Choledochoduodenostomy is an Effective Alternative Surgical Technique for the Common Bile Duct Injury and Liver Transplantation: Literature Review

Abstract

Biliary reconstruction is one of the final steps in liver transplantation. The most common approach is duct-to-duct anastomosis (DD), also known as choledochocholedochostomy. However, in patients with deviations from normal anatomy or physiology, as in patients with Primary Sclerosing Cholangitis (PSC), this approach may not be feasible. Choledochoduodenostomy (CDD), roux- en- Y choledochojejunostomy (CJS), and roux-en-y hepaticojejunostomy (RY) can serve as an alternative approach. RY CJS are more commonly applied due to risks associated with CDD. Although the complications in CDD are often equivocal to CJS and RY. CDD offers the benefit of being closer to normal anatomy and allowing easier access to the biliary system if there is a need for future ERCP. For biliary reconstruction in liver transplant patients with altered anatomy, as in PSC, CDD should be implemented in suitable candidates.

Hypothesis

The goal of this project is to determine the effectiveness of choledochoduodenostomy at the time of liver transplant for those who are not a candidate for choledochocholedochostomy.

Introduction

Primary Sclerosing Cholangitis (PSC), the inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts, commonly presents without symptoms. Symptomatic patients present with right upper quadrant pain, pruritus, weight loss, jaundice, and commonly occur in those with inflammatory bowel disease. PSC can progress to cirrhosis and end stage liver disease [1]. The median survival until liver transplant or death is 21.3 years with the only definitive treatment being liver transplant. Median disease duration until liver transplant is 8.1 years [2]. Even with liver transplantation there is a risk of recurrence of PSC [3]. However, patients with PSC have one of the greatest survival rates compared to all patients who undergo liver transplant [4].

Liver transplantation is one of the primary treatments for end-stage liver disease, acute liver failure, and both benign and malignant conditions such as hepatocellular carcinoma [5]. Biliary complications accounts for 31% of all complications due to liver transplant, making biliary reconstruction one of the biggest challenges to overcome [6,7]. The most common type of biliary reconstruction is duct-to-duct anastomosis (DD) also known as choledochocholedochostomy. It connects the bile duct of the recipient to that of the donor, maintaining a normal anatomy [8-10] DD becomes challenging in cases where there is mismatch of duct size between donor and recipient, extensive recipient surgical history, or adhesions. In PSC particularly, normal anatomy can be disrupted, and increased risks of cholangiocarcinoma, stricture, and anastomotic leak have led to preference for RY approach in OLT for PSC [11-13]. Choledochoduodenostomy (CDD), Choledochojejunostomy (CJS), and Roux-en-y hepaticojejunostomy (RY) may serve as alternatives [14]. Roux-en-Y hepaticojejunostomy RY connects the donor hepatic ducts to the recipient jejunum. Choledochojejunostomy (CJS) connects the donor common bile duct to the recipient jejunum. An additional approach is Choledochoduodenostomy (CDD), performed by connecting the donor common bile duct and recipient duodenum (Figure 1) [15]. Similar to DD, this results in closer to normal anatomy but is less favored compared to CJS and RY due to complications, most notably sump syndrome and cholangitis.

Figure 1:Choledochoduodenostomy anastomosing the donor common bile duct to the recipient duodenum [15].

In individuals with contraindications to DD for biliary reconstruction in liver transplant. CJS and RY have traditionally been viewed as primary alternatives. In this study, we hope to further investigate the benefits of CDD.

On the Space F_p of Proton’s Wave Functions

In patients with undergoing OLT for PSC or who have other contraindications for DD, CJS and RY are often favored over CDD for bile reconstruction because of associated rare complications of sump syndrome and cholangitis [16,17].

Sump syndrome is a rare, feared phenomenon where the remnant common bile duct collects stones, food particles, or bile and serves as a foothold for bacteria [24]. Rates of sump syndrome in patients who have undergone CDD are reported from 0-9.6% [18,25]. Although traditionally associated with CDD, it has been reported as a complication of both RY and CDD [16,24,26].

The biliary reconstruction in CDD is closer to normal anatomy compared to RY, which provides a variety of benefits. CDD results in easier laparoscopic access if future biliary duct exploration is required [9,23] While rates of ERCP or PTC are similar between biliary anastomosis types, intervention was required in one-third to nearly half of recipients [18]. Altered anatomy, short intestines, and adhesions can make ERCP challenging in patients with Roux en Y anatomy. Many alternative approaches exist, with preferred options notably including laparoscopic assisted ERCP which is resource intensive, requiring an operating room, and subjecting the patient to another intraabdominal surgery [27]. ERCP following CDD can be performed in the traditional fashion.

In addition to allowing easier endoscopic access to the biliary system, preserving small bowel anatomy with CDD allows the small bowel to continue normal physiologic function. Rerouting of the small bowel with RY can result in numerous nutritional deficiencies, as well as hypersecretion, peptic ulcers, and gastrointestinal haemorrhages [28]. This also allows for an operation that is arguably less technically challenging, requiring fewer anastomoses compared to RY. Operating time for CDD is decreased compared to RY [22,28]. Mean blood loss has been shown to be decreased in CDD compared to RY [22,28]. Additionally, length of hospital stay has been shown to be decreased in patients undergoing CDD compared to RY or CDJ [22,29].

Conclusion

Among individuals undergoing orthotopic liver transplant and unsuitable for choledochocholedochostomy, choledochoduodenostomy should be considered as it does not have increased rates of complication, better approximates native anatomy, and reduces the technical challenge of potential interventions in the future compared to roux en y or choledochojejunostomy

Acknowledgments

None.

Conflicts of Interest

None.

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