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\begin{document}

\title{Impacted common bile duct stone managed by hepaticoduodenostomy: a case
report.}



\author[1]{Elroy Weledji}%
\author[2]{Ndiformuche  Mbengawoh}%
\author[1]{Frank Zouna}%
\affil[1]{University of Buea}%
\affil[2]{Limbe Regional Hospital}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\selectlanguage{english}
\begin{abstract}
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.%
\end{abstract}%



\sloppy


\textbf{Key Clinical message}

A bypass procedure such as a hepaticoduodenotomy may be an alternative
to the traditional choledochoduodenostomy in the management of the
retained, impacted distal CBD stone especially in the presence of
sepsis.

\textbf{Introduction}

The management of common bile duct (CBD) stones is well established. An
algorithm showing the available strategies for the management of CBD
stones following a routine or selective per-operative cholangiogram or a
pre-operative endoscopic retrograde cholangiopancreatogram is
illustrated in figure 1{[}1{]}. Although the laparoscopic exploration
for CBD stones 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 carry
out a choledochoduodenostomy, or removing the stone through a
transduodenal sphincteroplasty {[}4{]}. We present herein a
hepaticoduodenostomy 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.

\textbf{Case Presentation}

A 40-year-old fit black African farmer was admitted as an emergency with
a 3-week history of gradual onset epigastric pain which 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 a 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
mmHg, heart rate of 81 beats/min, respiratory rate of 22 breaths/min and
a temperature of 37.2\textsuperscript{0} C. He had an icteric sclera and
a tender right hypchondrial mass with a positive Murphy's sign
consistent with an acute cholecystitis. An abdominal ultrasound scan
demonstrated an acute cholecystitis with a distally impacting CBD stone.
A full blood count and renal function tests were normal. Hepatitis and
HIV screen were negative. Liver function tests showed an obstructive
picture with raised alkaline phosphatase 763.52ui/l (n: 38-126ui/l),
ALAT 80ui/l ( n: 0-41), ASAT 32ui/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 nor common bile duct 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 post-operative 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 post operative day he developed basal pneumonia
which was treated aggressively with intravenous antibiotics, oxygen
therapy and chest physiotherapy. On the 20\textsuperscript{th} post
operative day there was a sudden biliary leakage via the healing midline
abdominal wound. A contrast computed tomography (CT) scan revealed a
voluminous right hypochondrial and perihepatic peritoneal purulent
collection measuring 682 cc and, an impacted calculi at the base of the
CBD. The pancreas was normal. A difficult emergency laparotomy revealed
severe biliary leak from the dehisced cystic duct stump with dense
adhesions. This was doubly resutured with 2.0 vicryl. Full Kocherisation
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
hepaticoduodenostomy). Because of the inflamed cystic duct stump and
adhesions surrounding the CBD, we opted for a more proximal approach in
a hepaticoduodenostomy. A vertical incision was made in the CHD, and a
longitudinal incision made in the adjacent duodenum which was then
sutured transversely. This side- to side anastomosis was performed in a
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 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 CT scan was
planned to assess the nature of the extrahepatic biliary tree and
ascertain if the calculi had spontaneously passed.

\textbf{Discussion}

This case demonstrates an open hepaticoduodenostomy procedure being used
to rescue the adverse sequelae of an impacted distal CBD stone in a low
resource setting. A choledochoduodenostomy (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 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 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 re-sutured dehisced cystic duct stump and, the
inflammation and adhesions below, a higher approach (
hepaticoduodenostomy) was utilized (Figure 2). It is essential to ensure
that the choledocho/hepaticoduodenostomy is at least 2.5 cm long in
order to avoid stenosis, recurrent cholangitis and further stone
formation {[}9{]}. Except for significant post-operative biliary leakage
which was managed conservatively, the outcome was successful as the
jaundice, pain and rigors resolved. Biliary anastomoses do not seal
easily as intestinal anastomoses and, thus the indication for a
sub-hepatic drain {[}10{]}. A hepaticoduodenostomy for obstructive
common bile duct stone has not been reported in the English literature.
Hepaticoduodenostomy (HD) is becoming an alternative to the Roux-en-Y
hepaticojejunostomy (HJ) in reconstruction after excision of a
choledochal cyst because of fewer complications such as adhesive bowel
obstruction, anastomotic leakage and peptic ulcer. Apart for 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 {[}13{]}. It is
appropriate that most patients with CBD stones are treated at the time
of cholecystectomy. Thus the importance of performing intra-operative
cholangiography during a cholecystectomy and exploring the CBD to
retrieve any stone. 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 common bile duct 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 {[}14{]}. There is
also the risk of damage to the hepatic artery or portal vein {[}1,
13{]}. 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 (Figure 1) {[}1{]}.Currently, the
rational utilization of laser lithotripsy and an appropriate basket in
laparoscopic common bile duct exploration (LCBDE) may avoid conversion
to open procedures in patients with impacted CBD stones {[}3, 15{]}.
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
laparoscopic intra-operative CBD exploration). 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 hepaticoduodenotomy
may be an alternative to the traditional choledochoduodenostomy in the
management of the retained, impacted distal CBD stone especially in the
presence of sepsis and adhesions around the supraduodenal common bile
duct and, in a low resource setting {[}16{]}.

\textbf{Declarations}

Ethical statement: The authors are accountable for all aspects of the
work in ensuring that questions related to the accuracy or integrity of
any part of the work are appropriately investigated and resolved. All
procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or
national research committee/s and wth the Helsinki Declaration (as
revised in 2013). Written informed consent was obtained from the
patient.

\textbf{Acknowledgements}

Fundings: None

\textbf{Footnote}

Reporting Checklist: The authors have complieted the CARE checklist

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Figure 1: Algorithm showing the available strategies for management of
common bile duct stones (1) \{with permission\}

Figure 2: Schematic diagram of hepaticoduodenostomy

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