External choledochoduodenostomy. An evaluation of 125 cases

Abstract

EXTERNAL choledochoduodenostomy is an operation which, although it has been practised for well over 70 years, has had varying degrees of popularity, and has never been widely accepted. The uncertainty has probably arisen from the fact that, although small groups of cases have been spasmodically reported from various centres, no large group has been analysed to determine the long-term effects, both on the common duct itself, and secondarily on the liver. Moreover, certain cases have been quoted from time to time where the common bile-duct after choledochoduodenostomy has become occluded by food debris such as tomato skin, leading to intermittent jaundice and fever. Most surgeons have therefore been very cautious about the operation. Obviously a follow-up on this operation must first of all determine whether the stoma remains patent; previous reports seem to have neglected this aspect. The following survey of 125 cases, operated on between 1947 and 1960, has been carried out over the last 3 years in order to determine the above and other factors, and generally to evaluate the operation. The average interval between operation and review was 5 years 3 months, the longest 10 years and 3 months, and the shortest 12 months. HISTORYRiedel was the first to report the operation in a brief paper produced in July, 1888 (I888a, b). Plenk (Plenk and Hartl, 1949; Hartl and Raindl, 1951) of Lenz, in 1949, reported on 95 cases he had treated privately, with I post-operative death. Seventy-one of these cases had a frankly purulent cholangitis secondary to stones. H e also described 293 hospital cases and states that no case of post-operative ascending cholangitis had been encountered in any of these. He emphasized that purulent cholangitis would be cured if the stoma was large enough, as the most important thing was drainage. Becker Bernhard (1950) insisted that purulent cholangitis was not an ascending infection from the duodenum but a descending, and that all cholangitis is rapidly cured when the bile can escape freely. He regarded the operation simply as the right way of draining an abscess.Finsterer wrote several papers on the subject from 1932 onwards (1932, 1942a, b, 1952), and in 1952 reported enthusiastically on 233 cases where the operation was carried out largely for suppurative cholangitis, or when white bile was present. Many of these cases were done at the time of famine edema, and yet his mortality was 12 per cent. This was less than his mortality for drainage of the common duct, which was 21 per cent, and for transduodenal choledochotomy, which was 27 per cent. He noted that, with a follow-up of from 3 to 25 years, the late results were good and no ascending infection was observed. Three were reported not cured and in 2 cases the stoma had closed. He found that the late results were better than after biliary drainage or transduodenal exploration of the ampulla. He emphasized that the operation gave a lower mortality and better longterm results, and that it was essential for the stoma to be 2-3 cm. in length.Sanders...

Choledochoduodenostomy in treatment of chronic pancreatitis and choledocholithiasis.

“…She has remained well since then. Capper (1961) reported his series of choledochoduodenostomies in which a similar technique to ours was used. He found that all nine patients with chronic pancreatitis were completely relieved.…”

“…Hosford (1957) and Capper (1961) in this country and Sanders (1946) and Hurwitz and Degenshein (1964) in America all report no recurrence of calculi after side-to-side choledochoduodenostomy for choledocholithiasis. These results, together with our own findings, confirm our belief that this operation is now the treatment of choice for multiple stones in the common bile duct.…”

Choledochoduodenostom a reappraisal of its indications based on a study of 64 patients

“…-- Table Z gives the indications for choledochoduodenostomy with benign disease in this series, and Table IZ compares these with two other series (Capper, 1961;Madden and others, 1970), in which the similarities will be noted.…”

Spontaneous closure of choledochoduodenostomy: Diagnosis by endoscopy and ERCP

“…Many writers favour choledochoduodenostomy as the operation of choice for lower common bile duct obstruction (21,(25)(26)(27) and routinely following exploration of the common bile duct (28), but this view is not shared by Kune (29) who stated that the long term failure rate following choledochoduodenostomy is about three times greater than after transduodenal sphincteroplasty and that the latter operation is probably advisable in the younger or fitter patient where a biliary drainage procedure for benign disease is indicated. This controversy is well illustrated by the findings in our patients in whom complete closure of the choledochoduodenostomy occurred despite there having been a stoma of at least 2cm in diameter, as recommended by Johnson and Stevens (30).…”