Choledochoduodenostomy (CDD) is a surgical procedure to create an anastomosis, a surgical connection, between the common bile duct (CBD) and an alternative portion of the duodenum. In healthy individuals, the CBD meets the pancreatic duct at the ampulla of Vater, which drains via the major duodenal papilla to the second part of duodenum. In cases of benign conditions such as narrowing of the distal CBD or recurrent CBD stones, performing a CDD provides the diseased patient with CBD drainage and decompression. A side-to-side anastomosis is usually performed.
Bile from the gallbladder is carried to the CBD and emptied into the duodenum. CBD drainage might be obstructed due to distal CBD stricture, which is narrowing of the CBD due to the presence of scar tissue within the duct, and choledocholithiasis, the presence of gallstones. Obstruction can occur when gallstones may be too large to pass through the CBD into the duodenum.
Liver tests are performed before and after the operation. During surgery, the duodenum should be repositioned in close proximity with the CBD to ensure a tension-free anastomosis. 8 incisions are made, with one in the CBD and one in the duodenum. Sutures are performed between the incisions to create a new pathway. Postoperative complications include inflammation and narrowing within the surgical site and sump syndrome. Given that the duodenum is in a diseased state, or a tension-free anastomosis cannot be created, a CDD should not be performed and alternative bypass procedures could be considered. Currently, CDD accounts for approximately 1% of all biliary operations to provide CBD drainage. 38% of the patients undergo CDD as a primary operation (first treatment given for a disease) and 60% of the patients undergo CDD as a secondary procedure (a surgical procedure which is performed to improve conditions found to exist during the primary surgery). CDD is more often performed in the elderly with the mean age of the patients being around 61 years.
Medical Uses and Indications
CDD creates an anastomosis to allow free flow of bile from the CBD into the duodenum. Side-to-side anastomosis and end-to-side anastomosis are two procedures that can be done. Side-to-side anastomosis is preferred as the distal CBD blood supply is poor and more suitable to the laparoscopic approach, which requires limited anterior CBD dissection. Performing an end-to-side anastomosis risks ischemia and recurrent stenosis.
CDD is an alternative to choledochojejunostomy, a procedure which involves creating an anastomosis of the CBD to the jejunum. CDD is less technically challenging as the procedure is fast and simple with less anastomotic sites and does not require the creation of a Roux-en-Y anastomosis. It also has better endoscopic access to the biliary tree and more physiologic bile drainage.
CDD is used in the treatment of biliary obstruction caused by various factors shown below or when alternative treatment options were not accessible. Other less common indications include operative injuries, or chronic dilation of the CBD.
Indications
Choledocholithiasis
Gallstone disease is considered to be one of the most common digestive diseases. It is prevalent regardless of ethnicity with rates in the United States and Europe reported to be approximately 10-15%. It affects about 25 million people in the US and nearly 1 million people diagnosed annually will need to be treated. Studies have shown that 58-72% of patients with symptomatic gallstones will have ongoing symptoms and complications.
With multiple stones present, the difficulty in clearance of the CBD can lead to biliary blockage. A CDD allows for the passage of any retained gallstones, such as impacted stones, or stones where endoscopic treatments of extraction are not possible.
Ampullary Stenosis
The narrowing of the Ampulla of Vater is either verified by a 3mm instrumental probe being unable to pass through the ampulla, or the lack of dye flowing into the duodenum when a cholangiogram is carried out, indicating obstructed bile flow. Any attempts to enlarge the stenosis can lead to perforation of the duodenum wall or CBD, or damage to the pancreas, further limiting bile flow. This is present in approximately 10% of patients with persistent or recurrent biliary colic after cholecystectomy.