Mind the Sump! - Diagnostic Challenge of a Rare Complication of Choledochoduodenostomy

Abstract

Sump syndrome is a rare long-term complication of side-to-side choledochoduodenostomy (CDD), a common surgical procedure in patients with biliary tract disease in the era before endoscopic retrograde cholangiopancreatography (ERCP). Frequently only pneumobilia, serving as sign for functioning biliary-enteric anastomosis, is reminiscent of the former surgery. We present the case of an 81-year-old patient with sump syndrome who presented with clinical signs of ascending cholangitis, decades after the initial CDD procedure. Finally the detailed medical history that was taken very thoroughly in combination with the presence of pneumobilia led to the suspicion of sump syndrome. Sump syndrome was diagnosed by ERCP, and after endoscopic debris extraction and antibiotic treatment the patient recovered quickly. In the ERCP era little is known about CDD and its long-term complications, especially by young colleagues and trainees. Therefore this report provides an excellent opportunity to refresh the knowledge and raise awareness for this syndrome.

Evaluation of choledochoduodenal anastomosis in benign biliary obstruction

“…CDA is associated with a low incidence of dehiscence (from 0% to 3.5%) [20][21][22]25 . In one patient in our study, a minimal anastomotic dehiscence with the appearance of a controlled biliary fistula was reported, which was conservatively treated and controlled till it resolved (without any reintervention).…”

Sump Syndrome: A Rare Long-Term Complication of Choledochoduodenostomy

“…In the setting of a side-to-side CDD, the bile does not drain through the distal CBD anymore. Therefore the part of the CBD distal from the CDD anastomosis consequently transforms into a poorly drained reservoir, making this so-called “sump” prone to accumulation of debris [ 1 ]. Sump syndrome was first described in 1976, with a wide prevalence ranging from 2.5 to 15.7% after CDD [ 8 , 9 , 10 , 11 ].…”

“…Nowadays, CDD is widely replaced by ERCP [ 12 ], but we are still faced with its consequences and long-term complications in elderly patients due to global migration of people to the United States from developing and underdeveloped countries where ERCP is still not being used as a standard procedure. Sump syndrome is not precisely defined, but it results from accumulation of lithogenic bile, debris, or calculi as well as refluxed duodenal contents in the distal CBD, leading to biliary and/or pancreatic complications [ 1 ]. According to Marbet et al [ 13 ], reduced filling pressure as well as reduced peristalsis and drainage of the distal CBD caused by the upstream anastomosis play an important role in the pathophysiology of sump syndrome.…”

“…It can present with a variety of symptoms and clinical pictures such as recurrent pancreatitis, colicky pain, jaundice, and cholangitis. Therefore, the diagnosis of sump syndrome is challenging because no characteristic clinical or laboratory finding is highly specific [ 1 ]. Taking a detailed past medical history and having a high degree of suspicion appear to be the most important elements for diagnosing sump syndrome.…”

“…Sump syndrome is a rare long-term complication of side-to-side choledochoduodenostomy (CDD), a common surgical procedure done with cholecystectomy to improve biliary drainage done in the era before endoscopic retrograde cholangiopancreatography (ERCP) [ 1 ]. CDD is usually done for retained biliary stones or a dilated common bile duct (CBD).…”