Mini-invasive treatment of sump syndrome: OverStitch choledochoduodenostomy revision

A 72-year-old woman, who was unfit for surgery, was admitted with recurrent cholangitis. She had a history of cholecystectomy and side-to-side choledochoduodenostomy (CDD) for huge impacted stones. In the previous year, she had undergone multiple endoscopic retrograde cholangiopancreatographies (ERCPs) with endoscopic sphincterotomy, incomplete stone extractions, and plastic stent placement in a local hospital. Magnetic resonance cholangiography showed multiple stones throughout the biliary tree, which was dilated up to 4 cm, along with an incarcerated plastic stent.

Endoscopy with a frontal-view scope (GIF-1TH190; Olympus Europe) confirmed a 25-mm CDD in the duodenal bulb ([Fig. 1]). Management of the huge impacted stones by conventional techniques was not feasible; therefore, a 1.9-Fr bipolar electrohydraulic lithotripsy probe (Autolith; Northgate Technologies Inc.) was passed through the working channel of the endoscope to break the stones under direct cholangioscopy guidance ([Fig. 2]). The scope channel allowed the removal of all fragments. Final fluoroscopy revealed a large diameter, atonic, empty biliary tree with delayed biliary outflow. A plastic stent was then inserted from the common bile duct to the duodenum, through the papilla, to promote drainage ([Fig. 3]).

Fig. 1 Endoscopic view showing a side-to-side choledochoduodenostomy with impacted stones (asterisk) that were causing biliary obstruction and acute cholangitis.

Fig. 2 Cholangioscopic view showing the electrohydraulic lithotripsy probe (arrow) located 1 – 2 mm from the surface of the gallstones, and ready to generate optimal fragmentation pressure under direct endoscopic control. In the common bile duct an incarcerated plastic stent is easily recognizable (asterisk).

Fig. 3 Images following the removal of stone fragments showing: a atony and marked dilation of the biliary tree (the endoscope is easily recognizable inside the intrabiliary ducts with direct access through the choledochoduodenostomy); b antegrade endoscopic placement of a biliary plastic stent from the common bile duct to the second part of the duodenum (major papilla area; asterisk).

The patient returned 1 month later because of cholangitis. Endoscopy revealed a large amount of food debris in the biliary reservoir; a diagnosis of sump syndrome was made. Complete extraction of the food matter was performed. In order to prevent the recurrence of duodenocholedochal reflux, we decided to perform a stoma revision using the OverStitch device (Apollo Endosurgery; Austin, Texas, USA) to reduce the size of the CDD, leaving enough room for biliary outflow ([Video 1]). There were no post-procedural complications. The patient has remained asymptomatic during 1 year of follow-up ([Fig. 4]).

Video 1 Management of sump syndrome by electrohydraulic lithotripsy under direct cholangioscopy view and by choledochoduodenostomy revision using an endosuturing system

Fig. 4 Follow-up endoscopic evaluation at 2 months showing a reduced caliber of the choledochoduodenostomy, with no evidence of lithiasis or food/debris inside.

Sump syndrome is a rare long-term complication of CDD, with a reported prevalence of 2.5 % [1]. Endoscopic sphincterotomy is the treatment of choice but, if endoscopic treatment fails, surgery is advisable [2]. Evidence concerning endoscopic closure of a CDD is lacking [3] [4] [5]. This is the first report detailing an endoscopic revision of a CDD using endoscopic suturing.

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• References

• 1 Leppard WM, Shary TM, Adams DB. et al. Choledochoduodenostomy: is it really so bad?. J Gastrointest Surg 2011; 15: 754-757
• 2 Caroli-Bosc FX, Demarquay JF, Peten EP. et al. Endoscopic management of sump syndrome after choledochoduodenostomy: retrospective analysis of 30 cases. Gastrointest Endosc 2000; 51: 180-183
• 3 Ell C, Boosfeld C, Henrich R. et al. Endoscopic treatment of the “sump syndrome” after choledochoduodenostomy: a new technique using an amplatzer septal occluder. Z Gastroenterol 2006; 44: 1231-1235
• 4 Ellison JC, Tarnasky PR. Endoscopic management of sump syndrome: closure of choledochoduodenostomy. Gastrointest Endosc 2014; 80: 725-726
• 5 Ersoz G, Tekin F, Turan I. et al. A novel method for closure of a choledochoduodenostomy in sump syndrome. Endoscopy 2015; 47 (Suppl. 01) E365-E366