Original Article  /  Liver

Clinical features and treatment of sump

syndrome following hepaticojejunostomy
Gabriele Marangoni, Amir Ali, Walid Faraj, Nigel Heaton and Mohamed Rela
London, UK

BACKGROUND: Cholangitis after Roux-en-Y hepaticojejuno- KEY WORDS: biliary tract surgical procedures;
stomy is usually caused by anastomotic stricture. A small biliary tract disease;
number of cases present without evidence of obstruction and septicemia
are ascribed to reflux of gastro-intestinal content into the
biliary tree above the anastomosis (sump syndrome). Despite
prophylactic rotating antibiotic therapy, the cholangitic Introduction
episode may be severe and life-threatening.

T
he siphoning effect causing bile stasis, reflux
METHODS: From 2001 to 2006, six patients who had undergone of bilio-enteric contents into the common bile
an end-to-side hepaticojejunostomy presented to our institution
with recurrent episodes of biliary sepsis. Anastomotic stricture
duct (CBD) and cholangitis without evidence
was excluded by liver MRI/MRCP and percutaneous transhepatic of anastomotic stricture was originally described in
cholangiogram (PTC). Barium meal showed reflux of contrast choledochoduodenostomy and called "sump syndrome".[1]
into the biliary tree in all patients. Three patients had a short Sump syndrome has also been described as a rare
jejunal Roux limb (less than 50 cm) on pre-operative imaging. complication of choledochojejunostomy and, more
[2]
RESULTS:  Five patients underwent surgery and two of them recently, hepaticojejunostomy. Although not very
had two operations. One patient had a Tsuchida antireflux common, it is a potentially life-threatening complication.
valve and subsequently underwent lengthening of the The pathophysiology of the syndrome seems to differ
Roux loop. Three patients had lengthening of the Roux whether we consider side-to-side and end-to-side choledo-
loop; one underwent re-do hepaticojejunostomy and one
had concomitant revision of the hepaticojejunostomy and choduodenostomy or choledocho and hepaticojejuno-
lengthening of the Roux loop. The latter underwent further stomy.
lengthening of the Roux loop. Three patients are cholangitis- Side-to-side choledochoduodenostomy was originally
free 6, 36 and 60 months after surgery; two still experience performed with the aim to achieve drainage of the CBD
mild episodes of cholangitis. with low morbidity in high-risk patients. The segment
CONCLUSIONS: An adequate length of the Roux loop is of the CBD between the anastomosis and the ampulla of
important to prevent reflux. However, Roux loop lengthening Vater acts as a reservoir of stagnant bile with concomitant
to 70 cm or more does not always resolve the problem and formation of debris, stones and proliferation of bacteria
cholangitis, although generally less frequent and severe,
that cause cholangitis, pancreatitis and hepatic abscesses.
may recur despite appropriate reconstructive or antireflux
surgery. In these cases, life-long rotating antibiotics is the only In end-to-side choledochoduodenostomy, enteric material
available measure. refluxes into the biliary tree causing obstruction of
the ducts and favouring the formation of stones and
(Hepatobiliary Pancreat Dis Int 2011; 10: 261-264)
subsequent episodes of cholangitis.
Today, it is a standard practice to use Roux-en-Y
hepaticojejunostomy as the method of biliary recon-
struction due to the very low incidence of complications.[3]
Author Affiliations: King's College London School of Medicine at King's Ascending cholangitis is rare with this anastomosis and
College Hospital, Institute of Liver Studies, Denmark Hill, Camberwell, when it does occur the mechanism is different and could
London SE5 9RS, UK (Marangoni G, Ali A, Faraj W, Heaton N and Rela M)
be related to a short Roux limb with reflux of food into
Corresponding Author: Gabriele Marangoni, MD FRCSEd (Gen Surg), the biliary tree and disturbance in intestinal motility.
Institute of Liver Studies, King's College Hospital, Denmark Hill, SE5 9RS,
London, United Kingdom (Tel: +442032993672; Fax: +442032993575; We report 6 cases of sump syndrome after hepatico-
Email: gabrielemarangoni@virgilio.it) jejunostomy and discuss our experience in the light of
© 2011, Hepatobiliary Pancreat Dis Int. All rights reserved. the reported literature on this condition.

Hepatobiliary Pancreat Dis Int，Vol 10，No 3 • June 15，2011 • www.hbpdint.com • 261

 Hepatobiliary & Pancreatic Diseases International

Methods patient required 3 months of intensive care due to biliary

From 2001 to 2006, six patients (5 females and one sepsis-induced multiple organ failure. The presence of
male) with a mean age of 52 years (range 28-74), who anastomotic stricture was excluded with liver MRI/MRCP
had undergone an end-to-side hepaticojejunostomy, and percutaneous transhepatic cholangiogram (PTC). A
presented to our institution with episodes of biliary scan of hepatobiliary imino diacetic acid (HIDA) was
sepsis without evidence of anastomotic stricture. Biliary performed in 4 patients to assess hepatocyte excretion
reconstruction was performed after laparoscopic function and tracer/bile hold-up at the anastomosis.
cholecystectomy bile duct injury in 2 patients, after Diagnosis of sump syndrome was made with barium
open cholecystectomy bile duct injury in 1, for biliary meal showing reflux of contrast into the biliary tree above
stricture after liver transplant in 1, for ischemic stricture the anastomosis (Fig. 1) and with PTC demonstrating
3 months after open cholecystectomy in 1, and as part blind loop or efferent loop stasis and retrograde reflux of
of a pancreaticoduodenectomy procedure in 1. The first contrast into the biliary tree (Fig. 2). On pre-operative
episode of biliary sepsis was seen between 7 months and imaging, three patients seemed to have a short jejunal
36 years after hepaticojejunostomy. One patient developed Roux limb (less than 50 cm) and one had a distortion of
a liver abscess which was later treated conservatively the Roux loop at the level of the biliary anastomosis. The
with drainage and appropriate antibiotic therapy. The characteristics of the patients are listed in Table 1.
number of significant episodes of cholangitis per patient
(requiring hospitalization) ranged from one to nine. One
Results
Five patients underwent surgery. Two underwent two
operations and one was not considered amenable to
surgery (Table 2).
One Tsuchida anti-reflux valve operation was
performed with an uneventful hospital stay, but the
patient continued to experience cholangitis and
underwent lengthening of the Roux loop a year later.
One patient had revision of a previously fashioned
hepaticojejunostomy and concomitant lengthening
of the Roux loop as there was a slight dilatation of
the loop at the hepaticojejunostomy site. However, he
subsequently needed further lengthening of the Roux
loop to 100 cm 15 months after the first operation due to
Fig. 1. Reflux of contrast into the bile tree on barium meal study. ongoing cholangitic episodes and documented evidence

Table 1. Patients' characteristics

Diagnosis of sump
Patient Age Indications for hepaticojejunostomy
(months after
No. (yr) (year)
initial surgery)
1 30 Biliary stricture after LT (1995) 108
2 Bile duct injury after laparoscopic 24
65
cholecystectomy (2002)
3 74 Obstructive jaundice 3 months after 432
open cholecystectomy and excision
of hepatic hydatid cyst (1970)
4 56 Bile duct injury after open 204
cholecystectomy (1984)
5 28 Bile duct injury after laparoscopic 48
cholecystectomy (2000)-re-do
hepaticojejunostomy for
stricture (2001)
6 60 Pancreaticoduodenectomy for 12
Fig. 2. Stasis of contrast in the Roux loop on PTC. neuroendocrine tumor (2006)

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Clinical features and treatment of sump syndrome following hepaticojejunostomy

Table 2. Outcome of surgery

Patient ICU stay Hospital Recurrence of sepsis and follow-up
Surgery
No. (days) stay (days) (months)
1 Tsuchida valve (June 2004) Nil 8 Nil (60)
Lengthening of Roux loop (May 2005)
2 Lengthening of Roux loop and excision of excess blind loop 1 7 Persistent reflux on barium meal and mild
(February 2006) episodes on rotating antibiotics (50)
3 Revision of hepaticojejunostomy and lengthening of Roux loop Nil 10 Nil (36)
(March 2007)
4 Lengthening of Roux loop (April 2001) Nil 7 Two episode-cholangiopathy on MRCP (96)
5 / / / Persistent mild episodes of cholangitis on
rotating antibiotics
6 Revision of hepaticojejunostomy and lengthening of Nil 6 Nil (6)
Roux loop (October 2008)
Further lengthening of Roux loop (February 2010)

of reflux on barium meal. Three patients underwent

lengthening of the Roux loop (70 cm) for a very short
jejunal limb (20-40 cm). Of these, one had excision of a
redundant blind end of the Roux loop and one had a re-
do end-to-side hepaticojejunostomy at the same time.
Time from diagnosis to surgery varied from one
month to 1.5 years. In one case, the patient initially
refused the surgical option and in another the patient
was given time to recover from a prolonged intensive
care stay following a life-threatening cholangitis.
Mean hospital stay was 7.6 days (range 6-10 days).
Three patients have not experienced any more septic
episodes 6, 36 and 60 months after surgery. One patient,
Fig. 3. Holding up of tracer at the Roux loop on HIDA scan.
despite surgery, continued to have recurrent episodes
of cholangitis with documented reflux into the biliary
tree and is currently on rotating antibiotics, having
not experienced cholangitis for a year. One patient had Discussion
three cholangitis episodes in 8 years following surgery. Cholangitis after biliary reconstructive surgery is a
In this case, an MRCP showed some irregularity of the relatively common complication and its incidence
intrahepatic bile ducts, possibly suggesting features following Roux-en-Y hepaticojejunostomy is considered
of cholangiopathy without strictures or dilatation to be around 10%.[3] Sepsis is often caused by biliary
of the efferent loop, and is treated conservatively at stasis due to anastomosis stricture or lithiasis at the level
present. Patient 5, who had undergone two biliary of the anastomosis, but a number of cases occur without
reconstructions following bile duct injury, was not anatomical evidence of obstruction.
considered for surgical treatment as originally the MRCP and PTC are routinely used to exclude
injury was a high Bismuth type 4 injury and the second anastomotic strictures and PTC may also show
hepaticojejunostomy required three separate duct abnormal stasis of contrast in the Roux loop. HIDA scan
anastomoses (right anterior, right posterior and left can also be used to assess stasis, holding-up and delay of
ducts). In this case, the next step would have consisted clearance in the Roux loop (Fig. 3). Finally, barium meal
of a major liver resection. Because of refusing further shows reflux of contrast in the biliary tree with patent
surgery and experiencing only minor episodes of anastomoses and may suggest a short Roux loop.
cholangitis (without hospitalization), the patient is at An adequate length of the Roux loop is important
present under follow-up and treated conservatively with in order to prevent reflux of gastro-intestinal contents
rotating antibiotics. Should the septic episodes increase into the biliary tree; 50 cm is traditionally considered
in frequency and severity, surgery will be reconsidered. sufficient, although this is debatable and in fact other

Hepatobiliary Pancreat Dis Int，Vol 10，No 3 • June 15，2011 • www.hbpdint.com • 263


surgeons believe that 70 cm should be considered more
appropriate. In our series, 4 patients had a Roux loop
of 40 cm or less. However, in spite of lengthening of the
Roux or revision of the hepaticojejunostomy with a loop
length of 70 cm or more, three of them (patients 2, 4
and 6) continued to experience episodes of cholangitis
although hospitalization was not required, and one
(patient 2) presented with evidence of persistent reflux
on barium meal. One of these patients (patient 6) had
evidence of ongoing reflux without evidence of stricture
and further lengthening of the Roux loop has controlled
bile sepsis so far (6 months follow-up). Stasis of bile in
an excessively long blind end of the Roux loop could
be another anatomical mechanism underlying biliary
sepsis, but excision of the blind end and lengthening
of the loop did not resolve the problem in our patient,
similar to the report by Vrochides et al.[4]
Intestinal motility disorders may play an important
role. Collard and Romagnoli[5] studied bile reflux in a
group of patients who had undergone a variety of Roux
loop reconstructions and suggested that isolation of a
bowel segment from the duodenum with division of
one or two vascular pedicles in the mesentery disturbs
intestinal motility.
Ducrotte et al[6] found that whilst the duodenal
motility was normal, the motility of the limb and
jejunum below the jejunojejunostomy resulted in motor
abnormalities that could promote bacterial overgrowth
and sepsis. Most of the abnormalities are ascribed to
the presence of accessory pacemakers in the Roux loop
no longer controlled by the main intestinal duodenal
pacemaker.[7]
When the Roux loop seems correctly fashioned,
Orlando et al[8] suggested the creation of a Tsuchida
antireflux valve as previously described by Nakajo et
al[9] in porto-enterostomy (Kasai surgery). The valve
is fashioned by removing the seromuscular layers
of the jejunal loop for a distance of about 2 cm and
invaginating this area into the proximal jejunum. We
performed a Tsuchida procedure in a patient (patient 1)
who had a normal Roux loop length, without the same
effectiveness in preventing cholangitis. Lengthening
the Roux loop one year later to 70 cm achieved a better
result and the patient is currently cholangitis-free 5
years after surgery.
In conclusion, despite its rarity, sump syndrome
following hepaticojejunostomy is a clinical entity likely
to be encountered in a specialist center. Patients can
be quite symptomatic and occasionally present with
life-threatening cholangitis. Surgical correction of an
inadequately constructed Roux loop may successfully
264 • Hepatobiliary Pancreat Dis Int，Vol 10，No 3 • June 15，2011 • www.hbpdint.com
Hepatobiliary & Pancreatic Diseases International
manage this complication, but cholangitis can recur
despite appropriate reconstructive or antireflux surgery.
Although it is difficult to make recommendations due
to the small number of cases, these episodes following
surgery seem to be less frequent and less severe. In the
difficult cases, life-long rotating antibiotics (4 weeks
ciprofloxacin 500 mg bd alternating with 4 weeks
amoxicillin 500 mg tds) and supportive treatment of the
cholangitic episode are the only available measures.
Funding: None.
Ethical approval: Not needed.
Contributors: RM proposed the study. MG wrote the first draft and
analyzed data. AA and FW collected data and performed literature
search. HN and RM revised the manuscript. All authors contributed
to the design and interpretation of the study and to further drafts.
RM is the guarantor.
Competing interest: No benefits in any form have been received
or will be received from a commercial party related directly or
indirectly to the subject of this article.
References
1    Jones SA. The prevention and treatment of recurrent bile duct
stones by transduodenal sphincteroplasty. World J Surg 1978;
2:473-485.
2    Morrissey PE, Burns GA, Cohn SM. Sump syndrome
complicating Roux-en-Y hepaticojejunostomy: case report
and review of the literature. Surgery 1996;119:403-405.
3    Bismuth H, Franco D, Corlette MB, Hepp J. Long term results
of Roux-en-Y hepaticojejunostomy. Surg Gynecol Obstet
1978;146:161-167.
4    Vrochides D, Fischer SA, Soares G, Morrissey PE. Successful
treatment of recurrent cholangitis complicating liver
transplantation by Roux-en-Y limb lengthening. Transpl Infect
Dis 2007;9:327-331.
5    Collard JM, Romagnoli R. Roux-en-Y jejunal loop and bile
reflux. Am J Surg 2000;179:298-303.
6    Ducrotte P, Peillon C, Guillemot F, Testart J, Denis P. Could
recurrent cholangitis after Roux-en-Y hepaticojejunostomy
be explained by motor intestinal anomalies? A manometric
study. Am J Gastroenterol 1991;86:1255-1258.
7    Karlstrom LH, Soper NJ, Kelly KA, Phillips SF. Ectopic jejunal
pacemakers and enterogastric reflux after Roux gastrectomy:
effect of intestinal pacing. Surgery 1989;106:486-495.
8    Orlando G, Blairvacq JS, Otte JB, Goffette P, Ciccarelli
O, Sempoux C, et al. Successful treatment of recurrent
cholangitis after adult liver transplantation with a Tsuchida
antireflux valve. Transplantation 2004;77:1307-1308.
9    Nakajo T, Hashizume K, Saeki M, Tsuchida Y. Intussusception-
type antireflux valve in the Roux-en-Y loop to prevent ascending
cholangitis after hepatic portojejunostomy. J Pediatr Surg 1990;
25:311-314.
Received December 16, 2010
Accepted after revision February 8, 2011