Choledochoduodenostomy

Choledochoduodenostomy, first performed in 1891, has been used as an effective technique to provide biliary drainage in selected circumstances. It circumvents the problems of retained common duct stones and the sequelae of benign obstructive disease in the distal CBD. Indications for this procedure include choledocholithiasis and concomitant biliary stricture, giant stones, retained stones, large number of stones, ampullary stenosis, and a markedly dilated common duct. This procedure is performed less frequently than in the past because common duct stones are now more likely to be successfully removed endoscopically, and endoscopic sphincterotomy has become available.

In candidates for choledochoduodenostomy, the common duct should be at least 1.2 cm in diameter, preferably 1.4 cm. A cholecystectomy should be performed if the gallbladder is still present, since the choledo-choduodenostomy renders the gallbladder atonic, and it would become inflamed if not removed. Generally, a side-to-side anastomosis is made between the common duct and the duodenum at the level where the common duct crosses the duodenum (Fig. 4.34). The stoma must be at least 2.5 to 3 cm to allow effective biliary drainage and passage of any residual calculi. This procedure has been performed laparoscopically [57,58]. On upper GI series the biliary tree should fill freely and empty completely by 12 hours (Figs. 4.35 and 4.36). Air in the biliary tree does not necessarily indicate an adequate anastomosis and can be identified even if a stricture is present.

Complications, which occur in 5% of patients, include cholangitis, the sump syndrome, and loss of stomal patency secondary to stricture at the anastomotic site. A theoretical problem is cholangitis secondary to regurgitation into the biliary tree of intestinal contents with bacteria. Cholangitis in fact is an uncommon problem, and when it does occur, it is usually in association with technical problems and/or a strictured anastomosis [59].

The sump syndrome, defined as a collection of debris and/or litho-genic bile in the distal stagnant portion of the common duct, results in intermittent obstruction of the choledochoduodenal anastomosis that

Figure 4.34. Choledochoduodenostomy. A side-to-side anastomosis is created between the common duct and the duodenum at the level where the common duct crosses the duodenum.

Figure 4.34. Choledochoduodenostomy. A side-to-side anastomosis is created between the common duct and the duodenum at the level where the common duct crosses the duodenum.

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