We decided to perform an EUS-guided choledochoduodenostomy
(EUS-CDS) using a hot tip fully covered expandable metal stent (Boston Scientific, Xlumena Inc., Mountain View, CA, USA).
Additional risk factors for ERCP-related hemobilia which should be mentioned are variant anatomy, especially anomalous location of the ampulla, aggressive biliary balloon dilation or intraductal biopsying, vascular anomalies (e.g., associated with hereditary hemorrhagic telangiectasia), and transbiliary ductal drainage procedures (e.g., EUS-guided choledochoduodenostomy
and hepaticogastrostomy) [8, 21-24].
The reasons for conversion were: multiple stones (1), impacted calculus in the distal end of duct which was difficult to extract (2), frozen anatomy of Calot's triangle (1), nonretrieval of a stone (1), and requirement of choledochoduodenostomy
In cases where there is significant size mismatch between the donor and recipient bile ducts, additional measures which have been employed include: partially closing a patulous recipient CHD or CBD, spatulating the donor duct, everting the recipient CBD, creating a common orifice between the cystic and common ducts, side-to-side ductal anastomosis, or choledochoduodenostomy
. These techniques may be performed with or without the use of temporary internal stents.
For large duodenal diverticulum causing dilation and obstruction of the bile duct, choledochoduodenostomy
is the best approach and avoids the complications associated with attempts to resect the diverticulum.
The direct access technique includes EUS-guided choledochoduodenostomy
(EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), and EUS-guided gallbladder drainage (EUS-GbD) [8, 9].
Cholecystectomy and CBD exploration with T-tube drainage for CBD calculi in 8 patients and choledochoduodenostomy
in 10 patients.
Paione et al., "Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy
versus percutaneous drainage," Journal of Clinical Gastroenterology, vol.
Patients diagnosed intraoperatively, CBD repair using T-tube was done in13(76.5%) cases while in one (5.8%) case, choledochoduodenostomy
was done however patients who were diagnosed in postoperatively, initial drainage followed by choledochojejunostomy was done.
Of the group of patients who required surgical repair, 4 developed anastomotic strictures necessitating revision of their surgical repairs (3 hepaticojejunostomies, 1 choledochoduodenostomy
Operative procedures performed included Roux-en-Y hepaticojejunostomy in 19 (59.38%) cases, choledochoduodenostomy
in 7 (21.88%) cases, Roux-en-Y portoentrostomy and primary repair in 3 (09.37%) cases each.
Roux-en-Y-hepatico-jejunostomy (26.51%) was the most frequently performed procedure, followed by choledochoduodenostomy
and Roux-en-Y choledocho-jejunostomy (i.e.