Choledochoduodenostomy versus hepaticojejunostomy - a matched case-control analysis.

BACKGROUND: Choledochoduodenostomy (CD) is believed to cause certain long-term complications, such as sump syndrome and reflux gastritis. Therefore, CD is considered inferior to a Roux-and-Y hepaticojejunostomy (HJ). The aim of this study was to compare short- and long-term outcomes following CD and HJ for benign biliary diseases. METHODS: This was a retrospective, matched case-control study of patients undergoing biliary-digestive anastomosis for benign diseases between 2000 and 2016 in a tertiary centre. Patients undergoing CD and HJ were matched 1:1 based on age, sex, ASA-classification, indication, history of abdominal surgery or acute cholecystitis/pancreatitis. Short- and long-term outcomes were compared. RESULTS: Of 336 patients undergoing biliary-digestive anastomoses, 27 patients underwent CD. Matching resulted in two comparable groups of 26 patients each. Overall morbidity after HJ and CD was comparable: 30.8% versus 26.9% (p>0.999). Long-term complications occurred in 23.1% after HJ, and in 50% after CD (p=0.118). After CD, 2 patients (7.7%) developed sump syndrome. Both patients with an anastomotic stricture after HJ could be managed by endoscopic/radiological re-intervention, whilst all six patients with a stricture after CD required surgical re-intervention (p=0.016). CONCLUSION: Although short-term complications were comparable, the number of anastomotic strictures was higher in patients undergoing CD. We therefore conclude that HJ is the biliary bypass of choice while CD should be performed in selected patients only.

Choledochal malformations in adults in the Netherlands: Results from a nationwide retrospective cohort study.

BACKGROUND AND AIMS: Patients with a choledochal malformation, formerly described as cysts, are at increased risk of developing a cholangiocarcinoma and resection is recommended. Given the low incidence of choledochal malformation (CM) in Western countries, the incidence in these countries is unclear. Our aim was to assess the incidence of malignancy in CM patients and to assess postoperative outcome. METHODS: In a nationwide, retrospective study, all adult patients who underwent surgery for CM between 1990 and 2016 were included. Patients were identified through the Dutch Pathology Registry and local patient records and were analysed to determine the incidence of malignancy, as well as postoperative mortality and morbidity. RESULTS: A total of 123 patients with a CM were included in the study (Todani Type I, n = 71; Type II, n = 10; Type III, n = 3; Type IV, n = 27; unknown, n = 12). Median age was 40 years (range 18-70) and 81% were female. The majority of patients (99/123) underwent extrahepatic bile duct resection, with additional liver parenchyma resections in eight patients, only exploration in two, and a local cyst resection in eight patients. Postoperative 30-day mortality was 2% (2/123) and limited to patients who underwent liver resection. Severe morbidity occurred in 24%. In 14 of the 123 patients (11%), a malignancy was found in the resected specimen. One patient developed a periampullary malignancy 7 years later. CONCLUSIONS: In a large Western series of CM patients, 11% were found to have a malignancy. This justifies resection in these patients, despite the risk of morbidity (24%) and mortality (2%).

Treatment of mid-bile duct carcinoma: Local resection or pancreatoduodenectomy?

INTRODUCTION: Whereas distal cholangiocarcinoma (DC) is treated by pancreatoduodenectomy (PD), consensus is lacking on treatment of mid-bile duct carcinoma (mid-BDC) without involvement of the pancreatic head. Both PD or a local resection (LR) of the extrahepatic bile duct with lymphadenectomy are being used. The aim of this study was to compare outcomes after PD and LR for mid-BDC and, for reference, PD for DC. METHODS: Retrospective monocenter study including consecutive patients who underwent LR for mid-BDC (LR), PD for mid-BDC (PD-mid) and PD for DC (PD-distal) between 2000 and 2016. Clinicopathologic characteristics, postoperative outcomes and survival were compared. RESULTS: A total of 184 patients were included (LR, 22; PD-mid, 38; PD-distal, 124). Postoperative mortality was 0% following LR, 5% (2/22) for PD-mid and 3% (4/124) for PD-distal, p = 0.542. Major complications occurred in 5/22 patients (23%), 19/39 (50%) and 46/124 (37%) respectively, p = 0.103 (LR versus PD-mid, p = 0.038). Tumor size, differentiation grade and resection margin status were comparable across groups. Median number of resected lymph nodes was 5 (range 3-7), 9 (7-14) and 12 (8-16) respectively, p < 0.001. Median overall survival was 46 months (95%CI 10-82), 19 months. (95%CI 11-27), and 29 months (95%CI 23-35) respectively, p = 0.39 (LR versus PD-mid, p = 0.20). Disease-free survival also did not differ. CONCLUSION: LR is an acceptable treatment for selected patients with mid-BDC, showing less morbidity and comparable survival despite smaller lymph node retrieval.