Choledochoduodenal fistula in Mainland China: a review of epidemiology, etiology, diagnosis and management

Abstract

Purpose: Choledochoduodenal fistula (CDF) is an extremely rare condition even in the most populous nations. However, diagnostic tools are inadequate for the young surgeon to be made aware of such a rare condition before surgery. Hence, basic understanding of the epidemiology, etiology, and management for this unusual but discoverable condition are necessary and essential.

Methods: The exclusive case reports of CDF, which were published from 1983 to 2014 concerning mainland Chinese people, were performed to review the epidemiology, etiology, and management.

Results: A total of 728 cases were incorporated into this review among 48 papers. More than half of the CDF cases were female (416) with an average age of 57.3 years. CDF was usually caused by cholelithiasis (573 of 728). Epigastric pain (589 of 728) and cholangitis (395 of 728) were the most common symptoms of CDF. CDF was usually detected and confirmed by endoscopic retrograde cholangiopancreatography (ERCP) (475 of 728) in Mainland China. The fistulas larger than 1 cm (82 of 654) were recommended for surgical biliary reconstruction. Fistulas between 0.5 cm and 1.0 cm (467 of 654) which were followed frequently by cholangitis attacks also required surgery; the rest were recommended to have stone removal and/or the application of an effective biliary drainage. Fistulas less than 0.5 cm (105 of 654) were usually received conservative therapy.

Conclusion: CDF should be considered in differential diagnosis of recurrent epigastric pain and cholangitis. A possible ERCP should be arranged to investigate carefully. Depending on the size of fistula and clinical presentation, different programs for CDF are indicated, ranging from drug therapy to choledochojejunostomy.

Keywords: Biliary fistula; Disease management; Epidemiology.

Fig. 1. The distribution of choledochoduodenal fistula (CDF) in different districts of Mainland Chinese. Distribution in 48 articles regarding 728 cases of CDF fistula published from 1983 to 2014.

Fig. 2. The classification of choledochoduodenal fistula (CDF). (A) The Ikeda's classification. Type I was located on the longitudinal fold of the papilla, while type II was on the posterior wall of the duodenal bulb. (B) The Gong's classification. Type A is an orifice of CDF located more than 2 cm away from the papilla. Type B is an orifice of CDF located less than 2 cm away from papilla. Type C, or perapapillary CDF, is an orifice of CDF located on the papilla fold. 1, duodenum; 2, CBD; 3, pancreatic duct; 4, major duodenal papilla; 5, CDF.