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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 53  |  Issue : 5  |  Page : 195-197

Sump syndrome following choledochoduodenostomy


Department of GI and HPB Surgery, Asian Bariatrics, Ahmedabad, Gujarat, India

Date of Submission04-Oct-2019
Date of Decision02-Dec-2019
Date of Acceptance02-Jun-2020
Date of Web Publication19-Oct-2020

Correspondence Address:
Dhaivat Vaishnav
Department of GI and HPB Surgery, Asian Bariatrics, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_79_19

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  Abstract 


Sump syndrome is a rare long-term complication of side-to-side choledochoduodenostomy (CDD), a common surgical procedure in patients with biliary tract disease in the era before endoscopic retrograde cholangiopancreatography (ERCP). In the setting of a side-to-side CDD, the bile does not drain through the distal common bile duct (CBD) anymore. Therefore, the part of the CBD distal from the CDD anastomosis consequently transforms into a poorly drained reservoir, making this so-called “sump” prone to accumulation of debris. These patients are prone to cholangitis. We present a case of a 56-year-old woman with a history of side-to-side CDD 8 years ago who presented with cholangitis and ruptured liver abscess. Sump syndrome was diagnosed by magnetic resonance cholangiopancreatography. Laparoscopic peritoneal lavage was done for the ruptured liver abscess. After endoscopic debris removal and antibiotic treatment, the patient recovered well. In the ERCP era, little is known about CDD and its long-term complications. Therefore, this report provides an opportunity to refresh the knowledge and raise awareness of this syndrome.

Keywords: Choledochoduodenostomy, endoscopic retrograde cholangiopancreatography, sump syndrome


How to cite this article:
Vaishnav D, Narwaria M. Sump syndrome following choledochoduodenostomy. Formos J Surg 2020;53:195-7

How to cite this URL:
Vaishnav D, Narwaria M. Sump syndrome following choledochoduodenostomy. Formos J Surg [serial online] 2020 [cited 2020 Nov 24];53:195-7. Available from: https://www.e-fjs.org/text.asp?2020/53/5/195/298504




  Introduction Top


In the pre endoscopic retrograde cholangiopancreatography (ERCP) era, CDD was a common surgical procedure in patients with biliary tract disease. In the setting of a side-to-side CDD, the bile does not drain through the distal common bile duct (CBD) anymore. Therefore, the part of the CBD distal from the CDD anastomosis consequently transforms into a poorly drained reservoir, making this so-called “sump” prone to accumulation of debris.[1] When accumulated debris becomes symptomatic, it is called “sump syndrome,” a rare and late complication of choledochoduodenostomy (CDD).[2] Its prevalence has long remained uncertain and has been reported to vary between 0% and 9.6%.[3],[4],[5] Based on observations, two factors could explain the low frequency of this complication. First, a sump with a large anastomosis results in the efficient and consistent clearance of food debris that enters the bile duct. Second, although the upstream (hepatic) aspect of the duodenal anastomosis is frequently found to be widely patent, the downstream (sump) aspect is usually narrow and thus prevents the entry and impaction of food debris in the sump segment in most patients. The frequency of asymptomatic accumulation of debris after CDD remains unknown.


  Case Report Top


A fifty six year old lady with a medical history of hypertension, dyslipidemia, and history of cholecystectomy and CDD was referred to the emergency room with pain at epigastrium and right upper quadrant of the abdomen, loss of appetite, fever, and recurrent vomiting for 2 days. The vital signs were significant for high-grade fever temperature of 101°F), tachycardia (heart rate of 112 beats/min). Physical examination was significant for tenderness over the right upper quadrant of the abdomen. The primary surgical scar was normal. The rest of the physical examination was within the normal limits. Laboratory studies revealed a leukocytosis (white blood cell count of 26,200 cells/μL). Her liver function tests were normal, except mildly elevated alkaline phosphatase (169 IU/L). The international normalized ratio and partial thromboplastin time were normal. She was started on intravenous fluids and broad-spectrum antibiotics. Computed tomography (CT) of the abdomen, revealed a ruptured liver abscess in segment VI, VII, and VIII along with pneumobilia and suspected stone in distal CBD [Figure 1]. She was treated with laparoscopic peritoneal lavage as the abscess was ruptured. After lavage, she stabilized within 24 h of intensive care unit stay. To evaluate the biliary system, magnetic resonance cholangiopancreatography (MRCP) was done. MRCP showed functioning CDD with 2 stones in distal CBD, confirming the diagnosis of sump syndrome. The next day endoscopic sphincterotomy, stone removal, and stenting were performed. Her general condition improved with this and was subsequently discharged on the 5th day of admission.
Figure 1: Coronal image of magnetic resonance cholangiopancreatography-showing choledocho duodenostomy status with distal common bile duct stones

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  Discussion Top


A “sump” is defined as a covered cistern or reservoir. The term “sump syndrome” was coined after the observation of accumulated debris proximal to the papilla, in the distal bile duct reservoir of affected patients.[4],[5],[6] In the pre-ERCP era, CDD was a common surgical procedure in patients with biliary tract disease. In the setting of a side-to-side CDD, the bile does not drain through the distal CBD anymore. Therefore, the part of the CBD distal from the CDD anastomosis consequently transforms into a poorly drained reservoir, making this so-called “sump” prone to accumulation of debris.[1] Sump syndrome was first described in 1976, with a wide prevalence ranging from 2.5% to 15.7% after CDD.[6],[7],[8],[9] Nowadays, CDD is widely replaced by ERCP,[10] but we are still faced with its consequences and long-term complications in developing and underdeveloped countries where ERCP is still not being used as a standard procedure. Recently, sump syndrome secondary to endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent has been reported from a developed country.[11] Sump syndrome results from the accumulation of lithogenic bile, debris, or calculi, as well as refluxed duodenal contents in the distal CBD, leading to biliary and/or pancreatic complications.[1] According to Marbet et al.,[12] reduced filling pressure as well as reduced peristalsis and drainage of the distal CBD caused by the upstream anastomosis play an important role in the pathophysiology of sump syndrome. The diagnosis of sump syndrome is challenging because no characteristic clinical or laboratory finding is specific.[1] It can present with a variety of symptoms and clinical pictures such as recurrent pancreatitis, colicky pain, jaundice, and cholangitis. In our case, it presented with ruptured liver abscess. Taking a detailed medical history and having a high degree of suspicion appears to be the most important element for diagnosing sump syndrome. To increase the challenge, sump syndrome often becomes clinically manifest only several decades after the initial CDD procedure.[6],[12] Usually, patients are unaware of the procedure and no availability of medical records from the past makes the diagnosis of this disease very challenging. In addition to a detailed medical history, pneumobilia is another key element in establishing the diagnosis of sump syndrome.[13]

Nowadays, in the ERCP era, CDD is rarely performed and its complications, including sump syndrome, are almost forgotten, especially due to the long interval until clinical manifestations of sump syndrome occur after CDD.[14] In asymptomatic patients with prior CDD, an abdominal radiograph shows air in the biliary tree. In symptomatic patients, plain film demonstration of calcification in the right upper quadrant or pneumobilia and debris-filled dilated biliary ducts suggests sump syndrome as the clinical diagnosis. A sonogram may show pneumobilia, biliary duct dilatation, biliary stones, and changes of cholangitis, pancreatitis, pancreatic duct dilation, and liver abscess. CT/MRCP shows prior surgical changes, debris, stones in the distal CBD, and enhancement of the duct walls as a result of suppurative cholangitis or adjacent stone.[14]

Management of the sump syndrome has been described as early as 1976 by physicians performing ERCP.[4] In a retrospective analysis involving thirty cases of sump syndrome, the most common etiology was the accumulation of food-debris (67% of cases) and calculi (40% of cases).[4] Sump syndrome can also be treated surgically by creating a Roux-en-Y hepaticojejunostomy besides performing a biliary sphincterotomy and extracting the debris from the CBD through ERCP.[4]


  Conclusion Top


With the advent of ERCP and other related drainage procedures, open surgical procedures for the drainage of the biliary tract have decreased in frequency. More and more patients are being subjected to ERCP for therapeutic drainage of the biliary tree. CDD, which was once a popular procedure for the open biliary tree drainage, has become unpopular now. However, patients who have previously undergone CDD can still present with sump syndrome, decades after the primary procedure. High index of suspicion is required in such cases to timely and accurately diagnose the condition, which can become fatal otherwise if not aggressively treated in time as it may have lethal complications in the form of cholangitis or pancreatitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zeuge U, Fehr M, Meyenberger C, Sulz MC. Mind the sump! – Diagnostic challenge of a rare complication of choledochoduodenostomy. Case Rep Gastroenterol 2014;8:358-63.  Back to cited text no. 1
    
2.
Qadan M, Clarke S, Morrow E, Triadafilopoulos G, Visser B. Sump syndrome as a complication of choledochoduodenostomy. Dig Dis Sci 2012;57:2011-5.  Back to cited text no. 2
    
3.
Nauta RJ, Hile C, Nauta AC. Choledochojejunostomy revision performed by using the laparoscopic linear cutter. Am J Surg 2008;195:119-21.  Back to cited text no. 3
    
4.
Caroli-Bosc FX, Demarquay JF, Peten EP, Dumas R, Bourgeon A, Rampal P, et al. Endoscopic management of sump syndrome after choledochoduodenostomy: Retrospective analysis of 30 cases. Gastrointest Endosc 2000;51:180-3.  Back to cited text no. 4
    
5.
Mecklenburg I, Scheubel R, Messmann H. Sump syndrome and biliary adenocarcinoma 40 years after surgical choledochoduodenal fistula. Endoscopy 2007;39 Suppl 1:E194.  Back to cited text no. 5
    
6.
Leppard WM, Shary TM, Adams DB, Morgan KA. Choledochoduodenostomy: Is it really so bad? J Gastrointest Surg 2011;15:754-7.  Back to cited text no. 6
    
7.
Demirel BT, Kekilli M, Onal IK, Parlak E, Disibeyaz S, Kacar S, et al. ERCP experience in patients with choledochoduodenostomy: Diagnostic findings and therapeutic management. Surg Endosc 2011;25:1043-7.  Back to cited text no. 7
    
8.
Baker AR, Neoptolemos JP, Leese T, Fossard DP. Choledochoduodenostomy, transduodenal sphincteroplasty and sphincterotomy for calculi of the common bile duct. Surg Gynecol Obstet 1987;164:245-51.  Back to cited text no. 8
    
9.
Baker AR, Neoptolemos JP, Carr-Locke DL, Fossard DP. Sump syndrome following choledochoduodenostomy and its endoscopic treatment. Br J Surg 1985;72:433-5.  Back to cited text no. 9
    
10.
Stefanini P, Carboni M, Patrassi N, De Bernardinis G, Negro P, Loriga P. Transduodenal sphincteroplasty: Its use in the treatment of lithiasis and benign obstruction of the common duct. Am J Surg 1974;128:672-7.  Back to cited text no. 10
    
11.
Abraham H, Thomas S, Srivastava A. Sump syndrome: A rare long-term complication of choledochoduodenostomy. Case Rep Gastroenterol 2017;11:428-33.  Back to cited text no. 11
    
12.
Marbet UA, Stalder GA, Faust H, Harder F, Gyr K. Endoscopic sphincterotomy and surgical approaches in the treatment of the 'sump syndrome'. Gut 1987;28:142-5.  Back to cited text no. 12
    
13.
Feldstein RC, Bahamonde LG, Pena ME, Bernstein DE. Sump syndrome: A case of endoscopic biliary “rendez-vous” procedure. Pract Gastroenterol 2010;XXXIV: 42-4.  Back to cited text no. 13
    
14.
Mosquera-Klinger G, de la Serna Higuera C, Pérez-Miranda M. Endoscopic sump syndrome secondary to EUS-guided choledocho-duodenostomy with a lumen-apposing metal stent. Rev Esp Enferm Dig 2019;111:74-6.  Back to cited text no. 14
    


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