Biliary Bezoar: the sump syndrome and choledochoenterostomy.

The sump syndrome has been reported to occur infrequently following a choledochoenterostomy (duodenostomy or jejunostomy) for stone disease. The enterostomy stoma usually decreases in diameter following surgery allowing for reflux into the distal, inactive segment of the bile duct without adequate egress of the material. This stagnant portion of the bile duct functions as a reservoir for collection of debris and/or lithogenic bile resulting in intermittent obstruction of the stoma producing symptoms of pain and clinical and biochemical evidence of cholestasis and pancreatitis. This symptom complex has been labelled as the sump syndrome and has been effectively diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) and treated by duodenoscopic sphincterotomy. Occasionally the enterostomy stoma remains adequate but foreign material or debris aggregates to produce obstruction. The case described in this report matched the latter description and was diagnosed by a new endoscopic application, peroral choledochoscopy. This new technique and the recommendations for evaluation and treatment of the sump syndrome as well as alternate surgical techniques to avoid its occurrence will be discussed.