Sump Syndrome Research Articles

Imaging of the biliary sump syndrome.

Side-to-side choledochoduodenostomy is a safe and effective surgical technique to improve biliary drainage in selected patients. The segment of common bile duct between the anastomosis and the ampulla of Vater may act as a stagnant reservoir or sump. When debris, stones, or infected bile accumulates in the sump, usually because of malfunction of the ampulla of Vater, recurrent abdominal pain or symptoms of cholangitis, pancreatitis, or biliary obstruction may develop. This uncommon (0.14-1.30%) complication is known as the sump syndrome. On imaging studies, diagnostic findings are debris or stone(s) in the common bile duct. Suggestive findings are dilated bile or pancreatic ducts, and changes due to pancreatitis, cholangitis, or liver abscess. Patients with this syndrome frequently have multiple imaging studies before the condition is recognized. The purpose of this essay is to illustrate the imaging findings of this syndrome.

Iatrogenic Chymobilia— A Disease of the Nineties?

The last two decades have seen a strong swing towards preservation of some of the sphincters of the alimentary tract, namely, the pyloric and anal sphincters, while at the same time there has been increasing vandalism of the sphincter at the distal end of the common bile duct. Endoscopic papillotomy, first introduced in 1974, is a very useful procedure in selected patients but too liberal use of the technique may result in a harvest of new problems in years to come. The intact sphincter of Oddi prevents the entry of duodenal contents into the biliary tree; its division allows their free reflux. By the term ’chymobilia’ we mean the presence of chyme in the biliary tree. The Greek word chyme (juice) is combined with the Latin word bilis (bile) in a manner similar to the term haemobilia introduced by Sandblom in 19481. Following endoscopic sphincterotomy reflux of duodenal chyme occurs in most patients; aerobilia is seen in half and bacterobilia in all2. The results of surgical sphincterotomy are similar. The majority of these patients with bacterobilia do not develop classical symptoms of ascending cholangitis, namely pain, pyrexia, rigors and jaundice but 20 per cent have bouts of upper abdominal pain and associated elevation of the serum Gamma glutamyltranspepside3. Following biliary-enteric anastomosis both aerobic and anaerobic bacteria are involved4. Bacterobilia may not be as innocent as was initially thought, and for patients with immunosuppression, the risk of cholangitis is markedly increased5. In addition the reflux of chyme may set up chemical changes with resultant inflammatory reaction in the duct epithelium and periductal area. The clinical syndrome of ascending cholangitis often indicates outflow obstruction usually of an incomplete nature due to residual or recurrent stones or restenosis. However we have seen cholangitis in patients following sphincterotomy and other types of biliary-enteric anastomosis where a free-flowing, unobstructed biliary tree was demonstrated by percutaneous cholangiography and by retrograde barium and air studies of the ductal system. Goldman and colleagues reported on six patientswho suffered repeated episodes of cholangitis despite widely patent biliary-enteric anastomoses6. Debris is frequently seen in the duct following fenestration whether it be choledochoduodenostomy where the sump syndrome can occur, or after simple surgical or endoscopic sphincterotomy. These ductal filling defects are sometimes referred to as false calculi images. Escourrou and colleagues found evidence of reflux from the duodenum into the biliary tree in 65 per cent of patients after endoscopic sphincterotomy but state that they never observed clinical symptoms related to

POST‐CHOLEDOCHOENTEROSTOMY ‘SUMP SYNDROME’

The 'sump syndrome' is an uncommon, late complication of a side-to-side choledochoenterostomy. Five patients with this syndrome were encountered over a 5-year period. Pain or cholangitis was the clinical presentation in four patients, whereas one patient presented with secondary septic arthritis and a hepatic abscess. Liver function tests were mildly abnormal in each patient. All patients had a stomal size of less than 1 cm as assessed by forward- or side-viewing endoscopy. Endoscopic retrograde cholangiography revealed either stones or debris in the distal common bile ducts of all patients. Four patients had a surgical clearance of their duct with concurrent closure of the choledochoduodenostomy in three patients and the creation of a Rouxen-Y end-to-side choledochojejunostomy in the fourth patient. The other patient had an endoscopic sphincterotomy performed. After 1-4 years of follow-up, four patients have had a total resolution of symptoms. The other patient with follow-up for 4 years has had one episode of cholangitis which resolved rapidly with antibiotic treatment. The pathogenesis and clinical spectrum of the sump syndrome are reviewed and current management strategies are discussed.

Endoscopic management of bile duct stones

Endoscopic sphincterotomy is the procedure of choice for choledocholithiasis in patients who have had a cholecystectomy. The bile duct is cleared of stones in about 80 to 90 percent of patients. Available data, largely retrospective, suggest that surgery and endoscopic sphincterotomy are about equal with respect to removal of stones, morbidity, and mortality. Certain technical problems are discussed, including inability to insert the papillotome, the large stone, and problems relating to anatomy such as peripapillary diverticulum and prior gastrectomy. The treatment of patients with bile duct stones who have not had a cholecystectomy, with and without cholelithiasis, is controversial. Endoscopic sphincterotomy without subsequent cholecystectomy is adequate treatment for the majority of patients who are unfit for surgery, even if there are stones in the gallbladder, provided they are asymptomatic after endoscopic removal of stones from the bile ducts. endoscopic sphincterotomy has been performed in the treatment of gallstone-induced pancreatitis, acute obstructive cholangitis, and sump syndrome. The complication rate for endoscopic sphincterotomy ranges from 6.5 to 8.7 percent, with a mortality rate of 0 to 1.3 percent. The most common serious complications are perforation, hemorrhage, acute pancreatitis, and sepsis.

Endoscopic therapy of the sump syndrome.

Seventeen consecutive patients with the sump syndrome were treated at the Middlesex Hospital between November 1983 and December 1987. Fifteen were treated primarily by endoscopic sphincterotomy and two primarily by resective surgery because of coincident severe painful chronic pancreatitis. Endoscopic sump clearance was successful in thirteen out of fifteen cases (87%) with no morbidity or mortality. The two endoscopic failures were managed surgically. Follow-up (mean 18 months; range 2-48 months) has shown complete resolution of symptoms in twelve (71%), with mild or moderate ongoing symptoms in the remaining five. All patients with ongoing symptoms after sump clearance had abnormal retrograde pancreatograms at the time of ERCP. Endoscopic sphincterotomy is the treatment of choice for the sump syndrome, with the possible exception of patients with coincident painful severe chronic pancreatitis, who may require pancreatic resection. Indeed, the sump may be a factor in the development and perpetuation of an obstructive chronic pancreatitis, and a trial of endoscopic clearance may be indicated even in these patients. The sump syndrome should no longer be regarded as a major long-term disadvantage of side-to-side biliary bypass, provided that the condition is considered early in those with compatible symptoms after biliary bypass, and appropriate investigation and treatment is instigated.

Pseudomonas infection of the biliary system resulting from use of a contaminated endoscope.

Pseudomonas infection of the biliary system resulting from use of a contaminated endo‐scope. ALLEN J.I., ALLEN M.O'C., OLSON M.M., et al.Endoscopic sphincterotomy and surgical approaches in the treatment of the ‘sump syndrome‘. MARBET U.A., STALDER G.A., FAUST H., et al.

Hepatic abscesses as a complication of the sump syndrome: Combined surgical and endoscopic therapy

Abstract The is an unusual complication of side-to-side choledochoduodenostomy in which the portion of the common bile duct distal to the anastomosis acts as a sump and may collect bile, stones, food, and other debris. Partial or complete obstruction of the stoma and resultant bacterial proliferation may result and lead to recurrent cholangitis or pancreatitis. A single hepatic abscess as a complication of the sump syndrome has been reported only once. We have recently seen a patient presenting with multiple hepatic abscesses as a complication of the sump syndrome. This is the first report of endoscopic treatment of this syndrome associated with a hepatic abscess. The literature on the endoscopic approach to this problem will be reviewed.

Endoscopic sphincterotomy and surgical approaches in the treatment of the 'sump syndrome'.

The 'sump syndrome' is a rare, late complication of choledochoenterostomies. We observed 13 patients with this syndrome. The clinical features included recurrent cholangitis, liver abscesses, and recurrent pancreatitis. Five patients were treated by surgery, eight patients endoscopically. Reviewing an average follow up period of 22 months (range 6-60) after therapeutic endoscopy and 57 months (range 1-126) after different surgical procedures, we conclude that endoscopic sphincterotomy with removal of the debris is as efficient a therapy of the 'sump syndrome' as surgical sphincteroplasty and entails a smaller risk for the patient. We therefore advocate that endoscopic papillotomy should first be tried in all cases of 'sump syndrome' in the absence of suprapapillary stricture of the bile ducts.

Operative Results of Side-To-Side Choledochoduodenostomy for Cholelithiasis

To clarify the clinical problems of side-to-side choledochoduodenostomy as an adjunct to surgical management of cholelithiasis, the operative results of 82 patients treated in our clinic during the past 10 years were studied. There were 73 patients with extrahepatic bile duct stone and 9 with intra- and extrahepatic bile duct stone. Their mean age was 64 years, and the ratio of males to females was 1.2:1. The operative mortality rate was 4.9%; early complications developed in 7% of the patients. Of all patients who were discharged, 32% developed late complications, and 22%, including 3 patients with sump syndrome, revealed ascending cholangitis. During follow-up, 13 patients died, 6 of them of cholangitis. A relationship between the occurrence of cholangitis and the size of anastomosis was investigated, but there was no obvious connection between them. Six (7.3%) patients underwent reoperations caused by cholangitis, residual or recurrent stones and stenosis of anastomosis. Good to excellent long-term results were seen in 78% of all patients, while fair to poor results were observed in the rest. Especially, results in patients with intra- and extrahepatic bile duct stones were poor. These results suggest that it is necessary to carefully consider the indication of this procedure for patients with cholelithiasis.

Precut papillotomy via fine-needle knife papillotome: a safe and effective technique

Endoscopic sphincterotomy is now an established method for removal of common bile duct calculi and treatment of ampullary stenosis, the sump syndrome, and certain cases of ampullary carcinoma. It is also generally performed prior to biliary endoprosthesis placement. I -: Despite refinements in fiberscopes and techniques, selective bile duct cannulation is unsuccessful in 10% to 15% of cases, even in the hands of experienced endoscopists.4When biliary cannulation fails, a precut papillotome is employed by some endoscopists. This papillotome consists of a I-em wire which can be bowed and extends to the tip of the catheter. A short incision is made in the 11 or 12 o'clock position in an attempt to cut the roof off the common channel to facilitate access to the common bile duct. This device may be associated with pancreatitis or perforation and is generally thought to be rather risky.4 Cotton states that precutting should not be used by beginners; it is an uncontrolled process and may leave the patients worse off than before. Other authors have utilized a straight 5-mm wire papillotome (needle knife) to gain access to the biliary tract when direct cannulation fails. s This technique involves the creation of an artificial choledochoduodenal fistula proximal to the papilla itself by making a 1to 1.5-cm long incision in the bulging intraduodenal common duct. This technique has not had widespread popularity due to its difficulty and potential risks of duodenal or bile duct perforation. Additional potential drawbacks of this technique are the possibility of stenosis of the artificial choledochoduodenostomy or the creation of a sump syndrome since the distal sphincteric mechanism remains intact.? This report deals with a new method of precut papillotomy with a fine wire needle knife.

Foreign bodies of the biliary tract. Endoscopic management.

In the period 1978-1984, 23 patients underwent endoscopic intervention for foreign bodies of the biliary tract. The patients are subdivided into three groups: the first group consists of 11 cases in which the foreign bodies were suture threads, either simple or as a nidus for gallstones; the second group consists of six patients with a sump syndrome of the biliary tract; the third group includes six patients who retained drainage tubes or stents after a biliary tract operation. In our series, endoscopic extraction was performed as a first-choice procedure. The high success rate may favor endoscopy as a low-morbidity, low-mortality approach and as an alternative to a relaparotomy.

Side-to-side choledochoduodenostomy in the management of choledocholithiasis and associated disease: Facts and fiction

Ascending cholangitis, the sump syndrome, and alkaline reflux gastritis are drawbacks commonly ascribed to side-to-side choledochoduodenostomy. Most surgeons consider side-to-side choledochoduodenostomy as a last resort measure to be utilized only in elderly patients and only on ducts wider than 15 mm. In trying to assess the pertinence of such alleged inconveniences and limitations, a series has been analyzed (retrospectively until 1976 and prospectively from then on). A total of 70 of these operations were performed from January 1973 to September 1982, on 53 women and 17 men. Twenty-six percent were less than 50 years of age, and 30 percent were over 70 years of age. Sixteen of the 70 operations were reoperations that took place several years after cholecystectomy. Intravenous cholangiographic films were obtained preoperatively for evaluation of the duct width which was less than 15 mm in 23 patients (33 percent). The follow-up period, surpassing 2 years in 35 patients (50 percent), includes clinical interviews and liver biochemistry measurements every 6 months, and endoscopic retrograde cholangiopancreatography 12 to 18 months postoperatively. There was one postoperative death (1.4 percent), and significant morbidity developed in five patients (7.1 percent). The postoperative hospital stay averaged 8 days. The long-term results were classified as excellent in 50 patients, good in 15 patients, fair in 3 patients, and poor in 1 patient. Side-to-side choledochoduodenostomy is a safe, very effective therapeutic measure, even when performed on ducts less than 15 mm wide, provided a few technical requirements are respected. It does not carry the inconveniences that have usually been ascribed to it. The excellent long-term results in the present series have allowed us to liberalize its utilization, especially in young patients.

Side-to-side choledochoduodenostomy in the management of choledocholithiasis and/or associated pathology--facts and fiction.

Ascending cholangitis, the sump or blind-sac syndrome and alkaline reflux gastritis are drawbacks commonly ascribed to this surgical procedure. Most surgeons look down at this operation as a last resort measure to be utilized only on elderly patients and only on ducts wider than 15 mm. Trying to verify the pertinency of such, alleged, inconveniences and limitations a personal series is analysed, retrospectively until 1976 and prospectively from then on. A total of 61 of these operations were performed (1973-81), on 47 women and 14 men, 25% below 50 years of age, 33% over 70,14 of them as Resurgery. Intravenous cholangiography was obtained, preoperatively, for evaluation of the duct width, which was less than 15 mm in 20 patients (32%). The follow-up period, surpassing 2 years in 26 (43%), includes clinical interviews and Liver biochemistries every 6 months and ERCP 12-18 months after surgery. One patient died during the immediate postoperative period and significant morbidity developed in 5 others (8,1%), the postoperative hospital stay averaging 7 days. The long term results on the survivors are classified as EXCELLENT in 48, GOOD in 8, FAIR in 3 and POOR in 1. It is concluded that this is a safe and very effective therapeutical measure, even when carried down on ducts less than 15 mm wide, provided a few technical requirements are respected. It does not carry the inconveniences usually ascribed to it. The excellent long term results of this series allow us to liberalize its utilization, even more so on young patients.

Peroral choledochoscopy in the sump syndrome: use of a thin caliber endoscope to negotiate a choledochoduodenostomy

Peroral choledochoscopy in the sump syndrome: use of a thin caliber endoscope to negotiate a choledochoduodenostomy

Duodenoscopic sphincterotomy in the treatment of the "sump syndrome".

The "sump syndrome" is recognized as a complication of a choledochoenterostomy (choledochoduodenostomy or choledochojejunostomy) performed for recurrent stone disease. A sump (a pit or well) develops in the distal, nonfunctioning limb of the common bile duct where lithogenic bile, gastrointestinal contents, and debris accumulate. This results in obstruction of the enterostomy stoma producing either cholangitis, pancreatitis pain, and/or cholestasis. It is thought that dysfunction of the sphincter mechanism contributes to the development of this syndrome. Filling defects in the bile duct are appreciated on gastrointestinal series when barium reflexes into the biliary tree through the patent stoma. Treatment has largely been surgical, but, more recently, the availability of ERCP has enabled the endoscopist to make a major contribution to the management of this syndrome. A nonsurgical alternative to treatment is duodenoscopic sphincterotomy which has been performed in 11 patients presenting with the sump syndrome. There have been no recurrences of stones in 10 patients while stones were found in one patient with an open sphincterotomy. In follow-ups of 3-30 months, there was satisfactory relief of symptoms in all patients. Because of these results, duodenoscopic sphincterotomy is recommended as a primary treatment modality in the sump syndrome.

Endoscopic incision of choledochal cysts (choledochocele).

Congenital cysts of the ble ducts and liver usually present with symptoms of compression, obstruction or infection. The management of these problems has been the surgical approach with extirpation or diversion techniques. Cysts of the common hepatic or bile ducts should be completely excised if possible while intrahepatic cysts are treated by anastomosis of the ducts to isolated intestinal loops. Diversion techniques for distal intraduodenal cysts leads to development of the sump syndrome, and, it has been our experience in two patients to treat these, choledochocele, by incision during performance of a sphincterotomy.

Choledochoduodenostomy, choledochojejunostomy or sphincteroplasty for biliary and pancreatic disease.

Choledochoduodenostomy, choledochojejunostomy, or sphincteroplasty are used in the treatment of selected patients with retained, recurrent, and impacted bile duct stones; strictures of the bile ducts; stenosis of the sphincter of Oddi; pancreatitis associated with biliary disease; choledochal cysts; fistulas of the bile duct; and biliary obstruction, either benign or malignant. From a group of approximately 1600 patients operated on for biliary and pancreatic disease during the 17-year period, 1962 to 1979, 153 patients who had choledochoduodenostomy, choledochojejunostomy or sphincteroplasty were identified. Follow-up information was available for 146 patients (95%). Overall, 84% of the patients had good results, 10% had fair results, and 3% had poor results. A 3% postoperative mortality rate was found, all in patients with unresectable malignancies. Treatment of bile duct obstruction, benign or malignant, was equally effective by choledochoduodenostomy or choledochojejunostomy. Jaundice resolved in all patients; three patients with benign strictures required reoperations for recurrent stricture formation, two after choledochoduodenostomy, and one after choledochojejunostomy. Recurrent cholangitis heralded the development of another stricture. Both choledochoduodenostomy and sphincteroplasty were used for patients with retained, recurrent or impacted duct stones. Pancreatitis did not occur in any patient after sphincteroplasty; the sump syndrome was not seen after choledochoduodenostomy. This review supports the view that choledochoduodenostomy is a safe and effective procedure. All three operative procedures were effective for the problems for which they were used; each procedure has a place in the treatment of recurrent or complicated biliary and pancreatic diseases. The procedures are complementary, not competitive. For certain problems, the operation performed depends upon the surgeon's preference and experience. The indications for and results of these operative procedures are discussed.

Choledochoduodenostomy in the treatment of benign biliary tract disease

During the 15 year period 1965 through 1979, sixty patients underwent choledochoduodenostomy for benign obstructive lesions of the biliary tract. Patients with traumatic and iatrogenic common duct strictures were excluded. Eighty-two percent of the patients were in the seventh to ninth decades of life. Twenty-seven patients (45 percent) had undergone a total of 40 previous biliary tract surgical interventions. Thirty-three patients (55 percent) in the older age group (average age 75 years) were subjected to choledochoduodenostomy as a primary procedure during the first surgical intervention on the biliary system. Cholangitis recurred in only one patient (in whom the sump syndrome was the culprit), while all other patients have been free of abdominal complaints, cholangitis and pancreatitis during follow-up of 1 to 15 years. There was no operative mortality; morbidity was 26 percent. Hospital stay averaged 15 days. These favorable results mark choledochoduodenostomy as a safe, simple and effective procedure in the treatment of benign biliary tract disease, particularly in aged and high risk patients.

Sphincteroplasty and choledochoduodenostomy for benign biliary obstructions.

Both sphincteroplasty and choledochoduodenostomy are valuable for choledocholithiasis, stenosis of the terminal bile duct, and occasional cases of pancreatitis. Selection of patients, technical details, and advantages and limitations of both operative procedures are presented. In a personal series of 600 benign biliary operations 73 patients had a sphincteroplasty or choledochoduodenostomy. Sixty of these had a sphincteroplasty without operative mortality, serious complication, or recurrence of biliary problems although 5 still have pain. A positive morphine-prostigmine test was a prime indication for surgery in these 5 patients. The evocative tests are now negative. Thirteen patients had a choledochonduodenostomy without mortality or significant complication. Twelve are symptom free but one has a "sump syndrome." Sphincteroplasty has been preferred because it gives dependent drainage, direct inspection of the ampullary area, and facilitates removal of impacted stones and debris. It is not always applicable and choledochoduodenostomy has been chosen in elderly poor risk patients or in those with pancreatic inflammation or periampullary duodenal diverticula. Both operations have specific advantages and limitations such that the surgeon should not use one to the exclusion of the other.

Roux-en-Y hepaticojejunostomy: a reappraisal of its indications and results.

A critical evaluation is made of 131 patients submitted to choledocho or hepaticojejunostomy. The main indications for hepaticojejunostomy were iatrogenic strictures of CBD (60 patients), and choledocholithiasis with markedly dilated duct (41 patients). The overall mortality rate was 4% representing principally renal hepatic failure, bile peritonitis and bleeding. The complications following hepaticojejunostomy included only in one case biliary fistula which required reoperation. The long-term results of 80 patients available for a followup study were as follows: 63 patients (78.7%) were symptom-free at 2-13 years followup; 8 patients had brief episodes of cholangitis which responded to antibiotic and corticosteroid treatment; 9 patients required reoperation for stricture of anastomosis. These overall results are a strong argument for hepaticojejunostomy which, compared with choledochoduodenostomy, avoids the hazards of the so-called sump syndrome and of the reflux of enteric contents in the CBD. An increased incidence of peptic ulcer disease in the patients submitted to hepaticojejunostomy was not observed. In very high strictures and in reinterventions anastomosis between left hepatic duct and Roux-en-Y jejunal limb was carried out. The results achieved with this technique, which was performed in 26 patients, were about the same following hepaticojejunostomy.