An uncommon and late complication of side-to-side choledochoduodenostomy (CDD), the 'sump syndrome', developed in a patient 4 years after surgery. Recurrent right upper abdominal pain, fever with chills and rigors and latterly, mild jaundice made her seek repeated hospital admissions which were treated successfully with antibiotics. During the last admission, ultrasonography, endoscopic retrograde cholangiography (ERC), computerized scanning (CT) and hepatic iminodiacetic acid (HIDA) scan using Tc99m confirmed multiple intrahepatic calculi with proximal dilatation, debris in the distal blind segment and delayed excretion through the CDD. At surgery, the choledochoduodenostomy was taken down and a Rouxen-Y hepaticojejunostomy (RHJ) was fashioned after ductal clearance. The closed end of the Roux loop was placed subcutaneously for subsequent percutaneous access for cholangiography and removal of calculi. She is asymptomatic and well 28 months after surgery.
We present a 64-year-old Malay lady who had undergone a choledochoduodenostomy (CDD) two years ago for obstructive jaundice. She was admitted with jaundice and underwent ultrasonography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio pancreatography (ERCP) and computed tomographic (CT) scanning of the liver and biliary tree. All the investigations confirmed a type IVa choledochal cyst. At operation, the grossly dilated biliary system was packed with a thick mucoid material and the mucosa of the bile ducts was visibly abnormal with scattered nodules. This mucoid material had caused occlusion of the entire biliary tree resulting in obstructive jaundice. To the best of our knowledge, this is probably the first report of obstructive jaundice caused by thick mucus. The peculiar management problems of this case and the risk of malignant change in choledochal cysts are discussed.
Twenty bilio-enteric anastomoses were performed or managed from May 1990 to December 1992. Recurrent pyogenic cholangitis (RPC) and pancreatic cancer were the commonest conditions which required drainage procedures. Roux-en-Y hepatico-jejunostomy (RHJ) was performed in 9 patients, 4 for RPC, one for pancreatic cancer, another for a cholangiocarcinoma, 2 following excision of choledochal cyst and one hepatico-jejunostomy was part of a Whipple reconstruction. Roux-en-Y side to side choledocho-jejunostomy (CDJ) was performed in one patient. Choledocho-duodenostomy (CDD) was performed in 6, 4 for obstructive jaundice due to choledocholithiasis, one for RPC and one in a choledochal cyst. One patient operated elsewhere presented with complications after a CDD. Palliative cholecysto-jejunostomy (CYJ) was carried out in 4 patients with pancreatic malignancy. All benign conditions were treated by hepatico-jejunostomy and choledocho-duodenostomy, while three patients with malignant conditions were treated by hepatico-jejunostomy. Permanent subcutaneous access loops were provided when recurrent problems were anticipated, 4 in RPC and one after subtotal resection of a cholangiocarcinoma. Based on this study, we found Roux-en-Y hepatico-jejunostomy a versatile drainage procedure, which was useful in both benign and malignant diseases.