Side-to-side choledochoduodenostomy in the management of choledocholithiasis and associated disease

Almeida, António Mendes de; Cruz, António Ginestal; Aldeia, Fernando

doi:10.1016/0002-9610(84)90101-6

Cited by 42 publications

(27 citation statements)

References 20 publications

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“…Reported complications of sump syndrome may include cholangitis, pancreatitis, hepatic abscesses, and secondary biliary cirrhosis, and likely correlate with the extent and duration of biliary stasis and subsequent obstruction. Occasionally, sump stagnation may result in bile salt deconjugation, leading to bacterial proliferation, malabsorption, and steatorrhea [10,12,13].…”

Section: Discussionmentioning

confidence: 99%

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Sump Syndrome as a Complication of Choledochoduodenostomy

et al. 2011

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Case Presentation and EvolutionA 71-year-old man initially underwent open cholecystectomy for biliary colic in 1990. Since then, he had been well until new symptoms began in 2009, when he presented to a community hospital reporting intermittent epigastric pain; ultrasound and computed tomography (CT) scans revealed choledocholithiasis.Because an endoscopic retrograde cholangiopancreatography (ERCP) and stone extraction at that hospital were unsuccessful, the patient underwent exploratory laparotomy with common bile duct (CBD) exploration, during which a CBD stone was removed and a side-to-side choledochoduodenostomy (CDD) was performed.Several months following temporary postoperative relief of his symptoms, the patient developed recurrent episodic right upper quadrant and epigastric pain, but without associated jaundice or fever. He was referred to Stanford University Medical Center, where he was seen by a gastroenterologist for evaluation and further management.His past medical history included atrial fibrillation, hyperlipidemia, diabetes mellitus type II, and vestibular neuritis. Drug history included metoprolol, atorvastatin, metformin, dabigatran, dronedarone, and diltiazem. The patient had no known drug allergies. Socially, the patient did not smoke and enjoyed only occasional alcohol. There was no family history of biliary tract disease.On examination, the patient appeared well and comfortable, was slightly underweight, and had a soft and nontender abdomen. The subcostal incision from his original surgery was visible but appeared well healed. Laboratory findings, including liver function tests, were normal (WBC 7.9, Hb 13.4, Hct 39.4, Plts 257, Na 139, K 3.9, Cl 104, CO2 23, BUN 12, Cr 0.9, PT 15.4, INR 1.3, PTT 48.5, T Bili 0.7, ALT 39, AST 16, Alk P 143, Glu 113, Ca 9.2). An echocardiogram revealed mild mitral, aortic, and tricuspid valve regurgitation, with an ejection fraction of 54%. Magnetic resonance cholangiopancreatography (MRCP) revealed a grossly dilated and tortuous CBD, as well as dilated common hepatic and intrahepatic ducts (Fig. 1a). A fluid-debris level was also seen in the CBD (Fig. 1b).Endoscopy revealed a patent side-to-side CDD anastomosis that could be entered with the gastroscope (Fig. 2). Moderate amounts of vegetable debris were seen in the CBD, and were removed using a rat-toothed forceps (Fig. 3). Using a duodenoscope, the CBD was also cannulated through the ampullary orifice and contrast injection showed an 18-mm-wide CBD with contrast extravasation through the stoma. Filling defects revealed further debris in the distal CBD, which were cleared using a balloon catheter through the CDD.Following ERCP, the patient was immediately relieved of his symptoms. However, within a few days, the symptoms recurred, and, again, included epigastric pain without jaundice or fever. Multiple further ERCPs were necessary, each revealing similar findings of vegetable debris within the CBD. Despite clearing the CBD during each procedure, the debris re-accumulated and symptoms always recurred.

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Section: Discussionmentioning

confidence: 99%

“…Studies report a low sump syndrome rate of 2.5% [3], ranging from 0 to 9.6% in the largest series [12][13][14]. Although sump syndrome does not require cholangitis or hepatic abscess formation for diagnosis, some series have relied on these complications for diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Sump Syndrome as a Complication of Choledochoduodenostomy

et al. 2011

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“…In studies carried out on patients with surgically fashioned choledochoduodenal fistulae, the long-term complication of the sump syndrome has been noted [8,9,11]. In this syndrome, the duodenobiliary reflux results in accumulation of debris and recurrent stones with or without bacterial proliferation in the blind sac.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic Choledochoduodenostomy (ECDT): A Practical Approach to Management of Impacted Papillary Gallstones and Ampullary Tumors

1992

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We report five cases of impacted papillary stones and two cases of ampullary carcinoma treated by endoscopic choledochoduodenostomy (ECDT) at Riyadh Armed Forces Hospital (RAFH).The procedure was carried out successfully in all five cases with impacted stones and in one of the two cases of ampullary carcinoma. No complications were noted. In the presence of the necessary endoscopic expertise and in cases of impossible cannulation of the papilla of Vater due to stone impaction or the presence of a papillary tumor, we recommend endoscopic choledochoduodenostomy (ECDT). This approach provides an access to the common bile duct thus allowing appropriate therapeutic procedures on the biliary system to be performed. Endoscopic removal of common bile duct (CBD) stones is an established, effective, and safe procedure, particularly in the very sick and elderly [1][2][3]. However, cannulating the papilla is not always successful and even in experienced hands, there is a failure rate of 10% to 15% [4]. This is particularly the case when gallstones are impacted in the para-papillary region or there are occluding tumors rendering cannulation of the papillary orifice impossible.Endoscopic choledochoduodenostomy (ECDT) was introduced as an alternative procedure for these sort of cases [5,6] and the results have so far been encouraging. Its indications include both impacted papillary stones and palliative treatment for bile duct and ampullary cancer [7].Between 1984 and 1989, we treated seven patients; five with impacted papillary stones and two with ampullary carcinoma using ECDT at the Gastroenterology Unit in Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia. This report describes the procedure in these seven patients and discusses its indications, morbidity, and outcome. Patients and MethodsA total of seven cases (five men and two women) age group 32 to 86 years (mean 59 years) with cholestatic jaundice were managed by the ECDT at the Gastroenterology Unit, Riyadh Armed Forces Hospital.Prior to treatment, all patients were admitted to the hospital, clinically examined, and the relevant blood tests and abdominal ultrasound examinations were performed. At endoscopy, routine premedication with midazolam and buscopan were given intravenously. A side-view duodenoscope (Videoscope JFX IT or IT10) was used.At endoscopy, the papilla was swollen (Figure 1a). After several unsuccessful attempts to cannulate the papilla with a conventional sphincterotome, this was removed and replaced by a needle knife (5 mm wire papillotome). A small incision was then carefully made on the roof of the papilla 1 to 1.5 cm proximal to the assumed site of the orifice and below the transverse duodenal fold (Figures lb and 1c). The flow of bile indicated the establishment of a communication between the common bile duct and duodenal lumen (Figure 1d). The conventional sphincterotome was then reintroduced and contrast was injected to visualize the biliary tree, and the cut further extended superiorly

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“…Especially, in many hospitals of Europe and North America, this procedure is carried out as an adjunct to choledocholithotomy, and excellent results have been reported [6,8]. On the other hand, in Japan this operation has also been performed when sim ilar operative procedures were indicated [5,9], But, many people have been critical of this procedure because a blind pouch in the lower region of the choledochus is formed by this operation, and there is a possibility for the occurrence of ascending cholangitis, the sump syn drome, recurrent bile duct stones and pancreatitis [1,3,4], In fact, many investigators, including the authors, have experienced such complications caused by side-toside choledochoduodenostomy.…”

Section: Discussionmentioning

confidence: 99%

“…However, this adjunctive procedure has ana tomic faults such as the possible accompanying problem of a distal blind pouch and double flows of bile, and there is also the possibility of occurrence of the sump syndrome or ascending cholangitis [1][2][3][4]. Therefore, in most Japanese hospitals this procedure is carried out only as an adjunct to surgery on poor risk patients with choledocholithiasis, or as a by-pass operation in the treatment of patients who had unresectable tumors in the region of the pancreas head [5], In Europe and North America, this adjunctive procedure is still performed at present for the management of choledocholithiasis and associated diseases [3,[6][7][8], In addition, there are many reports revealing good results in the follow-up studies. Therefore, we are interested in the actual long-term results after this procedure.…”

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confidence: 99%

Operative Results of Side-To-Side Choledochoduodenostomy for Cholelithiasis

Kinami¹,

Takata²,

Yamamoto³

et al. 1987

Dig Surg

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To clarify the clinical problems of side-to-side choledochoduodenostomy as an adjunct to surgical management of cholelithiasis, the operative results of 82 patients treated in our clinic during the past 10 years were studied. There were 73 patients with extrahepatic bile duct stone and 9 with intra- and extrahepatic bile duct stone. Their mean age was 64 years, and the ratio of males to females was 1.2:1. The operative mortality rate was 4.9%; early complications developed in 7% of the patients. Of all patients who were discharged, 32% developed late complications, and 22%, including 3 patients with sump syndrome, revealed ascending cholangitis. During follow-up, 13 patients died, 6 of them of cholangitis. A relationship between the occurrence of cholangitis and the size of anastomosis was investigated, but there was no obvious connection between them. Six (7.3%) patients underwent reoperations caused by cholangitis, residual or recurrent stones and stenosis of anastomosis. Good to excellent long-term results were seen in 78% of all patients, while fair to poor results were observed in the rest. Especially, results in patients with intra- and extrahepatic bile duct stones were poor. These results suggest that it is necessary to carefully consider the indication of this procedure for patients with cholelithiasis.

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Side-to-side choledochoduodenostomy in the management of choledocholithiasis and associated disease

Cited by 42 publications

References 20 publications

Sump Syndrome as a Complication of Choledochoduodenostomy

Sump Syndrome as a Complication of Choledochoduodenostomy

Endoscopic Choledochoduodenostomy (ECDT): A Practical Approach to Management of Impacted Papillary Gallstones and Ampullary Tumors

Operative Results of Side-To-Side Choledochoduodenostomy for Cholelithiasis

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