@Andrey, I am not a surgeon and therefore do not have any aswer for you. However, EPST is a very effective and safe procedure even in critical patients, so I think it is not so easy to find indications for a surgical operation which is time-consuming and not very safe in patients with severe pluri-pethologies.

Yes in selected cases. See this publication-

http://www.ncbi.nlm.nih.gov/pubmed/24160798

Also rarely in the setting of liver transplantation.

Andrey,Yes it is still being performed but not like earlier days.one of the indications we use is for inoperable bilio pancreatic malignancies where endoscopic stenting was not successfful or after trial dissection we could not resect.For benign pathologies like cbd stones or strictures by and large we donot do because of sump syndrome and the reflux leading to cholangitis.I have undone the proceedure in some of the cases where it was causing recurrent sump syndromeinspite of repeated ES.

Thank you for all the answers, dear colleagues!

However, the Dr.Reddy's opinion is closer to mine. As he expressed it in his usual short and precise way: "It is still being performed, but not like earlier days"

I must argue, on the other hand, that the EPST is not absolutely innocent and safe a procedure as our best friends therapeutists may imagine sometimes. There is the mortality and morbidity without any reliable trend to decline.

According to our national guidelines on Biliary Surgery, we do not make the choledochoduonestomy (CDS) in any case of significant enlargement of the head of the pancreas so that to avoid both some tension on the suture line with danger of the anastomotic leakage at the early post-operative period and the scar stricture of the stoma+sump syndrome in the remote follow-up.

Would you see at the picture below:

A) The pancreatic head is not enlarged; the CBD and the duodenum are close to each other; the CDS is possible.

B) The pancreatic head is enlarged severely so that there is a long distance between the CBD and the head along the antero-posterior axis. The CDS is not recommended here).

At second,

Dr.Verran, thank you so much for really interesting for me the reference. Unfortunately, it is unavailable. Nor myself, neither any library in my city do receive that journal.

To the best of my knowledge, there have been three main methods of the choledochoduodenostomy performance suggested:

A) by Urasch: according to this, the CBD is cut longitudinally, and the duodenum is cut in the transversal direction against the first cut. This method is hard to imagine that it can repair any normal anatomic condition to any extent. Indeed, the duct become angulated anteriorily, and the duodenum become twisted along its long axis. The sutures are under tension with danger of leakage or stricture  to develop (and the 'sump' is going to come up there too).

B) by Saypol (if I remember correctly): both the CBD and the duodenum are cut longitudinally. In this case, the duodenum is twisted to a lesser extent, but the general picture remains the same.

C) by Kirschner-Finsterer: the orifice is forming at the level of the retroduodenal part of the CBD. The duct is cut transversally, and the duodenum is cut longitudinally. There is no needness to make too wide opening because it is not under tension and will not diminish due to scarring. We have using this method 20 years more without any 'sumps' (save the two cases when it was used for the head carcinoma palliative treatment).

Dear Borodach

I performed choledochoduodenostomy today. Indication was malignant bile duct stone !(aproximately, 4 cm diameter)

The malignant stone?! How is it possible? Have you got some pictures?

And this is 'mine' recent stone that dropped from the common bile duct into the duodenum to cause the ileus. My students have destroyed it a little. They wondered what it was like from inside.

My colleagues took photographs. I will send photos

yes, it is still  frequently done in  many centers in my country . as result of shortage of instrumental interventions in such cases, due to lack of  experts in endoscopic  therapy and  unavailability of devices .i have done two such procedure  last year , one for cancer head pancreas  and other for CBD stone . for me it is procedure of choice because it is  simple ,rapid and has less morbidity  with keeping of same original anatomical relation of the GIT structures ..thank you

Please find attached photo

1) Dr.Tez,

So, are they some soft bilirubin concretions, are't they? Thank you.

2) To Dr.Hashim Jakob:

What is incidence of the gallstone disease in your country? Is it a common disease enough, or a rare one?

Sincerely,

Andrey

Dear Borodach

I think,they are  cholesterol stones

I would not give any references on this point, but it is rather a common way among the remote follow-ups published on Biliary Surgery. The results of the patients after the cholecystectomy only they put together with those after the cholecystectomy and EPST (or biliodigestive shunts). However, the procedures are different with the different results and the different scores on quality of life. The best are after cholecystectomy, followed by the EPST, and the worst functional results are after the CDS. The major challenge is not the 'sump'-sindrome, neither the cholangitis, They are very rare.

It is the enlarged bile inflow into the duodenum with the massive, not seldom deliterious duodeno-gastric and duodeno-esophagic refluxes from what the patients suffered most.

On the other hand, the choledochoduodenostomy is the procedure for most altered biliary conditions, and there is no choice usually.

Dear Andrey Borodach

Although as you have pointed out precisely that open Choledochoduodenostomy operation has been replaced largely by the endoscopic papillosphincterotomy (EPST), HOWEVER, The answer to your question is YES open choledochoduodenostomy is still being used and considered as important surgical tool in the management of common bile duct stones .

The following are articles which include the information which you have requested in your question (when and why this procedures was chosen to be performed and also information about the authors whom if you would like you can contact to get more information);

 Deutsch AA, Nudelman I, Gutman H, Reiss R. Choledochoduodenostomy an important surgical tool in the management of common bile duct stones. A review of 126 cases. Eur J Surg. 1991 Sep;157(9):531-3.( PMID: 1683577)

 Shrestha S1, Pradhan GB, Paudel P, Shrestha R, Bhattachan CL. Choledochoduodenostomy in the management of dilated common bile duct due to choledocholithiasis. Nepal Med Coll J. 2012 Mar;14(1):31-4.(PMID: 23441491)

1Department of Surgery, Nepal Medical College and Teaching Hospital, Jorpati, Kathmandu, Nepal. [email protected]

 Gupta BS. Choledochoduodenostomy: a study of 28 consecutive cases. Kathmandu Univ Med J (KUMJ). 2004 Jul-Sep;2(3):193-7.(PMID:16400213)

Author information: Department of Surgery, College of Medical Sciences, Nepal. [email protected]

 Srivengadesh G1, Kate V, Ananthakrishnan N. Evaluation of long-term results of choledochoduodenostomy for benign biliary obstruction. Trop Gastroenterol. 2003 Oct-Dec;24(4):205-7.(PMID:15164535)

Author information:1Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006.

The following are also two interesting case reports in which choledochoduodenostomy was the only option of surgical treatment and has been performed successfully;

1] A 14-Year-Old Girl With Abdominal Pain and Emesis

Authors: Meena Thayu, MD, Michael Nance, MD, Petar Mamula, MDSeries Editors: David A. Piccoli, MD, Petar Mamula, MD

October 19, 2006

AUTHORS AND DISCLOSURES

Meena Thayu, MD, Attending Physician, Division of Gastroenterology, Hepatology & Nutrition, The Children's Hospital of Philadelphia; Instructor in Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; E-mail: [email protected]

Michael Nance, MD, Attending Physician, Division of Pediatric, General and Thoracic Surgery, The Children's Hospital of Philadelphia; Associate Professor of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Petar Mamula, MD, Director, Endoscopy Suite, Division of GI & Nutrition, The Children's Hospital of Philadelphia; Assistant Professor of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

David A. Piccoli, MD, Chief, Division of Gastroenterology & Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Professor of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

2] Management of Patient With Mirizzi's Syndrome?

Wayne H. Schwesinger, MD

September 11, 2002

In this report the following conclusion was presented and which complies with your opinion 100%;

Because of the variability of the underlying disease in Mirizzi's syndrome, treatment must be individualized. In most patients; an open operation is preferred over a laparoscopic procedure because of the extreme anatomic distortion that is present in the triangle of Calot as a result of the intense inflammation.

Wayne H Schwesinger, MD

Professor of Surgery and Head of General Surgery Section, Department of Surgery, University of Texas Health Science Center; Director of Surgical Endoscopy, Department of Surgery, University Health System, San Antonio, Texas.

Regards

Choledochoduodenostomy is a very, very rare procedure (reflected by the scarcity of literature). The procedure is associated with increased rates of infections and stone formation. Standard procedure is ERCP and in selected cases BDA with Roux-en-Y.

To Dr.Abou-Hussein:

Thank you so much for the opinion expressed here and for the links kindly provided! You have done so good and profound search through the world literature that I feel shame.  Separate thanks for the role of choledochoduodenostomy in the management of Mirizzi's syndrome.

To Dr.Nashan:

Thank you for the post. May I ask a question about the thesis about "the procedure is associated with increased rates of infections and stone formation"? Is this from your own experience, or just some alien data from literature? And  - is it said about the 'sump' syndrome, or something else is meant?

The procedure does not belong to the modern armamentarium since it has been replaced by ERCP or, of not feasible BDA. My experience touches literature as well as the few cases we had to switch to BDA. Furthermore, it does not belong to the curricula for general or visceral surgery.

Dr.Nashan,

At first, thank you for the answer. If you do not mind, I would like to add a couple of questions to understand your answer about your 'few cases' completely:

1) Which disease was the indication to the first biliodigestive shunting: a tumor, a scar stricture, or common bile duct stones?

2) What namely made you (or your colleagues) to switch from the CDA to the BDA? The words like 'infection' or 'stone' are seemingly not quite suitable here. They are too vague and indefinite.

Dr Borodach,

Thank you for your reply. I do think that we need to find common ground with regard to indications:

1. Do you agree that ERCP is the standard procedure? yes or no

2. Do you agree that BDA is the second choice after ERCP or in cases where ERCP is not feasible? yes or no

3. Do you agree that PTCD follows if neither ERCP or BDA are possible? yes or no

4. Please explain where you see the indication for CDA?

If your answer is no, please explain.

Dr.Nashan,

Thank you for this post and the short questionnaire provided. Please, find my answers below. However, I'd like to extent some of them a little far beyond just 'yes' or 'no' for the reason that different clinical and pathological entities should not be operated upon always in the same way.

1. "...[is] ERCP ... the standard procedure? yes or no". The standard procedure for what?

I beg pardon my boring, but the Endoscopic Papillosphincterotomy (EPST) is not the same as the ERCP (the Endoscopic Retrograde Cholangiopancreaticography). The EPST is the gold standard for the stones located in the common bile duct or/and a little further, in the common hepatic duct. This pathologic condition usually comes along with the scar (or, rarer, the hypertrophic) stenosis of the Vater's papilla, the terminalmost and completely intraduodenal part of the common bile duct or of the so called "common canal".

Unfortunately, the most part of patients suffering from the common bile duct stone(s) is the elder group of the gallstone population, on the 7th decade of life and older. This very group is prone to the aging connective tissue dystrophy and develop various hernia and hernia-like alterations including the paravaterian diverticula (up to 10-15 per cent). The PVD type C and sometimes B are contraindication for the EPST to perform due to the high risk of the so called 'retroduodenal perforation'. Besides, the PVD is one of the pathogenetic factors for the post-PST acute pancreatitis to occur due to putative anaerobe influx into the Wirsung from the PVD cavity. So, there are about 1-5% of the CBD stones those not destined for the EPST (PVD type C+a really few amount of those after B-II gastrectomy, unremovable and unlithotriptoble giant carbonate stones, etc.). Taking in mind that the gallstone disease prevalence is about 300 per 100,000 of general population and app.5-10 per cent among them have had the CBD stones, these figures are not negligible.

Several lines about the EPST inself (for the especially patient readers):

Some authorities regard the papilla and its muscular and valve apparatus as having not much matter and propose to make the EPST as some "approach stage" due to some strictly technical indications like 'to make ERCP easilier', and so on. On the other hand, many other researchers believe that both the papilla and the sphincter called for R.Oddi is the essential mechanism those should preserved in as many cases as only possible. The periportal fibrosis and chronic inflammative infiltration of the liver parenchyma development was detected in all the cases still studied [T.C.K.Tham, D.L.Carr-Locke, J.S.A.Collins. Endoscopic sphincterotomy in the young patient: is there cause for concern? Gut 1997.40:697-700; Bailli J. Biliary sphincterotomy: less benign than once thought? / J.Bailli // Curr. Gastroenterol. Rep. 1999. 1(2):102-6; etc.].

As for tumors and pseudotumors of the pancreatic head complicated with the common bile duct obstruction and 'surgical' jaundice, the EPST cannot reach success because the CBD stricture is usually too long to be dissected. Rarely and if one has the vast experience and the golden hands, the EPST may be used there to deliver a biliary stent via the papillotomy orifice over the altered part of the duct upwards.

There may be one more indication for the EPST exists, namely, the ductogenic biliary microlithiasis, one of the possible factors contributing to the acute 'idiopathic' pancreatitis development (according to [F.J.Bel, L.Aparisi, G.Garcia-Tell, et al. El drenaje biliar en el diagnostico de la microlitiasis. Valor en la pancreatitis aguda idiopatica y en el dolor en hipocondrio derecho persistente. Rev. Esp. Enferm. Dig. 1994.85(5):343-7] it accounts for app.5% of all cases of the biliary microlithiasis).

2.Do you agree that BDA is the second choice after ERCP? No, I do not.

 - to be continued -

My 2c worth. It is unusual in medicine with the spectrum of patients that we see to be able to have strict treatment algorithms for the spectrum of patients who present with the various hepatobiliary conditions. Flexibility is important along with being able to tailor protocols such that patient outcomes are optimised. One also has to take into account the availability of local expertise. 

Dr.Verran,

Thank you for the deepest jugement of the (wide) spectrum of patients with the gallstone disease and flexibility of treatment modalities and even of the availability of local expertise. Indeed, the reformation of the Soviet healthcare management into the new Russian healthcare has been going on from the 90s, and practising physiceans, and university professors, and our patients altogether are not very lucky as result. I may be wrong from the general point of view, but I can see what I would call "a kind of feudal fragmentation on the level of the municipal healthcare". There are ex-primary, ex-secondary, and ex-tertiary medical centers left those are almost completely separated from each other, so that their level varies greatly in the same city with population about 2 million.

However, approximately 3,000 cholecystectomies been performed each year with the incidence of the common bile duct stones about 150-180 cases in a year, and 120-150 EPST are performed (for details, you can see the link below). The indication for the choledochoduodenostomy due to unavailability of the EPST exists, but it accounts for minority of cases. The main reasons for the CDS were enlisted above.

Best regards,

Andrey Borodach

P.S. Unfortunately, I do not understand what does mean 'my 2c worth'. Is this an idiomatic expression?

https://www.researchgate.net/post/Is_it_really_true_that_the_common_bile_duct_stone_rate_in_the_acute_cholecystitis_is_higher_compared_to_the_chronic

I am looking after new papers about  choledochoduodenostomy, and it seems that there are not new papers. I must say that I still perform it laparoscopically in patients over 80 years to avoid repeating ERCP and stone extraction many times. Bile duct must be more than 15 mm and harbor many stones. Best regards.

Miguel Statti