Sump Syndrome as a Complication of Choledochoduodenostomy

Abstract

Case Presentation and EvolutionA 71-year-old man initially underwent open cholecystectomy for biliary colic in 1990. Since then, he had been well until new symptoms began in 2009, when he presented to a community hospital reporting intermittent epigastric pain; ultrasound and computed tomography (CT) scans revealed choledocholithiasis.Because an endoscopic retrograde cholangiopancreatography (ERCP) and stone extraction at that hospital were unsuccessful, the patient underwent exploratory laparotomy with common bile duct (CBD) exploration, during which a CBD stone was removed and a side-to-side choledochoduodenostomy (CDD) was performed.Several months following temporary postoperative relief of his symptoms, the patient developed recurrent episodic right upper quadrant and epigastric pain, but without associated jaundice or fever. He was referred to Stanford University Medical Center, where he was seen by a gastroenterologist for evaluation and further management.His past medical history included atrial fibrillation, hyperlipidemia, diabetes mellitus type II, and vestibular neuritis. Drug history included metoprolol, atorvastatin, metformin, dabigatran, dronedarone, and diltiazem. The patient had no known drug allergies. Socially, the patient did not smoke and enjoyed only occasional alcohol. There was no family history of biliary tract disease.On examination, the patient appeared well and comfortable, was slightly underweight, and had a soft and nontender abdomen. The subcostal incision from his original surgery was visible but appeared well healed. Laboratory findings, including liver function tests, were normal (WBC 7.9, Hb 13.4, Hct 39.4, Plts 257, Na 139, K 3.9, Cl 104, CO2 23, BUN 12, Cr 0.9, PT 15.4, INR 1.3, PTT 48.5, T Bili 0.7, ALT 39, AST 16, Alk P 143, Glu 113, Ca 9.2). An echocardiogram revealed mild mitral, aortic, and tricuspid valve regurgitation, with an ejection fraction of 54%. Magnetic resonance cholangiopancreatography (MRCP) revealed a grossly dilated and tortuous CBD, as well as dilated common hepatic and intrahepatic ducts (Fig. 1a). A fluid-debris level was also seen in the CBD (Fig. 1b).Endoscopy revealed a patent side-to-side CDD anastomosis that could be entered with the gastroscope (Fig. 2). Moderate amounts of vegetable debris were seen in the CBD, and were removed using a rat-toothed forceps (Fig. 3). Using a duodenoscope, the CBD was also cannulated through the ampullary orifice and contrast injection showed an 18-mm-wide CBD with contrast extravasation through the stoma. Filling defects revealed further debris in the distal CBD, which were cleared using a balloon catheter through the CDD.Following ERCP, the patient was immediately relieved of his symptoms. However, within a few days, the symptoms recurred, and, again, included epigastric pain without jaundice or fever. Multiple further ERCPs were necessary, each revealing similar findings of vegetable debris within the CBD. Despite clearing the CBD during each procedure, the debris re-accumulated and symptoms always recurred.

Taking an Alternate Route Home: Stenting of Choledochoduodenal Fistula

“…Sump syndrome may occur as a complication of allowing biliary drainage through an alternative route like CDF, as the food, stones, and debris accumulate at the distal CBD, thereby further obstructing normal biliary drainage. 6 CDFs can be treated surgically; however, a surgical option may not be appropriate in patients requiring palliative care. 7 As we demonstrate, endoscopically stenting these CDFs may serve as a reasonable alternative pathway for allowing biliary drainage and palliation when percutaneous transhepatic catheter drainage cannot be pursued.…”

Taking an Alternate Route Home: Stenting of Choledochoduodenal Fistula

“…Sump syndrome may occur as a complication of allowing biliary drainage through an alternative route like CDF, as the food, stones, and debris accu-mulate at the distal CBD, thereby further obstructing normal biliary drainage. 6 CDFs can be treated surgically; however, a surgical option may not be appropriate in patients requiring palliative care. 7 As we demonstrate, endoscopically stenting these CDFs may serve as a reasonable alternative pathway for allowing biliary drainage and palliation when percutaneous transhepatic catheter drainage cannot be pursued.…”

Is It Really SUMP Syndrome? A Case Report

“…Sump syndrome or blind sac syndrome is a rare, long-term complication in patients with a history of a side-to-side choledochoduodenostomy (CDD) [1-3]. Side-to-side CDD was originally performed to achieve decompression of the biliary ducts, typically the common bile duct (CBD), with low morbidity in high-risk patients, which was done in the era before ERCP (pre-ERCP) [1,3-4]. Most surgeons consider it the last resort in elderly patients with abnormally wide ducts [3].…”

“…The term “sump” comes from the segment of the common bile duct between the anastomosis (biliary-enteric) and the Ampulla of Vater, which may act as a stagnant reservoir for debris, stones, and static bile, i.e. sump [1,4,8-10]. This predisposes the patient to inflammatory/infectious changes in the biliary tree, with signs and symptoms including intermittent pain and tenderness in the right upper quadrant (RUQ), fever, jaundice, chills, nausea, and vomiting [2,6-8,11].…”