Choledochoduodenostomy, Choledochojejunostomy or Sphincteroplasty for Biliary and Pancreatic Disease

Choledochoduodenostomy, choledochojejunostomy, or sphincteroplasty are used in the treatment of selected patients with retained, recurrent, and impacted bile duct stones; strictures of the bile ducts; stenosis of the sphincter of Oddi; pancreatitis associated with biliary disease; choledochal cysts; fistulas of the bile duct; and biliary obstruction, either benign or malignant. From a group of approximately 1600 patients operated on for biliary and pancreatic disease during the 17-year period, 1962 to 1979, 153 patients who had choledochoduodenostomy, choledochojejunostomy or sphincteroplasty were identified. Follow-up information was available for 146 patients (95%). Overall, 84% of the patients had good results, 10% had fair results, and 3% had poor results. A 3% postoperative mortality rate was found, all in patients with unresectable malignancies. Treatment of bile duct obstruction, benign or malignant, was equally effective by choledochoduodenostomy or choledochojejunostomy. Jaundice resolved in all patients; three patients with benign strictures required reoperations for recurrent stricture formation, two after choledochoduodenostomy, and one after choledochojejunostomy. Recurrent cholangitis heralded the development of another stricture. Both choledochoduodenostomy and sphincteroplasty were used for patients with retained, recurrent or impacted duct stones. Pancreatitis did not occur in any patient after sphincteroplasty; the sump syndrome was not seen after choledochoduodenostomy. This review supports the view that choledochoduodenostomy is a safe and effective procedure. All three operative procedures were effective for the problems for which they were used; each procedure has a place in the treatment of recurrent or complicated biliary and pancreatic diseases. The procedures are complementary, not competitive. For certain problems, the operation performed depends upon the surgeon's preference and experience. The indications for and results of these operative procedures are discussed.     

Laparoscopic choledochoduodenostomy

Laparoscopic cholecystectomy has become the gold standard for treatment of patients with symptomatic cholelithiasis. Management of common bile duct stones in the era of laparoscopy is an area of controversy. Although perioperative endoscopic retrograde cholangiography remains as a widely used procedure, experience is accumulating on the exploration of the common bile duct with the laparoscope. A biliary drainage procedure is indicated in selected patients with choledocholithiasis. Initially described by Reidel in 1892, side-to-side choledochoduodenostomy has become a popular biliary-enteric anastomosis technique in the last century. We describe two patients with recurrent choledocholithiasis and biliary obstruction due to benign biliary strictures. Both patients underwent laparoscopic common bile duct exploration and stone extraction. A side-to-side choledochoduodenostomy is then performed laparoscopically as a drainage procedure. Laparoscopic choledochoduodenostomy resulted in resolution of jaundice and relief of biliary obstruction. Laparoscopic choledochoduodenostomy can be an acceptable alternative to the open choledochoduodenostomy. In addition to a tension-free anastomosis and an adequate-sized stoma, intracorporeal suturing and knot-tying skills are also essential to the success of this procedure.     

Long-term prognosis after treatment of patients with choledocholithiasis

OBJECTIVE: This study was conducted to examine the long-term prognosis of after treatment of patients with choledocholithiasis, including the recurrence of lithiasis, and to thereby determine the best treatment modality for choledocholithiasis based on its pathological entity. SUMMARY BACKGROUND DATA: Choledocholithiasis can be caused by either primary bile duct stones that originate in the bile duct or by secondary bile duct stones that have fallen out of the gallbladder. The recurrence rates vary depending on the type of choledocholithiasis. METHODS: Two-hundred thirteen outpatients who were treated for choledocholithiasis from 1982 to 1996 were selected as subjects and monitored for a period ranging from 5 to 19 years (mean, 9.6 years). The 213 patients were divided into 3 groups: 87 patients who had undergone choledocholithotomy and T-tube drainage (including the use of the laparoscopic method), 44 patients who had undergone choledochoduodenostomy, and 82 patients whose stones were removed by endoscopic sphincterotomy (EST). Recurrence of lithiasis was examined for each type of treatment modality. RESULTS: Choledochoduodenostomy was performed in 44 cases for the purpose of preventing any recurrence. The recurrent rate was analyzed in 169 cases. Choledocholithiasis recurred in 17 of the 169 cases (10.1%). The remaining 152 patients that showed no recurrence of lithiasis were examined and compared. The diameter of the common bile duct measured during the initial treatment was more dilated in patients with recurrent lithiasis (16.6 +/- 5.9 mm) than in patients without any recurrence (9.8 +/- 4.9 mm; P < 0.05). Peripapillary diverticula were observed in 10 of the 17 patients with recurrent lithiasis (58.8%), and in 34 of the 152 nonrecurrent patients (22.3%), showing that diverticula were more common in recurrent cases (P < 0.05). Furthermore, while primary bile duct stones were found in 11 of the 17 cases with recurrent lithiasis (64.7%), primary stones were found in only 37 of the 152 nonrecurrent patients (24.3%), showing primary bile duct stones were also more common in recurrent patients (P < 0.05). The recurrent patients were examined by surgical procedure. Nine patients with choledocholithotomy and T-tube drainage had a recurrence (10.3%), and 8 patients in the EST group had a recurrence (9.8%). The recurrence rates for these procedures were higher than for cases with choledochoduodenostomy (recurrence rate: 0%, P < 0.05). In particular, lithiasis recurred in 5 of the 12 patients with T-tube drainage for primary bile duct stones (41.7%). CONCLUSION: Although choledocholithotomy and T-tube drainage, including open and laparoscopic surgery, is presently a common procedure for choledocholithiasis, this procedure will not necessarily prevent a recurrence of the disease. For older patients with primary bile duct stones, choledochoduodenostomy or EST is recommended.     

End-to-side choledochoduodenostomy: A widely applicable procedure for biliary reconstruction

End-to-side choledochoduodenostomy was originally used for reconstruction between the duodenum and the biliary tree in iatrogenic bile duct stricture. However, we believe the procedure could be applied for various biliary disorders. We have recently shown the high carcinogenicity of biliary epithelium in patients with pancreaticobiliary maljunction, and consequently we recommend excision of the bile duct, along with appropriate reconstruction of the biliary system to divert the flow of pancreatic juice from bile fluid, to prevent carcinoma in biliary epithelium even in patients without dilatation of the bile duct. The conditions causing primary or recurrent bile duct stones must be removed. We employed this procedure for biliary reconstruction in 42 patients with pancreatico-biliary maljunction and in 30 patients with various benign biliary diseases, such as bile duct stones and benign biliary stenosis. We also used the procedure for palliation in 6 patients with malignant tumors around the head of the pancreas. Among these 78 patients over 20 years, we experienced 5 cases of reflux cholangitis with anastomotic stenosis, for which conservative dilatation was required. This procedure of end-to-side choledochoduodenostomy could be widely applicable for biliary reconstruction in terms of its being simplicity, minimal invasiveness and the establishment of a single physiological route for bile flow into the duodenum.     

Histopathologic changes in the intra- and extrahepatic biliary tree in patients with postcholecystectomy choledocholithiasis

To assess the incidence of biliary stasis in recurrent choledocholithiasis, 155 patients with postcholecystectomy choledocholithiasis, all of whom were recommended for choledochoduodenostomy, are presented in this paper. Data show that in patients of advanced age and with a long history of the disease there is a higher incidence of common bile duct dilatation, primary common bile duct stones, and increased bile contamination rate. Furthermore, these elements are associated with advanced pathologic changes in the liver and biliary tree histology. This hypothesis is supported by barium meal studies through the constructed choledochoduodenostomy where the extent and progress of those pathologic changes have been illustrated by visualization of the entire biliary tree at different postoperative intervals. In this series of patients, the progress of the liver and biliary damage was studied after the relief of the obstruction. It would appear reasonable to accept that in patients with the above-mentioned characteristics, the evidence of biliary stasis is clear. In these patients, the demand for a drainage procedure supplementary to choledochotomy seems to be warranted in order to eliminate the risk of recurrent choledocholithiasis as a result of existing biliary stasis.     

Choledochoduodenostomy for benign biliary tract disease in the elderly

Endoscopic sphincterotomy is an available nonoperative alternative treatment for recurrent or residual common bile duct stones. Nevertheless, immediate, intraoperative and definitive treatment is needed in patients with common duct stones and other pathologies that are prone to develop into such complications, which is important especially in aged high-risk patients during recurrent operations and nonoperative instrumental interventions. To evaluate the safety of choledochoduodenostomy in elderly patients, we reviewed our experience with 55 patients over the age of 70 years with benign biliary tract diseases. Even though the majority of patients (69%) had obstructive jaundice and were operated on urgently, there was one death (1.8%) due to cardiac failure, and nine (16.3%) early postoperative complications including subphrenic abscess, disruption of wound and pneumonia (one case of each), wound infection (three cases) and urinary tract infections (three cases). There were no complications related to the procedure itself. In a follow-up period of one to 12 years, neither cholangitis nor sump syndrome were documented.     

Choledochoduodenostomy for choledocholithiasis. Indications and functional results

Choledochoduodenostomy in the prevention and treatment of patients with common bile duct stones has been frequently discussed during several years. The introduction of endoscopic sphincterotomy, with excellent results and low morbidity necessitate further examination of the indications for and the value of this procedure as an adjunct to choledocholithotomy. Twenty patients with a mean age of 73 years have been operated on with choledocholithotomy and subsequent choledochoduodenostomy. In 7 of the patients the anastomosis was performed at a primary operation, in 11 at a secondary and in 2 at a third operation. Seven of the patients had primary bile duct stones, while thirteen had multiple stones, either unextractable or with a doubtful clearance. There was no postoperative mortality and only one early complication, a pneumonia. Eighteen of the 20 patients are free of symptoms postoperatively and have normal liver function tests and verified open anastomoses. Two patients had recurrent postoperative cholangitis, one due to a stricture in the anastomosis, which was reoperated, and one due to multiple retained stones intrahepatically despite an open anastomosis. In conclusion choledochoduodenostomy is easy to perform with low morbidity even in old-aged, high-risk patients. It is a safe and effective method in the prevention of retained or recurrent stones.     

Primary intrahepatic lithiasis: report of a case treated by laparoscopic bilioenteric anastomosis

Recent advances in videolaparoscopic surgery have made this method the treatment of choice for many biliary diseases. However, it has not been used in certain cases, such as primary intrahepatic lithiasis. The authors report a case of a 62-year-old woman with a history of several episodes of cholangitis. Investigation revealed dilated intra- and extrahepatic bile ducts with intrahepatic stones. The patient underwent laparoscopy, and intraoperative cholangiography disclosed an enlarged common duct with absence of stones and the presence of multiple calculi in the intrahepatic biliary tree. A choledochotomy followed by choledochoscopy was performed, which revealed several intrahepatic pigmented stones that were completely retrieved, followed by a laterolateral choledochoduodenostomy to decompress the biliary tree and to allow the migration of residual or recurrent stones. The patient had an uneventful recovery and was discharged on the fourth postoperative day. After 15 months of follow-up the patient is asymptomatic with normal results of liver function tests. Late postoperative upper digestive endoscopy showed a patent choledochoduodenostomy.     

Reoperation of Biliary Tract by Laparoscopy: a Consecutive series of 26 Cases

Background: In the past, previous operation of biliary tract represented a contraindication to perform reoperation by laparoscopy. As experience with laparoscopic techniques and instrumentation has expanded, reoperation of biliary tract with laparoscope has become an accepted procedure in the management of cholelithiasis. We present our interesting experience with regard to reoperation of biliary tract by laparoscopy.

Material and methods: Laparoscopic operation of biliary tract was performed on 3,674 consecutive patients from April, 1992 till June, 2005. Among these patients, 26 had a previous open operation of biliary tract and their clinical data were retrospectively analyzed as follows: seven cases had complicated intrahepatic bile duct stones (restricted at hepatic duct of the first and second order). Diameter of common bile duct in patients with common duct stones was above 1.2 cm, the number of stones for each patient was more than 3 and all the biggest stones exceeded 1 cm. In the 26 patients, pre-operatively, stenosis of bile duct and malignant tumour were excluded by both radiological examination and detection of serological tumour markers.

Results: The mean operative time was 125 min (75–190 min). Reoperations of biliary tract by laparoscope were successfully accomplished in 25 patients. One patient was converted to open operation and the common duct stones were removed by right angle forceps through short incision. None of the patients developed any severe complication, all of them recovered and were successfully discharged. Three cases with retained calculuses were successfully cured by removing these through the sinus tract of T tube.

Conclusions: Laparoscopic procedure is minimally invasive, safe and feasible for laparoscopic experts in case of reoperation of biliary tract. It is also a first method for patients for whom endoscopic sphincterotomy is contraindicated.     

A simplified surgical approach in choledochal lithiasis reducing the complexity and severity of this surgery. Study of a series of 153 cases

The surgical treatment of stones of the common bile duct by transcystic extraction of stones without biliary and peritoneal drainage greatly simplifies biliary surgery. Postoperative course and average hospital stay are similar to those encountered after conventional cholecystectomy. This surgical option was successfully achieved in almost 60% of the 153 patients with stones of the common bile duct of our series, operated between 1981 and 1987. Other patients were treated more conventionally because of failure or impossibility of complete transcystic extraction of stones. A choledochoduodenostomy was performed in 28 patients. In a limited number of patients (n = 12) endoscopic sphincterotomy was associated pre or postoperatively with the surgical treatment. Although 25% of the patients were older than 75 years, there was no operative mortality, which demonstrates that biliary surgery can be performed safely without any vital risk. Successful transcystic extraction of stones simplifies the course of stones of the common bile duct and should be attempt more often.     

应用胆胰管内窥镜经胆囊管胆道探查21例临床分析

目的探讨应用胆胰管内窥镜经胆囊管行胆道探查的临床应用价值。方法 2011年1月～2012年1月,对21例急、慢性结石性胆囊炎合并或可疑合并肝内外胆管结石者,在开腹胆囊切除术中应用德国PolyDiagnost公司组合式、软性、可旋转纤维内窥镜（外径F8）经胆囊管行胆道探查、取石。结果 2例肝内胆管结石,用套石篮顺利取出。胆总管结石14例,其中6例经胆囊管顺利取出,4例钬激光击碎结石取出,2例行胆囊管汇入胆总管处微切开取石,未成功2例,行传统胆总管切开取石T管引流。5例未见明显结石及十二指肠乳头狭窄。术后胆漏1例,无胆道残余结石等并发症发生。术后随访6～18个月,平均13个月,无结石复发。结论应用胆胰管内窥镜经胆囊管进行肝内外胆管探查,避免了胆总管切开和放置T管,提高了胆道结石诊断的准确率,是一种安全简便、创伤小、恢复快的方法。     

Surgical treatment of lithiasis of the common bile duct: our experience

On the basis of their personal experience of biliary pathology, the authors present their opinion of surgical treatment of benign diseases of the common bile duct. From 1980 to 1988 a total of 930 patients were assessed, 140 of whom were affected by choledocholithiasis. Data confirmed that, with the exception of choledochotomy as a direct approach for removing stones, good results were achieved using papillosphincterotomy, since this technique best restores the physiology of the biliary tract. In cases where common duct dilation exceeded 20 mm or where the patient was in poor clinical condition, bile was drained into the gut forming a side-to-side choledochoduodenostomy.     

胆总管十二指肠吻合和胆管空肠吻合术式选择的临床意义分析—附120例

目的:探讨胆总管十二指肠侧侧吻合术与胆管空肠Roux-en-Y吻合术的术式选择及远期疗效。方法:总结行胆肠吻合术的120例胆道梗阻病例。原发疾病包括:复发性胆管结石并胆管狭窄65例、先天性胆管囊性扩张症22例、晚期胆道与胰腺肿瘤28例、医源性胆管损伤5例。其中行胆总管十二指肠侧侧吻合术30例(25%),胆管空肠Roux-en-Y吻合术90例(75%)。结果:术后全部病人恢复良好,术后随访98例,随访率81.7%,随访时间为6个月～4年,所有患者术后近期黄疸消退,肝功能恢复,能正常工作生活。远期生存质量评估:胆总管十二指肠吻合术后生存质量优良与良好91.3%(21/23),不良8.7%(2/23);胆管空肠Roux-en-Y吻合术后生存质量优良与良好92.0%(69/75),不良8.0%(6/75)。结论:胆总管十二指肠侧侧吻合术和胆管空肠Roux-en-Y吻合术都能很好起到引流胆汁的效果,严格掌握适应证和精细的手术操作是有效引流、缓解胆道梗阻的保证。     

Reoperative surgery in cholelithiasis

From 1965 to 1980, reoperations for residual or recurrent stones were performed on 78 out of 962 Japanese patients with cholelithiasis. The majority of patients who required reoperation had intrahepatic stones. Most of the causes of reoperation were residual stones due to incomplete removal or the non-detection of intrahepatic stones at the previous surgery. Very careful examination of the intrahepatic biliary trees should be done in patients with biliary tract diseases, because in many, the first operation was done during their youth. To remove the intrahepatic calculi completely, hepatic lobectomy should be considered as a final procedure. The causes of reoperation of common duct stones were residual in 60 per cent and recurrent in 40 per cent. Definitive surgery should be done at the first or at least the second operation to avoid irreversible hepatic disorders which have untoward effects on the prognosis. It is important not only to remove the stones but also to relieve the bile stasis in the biliary tract.     

Choledochoduodenostomy in the treatment of benign biliary tract disease

During the 15 year period 1965 through 1979, sixty patients underwent choledochoduodenostomy for benign obstructive lesions of the biliary tract. Patients with traumatic and iatrogenic common duct strictures were excluded. Eighty-two percent of the patients were in the seventh to ninth decades of life. Twenty-seven patients (45 percent) had undergone a total of 40 previous biliary tract surgical interventions. Thirty-three patients (55 percent) in the older age group (average age 75 years) were subjected to choledochoduodenostomy as a primary procedure during the first surgical intervention on the biliary system. Cholangitis recurred in only one patient (in whom the sump syndrome was the culprit), while all other patients have been free of abdominal complaints, cholangitis and pancreatitis during follow-up of 1 to 15 years. There was no operative mortality; morbidity was 26 percent. Hospital stay averaged 15 days. These favorable results mark choledochoduodenostomy as a safe, simple and effective procedure in the treatment of benign biliary tract disease, particularly in aged and high risk patients.     

超细胆道镜在术中经胆囊管胆道探查的临床应用

目的探索胆道探查手术中应用超细胆道镜的临床价值。方法开腹或腹腔镜手术切除胆囊后保留残留胆囊管0．5～0．6cm,经胆道探条或血管分离钳机械扩张胆囊管,直至CHF—XP20超细纤维胆道镜随意插进胆总管,观察胆总管、肝总管及左右肝管,同时可以经胆道镜活检孔道插入配置的取石网篮取石,或插入配置的活检钳进行组织活检。结果332例胆总管内小结石（0．3～0．5cm）,其中25例合并肝内一级胆管结石,术中经超细纤维胆道镜检查证实后,使用网篮顺利取出;9例胆总管内隆起样病变取组织活检,其中炎性息肉样病变5例,轻一中度不典型增生病变4例;胆总管下端炎性狭窄及乳头肌收缩功能减退24例。365例经胆囊管进行均顺利完成超细纤维胆道镜检查及治疗,术中未出现胆道持续出血、胆道穿孔及术后胆道感染等并发症。295例随访3～12个月（平均7．5月）,未发现术后残余结石,继续随访13～18个月（平均15．5月）,胆总管结石复发12例。结论超细纤维胆道镜经胆囊管进行胆道探查手术有严格适应征,合理、选择性的应用可避免总胆管切开。     

胆道再手术的原因及对策

目的：探讨胆道再手术的原因和对策。方法：对1994年12月－20000年12月间胆道再手术102例进行回顾性分析。结果：75例行胆管切开取石,其中12例同时行肝叶切除,5例胆总管十二指肠合改行胆总管空肠Roux-en-Y吻合或再做其他术式,12例胆道恶性肿瘤分别行根治术,内外引流和PTCD,4例行胆管整形和胆肠吻合术,4例行囊肿切除胆肠Roux-en-Y吻合,2例行残余胆囊和胆囊残株炎切除,胆道再手术主要原因是结石复发（52．0％）,残石（21．6％）,恶性肿瘤（11．8％）,术式选择或操作不当（8．8％）,及胆管狭窄（3．9％）,续集：为降低胆道再手术率,强调应明确术前诊断,采用正确的术式,术中胆道镜,胆道造和B超检查,审真操作,积极进行根治性手术,尽量避免急诊手术和术后经T管窦道取石。     

Retained and recurrent bile duct stones: operative management

Retained and recurrent bile duct stones can now be treated by a variety of nonoperative means. These include retrieval through instrumentation of the T-tube tract, chemical dissolution, endoscopic papillotomy, or lithotripsy. Operative management, however, is an alternative means of therapy that carries negligible mortality, minimal morbidity, and a high success rate. If operative management is used, for most patients common duct exploration, stone retrieval, and T-tube insertion will suffice. However, if the patient has risk factors that suggest the possibility of further stone disease, a drainage procedure such as a sphincteroplasty or choledochoduodenostomy should be added. Nonoperative management is now the first choice for managing retained or recurrent bile duct stones. If these methods fail or cannot be utilized, operative management can be used with a similar low mortality, low morbidity, and high success rate.     

腹腔镜和内窥镜联合治疗复发性胆总管结石

目的 :探讨腹腔镜和内窥镜联合治疗复发性胆总管结石的方法。方法 :回顾总结经内窥镜鼻胆管引流术 (ENBD)配合实施腹腔镜胆总管探查 (LCBDE)、Ⅰ期缝合术 (内衬ENBD导管 )治疗胆道术后复发性胆管结石 2 2例的临床资料。结果 :2 1例手术成功 ,1例中转开腹 ,全部Ⅰ期缝合胆总管探查切口。术后无残石及胆瘘等并发症。手术时间 1 5 7± 31 4min ,术后住院 9 6± 1 2d。随诊 1 7例未见复发。结论 :应用腹腔镜和内窥镜联合治疗胆总管复发结石安全、可行 ,体现了微创治疗的优点 ,但分离粘连及解剖、缝合胆总管较困难 ,治疗初期应适当放宽中转开腹手术的指征     

The management of retained and recurrent bile duct stones

The records of 156 consecutive patients treated for retained and recurrent bile duct stones between 1965 and 1980 were reviewed to compare current management techniques. One hundred sixty-eight procedures were performed in the 156 patients: 36 endoscopic sphincterotomies, 89 common bile duct explorations, and 43 common bile duct explorations with drainage procedure. Mean follow-up was 7.2 years. The overall success rates were 81% for endoscopic sphincterotomy, 80% for common bile duct exploration, and 86% for common bile duct exploration with drainage procedure. Five variables were evaluated in regard to the success of these procedures: (1) the time interval between cholecystectomy and the next procedure on the biliary system, (2) the number of previous biliary procedures or operations performed, (3) the diameter of the common bile duct, (4) the number of stones in the duct and their size, and (5) morbidity and mortality. The time interval and number of previous biliary procedures did not affect the success of any procedure group. Endoscopic sphincterotomy has become our procedure of choice. When common bile duct exploration with drainage procedure is performed and a dilated bile duct or more than five bile duct stones are found, the addition of a drainage procedure provides better long-term results.