Impacted common bile duct stone managed by hepaticoduodenostomy.

A bypass procedure such as a hepaticoduodenostomy may be an alternative to the traditional choledochoduodenostomy in the management of the retained, impacted distal common bile duct stone especially in the presence of sepsis. In low-resource settings with lack of fluoroscopy, fibreoptic instruments (choledoscope) or radiologically guided wire baskets or balloons for stone retrieval, there are operative hazards in blindly exploring the common bile duct. We present herein a hepaticoduodenostomy performed for a retained, impacted distal common bile duct stone in a low-resource setting with a good outcome. This impacted stone had complicated an open cholecystectomy for acute cholecystitis by causing the dehiscence of the cystic duct stump as a result of distal biliary obstruction. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.

INTRODUCTION

The management strategy for impacted common bile duct (CBD) stone will depend on personal experience, equipment availability, time and the availability of other departmental expertise [1-3]. Although the laparoscopic exploration for CBD stones has gained grounds over endoscopic retrograde cholangiography (ERCP) and sphincterotomy and duct clearance, there is no consensus as to the ideal approach [2, 3]. For a distally impacted CBD stone in a low-resource setting, an open approach will entail either leaving the stone where it is and carry out a choledochoduodenostomy (CD), or removing the stone through a transduodenal sphincteroplasty [4]. We present herein a hepaticoduodenostomy (HD) performed for an impacted distal CBD stone. This retained and impacted stone had complicated an open cholecystectomy for acute cholecystitis by causing biliary leakage from the dehisced ligated cystic duct stump due to back pressure of bile.

CASE REPORT

A 40-year-old fit black African farmer was admitted as an emergency with a 3-week history of gradual onset, constant epigastric pain radiating to the back and chest. He had recurrent abdominal pain in the past 6 years managed conservatively. On this occasion he complained of fever and there was jaundice with a dark urine but no pale stool. He had no risk factors for chronic liver disease. On examination, his blood pressure was 153/92 mmHg, heart rate of 81 beats/min, respiratory rate of 22 breaths/min and a temperature of 37.2°C. He had an icteric sclera and a tender right hypochondrial mass with a positive Murphy’s sign. An abdominal ultrasound scan demonstrated an acute cholecystitis with a distally impacting CBD stone. Full blood count and renal function tests were normal. Hepatitis and HIV screen were negative. Liver function tests showed an obstructive picture with raised alkaline phosphatase 763.52 ui/l (n: 38–126 ui/l), alanine transaminase 80 ui/l (n: 0–41), aspartate transaminase 32 ui/l (n: 0–42). Following intravenous fluid hydration, broad spectrum antibiotics and intramuscular vitamin K, he consented to a cholecystectomy and a transduodenal sphincterotomy/plasty as facilities for a safe CBD exploration were not available. At operation, there was an acutely inflamed, intrahepatic, gangrenous gallbladder, no palpable gallbladder or CBD stone and an undilated CBD. The patient was unstable anaesthetically, and a staged approach in initially treating the gallbladder sepsis by a difficult retrograde cholecystectomy was taken. On the 20th postoperative day there was a sudden biliary leakage via the healing midline abdominal wound. A contrast computed tomography scan revealed a voluminous right hypochondrial and perihepatic peritoneal purulent collection measuring 682 cc and, an impacted calculi at the base of the CBD. A difficult emergency laparotomy revealed severe biliary leak from the dehisced cystic duct stump with dense adhesions. This was doubly resutured with 2.0 vicryl. Kocherization of the duodenum allowed the duodenal bulb to lie comfortably against the dilated CBD which changed our decision for a more straight forward bypass procedure (CD or HD). A more proximal HD approach (Fig. 1) was taken because of the inflamed cystic duct stump, sepsis and adhesions surrounding the CBD. A vertical incision was made in the CHD, and a longitudinal incision made in the adjacent duodenum which was then sutured transversely in a one layer of continuous sutures of 3/0 absorbable material (vicryl). At completion the anastomosis was diamond-shaped with a stoma diameter of at least 3 cm d and a sub-hepatic drain inserted. The surgery was complicated by severe biliary leakage from the anastomosis which subsided in about 2 weeks. The symptoms of jaundice, pain and fever resolved and the patient was discharged a month after the initial operation. At 1-year follow-up, the patient was asymptomatic and well.

Figure 1

Schematic diagram of hepaticoduodenostomy.

DISCUSSION

This case demonstrated a more proximal HD as an alternative to the traditional CD in the management of an impacted distal CBD stone in the hostile surroundings of a supraduodenal CBD. The impacted CBD stone was not addressed in the index surgery because (i) the facilities for a safe open CBD exploration were not available, (ii) the CBD was not initially dilated to allow a safe approach, (iii) there was still a chance of spontaneous passage of the CBD stone, (iv) the primary source of sepsis was the cholecystitis as there was as yet no cholangitis that would have required an initial emergency CBD exploration and cholecystectomy. CD had traditionally been indicated for palliation in patients with CBD obstruction caused by malignancy, or in elderly patients with impacted stones [5]. A recent prospective study demonstrated CD as highly effective treatment for choledocholithiasis in the presence of a dilated CBD, in all age groups with low morbidity and mortality provided a wide anastomosis (>2.5 cm) was accomplished [6]. It has been reported as a more effective treatment of CBD stones than T-tube drainage but regarded as an obsolete therapeutic method due to fears of higher morbidity, reflux cholangitis, hepatic abscess, stone recurrence, pancreatitis and the ‘sump’ syndrome (bile stasis, reflux of duodenal contents into the terminal CBD, bacterial overgrowth) [7-9]. The HD procedure benefited the patient by relieving the jaundice in the presence of sepsis and provided a chance of a later spontaneous passage of the CBD stone. By not distorting the anatomy of the extrahepatic biliary tree via a side-to-side anastomosis, HD would allow an ERCP if required and available. Except for significant postoperative biliary leakage which was managed conservatively, the outcome was successful. Biliary anastomoses do not seal easily and, thus the indication for a sub-hepatic drain [10]. Although HD for obstructive CBD stone has not been reported in the English literature, it is becoming an alternative to the Roux-en-Y hepaticojejunostomy after excision of a choledochal cyst and for type IV Mirizzi’s syndrome because of fewer complications [11, 12]. As ~12% of patients undergoing surgery for symptomatic gallbladder stones have CBD stones, it is appropriate to perform intraoperative cholangiography during a cholecystectomy [13]. Pre or postoperative ERCP is the best option if available but the laparoscopic approach has the advantage in being able to deal with the gallbladder and CBD stone/s simultaneously via a laparoscopic cholecystectomy and exploration of CBD [13-15].

AUTHORS’ CONTRIBUTION

E.P.W. was the main author and surgeon. He developed the conception of the work, designed the work, acquired, analysed and interpreted the data; N.Z.M. assisted in surgery and revised the work; F.Z. contributed to acquisition of data and revised the work for important intellectual content.