Choledochoduodenostomy: Definition and Clinical Indications
What is Choledochoduodenostomy?
Choledochoduodenostomy is a surgical procedure that creates a side-to-side anastomosis between the common bile duct and the duodenum to bypass biliary obstruction, but it has largely fallen out of favor due to serious complications including early bile and duodenal leakage. 1
The procedure involves creating a direct connection (typically >2 cm wide) between the dilated common bile duct and the first portion of the duodenum using fine suture technique (5-0 or 6-0) with single-layer stitching. 2
When is it Recommended?
Primary Indications (Historical Context)
Choledochoduodenostomy is indicated for selected patients with: 3
- Recurrent or impacted common bile duct stones that cannot be managed endoscopically
- Giant bile duct stones (common bile duct diameter must be ≥1.2 cm for technical feasibility) 4
- Benign biliary strictures causing obstruction
- Chronic recurrent cholangitis refractory to other treatments 5
Critical Prerequisites
The common bile duct diameter is paramount—the critical minimum size is 1.2 cm. 4 The procedure requires: 2
- Wide anastomosis (>2 cm)
- Tension-free connection
- Good mucosal apposition between healthy, well-vascularized tissues
- Surgeon with appropriate biliary surgery experience
Why It's Largely Avoided
Choledochoduodenostomy has not gained widespread use and is currently mostly avoided due to the serious clinical implications of early bile and duodenal leakage. 1 This is particularly critical in liver transplantation settings where these complications can be catastrophic. 1
Major Complications
Early postoperative complications include: 2
- Bile leakage and duodenal perforation (most serious early complications)
- Risk of progression to peritonitis, sepsis, and multiorgan failure if not promptly recognized 2
- Sump syndrome (though historically reported in only 5% of patients) 3, 4
- Recurrent cholangitis 3
Contraindications
The procedure is contraindicated in: 2
- Patients with cirrhosis
- Patients requiring future endoscopic access to the biliary tree
Preferred Alternative Approaches
For Bile Duct Obstruction
For patients with bile duct obstruction from pancreatic cancer or other malignancies, bypass of the common bile duct (choledochojejunostomy) or common hepatic duct (hepaticojejunostomy) to the jejunum is preferred because it provides more durable and reliable palliation. 1
For Liver Transplantation
In liver transplantation for PSC, duct-to-duct anastomosis should be performed in patients without significant extrahepatic disease and no suspected biliary dysplasia, as it provides similar outcomes to choledochojejunostomy but with easier endoscopic access and possibly lower risk of ascending cholangitis. 1
For Common Bile Duct Stones
Biliary sphincterotomy and endoscopic stone extraction is the primary recommended treatment for patients with common bile duct stones post-cholecystectomy. 1
Management of Choledochoduodenostomy Complications
If bile leakage occurs: 2
- Initial management: percutaneous drainage of collections and broad-spectrum antibiotics
- ERCP with biliary sphincterotomy and stent placement if conservative measures fail
- For major leaks with peritonitis: urgent referral to hepatobiliary center for potential surgical revision
Clinical Bottom Line
While choledochoduodenostomy can achieve good results in highly selected patients (84% good results in historical series), modern practice favors hepaticojejunostomy or choledochojejunostomy for surgical biliary bypass, and endoscopic approaches for most benign biliary obstructions. 3, 1 The procedure should only be considered when the common bile duct is significantly dilated (≥1.2 cm), endoscopic options have failed, and the patient has no contraindications, with surgery performed only by experienced biliary surgeons. 4, 2