Discussion
This case demonstrates an open hepaticoduodenostomy procedure being used
to rescue the adverse sequelae of an impacted distal CBD stone in a low
resource setting. A choledochoduodenostomy (CDD) had traditionally been
indicated for palliation in patients with CBD obstruction caused by
malignancy, or in elderly patients with impacted stones [5]. A
recent prospective study demonstrated CDD as highly effective treatment
for choledocholithiasis (CBD stones) in the presence of a dilated CBD,
in all age groups with low morbidity and mortality provided a wide
anastomosis was accomplished [6]. It has been reported as a more
effective treatment of CBD stones than T-tube drainage but regarded as
an obsolete therapeutic method due to fears of higher morbidity, reflux
cholangitis, hepatic abscess, stone recurrence, pancreatitis and
“sump” syndrome [7]. ‘Sump’ syndrome is theorized to occur from
bile stasis and reflux of duodenal contents into the terminal CBD with
bacterial overgrowth, resulting in cholangitis or hepatic abscess. The
side- to-side CDD is a safe and definitive procedure for the
decompression of lower CBD obstruction and has good long-term results
with infrequent complications including the ‘sump’ syndrome [8].
Because of the re-sutured dehisced cystic duct stump and, the
inflammation and adhesions below, a higher approach (
hepaticoduodenostomy) was utilized (Figure 2). It is essential to ensure
that the choledocho/hepaticoduodenostomy is at least 2.5 cm long in
order to avoid stenosis, recurrent cholangitis and further stone
formation [9]. Except for significant post-operative biliary leakage
which was managed conservatively, the outcome was successful as the
jaundice, pain and rigors resolved. Biliary anastomoses do not seal
easily as intestinal anastomoses and, thus the indication for a
sub-hepatic drain [10]. A hepaticoduodenostomy for obstructive
common bile duct stone has not been reported in the English literature.
Hepaticoduodenostomy (HD) is becoming an alternative to the Roux-en-Y
hepaticojejunostomy (HJ) in reconstruction after excision of a
choledochal cyst because of fewer complications such as adhesive bowel
obstruction, anastomotic leakage and peptic ulcer. Apart for higher
postoperative reflux/gastritis it has a shorter hospital stay and
similar operative benefits and outcome [11]. The utilization of HD
for type IV Mirizzi’s syndrome has also recently been reported [12].
Approximately 12% of patients undergoing surgery for symptomatic
gallbladder stones will also have stones in the CBD [13]. It is
appropriate that most patients with CBD stones are treated at the time
of cholecystectomy. Thus the importance of performing intra-operative
cholangiography during a cholecystectomy and exploring the CBD to
retrieve any stone. The lack of fluoroscopy (image intensifier),
fibreoptic instruments (choledoscope) or radiologically guided wire
baskets or balloons in our setting did not make this possible. The
operative hazards in blindly exploring the common bile duct for
retrieving an impacted distal stone using a Desjardin (stone-grasping)
forceps, or a Bake’s dilator that can be passed down the CBD to allow
division of the papilla and biliary sphincter in a transdudenal
sphincteroplasty include damage to the biliary tree and the production
of a false passage by overzealous instrumentation [14]. There is
also the risk of damage to the hepatic artery or portal vein [1,
13]. A post- ERCP and sphincterotomy for retrieval of the impacted
stone if available would have been useful in this case, but if it failed
an open exploration is indicated (Figure 1) [1].Currently, the
rational utilization of laser lithotripsy and an appropriate basket in
laparoscopic common bile duct exploration (LCBDE) may avoid conversion
to open procedures in patients with impacted CBD stones [3, 15].
Generally, the laparoscopic approach has the advantage for the patient
over ERCP and sphincterotomy by being able to deal with the gallbladder
and CBD stone/s simultaneously (i.e. laparoscopic cholecystectomy and
laparoscopic intra-operative CBD exploration). This is corroborated by
the fact that the standard treatment for symptomatic gallstones is
laparoscopic and there are few exceptions to a trial of a laparoscopic
approach. However, open bypass procedures such as a hepaticoduodenotomy
may be an alternative to the traditional choledochoduodenostomy in the
management of the retained, impacted distal CBD stone especially in the
presence of sepsis and adhesions around the supraduodenal common bile
duct and, in a low resource setting [16].