The primary indications for CDD are benign causes of biliary obstruction including chronic pancreatitis and distal biliary stricture related to choledocholithiasis. In the current era of endoscopic retrograde cholangiography, the frequency of operative biliary bypass has decreased; nonetheless, CDD remains an important part of the general surgeon’s armamentarium.

Patients with distal biliary obstruction will typically present with right upper quadrant abdominal pain and associated jaundice. If cholangitis is attendant, fever and chills (Charcot’s triad) or, in more severe cases, hypotension and altered mental status (Reynolds’ pentad) may be evident.

Elevated serum hepatic chemistries are essential to the diagnosis of significant biliary obstruction. Total and direct bilirubin, alkaline phosphatase, and gamma-glutamyltransferase are elevated preferentially to the hepatic transaminases in cases of biliary obstruction as contrasted to intrinsic hepatic disease.

Patients with chronic pancreatitis who present with biliary obstruction may have a reversible component to the inflammatory obstruction, and thus are often best managed initially with endoscopic stenting. In cases with persistent biliary obstruction due to constricting fibrosis in the pancreatic head, marked by elevated serum hepatic chemistries and a dilated CBD, surgical intervention is warranted. In patients with an accompanying inflammatory pseudotumor in the head of the pancreas or a concern for malignancy, pancreatic head resection may be indicated. When resection is not indicated, CDD is an excellent means of biliary bypass while minimizing perioperative morbidity and preserving pancreatic parenchyma.

Patients with a terminal biliary stricture due to long-standing choledocholithiasis do well with CDD. Common indications include a dilated CBD (>1.5 cm); multiple CBD stones; and primary, recurrent, or recalcitrant choledocholithiasis.

Right upper quadrant ultrasound is the frontline test for biliary obstruction, visualized as dilated intrahepatic and extrahepatic biliary ducts. It is highly sensitive, noninvasive, inexpensive, readily available, and requires no radiation.

Contrast-enhanced computed tomography (CT) is a useful modality to evaluate abdominal pain. CT will demonstrate a dilated biliary tree and can help in the evaluation for causative-associated pathology including choledocholithiasis, chronic pancreatitis, and periampullary malignancy.

Magnetic resonance cholangiopancreatography (MRCP) can give detailed information about biliopancreatic ductal anatomy and pathology (T2 weighted images) and soft tissue abnormalities related to pancreatitis or neoplasm (T1 weighted images). MRCP is an important tool for assessment of biliary obstruction because of the advanced ductal imaging capability.

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary initial therapeutic approach to biliary obstruction in the current era. ERCP can be both diagnostic and therapeutic in the management of biliary obstruction. It can be used to identify stones and apply a variety of maneuvers that facilitate stone clearance:

Strictures can be dilated and stented endoscopically. Even with alternative strategies (metal stents, multiple plastic stents), endoscopic stenting lacks durability in the management of chronic, longer segment CBD strictures due to chronic pancreatitis and stone disease and CDD is often employed in these cases.

Endoscopic ultrasound (EUS) can be helpful in the careful evaluation of the terminal biliary tree for the diagnosis or exclusion of malignant obstruction and the assessment for occult cholelithiasis. EUS has also been more recently used for an endoscopic-directed choledochoduodenal stent.

Percutaneous transhepatic cholangiography (PTC) is undertaken to study the biliary tree and allow for biliary drainage in cases where endoscopic transampullary access is not possible. Maturation and dilation of the tract after PTC can allow for percutaneous instrumentation to be used under radiographic guidance to clear stones from the biliary tree.

CDD is indicated in patients with a benign terminal biliary stricture, with an associated dilated CBD (>1.5 cm diameter), most commonly due to chronic pancreatitis or choledocholithiasis. CDD has been effectively used in the management of malignant biliary obstruction.

When planning a biliary bypass procedure, a neoplastic cause for biliary obstruction should be sought out and recognized, as a malignant (or potentially malignant) process may call for a divergent operative approach.

When biliary bypass is indicated in unresectable periampullary malignancy, CDD may be selected as an alternative to hepaticojejunostomy.

Classically, the CDD anastomosis is performed in a sideto-side fashion but may also be performed with an end
(bile duct) to side (duodenum) technique, particularly when using a laparoscopic approach. Both methods are presented.