Choledochoduodenostomy
3/5/15
COMPLICATION, 3/2/15
Faculty/Resident: Bittner/Kaplan/Uchiyama
Diagnosis: Choledocholithiasis
Procedures:
2/16/15: Open common bile duct exploration,
choledochoduodenostomy, lysis of adhesions, upper endoscopy
3/2/15: Incision and drainage of deep abdominal wound
infection
Other Involved Services: Interventional radiology, Internal
medicine
Complication: Wound infection
Outcome: Resolution of wound infection after I&D
BACKGROUND
H&P:
84 yr old female presented to General Surgery
ACC clinic on 1/13/2015 after hospitalization at
Community Memorial Hospital (12/29/2014)
with weakness, dizziness, itchiness & 18lb
weight loss over previous 2 months.
CMH labs: Elevated bilirubin, AST, ALT, ALP
BACKGROUND
PMHx: Atrial fibrillation, CVA, uncontrolled essential
hypertension, Raynaud’s phenomenon, hyperlipidemia
PSHx: Open roux-en-y gastric bypass (1980), open
cholecystectomy, total abdominal hysterectomy, laparoscopic
ovarian cystectomy, total knee replacement, breast reduction
Family Hx: Heart disease, HTN
Social Hx: Denied tobacco, drug or alcohol use.
Medications: Amlodipine, Carvedilol, B12. dicyclomine, Pepcid,
hydroxyzine, Losartan/HCTZ
BACKGROUND
PHYSICAL EXAM (from clinic visit 1/13/15):
Gen: Thin 84 yr old female, NAD
HEENT: Sclera non-icteric
Lungs: CTAB
Heart: RRR
Abdomen: Soft, non-tender/non-distended, old well healed
vertical midline incision & right subcostal Kocher incision, no
palpable masses or hernias
BACKGROUND
CT A/P (w/o IV contrast, CMH)
BACKGROUND
CT A/P (w/o IV contrast, CMH)
BACKGROUND
RUQ US (1/5/15, VCU)
BACKGROUND
RUQ US (1/5/15, VCU)
BACKGROUND
RUQ US (1/5/15, VCU)
BACKGROUND
MRCP (1/20/15, VCU)
BACKGROUND
MRCP (1/20/15, VCU)
BACKGROUND
IR (1/27/15, VCU) - PTC tube placement
BACKGROUND
Operative Course:
2/16/15: Exploratory laparotomy, lysis of adhesions, open
common bile duct exploration, choledochoduodenostomy,
upper endoscopy
Intraoperative bile cultures: VRE (E. faecalis)
Postop Course:
2/18/15: Epidural removed
2/20/15: Discharged to rehab facility
2/27/15: PTC tube studied & removed by IR
BACKGROUND
IR (2/27/15, VCU) - PTC removed
BACKGROUND
Operative Course:
2/16/15: Exploratory laparotomy, lysis of adhesions, open
common bile duct exploration, choledochoduodenostomy, upper
endoscopy
Intraoperative bile cultures: VRE (E. faecalis)
Postop Course:
2/18/15: Epidural removed
2/20/15: Discharged to rehab facility
2/27/15: PTC tube studied & removed by IR
3/1/15: Sent from rehab facility to ED with incisional drainage, leukocytosis
3/2/15: Incision and drainage of deep abdominal wound infection, cultures
positive for E. Faecium (VRE)
ASSESSMENT
Clavien-Dindo Classification
FISHBONE
PRE-OP
POST-OP
1. Bile duct obstruction/cholangitis
2. Bile duct instrumentation (PTC)
3. Recent weight loss/poor nutrition
1. ?Extended postoperative antibiotic coverage
2.
3.
OUTCOME
1.
Peri-operative antibiotic selection
1. Wound infection
2. Case length >2 hours
3.
INTRA/PERI-OP
PATIENT SPECIFIC FACTORS: Age, Patient comorbidities – HTN, HLD, Atrial Fibrillation
4 minutes
INDICATION FOR OPERATION
• Primary common duct stone formation as a late
complication after cholecystectomy with failed stone
extraction
DISCUSSION
1. Primary common bile duct stone formation after
cholecystectomy
2. Choledochoduodenostomy
PRIMARY CBD STONE FORMATION
AFTER CHOLECYSTECTOMY
• Primary CBD stone formation years after cholecystectomy
associated with bile stasis, cholangitis, foreign bodies
• Multiple publications from 1897-present cite suture material
as the nidus for stone formation
• Other foreign bodies attributed to stone formation mentioned
in literature: shrapnel, buck shot, wire fragments, vegetable
residue, fish bone, surgical clips
PRIMARY CBD STONE FORMATION
AFTER CHOLECYSTECTOMY
• Cameron et al (Annals of Surgery, 1977) published results of a
series of patients after cholecystectomy with primary CBD
stones who underwent CBDE from 1952-75
– Previous cholecystectomy ± CBD exploration with 2 year asymptomatic
period postoperatively without evidence of long cystic duct remnant
or strictures
– Morphologically soft, crushable, light brown stones/sludge in CBD
• Pathogenesis not completely clear
(Dilated ducts after cholecystectomy → Stasis → Stone Formation)
PRIMARY CBD STONE FORMATION
AFTER CHOLECYSTECTOMY
• GI literature quotes CBD stone clearance rate exceeds 90%
with ERCP/sphincteroplasty
• Recurrence of CBD stones in patients treated with ERCP not
uncommon
• Management of patients in which duct is unable to be cleared
or with recurrent primary choledocholithiasis
–
–
–
–
Repeat ERCP
Choledochoduodenostomy
Choledochojejunostomy
Transduodenal sphincteroplasty
CHOLEDOCHODUODENOSTOMY
• First published experience with CDD was by R.L Sanders &
presented at the 57th Southern Surgical Association, 1945
– 25 patients (15 survived >6 months with “good” results)
– Side-to-side anastomosis performed
– Descried important of dilated CBD to achieve optimal outcome
• Only 2 large case series were published in the subsequent 20
years by Schwartz (1959) & Madden (1965)
– General consensus that it is critical for CBD to measure at least 15mm in diameter for
success
Side-to-Side Technique
Mastery of Surgery, 6th Edition
End-to-Side Technique
Scientific American Surgery, 2014
CHOLEDOCHODUODENOSTOMY
• Advantages:
– No need for construction of roux limb or additional anastomosis (JJ)
– No potential for internal hernia compared with hepatojejunostomy
– Side-to-side choledochoduodenal anastomosis avoids the issue of a
residual unretrievable distal stone
– Requires less enterolysis/mobilization in patients with adhesive
disease & portal hypertension
– Facilitates subsequent endoscopic interventions
CHOLEDOCHODUODENOSTOMY
• Disadvantages
– Two feared complications: Cholangitis & sump/blind sac syndrome
(published incidence 0.5-9.6%)
• Pathogenesis of cholangitis related to reflux of pancreatic secretions and bacteria
(function of sphincter of Oddi)
• Chronic relapsing cholangitis possibly related to late development of
cholangiocarcinoma
– Not ideal for palliative management of malignant causes of bile duct
obstruction
Conclusions
• Foreign bodies & stasis are a nidus for primary CBD stone
formation after cholecystectomy
• ERCP/sphinterotomy is effective and ideal for sick/elderly
patients but papillary restenosis may occur
• If endoscopically inaccessible, PTC tube placement and stone
retrieval is an option
• Options for surgical management include CDD, HJS,
transduodenal sphincterotomy
• Major complications of CDD include cholangitis, sump
syndrome
Nonoperative dilatation, performed either endoscopically or
percutaneously, can be used successfully to manage which of the
following causes of bile duct stricture?
A. Oriental cholangiohepatitis.
B. Distal bile duct stricture due to chronic pancreatitisIncorrect.
C. Complete transection of the bile duct during laparoscopic
cholecystectomy (the so-called "classic" laparoscopic
cholecystectomy injury)
D. Postoperative bile duct stricture following
hepaticojejunostomy for reconstruction during a Whipple
procedure
Answer: D
• Nonoperative management of bile duct strictures is an option in many
cases of biliary strictures; however, this approach has technical limitations
because of the anatomic or clinical situation. In the so-called "laparoscopic
bile duct injury," complete bile duct transection and discontinuity of the
biliary tree eliminates the possibility of nonoperative management.
Percutaneous dilatation of biliary enteric anastomosis has been shown in
a number of series to have a success rate approaching that of surgical
reconstruction. Oriental cholangiohepatitis is an unusual infection of the
biliary tree frequently associated with infection by Clonorchis sinensis and
other parasites. Cholangiography shows numerous strictures of the
intrahepatic and extrahepatic biliary tree and bile ducts filled with sludge
and stones. Surgical management consisting of cholecystectomy and
improving biliary drainage by means of a Roux-en-Y
choledochojejunostomy or choledochoduodenostomy is necessary for
almost all patients. There has been limited experience with the role of
balloon dilatation of distal bile duct stricture secondary to chronic
pancreatitis with little long-term follow-up. The length of the stricture as
well as the chronic associated fibrosis caused by pancreatitis makes this
option less attractive.
Compared with endoscopic sphincterotomy, transduodenal sphincteroplasty
is associated with which of the following?
A. Decreased incidence of restenosis
B. Improved symptomatic relief
C. Shorter length of hospitalization
D. Ability to perform concomitant diagnostic evaluation
E. Increased incidence of pancreatitis
Answer: A
When properly performed, transduodenal sphincteroplasty
results in decreased incidence of restenosis when compared
with endoscopic treatments.
Which of the following statements is true concerning bile duct strictures
caused by chronic pancreatitis?
A. The course of untreated bile duct stricture caused by chronic pancreatitis is
usually benign and not progressive.
B. Most patients present with marked jaundice.
C. Serum bilirubin is the most sensitive laboratory finding in diagnosing bile
duct strictures caused by chronic pancreatitis.
D. Common bile duct strictures can be expected to develop in almost 50% of
patients with alcohol-induced chronic pancreatitis.
E. A suitable option for surgical management is choledochoduodenostomy.
Answer: E
•
Chronic pancreatitis is an uncommon cause of benign bile duct strictures (<10% of
cases). The clinical problem in chronic pancreatitis is a distal bile duct obstruction
resulting from inflammation and parenchymal fibrosis of the gland. These
strictures classically involve the entire intrapancreatic segment of the common bile
duct and are associated with dilatation of the entire proximal biliary tree. In most
cases the cause of chronic pancreatitis is alcoholism. Common bile duct strictures
have been reported to occur in 3% to 29% of patients with chronic alcoholic
pancreatitis. In a review of a number of clinical studies, the overall incidence of
common bile duct strictures in patients with chronic pancreatitis was 5.7%. The
clinical presentation of patients with common bile strictures secondary to chronic
pancreatitis is variable. Some patients have no symptoms, and the diagnosis of bile
duct stricture is suggested only by abnormal liver function test results. The serum
alkaline phosphatase appears to be the most sensitive laboratory finding and is
elevated in more than 80% of patients. Indications for surgical management of
common bile duct strictures caused by chronic pancreatitis are clear in patients
with significant pain, jaundice, or cholangitis. In general, biliary bypass, either as a
Roux-en-Y hepaticojejunostomy or a choledochoduodenostomy, is indicated in
patients who are asymptomatic with persistent elevation of serum alkaline
phosphatase because changes from obstructive biliary cirrhosis have been
observed in patients with long-standing, functionally significant biliary
obstruction caused by chronic pancreatitis.
A 70-year-old woman presents with fever, right upper quadrant abdominal
pain, jaundice, hypotension, and mental status changes. Labs demonstrate
leukocytosis, a direct of 3.5 mg/dL, and elevated transaminases in the
presence of a normal amylase and lipase assay. Abdominal ultrasonography
shows a common bile duct diameter of 1.5 cm. In addition to ICU admission,
fluid resuscitation, and the initiation of antibiotics, the most appropriate
intervention for this patient is:
A. Endoscopic retrograde cholangiopancreatography (ERCP) with stone
extraction and sphincterotomy
B. Percutaneous transhepatic cholangiography (PTC) and drain placement
C. Open common bile duct exploration with extraction of stones
D. Choledochoenterostomy
E. Biliary t-tube placement
Answer: A
This patient clinically has “Reynolds’ pentad” and is in septic shock from
cholangitis. In addition to resuscitation and initiation of antibiotics, source
control is absolutely necessary. The preferred management strategy with
the least morbidity would be ERCP with stone extraction and
sphincterotomy. Open common bile duct exploration,
choledochoenterostomy, and biliary t-tube placement require laparotomy
which would impart a higher morbidity upon this patient, but may be
necessary if gastroenterology is unable to perform an ERCP for this
patient. PTC drainage is an alternative to ERCP but does not remove the
obstructing stone.
A 63-year-old woman has severe jaundice and back pain. She has been losing
weight for three months. Workup reveals obstructive jaundice secondary to a
distal common bile duct tumor. Among the following, the preoperative
laboratory test most likely to be abnormal is:
A. Prothrombin time (PT)
B. Serum potassium
C. Serum bicarbonate
D. Partial thromboplastin time (PTT)
E. Carcinoembryonic antigen (CEA)
Answer: A
Among the laboratory tests listed, prolongation of the prothrombin time
(PT) is most characteristic of patients with severe obstructive jaundice of
long standing. Biliary obstruction deprives the duodenum and small intestine
of the bile necessary for the formation of micelles. Micelles have a hydrophilic
external environment and a hydrophobic core and are essential for aiding fat
digestion (by increasing the available surface area for enzymatic activity), as
well as for absorption of the fat soluble vitamins A, D, E, and K. Vitamin K is a
necessary cofactor for hepatic synthesis of prothrombin, and factors VII, IX,
and X. Continuing vitamin K deficiency will eventually be manifested as an
elevation in the PT.
Which of the following statements regarding elective repair of a bile duct
stricture is true?
A. End-to-end bile duct anastomosis is an appropriate option.
B. Stenting for approximately 1 year is necessary for an anastomosis
performed at the distal common bile duct.
C. Preoperatively placed biliary catheters facilitate dissection and
identification of the injury and facilitate reconstruction.
D. A transanastomotic stent is necessary for a successful result.
Answer: C
Several principles are associated with successful repair of a biliary injury or stricture:
(a) exposure of healthy proximal bile ducts that provide drainage to the entire liver; (b)
preparation of a suitable segment of intestine that can be brought to the area of the
stricture without tension, most frequently a Roux-en-Y jejunal limb; and (c) a creation
of a direct biliary-enteric mucosal-to-mucosal anastomosis. The choice of procedure is
dictated by the location of the stricture, the history of previous unsuccessful attempts
at repair, and the surgeon's personal preference. Simple excision of a bile duct
stricture and end-to-end bile duct anastomosis or repair of the damaged duct can
rarely be accomplished because of the invariable loss of duct length as a result of
fibrosis associated with the injury. Thus, in almost all cases, hepaticojejunostomy
constructed to a Roux-en-Y limb of jejunum is the preferred procedure. Many
surgeons believe that a transanastomotic stent is helpful in almost all cases. A number
of series, however, have had successful results without the use of such stents. The use
of preoperatively placed percutaneous catheters facilitates the identification of the
proximal biliary segment, which can be difficult because of retraction high into the
porta. The catheters also facilitate mobilization and the anastomotic technique
including the placement of Silastic (Dow Corning, Midland, MI) biliary catheters. The
length of stenting depends on the location of the stricture. If the stricture involves the
common bile duct or common hepatic duct at least 2 cm distal to the hepatic duct
bifurcation and adequate proximal bile duct mucosa can be identified, the use of longterm biliary stenting is not necessary. In these situations, transanastomotic stenting
for 4 to 6 weeks after the operation is adequate. A longer period of stenting is
necessary if adequate proximal bile duct is not available or if a good mucosal-tomucosal anastomosis cannot be completed.