Operation to reconnect the common bile duct into the duodenum

[pavel_arnaudov]

Dear Dr. Kevin,

Thank you very much for the constant support you provide
to people like me all over the world!
I am a 29 years old male. I do not drink alcohol.
(Never drank). I have a little high Blood Pressure and I
am under a lot of stress. I was diagnosed (through
Ultrasound, X-Rays, ERCP) with papilla blocked by
gallbladder stones (small, but many - like mud).
I had very high liver enzymes level (AST 120, ALT 400,
GGT 720). They cut into the papilla (12mm)
(endoscopic papilliary sphincterotomy) to drain the
stones and the enzymes level went to
normal for a few days and then back up again.
They repeated the process cutting 5 mm more (17mm).
I don't know the enzymes levels right after the
second procedure, but 10 days later they were high
again: AST 250, ALT 580, GGT 216.

The doctor prescribed me a pill "Ursofalk"
(Ursodiol, often known as "Actigall" in the US)
intending to dissolve the gallbladder stones.
One month later the levels are lower, but still
very high: AST 150, ALT 450, GGT 87.

GGT being much lower hopefully means the stones
start dissolving, but what should I do?

1. Should I wait for 6 months taking  this pill or
   may be even one or two years?

2. Isn't it too dangerous to keep the enzymes levels
   so high for so long or the pill itself drives them
   higher? Is that OK?

3. I read that "Ursofalk"/"Actigall" dissolves
   cholesterol stones only. How can it be determined
   what is the kind of stones thatI have?

You had advised me a couple of months ago that most
likely it is the sphincter. I believe the doctors here
reached the same conclusion and now I hear about an
operation, which would reconnect the common bile duct
directly into the duodenum thus bypassing the papilla/
sphincter and keeping the new opening always open.

4. Is such an operation really necessary? or I should
   continue with the pill longer or any other solution?

5. What are the risks in this operation? Success rate?
   (It sound like a very complicated procedure to me)

6. Does such change inncrease the risk for duodenum
   cancer or any other known side effects?

7. Did the papilla incisions heal and thus causing
   the high enzyme levels again?

8. Can a third incision into the papilla be kept
   open (by putting some material to keep it open)?

9. If it does stay open  - would that be a problem,
   providing a free flow of the products of the
   Pancreas into the duodenum?

Thank you very much for your help!
Best Regards,

Patient29

[surgeon]

The operations you had were done thru a scope. The sphincterotomy to which I referred is done surgically, open. The sphincter is cut more widely than can be done with a scope, and it is sutured open; so the chances are much less that it could scar down again. So there are two main surgical options; one of which is similar to but much more extensive and effective than what you've had.

[pavel_arnaudov]

Hello Surgeon,

The exact definition of the operation (endoscopic), which I had
twice (12mm first and the another 5mm, going to 17mm) is:
"endoscopic papilliary sphincterotomy".
Isn't that actually one of the two operations that you are talking about? If yes, does this mean that I am left with the
other option only or I may also have this one third time and
try to put some small tube in the sphincter to keep it open for
a while (not sure how long does that have to/can be) just to
get it used to staying open wider?

Thanks
Patient29

[surgeon]

I don't agree that "free flow" is not the normal case: the liver makes around a liter of bile/day, of which a small amount is stored in the gallbladder and is squeezed into the duodenum when the gallbladder contracts. But the rest is constantly dripping. People whose gallbladders have been removed have only constant flow of bile, and the vast majority have no ill effects. Pancreatic juice flow also responds to various stimuli and is not at a constant level, but there is no restriction to flow once it leaves the pancreas, except in pathological circumstances, such as yours. So, again, there's no expected adverse effect on digestion from eliminating the sphincter mechanism by one means or another.

With a very large bile duct, either of the two operations I mentioned are possible, and relatively straightforward and have a high success rate. I'm quite sure that with whatever procedure is done, the gallbladder would be removed. It seems that repeat endoscopic procedures are not likely to be long-term successful in your case (recognizing that any opinion from this far away is of very limited value.)

[pavel_arnaudov]

Hello Sergeon,

Thank you for the comments. Here is some clarification to
what I seem to have missed:
- Yes I still have the gallbladder.
- No X-Ray or UltraSound can notice any type of stones.
  Still there were some small ones (as mentioned: mud-like)
- Bile Duct is very very enlarged.
- Free flow of pancreatic products (as well as bile) is not the
  normal case. If bile is kind of "OK" to flow freely in the
  duodenum, is that the case for what the pancreas produces?

Thanks again!
Regards,

Patient29

[surgeon]

1) If you still have your gallbladder, it ought to be removed. Dissolving stones, if it works at all, will be temporary at best.
2) The enzyme levels per se are not a problem; it's a question of why they're elevated. It could be the pills, it could be pressure in the bile duct, it could be the gallbladder if you still have it.
3) Generally, if the stones are seen to have calcium in them on a plain xray, they won't dissolve
4) If the problem is the sphincter (and from the data you provide, it's not possible to say), and if several "cuts" haven't worked, then some sort of operation may be needed. The specific operation depends, among other things, on the diameter of your bile duct. If it's not enlarged, the procedure to join it to the duodenum may not be possible. Instead, a surgical sphincterotomy, which accomplishes what the endoscopic ones does, but with a larger opening and a very small chance of re-narrowing, would be the option. Continuing the pills, especially if there's still a gallbladder (and even if there's not, pills won't work longterm if the sphincter is too narrow) is not a permanent solution
5) There are two basic operation choice (see above); neither is highly complex for an experienced surgeon. The risks are similar: leakage of bile for awhile (which is not a big deal -- a drain is placed just in case, and would prevent it from causing problems until it dried up, which usually happens quickly. Bleeding and infection are risks of any major operation; very small risks, typically. Assuming the problem has been correctly identified, the success rate of either is very high.
6) There's no risk of cancer, etc. With the operation that attaches the bile duct to the duodenum (choledochoduodenostomy) there's some chance of infection of the bile because of a "dead space" beyond the new opening in which food can accumulate in the stump of the bile duct. If the opening is large enough, it's not very likely, but it's a reason why many prefer the sphincterotomy operation instead.
7) It's possible
8) A tube (stent) is sometimes left in for a prolonged period to prevent re-narrowing. It can't be left in permanently usually
9) Free flow is not a problem; it's the goal.

[Kevin Pho, MD]

I am not a surgeon, and I see that our surgical colleague has answered the questions in his comments below.  I have reviewed the answers, agree with them, and will re-post here (as comments are not saved):

"1) If you still have your gallbladder, it ought to be removed. Dissolving stones, if it works at all, will be temporary at best.

2) The enzyme levels per se are not a problem; it's a question of why they're elevated. It could be the pills, it could be pressure in the bile duct, it could be the gallbladder if you still have it.

3) Generally, if the stones are seen to have calcium in them on a plain xray, they won't dissolve

4) If the problem is the sphincter (and from the data you provide, it's not possible to say), and if several "cuts" haven't worked, then some sort of operation may be needed. The specific operation depends, among other things, on the diameter of your bile duct. If it's not enlarged, the procedure to join it to the duodenum may not be possible. Instead, a surgical sphincterotomy, which accomplishes what the endoscopic ones does, but with a larger opening and a very small chance of re-narrowing, would be the option. Continuing the pills, especially if there's still a gallbladder (and even if there's not, pills won't work longterm if the sphincter is too narrow) is not a permanent solution.

5) There are two basic operation choice (see above); neither is highly complex for an experienced surgeon. The risks are similar: leakage of bile for awhile (which is not a big deal -- a drain is placed just in case, and would prevent it from causing problems until it dried up, which usually happens quickly. Bleeding and infection are risks of any major operation; very small risks, typically. Assuming the problem has been correctly identified, the success rate of either is very high.

6) There's no risk of cancer, etc. With the operation that attaches the bile duct to the duodenum (choledochoduodenostomy) there's some chance of infection of the bile because of a "dead space" beyond the new opening in which food can accumulate in the stump of the bile duct. If the opening is large enough, it's not very likely, but it's a reason why many prefer the sphincterotomy operation instead.

7) It's possible

8) A tube (stent) is sometimes left in for a prolonged period to prevent re-narrowing. It can't be left in permanently usually.

9) Free flow is not a problem; it's the goal."

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b