A novel method for closure of a choledochoduodenostomy in sump syndrome.

A 57-year-old woman with a history of a complicated open cholecystectomy and side-to-side choledochoduodenostomy (CDD) 25 years previously was admitted to our hospital with cholangitis. She had undergone five endoscopic retrograde cholangiopancreatography (ERCP) procedures with stone and debris extractions in another hospital during the preceding 2 years. ERCP revealed apatent biliary sphincterotomy and CDD orifice that was proximal to the papilla of Vater. Injection of contrast showed thatdye drained via the CDDanastomosis (●" Fig.1). Several small pieces of debris were extracted using a balloon-tipped catheter (Eliminator Biliary Balloon Dilators; ConMed, Utica, New York, USA), and an 8-cm long, fully covered self-expandingmetal stent (SEMS;WallFlex; Boston Scientific, Natick, Massachusetts, USA) was placed through the papilla of Vater (●" Fig.2). After a period of 3 months, the fully covered SEMSwas retrieveduneventfully, and complete closure of the CDD orifice was observed during the ERCP procedure (●" Fig.3a). A repeat injection of contrast confirmed the closure of the CDD orificewith no evidence of any drainage of the contrast dye (●" Fig.3b). Limited data exist regarding endoscopic closure of CDDs in sump syndrome. Ell et al. [1] used an amplatzer septal occluder for successful CDD closure; however, this technique seems to be difficult and may not be available in many endoscopy centers. Recently, Ellison et al. [2] used an over-the-scope clip; however, the success rate of this method depends on the diameter of the CDD orifice. In addition, we believe that this method could result in formation of a biliary stricture. The new method presented, using a fully covered SEMS, is technically easy, safe, and effective for closure of a CDD in sump syndrome. We suggest that a minimum stent indwell time of 3 months is needed for successful closure of a CDD.