End-to-side choledochoduodenostomy: A widely applicable procedure for biliary reconstruction

Abstract

End-to-side choledochoduodenostomy was originally used for reconstruction between the duodenum and the biliary tree in iatrogenic bile duct stricture. However, we believe the procedure could be applied for various biliary disorders. We have recently shown the high carcinogenicity of biliary epithelium in patients with pancreaticobiliary maljunction, and consequently we recommend excision of the bile duct, along with appropriate reconstruction of the biliary system to divert the flow of pancreatic juice from bile fluid, to prevent carcinoma in biliary epithelium even in patients without dilatation of the bile duct. The conditions causing primary or recurrent bile duct stones must be removed. We employed this procedure for biliary reconstruction in 42 patients with pancreatico-biliary maljunction and in 30 patients with various benign biliary diseases, such as bile duct stones and benign biliary stenosis. We also used the procedure for palliation in 6 patients with malignant tumors around the head of the pancreas. Among these 78 patients over 20 years, we experienced 5 cases of reflux cholangitis with anastomotic stenosis, for which conservative dilatation was required. This procedure of end-to-side choledochoduodenostomy could be widely applicable for biliary reconstruction in terms of its being simplicity, minimal invasiveness and the establishment of a single physiological route for bile flow into the duodenum.

Pancreaticobiliary maljunction and carcinogenesis to biliary and pancreatic malignancy

“…The most important point is to create a large stoma to prevent anastomotic stricture [69], which accompanies reflux cholangitis, causing intrahepatic bile duct cancer. Normal-sized bile ducts can be anastomosed without stricture [74].…”

“…For reconstruction methods after excision of the biliary tract, hepaticojejunostomy of Roux-en-Y fashion [14,69] or end-to-side hepaticoduodenostomy [70,71,74] can be used. The former is the most popular and the latter is a minimally invasive procedure.…”

Biliary carcinogenesis in pancreaticobiliary maljunction

“…As for reconstruction of the biliary tract, Roux‐en‐Y hepaticojejunostomy is widely accepted, but end‐to‐side hepaticoduodenostomy is also employed 55,56. Regardless of the method used, free drainage of bile is necessary to prevent ascending cholangitis and intrahepatic stone formation.…”

“…Todani et al55 sterssed that the anastomotic site of the bile duct must be at the bifurcation of the hepatic hilum, but we believe that anastomosis at the common hepatic duct is adequate in a patient who has no intrahepatic biliary dilatation. The size of the anastomosis must be the same as that of the bile duct 56…”

Surgical Strategy for Patients with Pancreaticobiliary Maljunction without Choledocal Dilatation.

“…29 In conclusion, resection of the extrahepatic biliary tract in PBM patients without bile duct dilatation, rather than cholecystectomy alone, should be the treat ment of choice for preventing bile duct carcinoma, the prognosis of which remains poor.…”