Choledochoduodenostomy (CDD) is a surgical procedure to create an

anastomosis An anastomosis (, plural anastomoses) is a connection or opening between two things (especially cavities or passages) that are normally diverging or branching, such as between blood vessels, leaf#Veins, leaf veins, or streams. Such a connection m ...

, a surgical connection, between the

common bile duct The common bile duct, sometimes abbreviated as CBD, is a duct in the gastrointestinal tract of organisms that have a gallbladder. It is formed by the confluence of the common hepatic duct and cystic duct and terminates by uniting with pancreati ...

(CBD) and an alternative portion of the

duodenum The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear, and the terms anterior intestine or proximal intestine m ...

. In healthy individuals, the CBD meets the

pancreatic duct The pancreatic duct, or duct of Wirsung (also, the major pancreatic duct due to the existence of an accessory pancreatic duct), is a duct joining the pancreas to the common bile duct. This supplies it with pancreatic juice from the exocrine pancre ...

at the

ampulla of Vater The ampulla of Vater, also known as the or the hepatopancreatic duct, is formed by the union of the pancreatic duct and the common bile duct. The ampulla is specifically located at the major duodenal papilla. The ampulla of Vater is an import ...

, which drains via the

major duodenal papilla Major (commandant in certain jurisdictions) is a military rank of commissioned officer status, with corresponding ranks existing in many military forces throughout the world. When used unhyphenated and in conjunction with no other indicators ...

to the second part of duodenum. In cases of benign conditions such as narrowing of the distal CBD or recurrent CBD stones, performing a CDD provides the diseased patient with CBD drainage and decompression. A side-to-side anastomosis is usually performed.

Bile Bile (from Latin ''bilis''), or gall, is a dark-green-to-yellowish-brown fluid produced by the liver of most vertebrates that aids the digestion of lipids in the small intestine. In humans, bile is produced continuously by the liver (liver bile ...

from the gallbladder is carried to the CBD and emptied into the duodenum. CBD drainage might be obstructed due to distal CBD stricture, which is narrowing of the CBD due to the presence of

scar tissue Scar tissue may refer to: Medicine * Scar, an area of fibrous tissue that replaces normal skin after injury * Granulation tissue, a product of healing in major wounds Film and television * ''Scar Tissue'' (1975 film), or ''Wanted: Babysitter'' ...

within the duct, and

choledocholithiasis Common bile duct stone, also known as choledocholithiasis, is the presence of gallstones in the common bile duct (CBD) (thus '' choledocho-'' + ''lithiasis''). This condition can cause jaundice and liver cell damage. Treatments include choledocho ...

, the presence of

gallstone A gallstone is a calculus (medicine), stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to ...

s. Obstruction can occur when gallstones may be too large to pass through the CBD into the duodenum. Liver tests are performed before and after the operation. During surgery, the duodenum should be repositioned in close proximity with the CBD to ensure a tension-free anastomosis. 8 incisions are made, with one in the CBD and one in the duodenum. Sutures are performed between the incisions to create a new pathway. Postoperative complications include inflammation and narrowing within the surgical site and sump syndrome. Given that the duodenum is in a diseased state, or a tension-free anastomosis cannot be created, a CDD should not be performed and alternative bypass procedures could be considered. Currently, CDD accounts for approximately 1% of all biliary operations to provide CBD drainage. 38% of the patients undergo CDD as a primary operation (first treatment given for a disease) and 60% of the patients undergo CDD as a secondary procedure (a surgical procedure which is performed to improve conditions found to exist during the primary surgery). CDD is more often performed in the elderly with the mean age of the patients being around 61 years.

Medical Uses and Indications

CDD creates an anastomosis to allow free flow of bile from the CBD into the duodenum. Side-to-side anastomosis and end-to-side anastomosis are two procedures that can be done. Side-to-side anastomosis is preferred as the distal CBD blood supply is poor and more suitable to the laparoscopic approach, which requires limited anterior CBD dissection. Performing an end-to-side anastomosis risks

ischemia Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems wi ...

and recurrent

stenosis A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture'' ...

. CDD is an alternative to choledochojejunostomy, a procedure which involves creating an anastomosis of the CBD to the

jejunum The jejunum is the second part of the small intestine in humans and most higher vertebrates, including mammals, reptiles, and birds. Its lining is specialised for the absorption by enterocytes of small nutrient molecules which have been previous ...

. CDD is less technically challenging as the procedure is fast and simple with less anastomotic sites and does not require the creation of a

Roux-en-Y anastomosis In general surgery, a Roux-en-Y anastomosis, or Roux-en-Y, is an end-to-side surgical anastomosis of bowel used to reconstruct the gastrointestinal tract. Typically, it is between stomach and small bowel that is distal (or further down the ...

. It also has better endoscopic access to the

biliary tree The biliary tract, (biliary tree or biliary system) refers to the liver, gallbladder and bile ducts, and how they work together to make, store and secrete bile. Bile consists of water, electrolytes, bile acids, cholesterol, phospholipids and co ...

and more physiologic bile drainage. CDD is used in the treatment of biliary obstruction caused by various factors shown below or when alternative treatment options were not accessible. Other less common indications include operative injuries, or chronic dilation of the CBD.

Indications

Choledocholithiasis

Gallstone disease is considered to be one of the most common digestive diseases. It is prevalent regardless of ethnicity with rates in the United States and Europe reported to be approximately 10-15%. It affects about 25 million people in the US and nearly 1 million people diagnosed annually will need to be treated. Studies have shown that 58-72% of patients with symptomatic gallstones will have ongoing symptoms and complications. With multiple stones present, the difficulty in clearance of the CBD can lead to biliary blockage. A CDD allows for the passage of any retained gallstones, such as impacted stones, or stones where endoscopic treatments of extraction are not possible.

Ampullary Stenosis

The narrowing of the Ampulla of Vater is either verified by a 3mm instrumental probe being unable to pass through the ampulla, or the lack of dye flowing into the duodenum when a

cholangiogram Cholangiography is the imaging of the bile duct (also known as the biliary tree) by x-rays and an injection of contrast medium. __TOC__ Types There are at least four types of cholangiography: # Percutaneous transhepatic cholangiography (PTC): Exam ...

is carried out, indicating obstructed bile flow. Any attempts to enlarge the stenosis can lead to perforation of the duodenum wall or CBD, or damage to the pancreas, further limiting bile flow. This is present in approximately 10% of patients with persistent or recurrent

biliary colic Biliary colic, also known as symptomatic cholelithiasis, a gallbladder attack or gallstone attack, is when a colic (sudden pain) occurs due to a gallstone temporarily blocking the cystic duct. Typically, the pain is in the right upper part of the ...

after

cholecystectomy Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the eighth most common operating room procedure performed i ...

Chronic Pancreatitis Chronic pancreatitis is a long-standing inflammation of the pancreas that alters the organ's normal structure and functions. It can present as episodes of acute inflammation in a previously injured pancreas, or as chronic damage with persistent pa ...

In addition to disrupted pancreatic function and physiology, long-term pancreatic inflammation can lead to distal CBD blockage. Chronic pancreatitis poses a high risk for developing

pancreatic cancer Pancreatic cancer arises when cell (biology), cells in the pancreas, a glandular organ behind the stomach, begin to multiply out of control and form a Neoplasm, mass. These cancerous cells have the malignant, ability to invade other parts of t ...

. Creating an alternative passage from the CBD to the duodenum is done when surgical resection of the tumour is not available. The prevalence of this disease is 0.05% in industrialised countries. This disease often develops in patients between the ages of 30 and 40, and is more common in men.

Malignant Malignancy () is the tendency of a medical condition to become progressively worse. Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not s ...

Neoplasm A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s

Cancerous tumours arising from the CBD, the ampulla, or the portion of the duodenum near the ampulla can result in distal CBD obstruction. When the masses are incapable of being surgically removed, CDD can be performed. In some cases where the growing tumour occludes the new pathway, CDD will only provide palliative relief. It is recommended to use alternative procedures that allow for relief farther away from the tumor. In the United States, an estimated 6000-7000 new cases of gallbladder carcinoma and 3000-4000 new cases of bile ducts carcinoma are diagnosed annually.

Contraindications

Contraindications for the procedure are based on the patient’s physiologic condition of the CBD and the duodenum.

Duodenal
Ulceration An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing o ...

Duodenal ulceration can lead to inflammation or fibrosis of the duodenum. Duodenal scarring or blockage makes it subpar for an anastomosis to be performed. As an alternative, a choledochojejunostomy can be performed.

Tumour Growth

Malignant cell growth, such as a pancreatic head tumor, can prevent proper repositioning of the duodenum to be in close contact with the bile duct. Performing a CDD may lead to a tension-filled surgical anastomosis, leading to bile leakage and

jaundice Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and sclera due to high bilirubin levels. Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme meta ...

. There is also the possibility of active tumour growth obstructing the CBD. Alternative procedures could be considered, such as a Roux-en-Y

hepaticojejunostomy {{Short pages monitor