|Year : 2019 | Volume
| Issue : 1 | Page : 33-38
Laparoscopic choledochoduodenostomy: Role, safety, and efficacy? Our experience of 64 cases
Rajkumar Janivakula Sankaran, Prabhakaran Raju, Akbar Syed, Anirudh Rajkumar, Hema Tadimari, Aanchal Kothari
Department of Gastrointestinal and Minimal Access Surgery, Lifeline Institute of Minimal Access, Chennai, Tamil Nadu, India
|Date of Submission||08-Mar-2018|
|Date of Acceptance||08-Mar-2018|
|Date of Web Publication||26-Sep-2019|
Dr. Hema Tadimari
Department of Gastrointestinal and Minimal Access Surgery, Lifeline Institute of Minimal Access, No. 47/3, New Avadi Road, Kilpauk, Chennai - 600 010, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Context and Aim: Biliary tract obstruction can be bypassed endoscopically or by laparoscopic bypass. This article aims at analyzing the perioperative outcomes of laparoscopic choledochoduodenostomy (LCDD) performed in a single hospital, in patients not amenable to endoscopic drainage, and compares outcomes from three other case series. This is a retrospective analysis of prospectively gathered data.
Materials and Methods: From April 2005 to March 2015, 64 patients with biliary stones and inflammatory or postpancreatitis strictures, refractory to endoscopy, underwent LCDD. The operation was performed using five ports technique. The calculi were first extracted through a vertical supraduodenal choledochotomy, followed by a confirmatory choledochoscopy. The biliary bypass was then constructed with a 2.5-cm choledochoduodenal anastomosis using a double-needle holder technique, single-layer interrupted sutures using 3.0 PDS, or Vicryl.
Results: A total of 64 patients underwent LCDD. Nine of these had chronic pancreatitis; the rest had choledocholithiasis with distal stricture. In total, 33 were women and 24 were men, with mean age of 42 years. Mean operative time was 95.9 min, mean blood loss was 160 ml, and mean postoperative length of stay was 4.5 days. There was one minor leak that was managed conservatively. There was no mortality. Follow-up ranged from 1 to 11 years. On a mean follow-up of 58.2 months, there were no long-term complications such as recurrent stones, cholangitis, or sump syndrome.
Conclusion: LCDD is an effective method of providing biliary bypass in well-selected patients, with uncommon short- and long-term complications.
Keywords: Biliary bypass, biliary stricture, choledocholithiasis, double-needle holder technique, laparoscopic choledochoduodenostomy
|How to cite this article:|
Sankaran RJ, Raju P, Syed A, Rajkumar A, Tadimari H, Kothari A. Laparoscopic choledochoduodenostomy: Role, safety, and efficacy? Our experience of 64 cases. Saudi J Laparosc 2019;4:33-8
|How to cite this URL:|
Sankaran RJ, Raju P, Syed A, Rajkumar A, Tadimari H, Kothari A. Laparoscopic choledochoduodenostomy: Role, safety, and efficacy? Our experience of 64 cases. Saudi J Laparosc [serial online] 2019 [cited 2019 Nov 15];4:33-8. Available from: http://www.saudijl.org/text.asp?2019/4/1/33/267858
| Introduction|| |
Up to 18% of patients undergoing laparoscopic cholecystectomy (LC) have choledocholithiasis. Initial endoscopic sphincterotomy (ES) followed by LC has become the treatment of choice in most centers. However, laparoscopic common bile duc (CBD) exploration with LC is an alternative. Like its open counterpart, laparoscopic choledochoduodenostomy (LCDD) became possible with technological advances. The requirement of advanced skills resulted in its low adoption., There are very few case series of LCDD reported in literature.,,,,,
In our unit, while choledocholithiasis clearance is predominantly endoscopic, patients with strictures and failed endoscopy, underwent LCDD.
We present our technique, results, and comparison with three other case series.
| Materials and Methods|| |
Sixty-four patients who underwent LCDD from April 1, 2005 to March 31, 2015 were included in the study. Indications for LCDD included a CBD diameter of 1 or more, evidence of CBD stones not amenable or treatable with endoscopic therapy and evidence of a bile duct stricture, diagnosed by magnetic resonance cholangiopancreatography (MRCP).
Preoperative workup followed a standard protocol including a detailed history and clinical examination, liver function tests, ultrasound abdomen, and MRCP. All patients received preoperative prophylactic antibiotic.
The technique used was consistently same and standardized in our unit. All the surgeries were done by a single, experienced surgeon (author 1).
Surgery was performed with patient in semilithotomy position, surgeon between the patient's legs and monitor at the patient's right shoulder.
Five ports were used, one 10-mm supraumbilical optical port, one 5-mm right mid-clavicular subcostal for GB retraction, and one 10-mm subxiphoid epigastric port for liver retraction and subsequently choledochoscopy, as is done in LC. One additional 5-mm port was placed in the right midclavicular line four fingerbreadths below the previous port as left-hand working. A fifth 5-mm port was used between the epigastric and supraumbilical port, 1–2 inches to the left of the midline as right-hand working.
After a diagnostic laparoscopy, Calot's triangle was dissected, cystic artery clipped and divided, cystic duct isolated and retained to permit traction on the gallbladder and exposure of the CBD.
Duodenum was kocherized when necessary (22 patients), to allow tension-free anastomosis. An anterior vertical choledochotomy of 2.5 cm was made, ensuring that the choledochal vessels at 3 o' clock and 9 o' clock positions were not injured, extending upward from just above the crossing of the duodenum and CBD. Occasional brisk bleeding from the edges of the bile duct incision, possibly indicating early portal biliopathy, was dealt with by a combination of pressure and oversewing to achieve hemostasis. The CBD stones and debris were extracted by a combination of mechanical extraction, copious sterile saline irrigation, and Fogarty balloon passage. Stone clearance was confirmed with intraoperative choledochoscopy using a 7-mm rigid cystoscope.
A horizontal duodenotomy of length equal to the choledochotomy was made in the first part of the duodenum.
Triangulation of anastomosis was achieved by a modified Gliedman technique. For this, a double-needle holder technique [Figure 1] was used – left-hand needle holder was passed into the bile duct from outside to inside starting at 9 o' clock position, then the right-hand needle holder was passed into the duodenum from inside to out, and this bite was secured with an intracorporeal knot. A 3 o' clock suture was secured in the same manner. The third suture at 6 o'clock, approximating the apex of the lower end of the choledochotomy to the midpoint of the posterior layer of the duodenotomy enabled a diamond-shaped anastomosis.
The posterior layer of the anastomosis was completed with interrupted sutures between these three stays. The anterior layer was then completed from lateral to medial with interrupted sutures [Figure 2]. The cystic duct was then clipped, divided, gallbladder dissected off the fossa sharply and extracted in a bag. The first 37 patients done between 2005 and 2009 were sutured with 3.0 Vicryl (polyglactin 910, medium-term absorbable, braided, Ethicon), and the subsequent 27 were sutured with 3.0 PDS (polydioxanone, monofilament of long absorption, Ethicon).
A closed drain was placed lateral to the anastomosis, directed toward Morrison space. Fascia and skin were closed as usual.
Patients were reviewed at 1-, 3-, and 6-month intervals, and then annually. Monitoring included clinical examination, liver function tests, ultrasound abdomen on every follow-up, and UGI'scopy at 2 years.
| Results|| |
Fifty-five patients had cholelithiasis, choledocholithiasis, and biliary stricture. Nine patients had chronic pancreatitis with progressive CBD stricture due to intrapancreatic fibrosis. Six patients failed endoscopic CBD clearance and were subsequently referred for surgery. The average diameter of CBD on MRCP was 16.5 mm. There were 33 male and 31 female patients. All the nine chronic pancreatitis patients were male. The mean age group in our study was 42 years (range 28–79 years). There was no failure of procedure; all 64 patients had complete clearance of CBD stones. There was no conversion to open surgery. The mean duration of surgery was 95.9 min. The average number of stones removed was 4.3 stones (range 1–7). The mean blood loss was 160 ml. There was one minor anastomotic leak with subhepatic collection and no peritonitis. This was managed by ultrasound-guided pigtail drain insertion. The patient was managed conservatively successfully and discharged on 7th postoperative day. There was no major leak requiring reexploration, intervention, or diversion. Mean duration of hospital stay was 4.5 days. There was no mortality. A total of 15 patients (23%) of 64 were lost to follow-up. The average follow-up was 58.2 months (range 12–132 months). On follow-up, there was no elevation of liver enzymes, recurrence of stones, ascending cholangitis, or evidence of sump syndrome. In the 41 patients that consented to UGI scopy on follow-up, there was no stricture, and a >2.1-cm patent anastomosis was found (endoscope passed across). Results were compared with three other case studies published in literature [Table 1], namely, Bayramov et al. (25 patients), Aguirre-Olmedo et al. (7 patients), and Chander et al. (27 patients).
This is the largest series of LCDD of 64 cases reported in literature till date.
The mean age was highest in Itzé group, 71 years (52–85 years) as compared to 42 years (28–79 years – our series), 45 14 (14–72 – Bayramov), and 45.7 13.5 (15–72 – Jagdish Chander). The youngest patient in our study had biliary stricture due to chronic pancreatitis and the oldest patient had choledocholithiasis with biliary stricture. The shortest mean duration of surgery was 95.9 min (our series), vis-a-vis 127 36 min (Bayramov), 286 min (Aguirre-Olmedo), and 156.3 25.4 min (Jagdish Chander). Average blood loss of 160 ml (our series) compared well with 186 ml (Itzé) and 143.3 85.5 (Jagdish Chander). Hospital stay duration of 4.5 days in our series compared favorably to (3–9 days) (Bayramov) and 6.4 3.8 (Jagdish Chander).
While the Bayramov series reported one minor and one major leak (which necessitated relaparoscopy and T-tube drainage) and one recurrent stone (which required hepaticodochojejunostomy), our series had one minor leak like the Jagdish Chander series.
In the Jagdish Chander series, average CBD diameter was 19.6 4.4 mm. On average, 11.5 15.7 stones were removed (range 1–70), whereas in our series, the mean CBD size was 16.5 mm and average stones removed was 4.3 (range 1–7), which possibly explains their higher operating time, as also pointing to a higher stone burden and possible later presentation in North India.
| Discussion|| |
Although endoscopic retrograde cholangiopancreatography/ES followed by LC is the first line of treatment in patients with choledocholithiasis with cholelithiasis, there are disadvantages with this approach. First, it increases cost and duration of treatment. Second, ES can fail because of impacted stones, distorted local anatomy, etc., the reported failure rate ranging from 4.4% to 10%., Third, ES is not without risk of morbidity and even mortality. Complications from ES such as acute pancreatitis (1%–5%), hemorrhage (1%–4%), duodenal perforation (1%–4%), and cholangitis (1%–5%) are reported, and last but not least, recurrent bile duct stone formation after ES ranges from 4% to 24%.,,,,,
The first CDD was performed and described by Riedl in 1888, for a patient with residual choledocholithiasis, but the patient died due to anastomotic leak. The first successful CDD was performed by Sprengel in 1891. There has been some concern surrounding this procedure, due to the initially reported complications such as reflux cholangitis, reflux gastritis, and sump syndrome. Recent studies have, however, shown the procedure to be safe and effective.
LCDD was first performed by Franklin et al. in 1991 for benign recurrent bile duct obstruction; however, very few cases series with limited number of patients have been published in literature. Most studies report a morbidity of 3.7%–13%, mortality of 0%–5.6%, stone clearance rate of 90%–100%, and good long-term results (80%–100%).,,
The indications for CDD include CBD obstruction or stasis secondary to stricture >1–1.5 cm length, primary or recurrent stones, multiple CBD stones (when cannot be cleared by endotherapy), impacted stones, and stricture due to chronic pancreatitis.
The technical challenge of this anastomosis is in taking multiple sutures with series of intracorporeal knots. We used the double-needle holder technique, and used alternate hands to take bites; this is a very useful technique for both the posterior and anterior walls. This ambidextrous technique permits alteration of the direction of the needle depending on the incident angle required for the anastomosis.
Usage of PDS or vicryl made no difference to the construction of the anastomosis. But for the smoothness of the suture-run, we have now adopted PDS as a primary suture material for choledochoduodenal anastomosis.
For effective anastomosis and low long-term morbidity, the common duct should be dilated to at least 1.5 cm to prevent anastomotic stricture. Another factor described for success of the anastomosis is performing a wide Kocherization when necessary., Both conditions were adhered to in our series, resulting in low long-term morbidity.
Our mean operative time was 95.9 min. The duration of surgery depends on factors such as stone burden, adhesions around the operative area, the surgeon's experience, and advanced laparoscopic skills, apart from mandatory good optics and equipment. The short operating time in this series reflects the conducive nature of less number of stones (1–7), adhesions encountered in only 3 patients, and several decades of advanced laparoscopic experience of the operating surgeon in a high-volume center. The other series report relatively longer operative times; there may be other confounding patient characteristics causing that difference.
Laparoscopic technique for treatment of benign biliary obstruction offers all the advantages of minimally invasive surgery, with less pain, less need for analgesia, early return to home and work, and less wound complications. We were able to provide all these advantages, with our mean duration of stay being 4.5 days. We believe that less pain and secured anastomosis played vital role in discharging our patients earlier. This was also borne out in the other compared studies.
Blood loss in CDD can be massive or even fatal if injury to portal vein or hepatic artery occurs. Another cause of torrential hemorrhage is injury from the collateral vessels in cases of portal biliopathy. None of our patients had either portal biliopathy or injury to the adjacent big vessels. Hence our mean blood loss was 160 ml. In 3 patients we had slightly higher bleeding (220 ml) due to the need for adhesiolysis between the bile duct and adjacent structures. Other series report 186 ml (Aguirre-Olmedo) and 143.3 85.5 (Jagdish Chander).
An anastomotic leak is a nightmare for any surgeon and may result from a number of factors independent of technique, such as patient age, comorbidities, nutrition, and level of jaundice. The leak can be minor or major. Minor leaks can be managed by interventional drainage and settle with conservative therapy. Major leaks require operative intervention and diversion with lavage to treat the peritonitis and sepsis. We had one patient who developed abdominal pain and tachycardia on the 1st postoperative day. An ultrasound scan of the abdomen revealed collection in the Morrison's pouch which was drained under ultrasound guidance with a pigtail catheter. The patient stayed in the hospital for 7 days and went home after removal of the catheter on the 7th day. We had no major leaks. The Bayramov and Jagdish Chander series have also reported one minor leak each. One major leak has been reported in Bayramov series.
Despite CDD being a treatment modality for recurrent CBD stones, recurrent or retained stones can occur after CDD. By ensuring meticulous confirmation of duct clearance with an intraoperative choledochoscopy, our series did not have retained or recurrent stones; one case of recurrent stone occurred in Bayramov series.
In global series with follow-up of up to 20 years, ascending cholangitis is reported to be rare (1%) when the surgery was performed with an initial stoma size of at least 2.5 cm. We found that to be factual in our series; two cases of cholangitis were reported in Bayramov series.
In CDD, the bile drains through the newly created stoma into the first part of the duodenum, bypassing the normal anatomical distal bile duct. This may lead to accumulation of debris in the distal excluded bile duct portion, resulting in sump syndrome. This was first reported in 1976. The underlying pathogenetic mechanism is reduced peristalsis of the excluded segment. As the symptoms are nonspecific, a high index of suspicion is needed. Among the series compared, only Bayramov series reported the problem. We did not encounter this problem, neither did the other two series, suggesting a lower than perceived incidence of the problem.
Postoperative morbidity after choledochojejunostomy (CJ) is reported as 20%–33%, and mortality as 1%–2%. Thus, the evidence does not suggest that CJ has less morbidity than CD.
We prefer to decompress the bile duct with CD rather than CJ because it is technically easier to anastomose the bile duct to duodenum rather than taking a Roux loop and constructing a bile duct–jejunal anastomosis, besides lowering operative time and cost. Furthermore, Roux-en-Y anastomosis warrants two anastomoses as compared to CD, adding a potential leak site. In addition, a Roux-en-Y creates a defect in the mesentery which predisposes to internal herniation despite meticulous closure. Very importantly, a choledochoduodenal anastomosis keeps the natural pathway open for further endoscopic intervention if necessary, unlike after a CJ. This has been emphasized in a French study by Panis et al.
| Conclusion|| |
Our series, the largest thus far reported in literature, with the longest follow-up, suggests that LCDD appears to be a definitive, safe, and effective solution for bile duct stricture with or without CBD stones. It should be the treatment of choice for patients with failed ES, persistent or recurrent cholestasis and stones following ES, narrow strictures and impacted stones. It also provides an opportunity for endoscopic resolution of any secondary biliary complications that may occur. However, a larger sample size would be required to confirm these outcomes and conclusions.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]