1344 Sump Syndrome With Massive Choledocholithiasis Requiring Electrohydraulic Lithotripsy

INTRODUCTION: Cholelithiasis is highly prevalent and affects 10-15% of the United States population. About 10-20% of the patients with symptomatic cholelithiasis have also choledocholithiasis; this is treated with ERCP and subsequent cholecystectomy. Recurrent CBD stones after ERCP occur in 4-24% and are caused mainly by bile stasis. CASE DESCRIPTION/METHODS: A 76-year-old female presented to our practice 3 years ago with cholangitis, requiring ERCP with removal of multiple stones and sludge. Balloon dilation with plastic stent placement was also performed due to distal CBD stenosis. She had a history of cholecystectomy and ERCP 25 years ago, complicated with bowel perforation. We performed 9 ERCPs subsequent to her first visit with us due to recurrent cholangitis. Because of the CBD stenosis and recurrent choledocholithiasis, biliary bypass with side-to-side choledochoduodenostomy (CDD) was performed. Six months after the CDD she had another episode of cholangitis. ERCP was performed but there was massive lithiasis in the CBD and stones could not be removed (Figures 1 and 2). Electrohydraulic lithotripsy (EHL) had to be used under direct visualization through the CDD and stones were removed using a combination of snare, balloon and basket (Figure 3). The CBD was completely cleared and a double-pigtail stent was placed at the CDD. Two days after the procedure the patient was discharged home and her LFTs were normal during follow up. DISCUSSION: CDD is a procedure performed to improve biliary drainage but its use has dramatically decreased after ERCP. Sump or “cul-de-sac” syndrome (SS) is a complication of CDD that results from bile stasis and the accumulation of debris in the segment of CBD between the anastomosis and the ampulla of Vater, facilitating bacterial proliferation and stone formation. The prevalence of SS after CDD is estimated to be between 0-9.6%. The current treatment for SS is decompression of the CBD distally with sphincterotomy and CBD clearance with basket and balloon. With our patient, we decided to avoid sphincterotomy since there was a long segment of distal CBD stenosis and the CDD opening was also wide enough to allow access to the CBD. The massive lithiasis in this patient might have been caused by the reflux of duodenal content into the CBD trough the CDD, but she also had recurrent choledocholithiasis even prior to the CDD and other factors were perpetuating the stone formation in the CBD. We present a unique case of SS with massive CBD lithiasis that required use of EHL through the CDD.