Choledochoduodenostomy

Joaquin S. Aldrete, MD, MS (Surg)

espite the recent advances in surgical techniques to Choledocholithiasis

D ,construct biliary/duodenal bypass procedures, mostly It is often difficult to clear the bile ducts, particularly if
brought up by minimally invasive methods, open choledo- multiple stones are present. Even with a postexploration
choduodenostomy (CDD) remains a useful procedure.
cholangiogram, stones may be overlooked. W h e n in
The literature clearly documents its minimal morbidity,
doubt, CDD is indicated to allow for the passage of any
low mortality, and excellent long-term results. Madden
retained calculi.
and colleagues 1 summarized the historical development
of CDD and most importantly described their experience
with 100 cases of CDD with a 3% operative mortality and Ampullary Stenosis
20% morbidity. Long-term follow-up in 83 patients for
When the surgeon cannot pass a three-mm probe through
benign conditions showed no episodes of cholangitis.
the ampulla and the intraoperative cholangiogram shows
Subsequently, numerous authors 2q 1 confirmed the excel-
little or no flow of dye into the duodenum, the possibility
lent long-term results for'open CDD.
of an impacted stone at or near the ampulla or of an
In 1991, we published our own experience with 71
ampullary stenosis is real. It may be difficult to determine
patients followed for five or more years after CDD3 2 Of
with certainty if this is truly an impacted stone or just
these patients, 38 were followed for at least five years, 25
ampullary stenosis. Persistence in removing the impacted
for at least 10 years, and eight for at least 15 years.
stone or passing the exploring instrument or even the
Choledocholithiasis, chronic pancreatitis, and postopera-
choledochoscope into the intrapancreatic portion of the
tive stricture were the indications for CDD. Postoperative
CBD carries a high risk of producing a "false passage,"
recurrent cholangitis was observed in three patients, all
perforating the wall of the d u o d e n u m or CBD, or
of w h o m had a common bile duct diameter less than 14
traumatizing the pancreas, leading to severe pancreatitis.
m m at the time of operation; the rest of the patients
'Under these circumstances and in the presence of a
analyzed had considerably larger bile ducts, with the
dilated CBD (more than 15 m m in diameter), CDD is a
average diameter being 18 m m + 0.9 standard error of
definitive, safe, and prompt solution.
the mean. We concluded that CDD was effective in
treating nonneoplastic obstructing lesions of the distal
common bile duct (CBD) in the long term, provided that Chronic Pancreatitis
the CBD is at least 16 m m in diameter.
O t h e r a u t h o r s 13-14 have confirmed long-term patency Obstruction of the distal CBD produced by chronic
for open CDD. Recently, two groups 15-16 reported on a pancreatitis is an indication for CDD once the possibility
limited number of patients who underwent a CDD using of a resectable malignant obstruction is excluded. Such
laparoscopic techniques. Although CDD can be per- clarification may prove difficult. In our series, 12 coexist-
formed laparoscopically, the long-term results remain to ent pancreatic carcinoma was not detected in nine
be evaluated, and comparison with conventional CDD is patients despite several needle biopsies of the pancreas.
premature.
Malignant Neoplasms
Indications
Malignant lesions originating in the ductal epithelium of
Reviewing the literature and m y own experience suggests the pancreas, the mucosa of the CBD, the ampulla, or the
to me that there are well-defined indications for a CDD. d u o d e n u m near the ampulla can produce obstruction of
the distal CBD. W h e n such neoplasms are unresectable,
the biliary obstruction can be effectively relieved by
Fromthe DepartmentofSurgery,SchoolofMedicine,UniversityofAIabamaat
BirminghamMedicalCenter,Birmingham,AL. CDD. However, in some cases, these rapidly growing
AddressreprintrequeststoJoaquinS.Aldrete,MD,MS(Surg),6229PaseoAlta tumors can quickly occlude a previously constructed
Rico,Carlsbad,CA92009-2111. palliative CDD. In these situations, it is better to use
Copyright9 2000byV~B.SaundersCompany
1524-153X/00/0204-0007510.00/0 other decompressing procedures farther away from the
doi:10.1053/otgn.2000.19143 unresectable tumor.

304 Operative Techniques in General Surgery, Vol 2, No 4 (December), 2000: pp 304-310

Choledochoduodenostomy 305

Operative Injuries to the Biliary Tree
Unfortunately, the newer minimally invasive approaches
to biliary surgery have not decreased the incidence of
operative injuries, and in fact may have increased the
incidence. In most cases when injury is not discovered at
the time it occurs, the distal CBD becomes unsuitable for
use in the reconstruction} 7 Therefore, a CDD cannot be
done, and reconstruction must be performed using the
common hepatic duct, often at the confluence of the two
main hepatic ducts, suturing it to a Roux limb of
jejunum. However, CDD may occasionally be useful in
the surgical treatment of injuries to the CBD. Specifically,
if the injury is detected at the time of surgery and is
located in the distal CBD, and the CBD happens to be
dilated to 16 mm or greater, then the injury may be
amenable to repair with a CDD. Moreover, if the CBD was
completely ligated at operation, resulting in a dilated
CBD (>15 m m in diameter), the anatomy may be
suitable for reconstruction by a CDD with expectations
for very good long-term results.
Chronically Dilated Bile Ducts
After exploration for a chronically dilated CBD 15 mm or
greater in diameter, it may be advisable to construct a
CDD rather than to close the choledochotomy over a
T-tube. Not only are there theoretical disadvantages to
using T-tubes, 18-19 but the CDD virtually eliminates the
risk of residual or recurrent choledocholithiasis. Obvi-
ously, the initial choledochotomy needs to be planned
with this in mind.

SURGICAL TECHNIQUE

Cystic duct Hepatic

~na ~ ~ ducts

Common bile
duct and
gastrohepatic Pylorus
ligament

plenic artery

Proper hepati
artery

m li

of duodenum

1 Under general endotracheal anesthesia, a right subcostal incision is made. (An upper midline incision is
also reasonable.) The duodenum, the supraduodenal portion of the common bile duct, and the gallbladder are
carefully inspected, palpated, and scrutinized for abnormalities. The diameter of the CBD is measured as
accurately as possible with a metal ruler or a caliper. The diameter should be at least 16 mm to allow
construction ofa CDD with an opening no smaller than 14 mm in diameter. The gallbladder is removed.
306 Joaquin S. Aldrete

I - I ~ ~ et n f

ilized
n

Infe~
vena

CBD

Cut edges of divided Descending retroperitoneal

posterior peritoneum duodenum mobilized with
division of peritoneum
(Kocher maneuver)

~- Because the first and fourth portions of the duodenum are fixed, in most patients it is necessary to
mobilize the second and third portions to facilitate cephalad displacement of the duodenum, which
allows the second portion to reach the anterior surface of the distal CBD for an anastomosis without
tension. Kocherization of the duodenum is performed by making an incision along the lateral border of
the second portion of the duodenum, elevating the posterior aspect of the duodenum and head of the
pancreas by blunt dissection, and partially exposing the anterior surface of the inferior vena cava.
Once mobilization of the duodenum and exposure of the distal CBD have been completed, careful
consideration should be given to the location of the separate incisions in the duodenum and CBD. In
general, the incision in the duodenum must be placed at or near the junction between the first and
second portions and slightly posterior; the incision in the CBD is made as distal as possible. The
surgeon then selects the type of anastomosis: end-to-side or side-to-side. There should be some
reluctance to completely transect the CBD to do an end-to-side CDD; thus most surgeons favor a
side-to-side anastomosis. However, the latter requires more extensive mobilization of the duodenum.
Both types of anastomosis will yield good results if done without tension and an adequate opening is
created. It is thus left to the surgeon's discretion to select the type of CDD best suited for each patient.
Either type of CDD must be constructed with precise suturing. I personally use double-armed 5-0
polypropylene suture with small atraumatic needles to construct the anastomosis in a continuous
running fashion. 1 cannot overemphasize that this suturing must be done under direct, clear vision of
each pass of the running suture. Maximal precision is best obtained by using optical magnification. A
CDD should be performed with the same technique and care as is used for anastomosing small arteries
and veins.
Choledochoduodenostomy 307

3 End-to-Side CDD. The CBD is

transected as distal as possible to al-
low for an anastomosis without ten-
sion. Two stay sutures are placed at
each corner of the anastomosis. The
sutures are gently pulled to tempo-
Stay suture in rarily approximate the incisions made
or "corner" of
in the side of the duodenum and the
;tomosis
end of the transected CBD. Careful
Cont scrutiny at this point is important to
in pos' check whether their size matches and
CDD approximation occurs without ten-
sion or twisting. The running suture is
then initiated, with the first suture
placed in the posterior lip of the
anastomosis, exactly in the middle of
each luminal opening. This continu-
ous technique is performed from in-
side the lumen, placing each suture at
a 90 ~ angle to the tissue, first running
one end toward its respective corner,
then running the other end toward the
opposite corner, finishing both where
the stay sutures had been previously
placed. To facilitate optimal vision of
the posterior lip of the anastomosis,
each loop of the running suture is left loose. Once each suture has reached its respective corner, the needles are brought outside the
lumen and the loose loops of the running suture are tightened by gently pulling simultaneously at each corner under direct vision.
The polypropylene suture slides easily. Caution is needed so that excessive tightening does not constrict the anastomosis. To avoid
this occurrence, the two stay sutures placed in each corner are tied at this point.

4 The anterior lip of the anastomosis is then com-

pleted by running each end of the suture, again leaving
the loops loose to facilitate the placement of each
successive stitch, again meeting in the middle of the
anastomosis. The ends of the anterior suture are
tightened using a fine nerve hook and tied with at least
eight knots.
308 Joaquin S. Aldrete

Continuous s
in posterior a,' in superior
of CDD anast( D anastomosis

5 Side-to-Side CDD. The incision in

the CBD must be planned carefully to
facilitate accurate apposition with the duo-

(
denum. Depending on the relationship
between the two organs, the incision can
be transverse or oblique; an oblique inci-
sion is shown here. This anastomosis is
constructed in a similar fashion as that
described for the end-to-side CDD.

/'

Stay suture in
inferior "corner" of
CDD anastomosis

Ligat~
6 In this side-to-side CDD at the stage of near comple-
of cy
tion, note that the most distal portion of the c o m m o n
bite duct is partially behind the d u o d e n u m and a small
segment goes through the head of the pancreas and
opens into the d u o d e n u m in the ampulla of Vater, which
appears stenotic, as c o m m o n l y occurs in patients who
require CDD. A single layer of polypropylene suture is
sufficient to create a waterproof anastomosis; however, it CBD
is possible to use two layers. The anastomosis should be
carefully examined for bile leakage, which seldom oc-
curs.
The completed anastomosis should have a diameter of
at least 14 mm. Because of this size, a T-tube or stent is
not needed. It is advisable to drain the area in proximity
to the anastomosis with one or two soft drains connected
to a closed vacuum suction system. Because no external
indwelling tubes are present, a postoperative cholangio-
gram cannot be done. In the rare occasions in which
jaundice persists for five or more days after the opera-
tion, an upper gastrointestinal series is the simplest test
to assess the patency and continence of the constructed
anastomosis.
Choledochoduodenostomy
Complications of CDD
Recurrent ascending cholangitis is the most notable
long-term complication following a CDD. 2~ This most
undesirable complication occurs almost exclusively when
CBD with
calculi and
biliary "mud"
Stenotic ampu
Conclusions
From a review of the literature and analysis of my own
experience, it can be concluded that CDD produces
excellent long-term results for the treatment of nonneo-
plastic obstructing lesions of the distal CBD. The caliber
of the CBD is of critical importance ( > 1 5 m m in
diameter), and meticulous and precise suturing tech-
niques are essential. Intrabiliary stents are not needed
under the stipulated requirements. Extensive technical
experience in performing precise small anastomoses with
sutures, particularly in the biliary ducts, is an important
consideration to ensure good results. If all of these
309
the CDD was constructed in the presence of a CBD
measuring less than 16 m m in diameter or when the
operative technique used was faulty, resulting in a
strictured anastomosis (Fig 7).
7 Diagrammatic depiction of a stenotic choledocho-
duodenostomy with a very small opening, obviously
incorrectly constructed, eventually leading to stagnation
of the flow of bile, dilatation of the biliary ducts, and
finally cholangitis, which is almost always caused by
stenosis of the distal common bile duct and not to
regurgitation of intestinal contents into the lumen of the
biliary tract.
precautions are followed carefully, then recurrent ascend-
ing cholangitis should not occur. In the absence of local
and/or systemic sepsis and under elective circumstances,
morbidity should be less than 9% and mortality 2% or
less. Furthermore, my own experience and that of several
authors who have also analyzed the long-term results
with CDD suggest that the notion of reserving CDD only
for elderly patients with limited (less than 10 years) life
expectancy should be reassessed, and m u c h younger
patients can be considered as candidates for CDD under
appropriate circumstances.
310
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