What is the step-by-step procedure for a choledochoduodenostomy?

Choledochoduodenostomy: Step-by-Step Surgical Technique

Choledochoduodenostomy is performed by creating a side-to-side anastomosis between the common bile duct and the first portion of the duodenum, typically indicated when the bile duct diameter is ≥1.2 cm and used for treating recurrent choledocholithiasis, bile duct strictures, or as part of bile duct injury repair. 1

Indications and Patient Selection

• The procedure is indicated for recurrent or impacted bile duct stones, bile duct strictures, stenosis of the sphincter of Oddi, and certain bile duct injuries 2
• The common bile duct must measure at least 1.2 cm in internal diameter to accommodate a safe anastomosis 1
• For bile duct injuries specifically, choledochoduodenostomy may be used for Type I injuries with severe damage requiring transection, though hepaticojejunostomy is generally preferred for major injuries 3

Preoperative Preparation

• Complete imaging of the biliary tree must be obtained using percutaneous transhepatic cholangiography (PTC), MRCP, or other appropriate modalities 3
• Broad-spectrum antibiotics should be initiated if biliary fistula, biloma, or bile peritonitis is present 3
• For bile duct injuries with inflammation or infection, delay definitive repair for 4-6 weeks after effective control of inflammation 3, 4

Surgical Steps

Step 1: Exposure and Mobilization

• Perform a Kocher maneuver to mobilize the duodenum and expose the first portion adequately 5
• Identify and isolate the common bile duct in the hepatoduodenal ligament 5
• Ensure the bile duct diameter is adequate (≥1.2 cm) before proceeding 1

Step 2: Bile Duct Preparation

• Make a 2-cm longitudinal incision in the anterolateral wall of the common bile duct 6
• Inspect the bile duct lumen to confirm removal of all stones and assess for strictures 5
• If performing repair for bile duct injury, remove all scar tissue and devitalized tissue from the bile duct stump, as anastomosis on ischemic or scarred tissue is the primary cause of postoperative leakage and stricture formation 7
• Ensure healthy, non-ischemic, non-inflamed, and non-scarred bile duct tissue is used for the anastomosis 3, 7

Step 3: Duodenal Preparation

• Create an adjacent 2-cm longitudinal incision in the first portion of the duodenum, positioned to align with the bile duct opening 6
• The duodenal incision should be made to allow a tension-free anastomosis 6

Step 4: Posterior Wall Anastomosis

• Place the two corner sutures first at the hepatic side corner of the common duct and the anal side corner of the duodenum 6
• Suture the posterior wall using interrupted 4-0 or 5-0 absorbable sutures, ensuring good mucosal apposition 7, 6
• Suture from one corner to the other, maintaining uniform margins and appropriate density 7

Step 5: Anterior Wall Anastomosis

• Complete the anterior wall in a similar manner using single-layer interrupted sutures 6
• Use fine suture technique (5-0 or 6-0) according to bile duct wall thickness, with either absorbable or non-absorbable materials 7
• Ensure moderate knotting strength and tension-free anastomosis throughout 7

Step 6: Final Inspection and Drainage

• Inspect the completed anastomosis for hemostasis and ensure no tension on the suture line 6
• Place abdominal drains as indicated 2

Technical Considerations and Pitfalls

• The anastomotic opening must be adequate (typically 2 cm) to prevent stenosis and allow free drainage 6
• Preserve blood supply to the bile duct during dissection, as vascularized ducts are essential for successful reconstruction 7
• Never perform anastomosis on ischemic, inflamed, or scarred bile duct tissue, as this guarantees failure 7
• The sump syndrome (accumulation of debris in the distal bile duct) has not been observed with proper technique 2

Expected Outcomes

• Overall success rates of 84% with good results have been reported for biliary bypass procedures 2
• The procedure can be performed with mortality rates not greater than T-tube insertion in appropriately selected patients 1
• Postoperative length of stay averages 4-6 days 8, 5
• Anastomotic stricture rates range from 10-20% when performed by experienced surgeons, typically occurring 11-30 months postoperatively 7

Laparoscopic Approach

• Laparoscopic choledochoduodenostomy follows the same principles but requires adequate laparoscopic experience 8
• The technique includes bile duct transection and end-to-side anastomosis in some series, with 83% of patients tolerating the operation without complications 5
• Median blood loss is minimal with the laparoscopic approach 5

When to Choose Alternative Procedures

• For major bile duct injuries with tissue loss or complete transection, hepaticojejunostomy (Roux-en-Y) is preferred over choledochoduodenostomy, with success rates of 80-90% 4
• Choledochojejunostomy is equally effective for bile duct obstruction and may be preferred when the injury involves the hepatic duct rather than the distal common bile duct 4, 2
• If local hepatopancreatobiliary expertise is unavailable, referral to a tertiary center is essential rather than attempting repair 7