Choledochoduodenostomy

3/5/15

COMPLICATION, 3/2/15Faculty/Resident: Bittner/Kaplan/UchiyamaDiagnosis: CholedocholithiasisProcedures: 2/16/15: Open common bile duct exploration, choledochoduodenostomy, lysis of adhesions, upper endoscopy3/2/15: Incision and drainage of deep abdominal wound infectionOther Involved Services: Interventional radiology, Internal medicineComplication: Wound infectionOutcome: 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, hyperlipidemiaPSHx: Open roux-en-y gastric bypass (1980), open cholecystectomy, total abdominal hysterectomy, laparoscopic ovarian cystectomy, total knee replacement, breast reductionFamily Hx: Heart disease, HTNSocial 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, NADHEENT: Sclera non-ictericLungs: CTABHeart: RRRAbdomen: Soft, non-tender/non-distended, old well healed vertical midline incision & right subcostal Kocher incision, no palpable masses or hernias

BACKGROUNDCT A/P (w/o IV contrast, CMH)

BACKGROUNDCT A/P (w/o IV contrast, CMH)

BACKGROUNDRUQ US (1/5/15, VCU)

BACKGROUNDRUQ US (1/5/15, VCU)

BACKGROUNDRUQ US (1/5/15, VCU)

BACKGROUNDMRCP (1/20/15, VCU)

BACKGROUNDMRCP (1/20/15, VCU)

BACKGROUNDIR (1/27/15, VCU) - PTC tube placement

BACKGROUNDOperative 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 removed2/20/15: Discharged to rehab facility2/27/15: PTC tube studied & removed by IR

BACKGROUNDIR (2/27/15, VCU) - PTC removed

BACKGROUNDOperative 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 removed2/20/15: Discharged to rehab facility2/27/15: PTC tube studied & removed by IR3/1/15: Sent from rehab facility to ED with incisional drainage, leukocytosis3/2/15: Incision and drainage of deep abdominal wound infection, cultures positive for E. Faecium (VRE)

ASSESSMENTClavien-Dindo Classification

FISHBONE PRE-OP POST-OP

1. Bile duct obstruction/cholangitis 1. ?Extended postoperative antibiotic coverage

2. Bile duct instrumentation (PTC) 2. 3. Recent weight loss/poor nutrition 3.

OUTCOME 1. Peri-operative antibiotic selection 1. Wound infection 2. Case length >2 hours

3.

INTRA/PERI-OP

4 minutes

PATIENT SPECIFIC FACTORS: Age, Patient comorbidities – HTN, HLD, Atrial Fibrillation

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 cholecystectomy2. 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 restenosisB. Improved symptomatic reliefC. Shorter length of hospitalizationD. Ability to perform concomitant diagnostic evaluationE. 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 sphincterotomyB. Percutaneous transhepatic cholangiography (PTC) and drain placementC. Open common bile duct exploration with extraction of stonesD. CholedochoenterostomyE. Biliary t-tube placement

Answer: AThis 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 potassiumC. Serum bicarbonateD. Partial thromboplastin time (PTT)E. Carcinoembryonic antigen (CEA)

Answer: AAmong 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: CSeveral 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 long-term 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-to-mucosal anastomosis cannot be completed.