HPB Surgery, 1996, Vol.10, pp.27-33
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Choledochoduodenostomy in the Management
of Common Duct Stones or Associated
Pathology- An Obsolete Method?
ANTONIO CASTRO MENDES DE ALMEIDA, NOEL MEDINA DOS
SANTOS and FERNANDO JOSI ALDEIA
University Hospital of Santa Maria- Medicina Operat6ria, Lisbon Medical School, Av.Egas Moniz,
1699 Lisboa Codex Portugal
(Received 17 December 1994)
Choledochoduodenostomy (CDD) has been reported as a more effective treatment ofCBD stones than T-
tube drainage but it is regarded as a last resort or obsolete therapeutic method due to fears of higher
mobidity, cholangitis, "sump" syndrome and liver dysfunction. We aimed to assess the aforementioned
issues analyzing prospectively our experience from 1976 through Dec.92.
Methods: CDD was performed in 89 females and 36 males,, aged 60.2+8.7 years, 26 during repeat surgery.
Duct stones were the indication in 94, Sphincter ofoddi (SO) dysfunction in 23 and obstructive pancreatitis
nodule in 8. Peroperative liver biopsies were obtained in 44 patients. The "follow-up" schedule (> 2.5 years
in 110) included clinical interview and LFT's on an yearly basis. Ultra sound (USG) was obtained every
one or two years. ERC was done in 10 symptomatic patients and in 25 others for protocul purposes. Liver
biopsies were taken four to nine years post surgery in 11 patients-five at relaparotomy for non-biliary
causes and six percutaneously by fine needle. Ductal mucosa biopsy could safely be performed in one
patient 10 years after surgery. The long-term results were classified as excellent, good,fair or poor. Poor
meant the need for further invasive therapy (resurgery or EST).
Results: There were two operative deaths (1.6%). The long-term results (123 survivors) were considered
excellent in 89, goodin 22,fair in 9 andpoor in three. Three patients died from unrelated causes and eight
others ceased the "follow-up" evaluation three to five years post surgery. All of them were considered as
having excellent or good results. A widely patent anastomosis of approximately 20 mms without mucosal
inflammatory changes was documented in every patient assessed via ERC. food "debris" was detected
within the distal duct of four patients yet it was easily flushed through the stoma. Normal tissue patterns
were observed in all long-term liver biopsies. Likewise the ductal mucosa biopsy failed to reveal any acute
or chronic inflammatory changes.
Conclusions." 1) CDD is ahighly effective short and long-term treatment of CBD lithiasis.2) It does not
lead to bacterial or "chemical" cholangitis, to "sump" syndrome or to hepatic dysfunction, provided a wide
anastomosis is accomplished.3) CDD should only be considered as obsolete after extensive, long-term,
prospective, randomized assessments of laparoscopic or combined laparoendoscopic approaches have
been shown to be as effective as or superior to CDD.
KEY WORDS: Common duct lithiasis laparoscopic cholecystectomy
bilio-digestive anastomoses cholangitis choledochoduodenostomy
INTRODUCTION
It is no longer disputed that laparoscopic cholecy-
stectomy is the procedure of choice in a large propor-
tion of patients suffering from symptomatic biliary
Correspondence to: Dr. A. C. Mendes de Almeida Praa Principe
Real, 23-3 Esq, 1200 Lisbon Portugal.
lithiasis. However controversy still remains as to what
should be considered the optimal treatment for pa-
tients who in addition to gall-bladder (GB) calculi also
harbour common bile duct (CBD) stones. Endoscopic
sphincterotomy (EST) became widely accepted as the
most appropriate treatment ofretained/recurrent duct
stones independent of the patient's age and risk. It is
also the most judicious treatment for CBD calculi in
elderly or otherwise "unfit" patients with GB "in situ".
27
28 A.C.M. DE ALMEDIA et al.
Thus, endoscopic removal of duct stones followed
by laparoscopic cholecystectomy is becoming the an-
ticipated scenario of the future because a higher inci-
dence ofduct stones occurs in people over 65. Shouldthe
duct calculi be detected laparoscopically, the re-
verse approach seems to be preferable. Nevertheless it
has been shown that EST doesn't offer significant
advantages with respect to morbidity, mortality and
success as compared to conventional CBDE1, and
that "fit" patients should be treated by surgery alone
without properative EST 2. There are two other ran-
dom and prospective studies that concluded that EST
followed by conventional or laparoscopic surgery
is not superior to surgery alone. Moreover debate
continues to question whether sphincter restenosis
and/or stone reformation are a long-term risks follow-
ing EST 5. Thus, although EST followed by surgery
may be regarded as an appealing approach 6, open
CBDE is still preferred by a large number of sur-
geons, specifically when deciding the most appropri-
ate therapy for a young, "fit", patient for whom the
long-term effectiveness of the elected procedure is a
major factor.
Among the various surgical modalities at our dis-
posal, choledochoduodenoustomy (CDD) has been
shown to be more effective when compared to tempo-
rary T-tube decompression in avoiding long-term mor-
bidity secondary to retained /recurrent stones7-1.
However, many surgeons consider CDD as a last re-
sort and even as obsolete due to fears of increased
operative morbidity and mortality risks, long-term
bacterial or "chemical" cholangitis and the possible
occurrence of the "sump" syndrome. There are also
concerns of eventual hepatic dysfunction and/or
parenchymatous changes resulting from repeated
bouts of cholangitis, from long-standing duodeno-
choledochal reflux of enteric secretions, or from the
loss of sphincter of oddi activity.
Continuing a previously reported study 11
we have
continued to investigate whether or not these fears
and/or alegations are justified and to define the short
and long-term efficacy of CDD.
PATIENTS, METHODS
This study reports the analysis of data retrospectively
retrieved from January 1973 through December 1975
and prospectively documented from 1976-Dec. 92 ac-
cording to a protocol. It relates to a consecutive series
of 125 CDD which were part of the management of
symptomatic biliary lithiasis. Table summarizes the
Table 1 Summary of data relating to 125 CDD (Jan.73-Dec.92)
Data Nr. %
Female Patients 89 71.2
Age (X+3xsd) in yrs 63.1+3x9.7
Male Patients 36 28.8
Age (X+3xsd) in yrs 58.7+3x 13.2
Nr. of Patients<50 yrs 28 22.4
Nr. of Patients>70 yrs 32 25.6
Primary Surgery 99 79.2
Resurgery 26 20.8
Duct width 10-15 mms 39 31.2
Duct width> 15 mms 86 68.8
Operative Morbidity 12 9.6
Operative Mortality 2 1.6
Choledocholithiasis 94 75.0
Obstructive Pancreatitis Nodule 8 6.0
SO dysfunction 23 18.0
data related to this sub-group of patients. Wgure
outlines our approaches to GB and CBD lithiasis
during primary and secondary surgery. All of the
aforementioned patients were evaluated and operated
upon by the same surgical team. The senior author was
either the acting surgeon or the first assistant attend-
ing the Chief Resident. Thus a uniform set of criteria
was ensured.
Other than a "standard" evaluation, the preopera-
tive "work-up included oral cholecystography (OCG)
or ultrasonography (USG), serum proteins and bio-
chemistry profiles, and liver function tests (LFT). The
clinical suspicion of actual or past presence of intra-
ductal calculi and/or of sphincter of Oddi dysfunction
(SO) would prompt us to obtain an intravenous
cholangiography (IVC) and/or endoscopic retrograde
cholangiography (ERC). We used IVC to confirm or
rule out the presence of a dilated CBD (>10-12 mms)
as suggested on USG. Most importantly we used it to
confirm the possible existence of a sluggish biliary
drainage into the gut 11, even though this test is known
to be unpredictable in diagnosing duct stones. The
criteria for the diagnosis of SO dysfunction and/or an
increased likelihood of choledocholithiasis were as
follows: 1) complaints of upper abdominal pain after
meals, 2) intermittent jaundice (bilirubin >3 mgrms), 3)
biochemichal cholestasis, 4) presence, up to 120 min-
utes, ofcontrast material within a dilated duct on IVC,
5) indications of a dilated duct on USG. Two or more
of these criteria complementing our clinical assess-
ment would prompt us to perform an ERC and/or a
thorough intra-operative search for the actual pres-
ence of intra-ductal calculi. This evaluation would
include a wide kocherization, a careful extra-ductal
and pancreatic head palpation, a direct measure-
ment of the duct diameter with a ruler above the
CHOLEDOCHODUODENOSTOMY- IS IT OBSOLETE? 29
57,5 w/out CBDE (3+)
709 CHTS, Stones 97
134 with CBDE(19%) SO dysf. 29
Pancreat.Nod. 8
T Tube
SPT o
CDJ
35 REOPER. CDE g22
Stones 19 [ T Tube
SO dysl'. 9
1SPT 3
Strictures, 5 D CDJ s (1')
Pancreat.Nod. 2 2 (1+)
Figure 1 Schematic outline of the surgical approaches to symptomatic biliary lithiasis during primary and secondary surgery
(Jan.73-Dec.92)
CHT-Cholecystectomy; CDE-Common Duct Exploration
SPT-Sphincteroplasty CDJ-Choledochojejunostomy
+-Operative Death; *-Referred from elsewhere
40
30
20
n=9
tO n=5
n=19
=29
Black Pigment
Mixed
Brown Pigment
Figure 2 Percentage of various types of duct calculi according to the morphological criteria of Madden [12], prospectively classiffied
(Jan.79-Dec.84)
cystic-choledochaljunction and, in selected instances,
an operative cholangiogram (OPC). Operative USG
or choledochoscopy were no used.
When deemed necessary a longitudinal choledocho-
tomy, following guidelines previously described ll,
would confirm or rule out the actual presence ofstones
and/or inflammatory changes such as thickened duct
walls, fibrin strands, hyperemic mucosa or biliary
"mud". As reported before 7,10, and herein illustrated
in Figure we broadened the indications for CDD in
the management of dilated (>10-12 mms) stone-con-
taining ducts. The choledocho-duodenal anastomosis
and corresponding technical requisites were already
reported 1. The fundamental aim was the construction
ofa wide (>20 mms), side-to-side, well blood-supplied
anastomosis. Stents were never used. The detection of
fibrotic scars or inflammatory changes secondary to
duodenal peptic ulcer disease or cholecystocholedo-
cho-duodenal fistula or any other anatomical distor-
tion contraindicated performing a CDD on various
occasions. Thus, some other form of biliary drainage
was considered (Figure 1).
Peroperative liver biopsies were obtained upon
written consent in 44 patients. From January 1979
through December 1984 we prospectively classified, as
per Madden's criteria 12, the intra-ductally detected
stones. As documented in Figure 2 these were classi-
fied as 1) pure cholesterol stones, 2) brown pigment,
calcium bilirubinate, stasis stones, 3) black pigment
calculi and 4) mixed type of stones. The prospective
"follow-up" schedule, covering more than four years
in 91 patients and over 12 years in 38 (Fig. 3), included
clinical interview by independent observer and LFT's
(same as preoperatively) every four to six months for
one year and yearly thereafter. USG was obtained
every one or two years. ERC was deemed necessary in
10 symptomatic patients and, for protocol study pur-
poses, was performed in 25 other consenting patients
three to six years post surgery. Our aim was to look for
retained/recurrent stones, mucosal inflammatory
30 A.C.M. DE ALMEDIA et al.
z:IS choledochoduodenostomies
112 Known tO b 3 'Late
at 18Lostto'lO:llow.up
AIIve>12 months 2/,...4% / 13-5Yrs Postop
90%
II1111
91 > 4 Yrs .."
38> 12 Yr$ ............
.....................'"
OP. Deaths
1.6%
EXCELLENT 89 (72%)
GOOD 22 (18%) results
long term )..
FAIR 9 (08%)
>"
P(X)R 3 (02%)
Figure 3 Length of"follow-up" and classification of long-term results of 123 CDD after a mean number of 9.3+3x4.2 years.
changes at the anastomotic level, the possible presence
of food "debris" within the distal "cul-de-sac" or any
other anatomical abnormality. Endoscopic biopsy of
the duct mucosa could be safely taken in one patient
10 years after surgery. Liver biopsies were obtained
four to nine years postoperatively in 11 consenting
patients five at relaparotomy for non-biliary causes:
carcinoma of the colon in two, gastric peptic ulcer in
one, ventral incisional herina in one and distal eso-
phageal peptic stenosis in one. Six had the biopsy
percutaneously by fine needle.
Based on the data, long-term results were classified
(Fig. 3). Excellent was defined as freedom from any
symptoms related to the biliary or upper G.I tract the
operation or a complication of the CBDE. Good was
defined as occasional and minor GI upset, psychoso-
matic complaints or wound imperfections, with nor-
mal LFT,s. Fair was defined as significant complaints,
manageable by non-invasive treatment, such as those
ascribable to the blindsac syndrome or to duodenal-
gastric reflux documented on endoscopy, with abnor-
mal LFT's in at least one occasion.Poor was defined as
residual or recurrent stones, cholangitis,jaundice and/
or severely deranged LFT's requiring further invasive
therapy- resurgery or EST.
Operative death or complications were considered
as those occurring within 30 days of surgery. Only
complications delaying the patient's discharge were
accounted for in Tables and 2. A wound infection
was defined as one with purulent discharge irrespec-
tive of negative bacteriology. Acute cholangitis was
diagnosed when the corresponding clinical syndrome
(jaundice, high spiking fever with rigors, sepsis, leuko-
cytosis) was confirmed by deranged LFT's and USG.
The persistence ofbile drainage through the operative
wound or out of a drain site that lasted for more than
five to six days or its radiographic documentation
by contrast extravasation, was taken as evidence of
Table 2 Postoperative Complications in 123 Patients (two opera-
tive deaths not included)
Complication Nr. %
*Wound Infection 5 4.1
*Pneumonia 2 1.6
*Congestive Heart Failure 2 1.6
*Biliary Fistula 2 1.6
*Sepsis 0.8
*Total 12 9.8
biliary fistula. The causes of death were established at
postmortem examination.
SHORT TERM RESULTS
There were two operative deaths (1.6%). A woman of
74 died on the seventh postop day of primary surgery
from massive upper GI bleeding. An intact stoma was
documented during autopsy. A woman of 62 died on
the third postop day after resurgery. Necrotizing pan-
creatitis with anastomotic disruption was observed on
postmortem examination. This patient had had sev-
eral episodes ofpancreatitis andjaundice after having
been submitted to cholecystectomy, choledocholitho-
tomy and T-tube decompression at another hospital
three years prior to being admitted to our Institution
withjaundice. Ofthe remaining 123 patients, 12 (9.8%)
developed significant morbidity (Table 2).
In 44 patients clinical and biochemical evidence of
jaundice and cholestasis was discernible on the day of
admission. Acute, non-suppurative, cholangitis was
the presenting clinical syndrome of 14 patients (11.2%).
Althoughunder antibiotic coverage, this syndrome com-
pletely subsided only three to five days after CDD had
been performed in five of the aforementioned patients.
Twenty-nine of 62 choledochal stones (46.7%)
were considered to be of pure brown pigment type.
CHOLEDOCHODUODENOSTOMY- IS IT OBSOLETE? 31
Evidence of peripheral layers of calcium bilirubinate
deposited around a central hard nucleus was observ-
able in 19 others (30.6%), as illustrated in Figure 2.
Evidence of cholestasis, suggesting large duct ob-
struction, was detectable in all 44 peroperative liver
biopsies.
cholestasis requiring further invasive therapy. All of
the other patients maintained normal LFT's (Table 3)
one to 19 years (9.3+34.2 sd) post CDD.
DISCUSSION
LONG-TERM RESULTS
Three patients were considered to have had a poor
result while most remained asymptomatic (72%) one
to 19 years (9.3+34.2) after having undergone a
CDD (Fig. 3).
A widely patent, oval or round-shaped anastomosis
was documented in all 35 patients undergoing long-
term endoscopic assessment. Endoscopically discern-
ible inflammatory changes, both distant and adjacent
to the anastomoticjunction, were not observed on the
duodenal or ductal epithelial linings. A ductal mucosa
biopsy 10 years after CDD revealed a normal histo-
logical pattern. Specifically, hyperplasia and hypertro-
phy of the mucous glands, which have been described
as striking features of chronic choledochitis 13, were
noticeably absent.
Although easily floating in and out the stoma, food
"debris" could be documented in four patients who
were otherwise asymptomatic. Retained/recurrent sto-
nes could not be detected on long-term ERC. Three
patients in whom we knowingly left behind distally
impacted calculi deemed to be irretrievable at the time
of surgery also were found without stones on ERC
examination.
Normal tissue patterns were seen in all specimens of
11 patients evaluated by liver biopsy more than four
years after surgery although evidence of cholestasis
suggesting large duct obstruction had been documen-
ted on peroperative liver biopsy in all of them.
Out of 123 long-term survivors, three patients sho-
wed persistent evidence of biochemical and clinical
When treating a patient suffering from symptomatic
CBD stones, one ofseveral approaches may be consid-
ered. Classically, a laparotomy, cholecystectomy and
CBDE followed by one ofvarious forms oftemporary
or definitive drainage of the biliary tree is performed.
Another type of management is an EST sometimes
followed by laparoscopic or conventional cholecys-
tectomy14. Laparoscopic choledochotomy and/or
transcystic clearance of duct stones is yet another
possible approach 15
though it needs further clinical
assessment. If the surgeon is treating an elderly, or
other higher risk patient the favoured option is the
endoscopic approach. This option is also preferred in
the presence of retained/recurrent calculi, independ-
ent of the patient's age and risk. A quite different
challenge is raised when treating a young, "fit" patient
in whom a more aggressive stone forming diathesis can
be expected thus increasing the possibility of acute
cholecystitis or of long-term reformation of intra-
ductal stones. In this particular situation, an open
CBDE is envisaged in many centers as the most reli-
able treatment modality. As we have already re-
ported v. 10
we favor a liberal utilization of a definitive
decompression of the biliary tree after choledocholi-
thotomy, preferably by way of a CDD, when treating
such a patient. EST and CDD are techniques that
overcome the problems created by the malfunctioning
SO, specifically the retention of missed stones or of
their reformation as a result of retrograde sphincter
pressure waves 16
and/or bile stasis and repeated bouts
of infection 7, 10,
17. Cetta's study 17
is particularly illus-
trative of this outcome. Our findings (Fig. 2) fully
corroborate those of Cetta.
Table 3 Mean values of long-term results of LFTs in 123 patients submitted to
CDD
LFT Normal range Values observed Values observed
in 120 patients three "outliners" +
(X+_-3xsd)
*Bilirubin 1' 0-4 gmol/1 2.2+3xl.6 16 18 22
* Bilirubin 30' 2-20gmol/1 11.9+3x6.2 62; 68; 78
* Alk.Phosphat. 30-90 IU/1 65.3+3x 17.5 320; 340; 360
* GGT 5-38IU/1 26.3+3x10.0 120; 180; 198
GGT Gamaglutamiltranspeptidase
+ Three patients classified as poor results
the only ones out of the range of normalcy
32 A.C.M. DE ALMEDIA et al.
It is undisputable that EST is more comfortable and
offers a shorter hospitalization than a formal opera-
tion. However the short-term effectiveness of retro-
grade EST has recently been shown 18
to be less than
perfect when compared to that of the current study.
Although all-comers were included in ours as well as in
the Manchester series, the immediate morbidity and
mortality rates were not significantly different. How-
ever, a mean number of 1.9 EST session were needed
to achieve a less than optimal 81.6% rate of complete
ductal stones clearance. This data compares unfa-
vorably to what we and others have accomplished with
CDD 19,
20. The complication and mortality risks of
EST have been variously defined and are therefore
not easily interpreted. The mortality of this procedure
has been reported 18,21
as occurring at a rate around 2%
when the same criteria utilized in surgical series is
adopted. It's worth emphasizing that in one of these
series 21, which included all-comers, the mean age ofthe
patients was within the same range as in the current
series. Possibly ofgreater significance is the fact that the
long-term effects of EST remain as yet incompletely
clarified 5, the rate of restenosis and thus the increased
chances of stone reformation having been described as
ranging from 3 to 10% 22,23. It must be stressed that two
recent random and prospective studies 3,
concluded
that the laparoendoscopic appraoch is not superior
to a standard cholecystectomy and CBDE, even in
terms of short-term efficacy. Another study 24
showed that the stone reformation is, actually, en-
hanced after EST and suggested that a non-function-
ing, partially restenosed, SO was responsible. The
data in our study does not support the contention
that bilio-duodenal bypass leads to hepatic dysfunction
resulting from repeated bouts of cholangitis, nor
does it support the claim that significant gastrointes-
tinal complaints such as persistent diarrhoea with
nutritional impairment occur. These complications,
which have been described as the sump or blindsac
syndrome, presumably derive from stasis and reflu-
xed duodenal contents in to the terminal common
duct, with bacterial overgrowth enhancing bile salt
deconjugation. This phenomenon leads not only to
diarrhoea, as observed in the "blind-loop" syndrome
arising anywhere else in the gut, but it also facilitates
deposition and reformation of calcium bilirubinate
stones 17,
24. In the present series, though, only three
patients were considered as poor results consequent
to repeated bouts of cholangitis. Recurrent stones
could not be documented in spite of an exhaustive
search. A very wide anastomosis could possibly be
the explanation.
In one ofthe patients considered to have had a poor
result, severely disturbed LFT's antedated our first
surgical procedure. At the time, a left hepatic duct
stenosis, presumably deriving from previous surgery,
was missed. We eventually corrected this patient's
cholangitic syndrome with a hilar Roux-Y hepatic-
ojejunostomy followed by long-term good results. A
poorly draining CDD, sited too high in the common
hepatic duct was the reason for a poor result in one
other patient. Long-term good results also ensued af-
ter a Roux-Y hepaticojejunostomy in this patient. Up
to this time we are unable to define the exact cause for
the third poor result. Repeated ERC examinations
failed to disclose any evidence of stoma stenosis, re-
current stones or any other form of biliary obstruc-
tion. The long-term results after EST were not entirely
satisfactory in this patient.
The blind-sac syndrome can be avoided by a wide
anastomosis. This prevents stasis, avoids the build-up
of excessive intra-ductal pressure and permits a free
flow of common duct contents including duodenal
refluxate as well as eventual retained/recurrent calculi
back into the duodenum. Using the triangular tech-
nique, as previously described 11, it is technically feasi-
ble to construct a biliary-duodenal anastomosis of
sufficient diameter as to prevent these complications
even on a duct 10 to 12 mms wide. The possible long-
term effects on liver function allegedly resulting from
loss of the odditic sphincter activity remain to be
determined. Certainly there was no evidence in our
study.
In conclusion our data, corroborating others 8,9,19,20,
indicate that CDD is a very safe procedure with mor-
bidity and mortality risks similar to those of EST
whenever similar cohorts of patients are compared.
The alleged late complications of liver dysfunction
and blind-sac syndrome are low enough in incidence
to warrant a broadening of indications for CDD in
young patients. It's beyond any dispute that EST
followed by laparoscopic or conventional cholecystec-
tomy is the most judicious treatment for a great num-
ber of patients with symptomatic duct lithiasis. It's
Worth emphasizing that most patients with this clini-
cal syndrome belong to an age group where other fatal
non-biliary diseases are likely to occur before So
restenosis and/or stone reformation do so. The declin-
ing number ofCDD in the current series, as illustrated
in figure 4, clearly directs our thoughts to this respect.
However in a young, "fit", patient it is our contention
that a carefully performed CDD is the most appropri-
ate, treatment of most dilated stone-containing ducts.
With the current emphasis on laparoscopic procedures
CHOLEDOCHODUODENOSTOMY- IS IT OBSOLETE? 33
%
40
35
30
25
20
15
10
5.
n:38 n-50]" n:21
77-e0 81-84 85-88 89-92
Figure 4 Number and percentage of CDD performed along five sequential periods of four years each.
and the rapidly advancing technology it is our
firm belief that we will be able to perform a correct
CDD entirely by laparoscopic means in the near fu-
ture. Until then, though, only after long-term, exten-
sive, prospective assessments of any other form of
treatment for duct lithiasis in a young population, be it
conventional, purely laparoscopic or combined lapar-
oendoscopic, are able to show an efficacy similar or
superior to that herein reported with conventional
CDD can this procedure be considered as obsolete.
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