Impacted Common Bile Duct Stone Managed by Hepaticoduodenostomy

Abstract

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 (CBD) stone, especially in the presence of sepsis. We present herein a hepaticoduodenotomy performed for a retained, impacted distal CBD 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.

Introduction

The management of common bile duct (CBD) stones is well established [1]. Although the laparoscopic exploration for CBD stones (LCBDE) has gained grounds over endoscopic retrograde cholangiography (ERCP) and sphincterotomy and duct clearance, there is no consensus as to the ideal approach [2, 3]. The management strategy chosen will depend on personal experience, equipment availability, time, and the availability of other departmental expertise [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 carrying out a choledochoduodenostomy (CDD) 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. We present the following case in accordance with the CARE reporting checklist.

Case Report

A 40-year-old fit black African farmer was admitted as an emergency with a 3-week history of gradual onset epigastric pain that was burning in nature, constant, and radiated to the back and chest. There were no exacerbating or relieving factors. He had recurrent abdominal pain in the past 6 years, which was managed conservatively. On this occasion, he complained of fever, and there was jaundice with dark urine but no pale stool. He had no relevant past medical history nor risk factors for chronic liver disease. On examination, he had a blood pressure of 153/92 mm Hg, 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 consistent with acute cholecystitis. An abdominal ultrasound scan demonstrated acute cholecystitis with a distally impacting CBD stone. A full blood count and renal function tests were normal. Hepatitis and HIV screens were negative. Liver function tests showed an obstructive picture with raised alkaline phosphatase 763.52 UI/L (n: 38–126 UI/L), ALAT 80 UI/L (n: 0–41), and ASAT 32 UI/L (n: 0–42). Following resuscitation with intravenous fluids, broad-spectrum antibiotics, and intramuscular vitamin K, he consented to a cholecystectomy and a transduodenal sphincterotomy/plasty. At operation, there was an acutely inflamed, intrahepatic, gangrenous gallbladder impacting on the CBD. There was no palpable gallbladder or CBD stone, and the CBD was not dilated. As the patient was unstable anaesthetically, the decision for a staged approach was made to initially treat the gallbladder sepsis, followed by postoperative observation for the possible spontaneous passage of the distal CBD stone, or the exploration of the CBD if the patient remained symptomatic. A difficult retrograde cholecystectomy was performed. On the 9th postoperative day, he developed basal pneumonia, which was treated aggressively with intravenous antibiotics, oxygen therapy, and chest physiotherapy. 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 impacted calculi at the base of the CBD. The pancreas was normal. A difficult emergency laparotomy revealed a severe biliary leak from the dehisced cystic duct stump with dense adhesions. This was doubly resutured with 2.0 vicryl. Full Kocherization of the duodenum allowed the upper aspect of the duodenum (duodenal bulb) to lie comfortably against the dilated CBD. This changed our decision from performing a transduodenal sphincterotomy/plasty to a more straight forward bypass procedure (a cholechoduodenostomy or a HD). Because of the inflamed cystic duct stump and adhesions surrounding the CBD, we opted for a more proximal approach with a HD. A vertical incision was made in the CHD, and a longitudinal incision was made in the adjacent duodenum which was then sutured transversely. This side-to-side anastomosis was performed with 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 2.5 cm. Following this procedure, a T-tube drainage of the CBD was not necessary. A sub-hepatic drain was inserted. The surgery was complicated by a severe biliary leak 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. But for the patient's financial difficulties, a follow-up contrast computed tomography scan was planned to assess the nature of the extrahepatic biliary tree and ascertain if the calculi had spontaneously passed.

Discussion

This case demonstrates an open HD procedure being used to rescue the adverse sequelae of an impacted distal CBD stone in a low-resource setting. A CDD 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 CDD as a highly effective treatment for choledocholithiasis (CBD stones) in the presence of a dilated CBD in all age groups with low morbidity and mortality, provided a wide anastomosis was accomplished [6]. It has been reported as a more effective treatment of CBD stones than T-tube drainage but is regarded as an obsolete therapeutic method due to fears of higher morbidity, reflux cholangitis, hepatic abscess, stone recurrence, pancreatitis, and “sump” syndrome [7]. “Sump” syndrome is theorized to occur from bile stasis and reflux of duodenal contents into the terminal CBD with bacterial overgrowth, resulting in cholangitis or hepatic abscess. The side-to-side CDD is a safe and definitive procedure for the decompression of lower CBD obstruction and has good long-term results with infrequent complications including the “sump” syndrome [8]. Because of the resutured dehisced cystic duct stump and the inflammation and adhesions below, a higher approach (HD) was utilized (Fig. 1). It is essential to ensure that the CDD/HD is at least 2.5 cm long in order to avoid stenosis, recurrent cholangitis, and further stone formation [9]. Except for significant postoperative biliary leakage which was managed conservatively, the outcome was successful as the jaundice, pain, and rigours resolved. Biliary anastomoses do not seal easily as intestinal anastomoses, thus the indication for a sub-hepatic drain [10]. A HD for obstructive CBD stones has not been reported in the English literature. HD is becoming an alternative to the Roux-en-Y hepaticojejunostomy in reconstruction after excision of a choledochal cyst because of fewer complications such as adhesive bowel obstruction, anastomotic leakage, and peptic ulcer. Apart from higher postoperative reflux/gastritis, it has a shorter hospital stay and similar operative benefits and outcome [11]. The utilization of HD for type IV Mirizzi's syndrome has also recently been reported [12]. Approximately 12% of patients undergoing surgery for symptomatic gallbladder stones will also have stones in the CBD [1]. It is appropriate that most patients with CBD stones are treated at the time of cholecystectomy. Thus, it is important to perform intraoperative cholangiography during a cholecystectomy and explore the CBD to retrieve any stones. The lack of fluoroscopy (image intensifier), fibreoptic instruments (choledoscope), or radiologically guided wire baskets or balloons in our setting did not make this possible. The operative hazards in blindly exploring the CBD for retrieving an impacted distal stone using a Desjardin (stone-grasping) forceps or a Bake's dilator that can be passed down the CBD to allow division of the papilla and biliary sphincter in a transdudenal sphincteroplasty include damage to the biliary tree and the production of a false passage by overzealous instrumentation [13]. There is also the risk of damage to the hepatic artery or portal vein [1]. A post- ERCP and sphincterotomy for retrieval of the impacted stone, if available, would have been useful in this case, but if it failed, an open exploration is indicated [1]. Currently, the rational utilization of laser lithotripsy and an appropriate basket in LCBDE may avoid conversion to open procedures in patients with impacted CBD stones [3, 14]. Generally, the laparoscopic approach has the advantage for the patient over ERCP and sphincterotomy by being able to deal with the gallbladder and CBD stone(s) simultaneously (i.e., laparoscopic cholecystectomy and intraoperative LCBDE). This is corroborated by the fact that the standard treatment for symptomatic gallstones is laparoscopic, and there are few exceptions to a trial of a laparoscopic approach. However, open bypass procedures such as a HD may be an alternative to the traditional CDD in the management of the retained, impacted distal CBD stone especially in the presence of sepsis and adhesions around the supraduodenal CBD and in a low-resource setting [15].

Fig. 1.

Schematic diagram of HD.

Statement of Ethics

This study protocol was reviewed and the need for approval was waived by the University of Buea Institutional Review Board. Written informed consent was obtained from the patient for the publication of details of their medical case and any accompanying images.

Conflict of Interest Statement

All the authors (E.P.W., N.Z.M., F.Z.) have completed the CARE checklist ICJME uniform disclosure form. The authors have no conflicts of interest to declare.

Funding Sources

This manuscript did not receive any funding.

Author Contributions

E.P.W. is the main surgeon and author. N.Z.M. was the assisting surgeon and contributed in literature search. F.Z. contributed in literature search. E.P.W., N.Z.M., and F.Z. approved the final version of the manuscript.

Data Availability Statement

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.

Funding Statement

This manuscript did not receive any funding.