients following ultrasonography. Intraoperatively, malrotation was present in 2 (2.70%) patients. In our study, operating time ranged from 60 to 195 min (mean: 118 min). Hospital stays ranged from 8 to 17 days (mean: 11.5 days). The post-operative biliary leak was seen in 7 (9.50%) patients, out of which 6 (8.11%) minor leaks were managed conservatively. Roux-en-Y HJ was performed on 1 (1.35%) patient with a major leak. In our series, 4 (5.40%) patients developed cholangitis; post-operative haemorrhagic nasogastric aspirate 5 (6.76%), post-operative pancreatitis 3 (4.05%) and wound infection 4 (5.40%) were observed and managed conservatively. None of the patients in our study developed an anastomotic stricture, bile gastritis and adhesive small bowel obstruction.

CONCLUSION

Resection of choledochal cyst with HD reconstruction is safe and feasible with short operative time. HD is a viable option for operative management of choledochal cyst with low complication rates and faster recovery.

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.

Endoscopic sump syndrome secondary to EUS-guided choledocho-duodenostomy with a lumen-apposing metal stent

Sump syndrome (SS) is associated with choledocho-duodenostomy (CDD) dysfunction, which occurs due to accumulation of detritus, biliary mud and food remains in the suprapapillary distal common bile duct. The prevalence is low after CDD. Currently, biliary drainage endoscopic ultrasound (EUS)-guided with a lumen-apposing metal stent (LAMS) is a new minimally invasive alternative for biliary stenosis for patients in whom endoscopy retrograde cholangial-pancreatography (ERCP) is not feasible. CDD via EUS-guided LAMS is increasing. Thus, SS has become a potential associated complication that was previously unreported in the literature.

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.

Necrotizing fasciitis of anterior abdominal wall following cesarean section in a low-risk patient

We report a case of a mono-microbial post-cesarean necrotizing fasciitis caused by methicillin resistant Staphylococcus aureus, in a low-risk healthy woman who presented with acute fulminant infection, sepsis and features of multi-organ dysfunction syndrome on sixth post-operative day. Aggressive management with multiple surgical debridement and supportive therapy was the key to favorable outcome in this case.

A case of postoperative recurrent cholangitis after pancreaticoduodenectomy successfully treated by tract conversion surgery

A 69-year-old man, who had undergone pylorus-preserving pancreaticoduodenectomy (PD) (Imanaga procedure) for duodenum papilla cancer 13 years prior, had a history of repeated hospitalization due to cholangitis since the third year after surgery and liver abscess at the 10th year after surgery. Gastrointestinal series indicated no stenosis after the cholangiojejunostomy. However, reflux of contrast media into the bile duct and persistence of food residues were observed. We considered the cholangitis to be caused by reflux and persistence of food residues into the bile duct. So, we performed the tract conversion surgery, Imanaga procedure to Child method. The postoperative course was good even after re-initiating dietary intake. He was discharged on the 19th day after surgery. He has not experienced recurrent cholangitis for 18 months. For patients with post-PD recurrent cholangitis caused by reflux of food residues like ours, surgical treatment should be considered because tract conversion may be an effective solution.

Hepaticojejunostomy for the management of sump syndrome arising from choledochoduodenostomy in a patient who underwent bariatric Roux-en-Y gastric bypass: A case report

INTRODUCTION

Rapid weight loss following bariatric surgery is associated with high incidence of gallstones and complications that may need bilioenteric diversion. This presents a specific challenge in the management of this group of patients.

CASE PRESENTATION

A 37 years old female underwent a Roux-en-Y gastric bypass (RYGB) in 2008 for morbid obesity. In 2009 she presented with obstructive jaundice and was diagnosed with choledocholithiasis successfully managed by open cholecystectomy and choledochoduodenostomy. In the following years, she developed recurrent attacks of fever, chills, jaundice, and right upper quadrant pain and her weight loss was not satisfactory. Imaging of the liver showed multiple cholangitic abscesses. Reflux at the choledochoduodenostomy site was suggestive of sump syndrome as a cause of her recurrent cholangitis and a definitive surgical treatment was indicated. Intraoperative findings confirmed sump at the choledochoduodenostomy site and also revealed the presence of a large superficial accessory duct arising from segment four of the liver with separate drainage into the duodenum distal to the choledochoduodenostomy site. A formal hepaticojejunostomy was done after ductoplasty. The Roux limb was created by transecting the jejunum 40cm distal to the foot anastomosis of the RYGB. The gastric limb was lengthened as part of this procedure which afforded the patient the additional benefit of weight loss.

CONCLUSION

Choledochoduodenostomy should be avoided in patients with RYGB due to the risk of sump syndrome which requires conversion to a formal hepaticojejunostomy.

Laparoscopic choledochoduodenostomy as an alternate treatment for common bile duct stones after Roux-en-Y gastric bypass

BACKGROUND

After Roux-en-Y gastric bypass (RYGB), the new gastrointestinal configuration does not permit easy endoscopic access to the biliary system in the standard fashion. Common bile duct (CBD) stones have proved to be a challenge for both the surgeon and the endoscopist in this setting. We shall review our experience with laparoscopic choledochoduodenostomy as a treatment of choledocholithiasis after gastric bypass.

METHODS

Between January 2000 and July 2012, 3115 patients underwent RYGB at our institution. Patients were included if they had postoperative CBD stones regardless of previous cholecystectomy. Treatment modality was laparoscopic choledochoduodenostomy. A retrospective chart review of a prospectively collected data was completed, noting the outcomes and complications of the procedure.

RESULTS

Of 3115 patients, 11 patients were included in this study. There were 8 female and 3 male patients with a mean age of 50.5 ± 10.9 (range, 34-66) years. The average time between primary RYGB and choledochoduodenostomy was 39.7 ± 33.8 (range 8-113) months. The average body mass index at primary surgery was 48.2 ± 8.1 (range 38.4-67.4) kg/m(2) and at choledochoduodenostomy was 29.5 ± 6.8 (range 22.7-46.9) kg/m(2). One patient had bile leak that was managed with drain. All patients had resolution of symptoms at a mean follow-up of 24.8 ± 26.9 (range 2-84) months.

CONCLUSION

This small case series suggests that, in experienced hands, laparoscopic choledochoduodenostomy is an option for safe and effective treatment of choledocholithiasis after gastric bypass.

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.

Long-term results of choledochoduodenostomy in benign biliary obstruction

AIM: To determine the long-term results of choledochodudenostomy in patients with benign billiary obstruction.

METHODS: This prospective study was conducted at Sheri Kashmir Institute of Medical Sciences Srinagar Kashmir, India over a period of 10 years from January 1997 to December 2007. The total number of patients who underwent choledochoduodenostomy during this period was 270. On the basis of etiology of biliary tract obstruction, patients were divided into a calculus group, an oriental cholangiohepatitis group, a benign biliary stricture group and others. Patients were followed for a variable period of 13 mo to 15 years.

RESULTS: Choledochoduodenostomy (CDD) with duo-denotomy was performend in four patients. CDD with removal of T- tube, CDD with left hepatic lobectomy and CDD with removal of intra biliary ruptured hydatid was performed in three patients each. In the remaining patients only CDD was performed. Immediate post operative complications were seen in 63 (23%) patients, while long-term complications were seen in 28 (11%) patients, which were statistically significant. Three patients died during hospitalization while four patients died in the late post-operative period.

CONCLUSION: Our conclusion is that CDD is safe and produces good long term results when a permanent biliary drainage procedure is required.

Choledochoduodenostomy: is it really so bad?

BACKGROUND

Choledochoduodenostomy (CDD) has been shunned by some surgeons for the management of the benign distal common bile duct stricture due to the potential complication of "sump syndrome." The feared sump syndrome is theorized to occur from bile stasis and reflux of duodenal contents into the terminal common bile duct with bacterial overgrowth, resulting in cholangitis or hepatic abscess. The true incidence and resultant morbidity of sump syndrome, however, are not well defined.

METHODS

With the approval of the Institutional Review Board, a retrospective chart review of all patients undergoing choledochoduodenostomy for benign disease at a single institution between 1994 and 2008 was undertaken. Data were collected with particular attention to operative indications, perioperative course, and long-term results. Long-term outcomes were assessed through clinical reports at outpatient follow-up, emergency room visits, and hospital readmissions.

RESULTS

Seventy-nine patients underwent side-to-side CDD for benign diseases over the 15-year period [51 (65%) men; mean age, 52 years (standard deviation (SD), 12)]. Indications for surgery included chronic pancreatitis (80%), choledocholithiasis (11%), and cholangitis (4%). Patients presented with abdominal pain (80%), nausea/vomiting (30%), and jaundice 13%. Sixty-one patients (77%) underwent an additional procedure at the time of their CDD, including lateral pancreaticojejunostomy (26%). There was no perioperative mortality. Postoperative complications occurred in 15 (19%) patients, including intraabdominal abscess (26%), wound infection (20%), and biliary leakage (13%). The mean hospital stay was 9.7 days (SD, 6.9). The mean follow-up was 6.2 years (SD, 4.2). There was no occurrence of cholangitis. Two patients (2.5%) developed hepatic abscess, which was managed by antibiotics and image-guided percutaneous drainage.

CONCLUSIONS

CDD is a safe and effective method of decompressing the distal common bile duct in benign pancreatobiliary disease. Long-term results are acceptable, with sump syndrome being a rare occurrence.

ERCP experience in patients with choledochoduodenostomy: diagnostic findings and therapeutic management

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP), besides reducing the need for surgery in a wide spectrum of biliary disease, is increasingly be used for the treatment of biliary complications of surgery. In this paper, we review our experience with postoperative ERCPs required after biliary surgery with a special focus on side-to-side choledochoduodenostomy (CD).

METHODS

The records of 70 patients with a history of CD who underwent ERCP from May 2000 to February 2006 were analyzed.

RESULTS

There were 70 patients, 32 (45.7%) women and 38 (35.6%) men, with a mean age of 56 (range, 21-80) years. Indications for ERCP were cholangitis in 46 (65.7%), abnormal liver function tests with abdominal pain and abnormal USG in 22 (31.4%), and abnormal liver function tests and abnormal USG in 2 (2.9%). Overall 133 ERCP were performed. Anastomotic stenosis was found in 14 (20%), benign biliary stricture above the anastomosis in 13 (18.6%), sump syndrome in 11 (15.7%), common bile duct stone in 8 (11.4%), malignancy in 4 (5.7%), hepatolithiasis in 1 (1.4%), and secondary sclerosing cholangitis in 1 (1.4%). ERCP was normal in 18 (25.8%). Patients were managed by stone extraction in 8 (11%), stent insertion in 22 (36%), balloon dilatation in 15 (21%), nasobiliary drainage in 11 (16%), and bougie dilatation in 2 (3%) patients.

CONCLUSIONS

We have reported one of the largest groups of patients with CD in the literature and showed that ERCP is a very important diagnostic and therapeutic tool for the management of biliary problems after CD.

Choledochoduodenostomy: reappraisal in the laparoscopic era

BACKGROUND

With the advent of interventional endoscopic procedures and with growing experience of laparoscopic surgery, the indications for open biliary procedures have become limited. This prospective study reviews the indications of open choledochoduodenostomy for benign biliary diseases and presents the short-term and long-term outcomes of this procedure in the present minimally invasive surgical era.

METHODS

Side-to-side choledochoduodenostomy was carried out for various benign obstructive pathologies of the biliary tract. The various parameters recorded were the demographic data, indications for surgery, early and late complications and the long-term outcome of the procedure.

RESULTS

Results of choledochoduodenostomy on 54 consecutive patients over a 9-year period are presented. The mean age was 49.7 years with a male to female ratio of 1:2.6. Thirty (55.5%) patients presented with obstructive jaundice and 42.6% had cholangitis. Overall hospital morbidity was 13% with zero mortality. After a mean follow up of 7.8 years, 96.3% patients had 'good' or 'fair' and 3.7% experienced 'poor' results. No recurrent disease or biliary malignancy was observed.

CONCLUSION

Open biliary drainage procedures may still be indicated in select patients where the facility or expertise for minimally invasive biliary procedures is not available. Choledochoduodenostomy remains an effective biliary drainage procedure with acceptable morbidity and mortality, especially in the high-risk and elderly population. The procedure should be regarded as an essential in the general surgical knowledge and training.

Long-term Survival of Dogs After Cholecystoenterostomy: A Retrospective Study of 15 Cases (1981–2005)

Fifteen dogs with extrahepatic biliary tract disease underwent cholecystoenterostomy. Long-term survivors were significantly older at presentation (mean age 140.5 months) than dogs that survived the first 20 days after surgery but subsequently died from causes related to the surgery or hepatobiliary disease (mean age 72 months). Dogs that died during the first 20 days had significantly more complications in the hospital than dogs that survived this period. The type of underlying hepatobiliary disease (i.e., benign or malignant) was not associated with either short-term outcome or long-term survival. Eight dogs died from causes related to surgery or hepatobiliary disease. Long-term complications included hepatic abscesses, acquired portosystemic shunts, pancreatitis, and vomiting.

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.

Choledochoduodenostom a reappraisal of its indications based on a study of 64 patients

The indications for choledochoduodenostomy in 64 patients are discussed and compared with those in other series from the literature. The essential indications are the presence of a dilated common bileduct with calculous disease or associated pathology at the lower end of the common bile-duct, particularly in the elderly and poor-risk patients. It is a safe procedure with few complications provided that a stoma of 2.5 cm. or more is made.

Coledocoduodenostomia laparoscópica

OBJETIVO: Estudar, a curto e médio prazos, o resultado e complicações da coledocoduodenostomia (CDD) realizada por via laparoscópica. MÉTODO: Estudo prospectivo de 20 pacientes com indicação de coledocoduodenostomia vídeo-laparoscópica operados na DIGEST no período de 1991 a 2003. RESULTADOS: Dos 20 pacientes com indicação para CDD laparoscópica, quatro tinham coledocolitíase associada à litíase vesicular, oito litíase residual de colédoco, dois estenose benigna e seis tumor periampolar. Houve duas conversões para ressecção de colédoco. Dentre as 18 CDD, todos tinham via biliar acima de 1,5 cm de diâmetro. Foi observado vazamento biliar pelo dreno cavitário em quatro casos (duração máxima de quatro dias) resolvidos espontaneamente, uma infecção de ferida e uma morte súbita no 2º. dia de pós-operatório. Os seis portadores de tumor periampolar tiveram sobrevida média de 7,2 meses evoluindo sem prurido ou icterícia até o óbito. CONCLUSÕES: Além da demonstração da viabilidade do método laparoscópico na realização da CDD, evidenciou-se que o posicionamento de trocarte adicional facilita a confecção da anastomose. Acredita-se que, a ocorrência de vazamento da anastomose possa diminuir com a experiência e que a CDD seja alternativa interessante na paliação dos tumores periampolares.

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.

Endoscopic management of sump syndrome after choledochoduodenostomy: retrospective analysis of 30 cases

BACKGROUND

Side-to-side choledochoduodenostomy is a frequently performed operation. Postoperative biliary "sump syndrome" is infrequent, a complication for which endoscopic sphincterotomy is regarded as the treatment of choice.

METHODS

We retrospectively analyzed 30 cases of sump syndrome and describe the symptoms, the delay before the appearance of symptoms, laboratory abnormalities, the nature of the biliary obstruction, and the outcome of endoscopic sphincterotomy including its efficiency and complications.

RESULTS

The median clinical latency was 5 years (range 1 month to 28 years), the median delay between surgery and diagnosis was 6 years (range 1 month to 28 years). Fourteen patients had abdominal pain with fever, 5 had isolated abdominal pain, 4 had post-prandial pain, 4 had hepatic abscesses, and 3 had acute pancreatitis. Liver function tests were abnormal in 79%. During endoscopic retrograde cholangiopancreatography, food debris was identified in 18 patients in the biliary sump, biliary calculi in 10 patients, and a mixture of food and calculi in 2 patients. All patients underwent endoscopic sphincterotomy without complication. Recurrence during a median follow-up of 36 months (range 3 months to 11 years) was not observed.

CONCLUSIONS

Sump syndrome most often becomes symptomatic only after a long delay. Abdominal pain with fever was the most frequent symptom. Liver function tests were abnormal in the majority of patients. Food debris was the most frequent cause. Endoscopic sphincterotomy appeared to be a safe, reliable treatment.

Laparoscopic Choledochoduodenostomy

Laparoscopic cholecystectomy has become the gold standard for treatment of patients with symptomatic cholelithiasis. Management of common bile duct stones in the era of laparoscopy is an area of controversy. Although perioperative endoscopic retrograde cholangiography remains as a widely used procedure, experience is accumulating on the exploration of the common bile duct with the laparoscope. A biliary drainage procedure is indicated in selected patients with choledocholithiasis. Initially described by Reidel in 1892, side-to-side choledochoduodenostomy has become a popular biliary-enteric anastomosis technique in the last century. We describe two patients with recurrent choledocholithiasis and biliary obstruction due to benign biliary strictures. Both patients underwent laparoscopic common bile duct exploration and stone extraction. A side-to-side choledochoduodenostomy is then performed laparoscopically as a drainage procedure. Laparoscopic choledochoduodenostomy resulted in resolution of jaundice and relief of biliary obstruction. Laparoscopic choledochoduodenostomy can be an acceptable alternative to the open choledochoduodenostomy. In addition to a tension-free anastomosis and an adequate-sized stoma, intracorporeal suturing and knot-tying skills are also essential to the success of this procedure.

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.

Long-term observations on morphological changes of choledochal epithelium after choledochoenterostomy in rats

Morphological changes of the common bile duct were observed macroscopically and microscopically 20 months after choledochojejunostomy and choledochocolonostomy in rats. The common bile ducts were remarkably dilated in all rats of both experimental models. Choledochal stones consisting of fatty acid calcium and calcium bilirubinate were seen in two of six rats with choledochojejunostomy and two of five rats with choledochocolonostomy. The main pathological change observed in both the groups was remarkable hyperplasia of the choledochal epithelium. Only one rat with choledochojejunostomy revealed normal epithelium with choledochal stone formation. Intestinal metaplasia was seen in two rats with choledochojejunostomy and all with choledochocolonostomy. Squamous pseudostratification of the epithelium indicating atypism was observed in two rats with choledochojejunostomy. Sialomucin producing cells and sulfomucin producing cells were seen in the hyperplastic portion of the epithelium. No malignant alteration of the epithelium was detected. These findings indicate that long-lasting exposure to digestive enzymes and bacteria causes epithelial hyperplasia and further exposure to digestive enzymes plays a major role in appearance of the epithelial atypism. Carcinogenesis of the choledochal epithelium under such an environment will need much more time to be established.

Choledochoduodenostomy. Analysis of 71 cases followed for 5 to 15 years

To investigate the long-term effectiveness of choledochoduodenostomy (CDD), the experience with 71 patients followed for 5 or more years after CDD was analyzed retrospectively. From 1968 to 1984, 134 patients underwent CDD. Eight patients (6%) died in the immediate postoperative period, 55 left the hospital, 8 of them were lost to follow-up, and 47 were followed but died before 5 years elapsed after CDD. The remaining 71 patients form the data base for this analysis: 38 were followed for more than 5 years, 25 were followed for more than 10 years, and 8 were followed for more than 15 years (mean 12.1 years +/- 1.3 SEM). Choledocholithiasis, chronic pancreatitis, and postoperative stricture were the indications for CDD. Cholangitis was observed in only three patients. The diameter of the common bile duct (CBD) was large in most patients (mean 18 mm +/- 0.9 SEM). These results infer that CDD is effective to treat non-neoplastic obstructing lesions of the distal CBD on a long-term basis and that the presence of a dilated CBD (more than 16 mm) that allows the construction of a CDD more than 14 mm is essential to obtain good results.

Palliative operations for pancreatic carcinoma

Controversies in palliation of pancreatic carcinoma include the best biliary bypass, the best gastric by-pass, and how routinely gastric bypass should be used. We reviewed the records of 142 patients who underwent palliative operations for pancreatic carcinoma at the Cleveland Clinic over a 5-year period. Direct choledochal-enteric anastomosis proved superior to cholecystojejunostomy because of the high incidence of postoperative biliary sepsis and obstruction with the latter. The lowest incidence of these complications was achieved with choledochoduodenostomy. Loop gastrojejunostomy and Roux-Y gastrojejunostomy resulted in similar complication rates and postoperative stays, but, because loop reconstruction was simpler, it was deemed superior. Blood loss, operative time, and hospital stay were similar in patients with loop gastrojejunostomy and patients with no gastric bypass. This finding, coupled with a 10% incidence of subsequent gastric outlet obstruction in those without gastric bypass, indicates that gastric bypass should be liberally applied in the palliation of pancreatic carcinoma.

Treatment of postcholedochoduodenostomy symptoms

Upper abdominal symptoms after side-to-side choledochoduodenostomy (CDDY) may be attributed to stagnant bile, food and calculi pooling in the distal bile duct 'sump' with resultant biliary or pancreatic duct obstruction and sepsis. Endoscopic sphincterotomy (ES) provides a means of draining this sump. The aim of this study was to assess outcome following endoscopic retrograde choledochopancreatography (ERCP) and ES in patients with post-CDDY symptoms. Eight such patients (M: F = 1:7) underwent ERCP between September 1981 and March 1987. Their median age was 60 years (range: 37-72 years) and the median period since CDDY was 11 years (range: 1-28 years). The median follow-up after ERCP was 18 months (range: 14-94 months). Presenting symptoms comprised postprandial (one) or intermittent (seven) abdominal pain, cholangitis (three), pancreatitis (one) and jaundice (one). ERCP revealed bile duct abnormalities in four, consisting of filling defects alone (two), anastomotic narrowing with filling defects (one) and sclerosing cholangitis. ES was performed in seven, of whom three (all with filling defects at ERCP) remain asymptomatic and three are significantly improved. One had recurrent pancreatitis for which a sphincteroplasty and pancreatic duct septectomy was performed. ES was not performed in one because of technical difficulties (there being no subsequent improvement). It is concluded that, in patients with post-CDDY biliary symptoms, endoscopic sphincterotomy relieves the symptoms by either producing drainage of the sump at the distal bile duct, or dividing a dysfunctioning sphincter of Oddi.

Retained and recurrent bile duct stones: operative management

Retained and recurrent bile duct stones can now be treated by a variety of nonoperative means. These include retrieval through instrumentation of the T-tube tract, chemical dissolution, endoscopic papillotomy, or lithotripsy. Operative management, however, is an alternative means of therapy that carries negligible mortality, minimal morbidity, and a high success rate. If operative management is used, for most patients common duct exploration, stone retrieval, and T-tube insertion will suffice. However, if the patient has risk factors that suggest the possibility of further stone disease, a drainage procedure such as a sphincteroplasty or choledochoduodenostomy should be added. Nonoperative management is now the first choice for managing retained or recurrent bile duct stones. If these methods fail or cannot be utilized, operative management can be used with a similar low mortality, low morbidity, and high success rate.

Surgical palliation for pancreatic cancer

The effectiveness of surgical palliation for pancreatic cancer has been reviewed. Jaundice should be relieved early as this eliminates distressing pruritus, improves the quality of life, and avoids the sequelae of prolonged extrahepatic obstruction. The procedure may prolong survival, but this has not been proved. Biliary obstruction is managed best by a simple loop cholecystojejunostomy. If the gallbladder is unavailable, a choledochojejunostomy is equally effective. Nonsurgical techniques such as percutaneous or endoscopically placed biliary stents may be appropriate in patients who are not candidates for surgery. A gastrojejunostomy should be done in all patients who have gastroduodenal obstruction by tumor. Most patients who undergo surgical biliary bypass also should have a gastrojejunostomy, even if gastroduodenal obstruction has not yet developed. Otherwise, more than 20 per cent of patients may need a second operation if gastroduodenal obstruction develops later. Pain, a problem in more than half of patients, is best relieved by an intraoperative celiac ganglion block with 50 per cent ethanol. Laparotomy is desirable in most of these patients with pancreatic cancer, because it provides tissue for diagnosis, allows a definite assessment of resectability, and produces effective palliation.

Hepatic abscesses as a complication of the sump syndrome: combined surgical and endoscopic therapy. Case report and review of the literature

The "sump syndrome" is an unusual complication of side-to-side choledochoduodenostomy in which the portion of the common bile duct distal to the anastamosis acts as a sump and may collect bile, stones, food, and other debris. Partial or complete obstruction of the stoma and resultant bacterial proliferation may result and lead to recurrent cholangitis or pancreatitis. A single hepatic abscess as a complication of the sump syndrome has been reported only once. We have recently seen a patient presenting with multiple hepatic abscesses as a complication of the sump syndrome. This is the first report of endoscopic treatment of this syndrome associated with a hepatic abscess. The literature on the endoscopic approach to this problem will be reviewed.

Is endoscopic sphincterotomy for disabling biliary-type pain after cholecystectomy effective?

Between 1979 and 1983, 50 patients were treated by endoscopic sphincterotomy for disabling biliary-type pain after cholecystectomy. Forty-six patients were seen at regular intervals for at least 12 months after the procedure and of these, pain resolved in six (13%), decreased in severity and/or frequency in 22 (48%), and continued unchanged in 18 (39%). Patients with bile duct dilation on a retrograde cholangiogram had a similar outcome to those with a bile duct of normal caliber. Twenty-five patients had a morphine-neostigmine test and endoscopic manometry of the sphincter of Oddi prior to the procedure, and the outcome appeared to be independent of results from these investigations. Subgroups of patients who benefit from sphincterotomy will be determined only by prospective studies in which criteria for inclusion are carefully defined so as to avoid heterogeneity within study groups.

Sump syndrome following choledochoduodenostomy and its endoscopic treatment

The clinical features of eight patients with 'sump syndrome' following side-to-side choledochoduodenostomy are reported. The syndrome is defined and its aetiology discussed with special reference to debris in the common bile duct, bacterial overgrowth and the clinical picture of acute cholangitis, which does not appear to be necessary for the diagnosis to be made. Five patients were successfully treated by endoscopic sphincterotomy and a sixth by endoscopic removal of food debris from the sump. The other two patients had further surgery.

Effects of sphincteroplasty and endoscopic sphincterotomy on the bacteriologic characteristics of the common bile duct

Forty-five patients with sphincter of Oddi stenosis had specimens of common bile duct cultured during ERCP before either sphincteroplasty or endoscopic sphincterotomy. All had sterile bile before sphincter ablation. Bile was recultured 6 to 36 months later during endoscopy at which time 70 percent of the sphincterotomy and 76 percent of the sphincteroplasty patients had bile colonized principally by enteric organisms. Growth was heavy to moderate in most of the patients and contained few nasopharyngeal organisms. Despite bactobilia, no patient had symptomatic cholangitis, presumably due to excellent drainage of bile. The most likely source of the bactobilia is from direct extension of duodenal organisms into the common bile duct.

Cancer of the head of the pancreas: an institutional review with emphasis on surgical therapy

A clinical review of 461 patients with adenocarcinoma of the pancreas is presented. Seventy-nine percent of the group underwent laparotomy, including laparotomy and biopsy (n = 134), bypass procedures (n = 207), and radical resection (n = 24). The operative mortality following cholecystoenterostomy or choledochoenterostomy was similar but survival was greater following the latter procedure. Thirteen percent having biliary bypass alone needed later gastric bypass. Radical resection is recommended under favorable conditions (6.6% in this series). The five-year survival in this group was 12.5% and the operative mortality was 9% over the last 10 years.

Surgical techniques for the liver and biliary tract

Surgical treatment of hepatic and biliary disease requires a thorough knowledge of pertinent anatomy and pathophysiology. Proper attention to both preoperative and postoperative care is important. This article describes many of the more common surgical manipulations of the liver and biliary tract, as well as pre- and postoperative considerations.

Transduodenal sphincteroplasty: an analysis of 118 consecutive cases

The results of 118 consecutive common bile duct explorations via transduodenal sphincteroplasty are presented and analysed. The operations were performed for suspected choledocholithiasis by one surgeon over a 10-year period. Choledocholithiasis was proved in 22 per cent of the cholecystectomies carried out during this period and tended to present significantly earlier in females, 14.5 per cent presenting before 35 years of age. One hundred and four survivors were traced and 93.5 per cent had achieved a good result at a mean 5-year follow-up.