Choledochoduodenal anastomosis: a technical tip to ensure the impermeability of the anastomosis

Our technique
After completion of the posterior wall of the choledochoduodenostomy, a Levin tube (nasogastric) FG18 is inserted through a small gastrotomy as far as to the anastomosis (fig. 1). The anastomosis is completed by suturing the anterior wall (fig. 2). The anastomosis is performed with one layer of interrupted 3/0 synthetic absorbable sutures. Following that, pieces of gauze are placed around the anastomosis and sterile water is passed through the Levin tube.
The gauze is checked for dampness and consequently the anastomosis is checked for impermeability. After that, the Levin tube is slightly withdrawn and remains like gastrostomy suitably immobilized, as gastric aspiration for 7-10 days. This technique has been used in 17 patients with excellent results.

Discussion
There are two advantages in the described technique, herein.
1. It contributes towards ensuring that the sutures are adequate and that there is not a leaking point.
2. Using the Levin tube for gastric aspiration we are able to do away with the nasal-gastric tube and the patient is thus spared the greatest post-operative discomfort, and as this type of anastomosis is carried out mostly in the elderly the absence of the nasogastric tube enables the patient to breathe more easily.
Today, because of important advantages in non-operative endoscopic methods, choledochoduodenostomy is relatively uncommon, when dealing with pathology of the common bile duct. The risk of cholangitis is a handicap in performing this method, despite the fact that studies in Japan have reported minimization of this risk. However, choledochoduodenostomy will continue to be necessary, depending on individual patients needs, such as recurrent choledocholithiasis, giant stones in common bile duct or in situations where endoscopic procedure is not feasible (4).
It is believed that this procedure is safe and simple and its practical benefits can be adopted by other surgeons.

References
1. Sprengel, O. - Uber einen Fall von Extirpation der Gallanblase mit Anlegung einer Communication zwischen Ductus Choledochus und Duodenum. Arch. Klin. Chir., 1981, 124:1913.
2. DiFronzo, L.A., Egrari, S., O'Connell, T.X. - Choledochoduodenostomy for palliation in unresectable pancreatic cancer. Arch. Surg., 1998, 133:820.
3. Riedel, H. - Uber den zungenfoermigen fortastz des recchten lebber-lappens und seine pathognostiche bedentung fur die, erkrankungen der gallenblose nebst bemerkungen gallenstein operationen. Berl. Klin. Wochenschr., 1888, 25:577.
4. De Aretxabala, X., Bahamodes, J.C. -Choledochoduodenostomy for Common Bile Duct Stones. World J. Surg., 1998, 22:1171.

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