LAUSR

Surgical choledochoduodenostomy is a technique for relieving biliary obstruction that has fallen into disuse due to advances in endoscopic and laparoscopic techniques. There is also a belief that choledochoduodenostomy predisposes patients to recurrent cholangitis due to contamination of the biliary tree with partially digested food in association with a sump syndrome from a relatively undrained distal bile duct. This results in infrequent use of this surgical technique, although it may still hold a place in treatment of benign disease. Furthermore, this is thought to lead to an increased risk of cholangiocarcinoma in the long term, although this remains controversial. Surgical drainage of the biliary tree is now most commonly performed by choledochoenterotomy with a rouxen-Y reconstruction, which is thought to limit these problems. However, with the increased use of endoscopic ultrasound (EUS) to provide biliary drainage this method of draining the biliary tree is likely to be seen with increasing frequency. Here we report a novel complication associated with EUS guided choledochoduodenostomy. An 83-year-old man presented with cholangitis having had a simple cholecystectomy many years previously. He had had no other previous biliary surgery. An endoscopic retrograde changiopancreatography (ERCP) was attempted but biliary cannulation failed due to difficulty accessing the ampulla in a large diverticulum. A decision was made to use EUS to access the bile duct in the first part of the duodenum (Fig. 1) and create an endoscopic guided choledochoduodenostomy. A wire was inserted into the biliary tree and the tract was enlarged with a needle knife to allow decompression of the biliary tree with a fully covered metal stent. Five weeks later the stent was removed and the cholechoduodenostomy was noted to be widely patent. A basket was used to clear the bile duct of a single large stone via the choledochoduodenostomy. Two years later the patient presented again with cholangitis. At ERCP, the choledochoduodenostomy was noted to have become tightly stenosed (Fig. 2), although it was still easy to cannulate. This was able to be dilated easily with a 12 mm balloon sphincteroplasty (Fig. 3) and debris within bile duct was cleared with an extraction balloon catheter. EUS biliary drainage is being used with increasing frequency especially after failed endoscopic access to the bile duct at ERCP. However, this technique is still in its infancy and not without complications. With the introduction of new techniques it is likely that novel complications will develop. Stenosis of a surgical choledochoduodenostomy, although described, was rare. This is probably because a large calibre anastomosis was created and there was accurate and tension-free apposition of the bile duct and duodenal