Is choledochoduodenostomy in the treatment of stones in the common bile duct an obsolete technique?

Abstract

The complex pathogenesis of bile duct stones, the anatomical properties of the biliary tree, the patient's age, associated diseases, as well as the technical devices available, may explain the great variety of procedures and preferences of different groups in the treatment of choledocholithiasis. Since no technique is infallible or free of complications, it seems unfair to argue that procedures whose efficacy has been proven by many authors are obsolete. This is the case of choledochoduodenostomy (CDS) in the treatment of common bile duct (CBD) stones. The complications associated with CDS, (ascending cholangitis, and “sump” syndrome) have been overemphasized and have led CDS to be rejected by many surgeons. Our experience with this technique is good and concurs with that of Madden and others.Data on 125 patients with CBD stones treated with CDS between 1968 and 1982 are analyzed. Sixty‐eight of them were female and the mean age was 61.4 years; 73.6% were more than 50 years old. There were frequent accompanying diseases, especially cardiovascular ones. More than half of the patients had a previous operation on the biliary tree. The duct diameter was always greater than 20 mm and it was frequently associated with stenosis of the distal choledochus. Floercken's technique of CDS was the most frequently used, after Kocher's maneuver had been performed. There was no intraoperative mortality. Postoperative mortality was 3.2% and is analyzed in detail. The incidence of postoperative complications was 42.4%. Most were septic complications or those ascribed to accompanying diseases. Late operative cholangitis was present in 1.6% of patients, comparable with reports of other authors. We encourage the use of CDS in the treatment of CBD stones provided that: (a) careful attention is paid to its clinical indications, considering that the patient may benefit from alternative techniques, for example, duodenoscopic papillotomy; and (b) choledochal dilatation is greater than 20 mm in diameter and the choledochal and duodenal walls are normal. We specifically recommend CDS as the primary operation for patients with “choledochal funnel syndrome.” The operation is simple, restores normal digestive function, and almost always resolves the problems of CBD stones in high‐risk patients.

Choledochoduodenostomy – A Follow-Up Study of 61 Cases

“…The total number of serious complications is compa rable to previous reports [5,9], though some report a lower frequency [4,6,17,18]. The number of complica tions is related to operations on high-risk patients [15,16,19], and 6 of the 7 deaths did occur in risk patients.…”

“…It has been stressed repeatedly that a dilated bile duct is a prerequisite for this operation [6,9,10,18]. In this study, 15 patients had a common bile duct of normal diameter.…”

“…Since endoscopic papillotomy is still associated with a certain rate of retained stones [1][2][3][4], choledochoduode nostomy remains an accepted surgical procedure for cal culi of the hepatic and common bile ducts [4][5][6][7], It is a procedure that has to be considered whenever the sur geon meets unexpected problems during a cholecystecto my, as it is superior to T-tube drainage with subsequent extraction of retained stones [8] and to transduodenal sphincterotomy [9]. Its value has been stressed in the elderly patient [10].…”

Risk factors and management of primary choledocholithiasis: a systematic review

“…CDS was first employed by Sprengel to deal with choledocholithiasis in 1891 57 . It was ever a definitive procedure for PC in the 1970s 58 .…”

Choledochoduodenostomy for Common Bile Duct Stones

“…The size of the CBD is an important factor. This criterion is variable, as some recommend a diameter of Ն 2 cm and others one of Ͼ 1.2 cm [5,6,8]. Thus the stoma must be wide enough to ensure good biliary drainage and prevent stenosis, a major factor in the production of cholangitis and recurrent lithiasis.…”