Choledochojejunostomy Group Research Articles

What is the better surgical treatment option for recurrent common bile duct stones?

PurposeRepeating endoscopic retrograde cholangiopancreatography (ERCP) in patients with recurrent common bile duct (CBD) stones is problematic in many ways. Choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) are 2 surgical treatment options for recurrent CBD stones, and each has different advantages and disadvantages. The aim of this study was to compare the 2 surgical options in terms of the recurrence rate of CBD stones after surgical treatment.MethodsThis retrospective multicenter study included all patients who underwent surgical treatment due to recurrent CBD stones that were not effectively controlled by medical treatment and repeated ERCP between January 2006 and March 2015. We collected data from chart reviews and medical records. A recurrent CBD stone was defined as a stone found 6 months after the complete removal of a CBD stone by ERCP. Patients who underwent surgery for other reasons were excluded.ResultsA total of 27 patients were enrolled in this study. Six patients underwent CDS, and 21 patients underwent CJS for the rescue treatment of recurrent CBD stones. The median follow-up duration was 290 (180–1,975) days in the CDS group and 1,474 (180–6,560) days in the CJS group (P = 0.065). The postoperative complications were similar and tolerable in both groups (intestinal obstruction; 2 of 27, 7.4%; 1 in each group). CBD stones recurred in 4 patients after CDS (4 of 6, 66.7%), and 3 patients after CJS (3 of 21, 14.3%) (P = 0.010).ConclusionCJS may be a better surgical option than CDS for preventing further stone recurrence in patients with recurrent CBD stones.

Choledochoduodenostomy in Liver Transplantation.

Biliary complications are frequent after liver transplantation and the method of biliary reconstruction is an important factor in this context. When duct-to-duct biliary anastomosis is not applicable, traditionally choledochojejunostomy (CJS) has been the method of choice. Choledochoduodenostomy (CDS) has emerged as an alternative technique with several potential benefits. We performed a retrospective cohort-study of all CDS-procedures (n=63) performed in our hospital from 2009 to 2013, comparing them to a cohort of CJS-procedures (n=63) from 2006 to 2009. Demographical data, patient and graft survival, and biliary complications were recorded. One-year patient and graft survival was similar in the two groups. The rate of biliary leaks (10/10, p=0,96) and anastomotic stenosis (2/3, p=0,66) were equal. 12 patients in the CDS group were subject to endoscopic retrograde cholangiography whereas 6 patients in the CJS group had double-balloon enteroscopy performed. Biliary anastomotic complications tended to be resolved endoscopically more often in the CDS-group compared to CJS, but this was not statistically significant (8/4, p=0,21). A trend towards increased risk of cholangitis was observed with CDS, although statistical significance was not reached (14/7, p=0,07). We conclude that CDS is an attractive alternative to CJS in liver transplantation. CDS is easily performed and favors endoscopic access to the biliary tree for diagnostic and therapeutic interventions. This can potentially reduce the rate of reoperations and patient morbidity, although CDS may increase the risk of cholangitis.

Choledochoduodenostomy as Biliary Reconstruction in Liver Transplantation

Introduction: Choledochoduodenostomy (CDS) has earlier been used for biliary reconstruction in gastroenterological surgery. There are few publications assessing CDS in orthotopic liver transplantation (OLT). Until present the standard method of bilioenteric reconstruction in OLT has been Roux-en-Y choledochojejunostomy (CDJ). There are several arguments in favor of CDS: The procedure is technically simple, and can be performed faster than CDJ. The anastomosis is easily accessible endoscopicallly, and anastomotic complications can often be resolved without reoperation. Endoscopic access to biliary/entero-entero anastomosis in CDJ is possible, but can be challenging. We present our initial experience with CDS, comparing results with CDJ. Methods: From Apr. 2009 to Sept. 2011, 31 patients received CDS during OLT, where duct-to-duct anastomosis was not indicated due to inflammatory biliary disease or anatomical conditions. CDS was chosen if the anastomosis could be performed without tension. As control group we identified 32 patients operated with standard CDJ immediately prior to the CDS cohort, from Oct. 2007 to Mar. 2009. All data were analyzed retrospectively. Early and late biliary complications were recorded. Results: There were no demographical differences between the CDS/CDJ groups. One critically ill patient in the CDS group was lost to follow up due to early death. The median MELD-score was equal in both groups (15/16). The diagnosis primary sclerosing cholangitis was predominant in both groups (73 %/83 %). All liver grafts were from deceased donors, median cold ischaemic times were 382/438 min respectively. During the early follow-up period (≤30days), anastomotic bile leakage occurred in 4 patients in each group (13%/12%). Anastomotic biliary obstruction occurred in 2 patients in each group (6%/6%). In the CDS group, biliary complications were successfully treated endoscopically with stents in 4 patients, 2 patients were re-operated. In the CDJ group 4 patients were re-operated, whereas 2 were stented endoscopically. One patient in each group was later re-transplanted due to non-biliary complications. In the CDS-group 5 (16%) patients experienced an infection considered to be possible cholangitis within 90 days, as opposed to 0 patients in the CDJ-group. All recovered after antibiotic treatment. Late anastomotic strictures have not been observed after CDS, one patient developed stricture after CDJ. Conclusions: Our data show that the risk of biliary complications with CDS is comparable to Roux-en-Y CDJ. CDS may increase the risk of cholangitis but this can usually be resolved with antibiotic treatment. We conclude that CDS is a safe method of biliary reconstruction in liver transplantation, when duct-to-duct anastomosis is not indicated.

Duodenal switch operation for juxtapapillary duodenal diverticula.

Since the first case of juxtapapillary diverticlum reported by Lemmel, several reports have demonstrated an association between periampullary diverticulum and gallstone disease. Thus, we compared the efficiency of the duodenal switch operation and choledchojejunostomy for patients who underwent surgery for cholangitis with juxtapapillary duodenal diverticula. We retrospectively studied 17 patients who had cholangitis associated with juxtapapillary duodenal diverticula. These patients were divided into 2 groups on the basis of the operative procedure: the duodenal switch operation group (DS group) and the choledochojejunostomy group (CJ group). The mean operative time and blood loss were significantly lesser in the DS group than in the CJ group (p<0.0001 and p<0.0005, respectively); however, the duration of nasogastric suction requirement and time after which oral ingestion of solid diet could be safely resumed after surgery were significantly longer in the DS group than in the CJ group (p<0.0001 and p<0.0001, respectively). Gallstone formation after the surgery did not occur in both groups. Duodenal switch operation is useful and less invasive for cholangitis associated with juxtapapillary duodenal diverticula and for preventing cholangitis for a long period after the operation; however, gastric stasis still remains a problem with this procedure.

Evaluation of biliary enteric anastomosis in benign biliary disorders.

Evaluation of various methods of biliary enteric anastomosis in benign biliary diseases (BBD). A surgeon operating for BBD needs to improve the internal drainage of bile to prevent stasis and its back-pressure effects. This is best obtained by biliary enteric anastomosis. A total of 121 cases of biliary enteric anastomosis in BBD were included in this study. The postoperative course and long-term outcome were studied prospectively. In the choledochoduodenostomy group, there were no leaks, no restrictures, and no mortality. Five (10.41%) patients had cholangitis attacks and 2 (4.17%) patients had sump syndrome. The choledochojejunostomy group had no leaks, no restrictures. Two (7.14%) patients had repeated cholangitis and 2 (7.14%) patients had sump syndrome, no mortality. The hepaticojejunostomy group had 3 cases of anastomotic leak of which 2 healed spontaneously and 1 needed resurgery. There was restricture in 2 cases, in which resurgery was successful-one death, no cholangiocarcinoma. Biliary enteric anastomosis is a safe and effective method for the management of BBD. The method should be selected according to the disease pathology and patient characteristics.

Approaches selection on palliative operation styles for malignant obstructive jaundice diseases

Objective To explore the selection of palliate operation styles for unresectable malignant obstructive jaundice diseases. Methods The clinical data of 112 cases of unresectable malignant obstructive jaundice diseases in the last 5 years were analyzed retrospectively. Results The rate of operation mortality was 7.1％ and the incidence rate of post-operative cholangitis was 17.3 ％.The survival time in the Roux-en-Y choledochojejunostomy group was (9.4±1.6) months, and there were no significant differences among laparotomy stent internal drainage group[(9.8±12.5)months]and the PTCD stent internal drainage group [(9.0± 3.1)months]. But survival time in the laparotomy bridge internal drainage group [(6.8±1.7)months]was significantly lower (P＜0.05). The survival times in the ERCP stent drainage group [(3.5±2.2)months]and exploratory laparotomy group [(2.8±2.7)months]were even more significantly lower (P＜0.01).Conclusion As a palliative operation for unresectable malignant obstructive jaundice diseases, Roux-en-Y choledochojejunostomy applies to the middle and distal obstruction,laparotomy stent internal drainage applies to hilar obstruction,ERCP stent drainage only applies to distal obstruction,and PTCD stent internal drainage applies to any part obstruction of the bile duct. The Roux-en-Y choledochojejunostomy, laparotomy stent internal drainage, and PTCD stent internal drainage would improve the life time and life quality of these patients. Key words: Neoplasms; Jaundice, obstructive ; Palliative care; Follow-up studies

Role of choledochojejunustomy in liver transplantation

Objective To study the role of Roux-en-Y choledochojejunostomy in the primary biliary reconstruction during orthotopic liver transplantation(OLT) and treatment of biliary complica-tions. Methods The two modes of biliary reconstruction and biliary complications were analyzed ret-rospectively in 28 cases receiving liver transplantation between March 2003 and December 2006 in our hospital. Duct-to-duct anastomosis (group CDC) was performed in 20 patients (76.9%), and chole-dochojejunostomy (group CDJ) in 8 (23.1%). Biliary complications included stenosis, bile leakage, calculosis and extensive biliary necrosis. Results Two patients died perioperatively and 5 developed biliary complications. The overall incidence was 19.2%. There was a lower incidence of biliary com-plication among patients in the choledochojejunostomy group (27.8%) than the duct-to-duct anasto-moses (0) (P<0.05). Bile stenosis occurred in 3 patients and bile leakage occurred in 2. The treat-ments were nasobiliary drainage in 1 patient,endoscopic stenting in 1, choledochojejunostomy in 2 and retransplantation in 1. Two patients died postoperatively. Conclusion Based on our experience, the rate of complications in Roux-en-Y choledochojejunostomy is significantly lower than common duct an-astomosis. Roux-en-Y choledochojejunostomy is a useful tool both for biliary reconstruction during OLT and for posttransplantation biliary complications treatment, especially when reconstruction biliar-y blood supply insufficient and endoscopic treatment fails. Key words: Liver transplantation; Biliary reconstruction; Choledochojejunostomy; Biliary complication

Choledochoduodenostomy is a Safe Alternative to Roux‐en‐Y Choledochojejunostomy for Biliary Reconstruction in Liver Transplantation

Bile duct reconstruction during liver transplantation is usually performed by a duct-to-duct anastomosis or a Roux-en-Y choledochojejunostomy (CDJ). Direct anastomosis of the bile duct to the duodenum (choledochoduodenostomy-CDD) is another option for biliary reconstruction. This technique has been used with good outcome for the treatment of choledochal cysts, ampullary stenosis, and major bile duct injuries; however, there is little published experience with CDD in liver transplantation. We provide preliminary evidence that CDD is a safe technique for biliary anastomosis in liver transplant recipients. From September 2000 to August 2007 a total of 619 adult first-time cadaveric or living donor liver transplants were performed at the University of Colorado Health and Science Center. Bile duct repair was performed by direct end-to-end anastomosis in 466 patients and by choledocoenterostomy in the remaining 153 patients, 82 of whom were cadaveric recipients. The cadaveric choledocoenterostomy patients were divided into two groups: CDD in 25 and CDJ in 57 recipients. There were no significant differences in the 1-year patient or graft survival between the cadaveric groups. The 1-year patient survival was 100% in the CDD group and 97.1% in the CDJ group. The CDD group did not experience more surgical complications compared to the CDJ group. Choledochoduodenostomy is a safe alternative to CDJ biliary anastomosis when a duct-to-duct anastomosis cannot be performed. There is no significant difference in mortality, graft survival, or biliary complications. In addition, CDD offers the advantage of postoperative access to the billiary system by endoscopy and avoids complications associated with the CDJ bowel anastomosis.

Role of choledochojejunostomy in the treatment of intrahepatic lithiasis

目的 探讨胆肠吻合术在治疗肝胆管结石中的指征和作用.方法回顾分析我院314例不伴有胆管狭窄或囊性病变的肝胆管结石,比较不同胆道引流下的残石率和手术疗效.结果全组无手术死亡,住院死亡率为1.6%.胆肠吻合组和T管引流组术后残石率无差异,但经胆道镜取石后,T管组术后总的残石率显著低于胆肠吻合组(0.5% vs 17.5%,P<0.01).肝切除+T管引流术后胆管炎发生率为8.2%,显著低于肝切除+胆肠吻合术.胆肠吻合组手术时间明显延长,手术并发症高于T管引流组.结论肝切除术+术中或术后胆道镜取石是治疗肝胆管结石最有效的方法.只有同时合并胆道狭窄或囊性扩张的病例,由于要切除病变的胆管,才必须行胆肠吻合术重建胆道引流。

Differential effects of jaundice and cirrhosis on β-adrenoceptor signaling in three rat models of cirrhotic cardiomyopathy

Background/Aims: Attenuated cardiac function has been reported in cirrhosis as well as in jaundice, but the mechanisms remain unclear. This study aimed to explore the differential effects of jaundice and cirrhosis on the heart. Methods: Three rat models of cirrhosis were studied: chronic bile duct ligation, bile duct ligation followed by choledochojejunostomy torelieve jaundice, and a less jaundiced model induced by thioacetamide administration. Controls underwent a sham operation. Cardiac function was assessed by measuring isolated ventricular papillary muscle contractility. Cardiac β-adrenergic receptor signaling was studied by measuring cAMP production stimulated at the receptor, G-protein, and adenylyl cyclase levels in the signaling pathway, using isoproterenol, aluminum fluoride and forskolin, respectively. Results: Serum bilirubin and bile salt levels were markedly elevated in the bile duct-ligated group, moderately increased in the thioacetamide rats, and normal in the choledochojejunostomy and sham-operated controls. Papillary muscle contractile force after maximal β-adrenergic receptor stimulation was decreased to a similar extent in all three cirrhotic models. In the bile duct-ligated and thioacetamide-in-duced cirrhotic rats, production of cAMP by all three drugs was significantly attenuated. However, the cAMP production in the choledochojejunostomy group was blunted only with isoproterenol and fluoride, and remained intact with forskolin stimulation. Conclusions: These results demonstrate that cirrhosis per se impairs cardiac function by attenuating the portion of the β-adrenergic receptor signaling pathway upstream of adenylyl cyclase. Furthermore, significant jaundice and/or cholemia can inhibit adenylyl cyclase, which may contribute to blunted cardiac contractility in jaundiced patients.

Bacterial Translocation from the Biliary Tract to Blood and Lymph in Rats with Obstructive Jaundice

Background.The disruption of the hepatocyte tight junctions observed in biliary obstruction suggests altered permeability of the blood–bile barrier. In this study the role of biliary obstruction and increased biliary pressure on the translocation of bacteria from biliary tract to bloodstream and lymphatic system were evaluated.Materials and Methods.Rats underwent distal bile duct ligation (BDL,n= 33) for two weeks or a sham celiotomy (n= 21). Seventeen of the 33 BDL rats underwent subsequent biliary decompression by a choledochojejunostomy (CJ). Two weeks after the final operation, a laparotomy was performed again and the CBD, the thoracic duct, and the caval vein were canulated. Next, a suspension containing 108Escherichia coli/ml was retrogradely infused in the CBD for 5 min at 5 or 20 cm H2O above the secretory biliary pressure.Results.A higher biliary infusion pressure resulted in a significant increase of cfuE.coliper milliliter of blood in all the three groups (Sham, BDL, CJ). BDL rats showed significantly more bacterial translocation to the bloodstream than the shams. After biliary decompression, translocation normalized to the control levels. At 5 cm H2O infusion pressure only one lymph culture was positive (CJ group). At 20 cm H2O overpressure, nine lymph cultures wereE.colipositive (P= 0.03). These were found mainly in groups with a nonobstructed bile duct (Sham and CJ 40% vs BDL 10%).Conclusion.Translocation of bacteria from biliary tract to bloodstream increased at higher intrabiliary pressures. Longstanding bile duct obstruction was an independent determinant for cholangiovenous reflux. Bacterial translocation to the lymphatic system did not parallel translocation to the bloodstream, although in the nonobstructed biliary tract, increased bacterial translocation to the lymphatic system was pressure related.