Open Journal of Endocrine and Metabolic Diseases, 2013, 3, 227-235
http://dx.doi.org/10.4236/ojemd.2013.34030 Published Online August 2013 (http://www.scirp.org/journal/ojemd)
Pathologico-Anatomic Categories of Choledochal
End-Piece Stenosis Due to Chronic Pancreatitis and
Clinical Significance
Yunfu Lv*, Xiaoguan Gong, Xiaoyu Han, Shunwu Chang, Ning Liu, Baochun Wang
Department of Surgery, People’s Hospital of Hainan Province, Haikou, China
Received May 26, 2013; revised June 26, 2013; accepted July 16, 2013
Copyright © 2013 Yunfu Lv et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Chronic pancreatitis caused by common bile duct segment stenosis is a common complication. It often
results in near side bile duct expansion, bile drain disorder, appearing serious obstructive jaundice, biliary cirrhosis, life-
threatening. However, chronic pancreatitis causes not bravery manager narrow some light, some heavy, and the clinical
manifestation is different too. We think there may be different kinds of pathological anatomy. As a result, we carried
out the research of this subject. Objective: To investigate the anatomicopathological classification of terminal stenosis
of the common bile duct (CBD) caused by chronic pancreatitis (CP) and the treatment. Method: A retrospective analy-
sis was made for the management of sympatomatic stenosis of the terminal end of CBD 47 CP cases. Autopsy was per-
formed in 25 bodies to verify our classification. Result: By analyzing operation and postoperative follow-ups to 47 pa-
tients with obvious choledochal dilatations (diameter ≥ 15 mm) due to chronic pancreatitis, the authors have found that
there exist three pathologico-anatomic categories of choledochal end-piece stenosis due to chronic pancreatitis. The
stenosis of type I is the external-pressing annular stricture (59.6%); type II is front wall of choledochus being com-
pressed one (31.9%); and type III is the pseudocystic oppression one (8.5%). Conclusion: The treatment of CP patients
complicated with terminal stenosis of CBD need individual consideration. Clinical Significance: Type I should be
treated with biliary-enterostomy owing to more serious stricture (only No.3 the Bake’s dilstors and smaller ones can be
passed through its stenotic segment). Type II Could be managed with T-tube drainage because of its slighter stricture
(Bake’s dilators bigger than No.6 and No.12 French urinary catheter can get through the Choledochal terminal). If there
aren’t biliary and pancreatic complicated diseases, non-operative treatment can be carried out. Type III can undergo
with the T-tube replacement between biliary tract and pseudocyst if pseudocystic decompression doesn’t lead to obvi-
ous stenosis (type IIIo and IIIb). If type III combines type I, the internal drainage should be performed in both ectatic
bile duct and cyst.
Keywords: Pancreatitis; Common Bile Duct Stenosis; Anatomicopathological Classification
1. Introduction
Chronic Pancreatitis (CP) is not rare in clinic. It’s linked
to alcohol damage, improper diet and bowel disease.
Caused by the former is often referred to as alcohol CP,
which is called gallstone caused by CP. Alcohol CP in
western countries is more, about 50% - 76% of CP pa-
tients [1-3]. In some countries with higher living stan-
dards, high protein, high fat diet is the another important
reason for the CP. In Asia, Africa and Latin America, on
the other hand, some of the poorest countries and regions,
such as India, cause of a diet low in protein and low fat
protein deficiency caused by CP accounts for about 28%
to 100%. At present our country although no bulk data
report, but some cholelith disease and biliary tract dis-
ease is a common cause of CP [4]. 20% - 30% CP can’t
find the exact etiology, known as chronic idiopathic pan-
creatitis.
CP divides into alcoholic, biligenic and idiopathic CP
in sustained inflammation of the pancreas, pancreatic
fibrosis substance morphology change and abdominal
pain as the main characteristics, which all can lead to
permanent damage to the pancreas secretion inside and
outside, and a variety of complications. CP cause the end
of the common bile duct stricture is a non-metabolic
*Corresponding author.
C
opyright © 2013 SciRes. OJEMD

Y. F. LV ET AL. 228
complications, and also one of common situations of bili-
ary duct stenosis. So far, documented CP cause the end
of the common bile duct stenosis which is more general,
reported only one type, namely fixed circular narrow [5,
6]. The narrow, however, can not explain any CP con-
currency in bile duct expansion, but surgery with Bake’s
dilator and French catheter probe, pancreatic biliary no
significant stenosis of practical problems. With this prob-
lem which begins from 1991, the author have observed
and studied 47 cases of CP complicated with bile duct ex-
pansion (diameter ≥ 15mm) and 25 cases of adult antopsy.
2. Materials and Methods
2.1. Clinical M a t e r ial
The group of patients consisted of 26 males and 21 fe-
males, with 49.3 years old of mean age (range, 28 - 72
years old). All patients had elevated alkaline phosphatase
(AKP) level (range, 136 - 1563 u/L); 25 of these patients
had elevated r-transpeptidase (r-GT) level; fifteen had
jaundice (median value of serum total bilirubin, 90.6
umol/L; range, 25.3 - 165 umol/L); and fifteen patients’
fasting blood-glucose values were more than 6.1 mmol/L.
six patients had undergone cholangitis; forty-three suf-
fered from epigastralgia; forty (85.1%) complicated cho-
lecystolithiasis and 7 cases with a history of being drunk.
61.7% of these patients experienced more than once the
attack of acute pancreatitis. Diagnostic examinations, in-
cluding B-ultrasonography examination to 47 patients,
and simultaneously, computed tomography (CT) exami-
nation to 21 patients, endoscopic retrography cholangio
pancreatography (ERCP) examination to 18 patients, and
percutaneous transhepatic cholangiography (PTC) ex-
amination to 14 patients, all prompted that these patients
had obvious intrahepatic and extrahepatic duct dilatations,
and displayed that thirty-seven patients contracted chro-
nic pancreatitis and five among them complicated pan-
creatic pseudocyst.
2.2. Surgical Situation
All patients had undergone operations owing to gall-
stones in 40 of them, pancreatic pseudocyst in 5, and
explorations for obvious choledochal dilatation compli-
cated with jaundice in 2 patients. In operation, we ob-
served that thirty patients had notable swelling, cirrhosis
pancreas; fourteen patients had a segmental swelling,
fibrous head and body of pancreas; and three patients had
a focal swelling, cirrhosis head of pancreas, including
one carcerization. In 31 patients whose pancreatic tissues
were excised in operation to make pathological examina-
tions, except one carcinoma of head of pancreas, the oth-
ers had been verified suffering from CP. All patients had
undergone cholecystectomy and choledochotomy with
exploration. In the course of operation, incising chole-
dochus, except that three patients were found in their bile
ducts three were 1 to 3 stone of size of willet, all the oth-
ers weren’t found stones, cysts, ascarides or tumors in
intrahepatic and extrahepatic ducts, confirmed by the
choledochoscope examination.
Only No. 1 to No. 3 Bake’s dilators and the French
urinary catheters below No. 10 could be passed through
the choledochal end-piece in 28 patients whose choledo-
chus traversed their pancreases, and the dilator’s bougies
could not be touched at the back of their pancreases. The
type of choledochal stenosis has been known as type I,
the external-pressing annular stricture (Figure 1). Opera-
tive procedure of this type is as following: two patients
of them, one owing to carcerization and another owing to
stones in the head of pancreas, had undergone pancrea-
toduodenostomy. The other 26 pantients were treated
with internal drainage, including 11 cholecystojejunosto-
mies, 12 Roux-en-Y cholecystojejunostomies and 3 Bra-
un’s anastomsis added to cholecystojejunostomies. Three
patients with pancreatic duct dilatation (diamter, 8 - 12),
two of them with stones in pancreatic duct and the other
with pancreatic pseudocyst in the body and tail, had un-
dergone internal drainage.
By comparison, No. 4 to No. 11 Bake’s dialators and
the French urinary catheters more than No. 12 could be
passed through the choledochal end-piece in 15 patients,
whose choledochus walked along the back of pancreas
and posterior wall wasn’t covered with pancreatic tissues.
Therefore, the dilator’s bougies could be touched at the
back of their pancreases. We named it stenosis of type II,
the compressed-front-wall of choledochal stenosis (Fig-
ure 2). Operative procedure of this type is as following:
two had undergone Roux-en-Y cholecystojejunostomy;
the other 13 were treated with T-tube drainage.
In remained 4 patients, their choledochal stenosis
cause by pancreatic pseudocyst, which compressed their
pancreas of head. We named it stenosis of type III, the
pseudocyst-constrictal stenosis (Figure 3). Operative
procedure of this type is as following: after their pseu-
docyst had been incised and decompressed, all 4 patients
Figure 1. I Solid circular stricture.

Y. F. LV ET AL. 229
had undergone exploration; one patient without chole-
dochal end-piece stenosis had experienced T-tube re-
placement added to cystojejunostomy. Two patients com-
plicated with stenosis of type I had undergone double
Renx-en-Y anastomosis (Figure 4), that is, cystojeju-
nostomy and anastomosis between dilatative biliary duct
and jejunum. The remained one complicated with steno-
sis of type II were treated with T-tube replacement in
choledochus and Roux-en-Y pseudocystojejunostomy.
2.3. Choledchal Dilatation Situation
All patients’ proximal choledochus had been found ob-
vious dilatation. The diameter of proximal choledochus
can be seen in Table 1.
Figure 2. II Compression sex is relatively narrow.
Figure 3. III cyst compression stenosis.
Figure 4. Expansion of the bile duct and cyst with jejunum
anastomosis respectively, namely double Roux en-Y anas-
tomosis.
Table 1. Proximal Choledochus diameter.
Diameter (mm)
type
15 - 20 21 - 25
total
I 8 20 28
II 11 4 15
III 2 2 4
total 21 26 47
Statistical Analysis
CBD and Akp values of stenosis type I are contrasted
with type II by t-test or t’-test. After dealt with statistic
package-SAS6.12, results are following:
Table 2. Compare parameters of CBD of type I & II.
Type case X ± S (mm) t p
I 28 21.25 ± 2.977
II 15 18.067 ± 2.987 3.3381 0.0018
Notes: These showed that CBD values of Type I are significantly different
with that of type II, CBD of type surpassed type II.
Table 3. Compare parameter of AKP values of type I & II.
Type case X ± S (μ/L) t p
I 28 644.39 ± 378.9651
II 15 374.3667 ± 198.187 3.29020.0021
Notes: these showed that AKP values of type I are significant different with
type II.
3. Results
None in the group died from operation. 41 patients’ ab-
dominaliga symptom had disappeared. Re-examinations
had been made after postoperatively 1 month, and results
were as follows: AKP values in all patients had reduced
to a mean value of 121 μ/L. Serum total bilirubin values
in 15 patients, which had elevated preoperatively, had
given down to a mean value of 17.3 umol/L. Postopera-
tive follow-up surveys had been made, at the median
follow-up of 42 months ranging from five months to
eight years. With the exception of 11 patients who lose
investigations, the other 36 (23 belonging to type I, 10
belonging to type II, 3 belonging to III) were obtained,
and there is 76.6% of follow up rate. Follow-up results
are as follows. Among those patients belonging to type I,
two patients suffered from chornic reflux cholangitis
after choledochoduodenostomy, whose symstoms had
appeared at interval and could be controlled by medicine.
One patient, who had treated with Roux-en-Y choledo-
chojejunostomy, had undergone secondary operation (in-
ternal drainage) owing to stones and anastomotic stenosis.

Y. F. LV ET AL. 230
One patient with pancreatic cancerization who had un-
dergonones after e pancreatico-duodenectomy had been
dead after 31 months. Among those patients who be-
longed to type II, one had undergone Roux-en-Y chole-
dochojejunostomy three years after the internal drainage,
whose chronic pancreatitis had acute attacks many times
and complicated jaccndice. Other patients had not unto-
ward effect. Among those patients belonging to type III,
one patient had a secondary internal drainage because of
the stenosis of anastomotic stoma after operation, and the
other 2 was normal.
Autopsy
To prove walks of common bile duct in pancreas, we had
dissected 25 adult corpses, and found that common bile
duct passed through pancreas in 17 of 25 corpses (ac-
counting for 68%). Common bile duct walked along the
back of pancreas which posterior wall was not covered
with pancreatic tissues in 8 corpses (accounting for 32%).
These approached with 61.3% and 38.7% reported by Fei
and Ran [7], and showed that two ways of choledochal
walk in pancreatic segment, which had been found in
operation, was objective reality.
4. Discussion
CP has three kinds, that is, total, segmental, and local.
Whichever has possibility to cause choledochal end-
piece stenosis and lead to obvious dilatation in proximal
bile duct, as long as leision implicates pancreatic head.
Its incidence rate is 3% - 46% in patients with CP [5,8-
14]. The majority of the reports are about 25%.
4.1. Etiopathogenesis
There are many reasons for choledochal end-piece steno-
sis due to chronic pancreatitis [15]. The followings are
main reasons:
1) The edematous and tumescent pancreatic head
crushs biliary duct to luminal stenosis. Especially in
stage of acute attack, the stenosis can be exacerbated.
After hydrops and hyperemia have extinguished, stenosis
of bile duct can gradually be abaled, even disappeared.
The process is reversible, and patients might have tem-
porary jaundice, and it generally needn’t surgery and
could obtain natural cure.
2) The hyperplastic and fibroid pancreas which con-
strictes and pulls bile duct could lead to choledochal
end-piece stenosis [16]. The process that can often be
seen in the advanced stage of chronic pancreatitis is ire-
versible, and stenosis of bile duct is permanent. Fibrosis
due to chronic pancreatitis could lead to not only chole-
dochal end-piece stenosis, but also original part of pan-
creatic duct [17-19] and duodenum stenosis [13]. Huiz-
inga et al. [20] had been proved by biopsy of liver that
the kind of patients could still compilate hepatic portal
fibrosis to different degrees.
3) Cyst compresses bile duct. Pancreatic pseudocyst in
the body or tail could not generally lead to obstruction of
biliary tract, but in the head could compress bile ducts to
stenosis or make former stenosis segment exacerbate and
prolong. Four of five pancneatic pseudocysts lie in the
head, and three among them make former stenosis seg-
ment prolong.
4.2. Diagnoses
1) Diagnosis of chronic pancreatitis: Over 60 percent
of patients with CP had a history of acute pancreatitis
attack. A few patients, whose symptoms were latent, had
always developed to chronic stage when found. 31% of
patients complicated diabetes. Patients with different
kinds of CP could still be questioned to different causes
of illness. For example, patients with alcoholic CP had
lasting excessive drunk at the same time. Patients with
biliogenic CP often complicated illness of billary tract
system, and so on. Epigastralgia is not sole characteristic
of CP. Because patients with biliary tract illness could
also have abdominal pain, moreover, 85% of patients had
not it. Russoll et al. had instanced that nineteen patients
had painless jaundice, and regarded as other kind of CP.
Part of patients could appear the following symptoms:
nausea, vomiting, fatty diarrhea, fatigue, indigestion, loss
of body weight, and might still complicate pancreatic
pseudocyst (10.6%) or pancreatic duct stones (6.4%).
Kamal [15] insisted that diagnosis of CP could be tenable
if there are the following condition over one: pancreas
calification, dilatation in pancreatic duct as well as van-
ish of scondary and tertiary pancreatic duct, pathologic
diagnosis by biomicroscopy. Prinz et al. [11] described
detailedly the picuture of pancreatic duct system that
were stenosis of initial segment of major pancreatic duct,
dilatation in distal pancreatic duct, or multiple, segmental
stenoses, and little branch blunt, distort, even disappear,
which was in accordance with extensive lesion due to CP.
Most of patients in the group could be seen calcified pla-
que and dilatation of pancreatic duct, and 66% of these
patients had been extracted pancreatic tissues to do path-
ological examination, proved with CP except a pancre-
atic cancer.
2) Diagnosis of choledochal stenosis: To a patient with
chdedochal dilatation, for the first time, B-ultrasono-
graphy, CT, ERCP, PTC and upper disgestive tract radi-
ography with barium as well should be adopted to know
whether there are stones, ascaris, tumor, congenital cho-
langiectasis, Constrictive papillitis, diverticultis of the
bypass duouenal or pericholedochal tumor. If the above
mentioned illnesses that can led to choledochal terminal
obstruction could be ruled out and diagnosis of CP could
be established, the obstruction should be considered due

Y. F. LV ET AL. 231
to CP.
Clinical manifestations and pathological changes caus-
ed by obstruction of biliary tract are as follows: jaundice
(31.9%), cholangitis (12.8%), biliary duct stone (6.4%),
biliary duct fibrosis (7.3%) [13] as well as biliary cirrho-
sis of liver (7.3%). As far as laboratory examination is
concerned, AKP examination has comparatively higher
diagnostic value and median AKP value of all patients in
the group is 3.53 times as much as highest limit of nor-
mal value. Pereira-Lima et al. [11] maintained that, in the
course of development of CP, choledochal end-piece
stenosis should be doubted if AKP value sustains on high
level, no matter whether serum bilirubin raises or not. If
AKP value is over three times as much as normal value,
lasting over 1 month, it could be operation indication on
choledochal stenosis. ERCP and PTC examinations are
effective methods to make a definitive diagnosis [21].
Especially in development of pancreatic duct, ERCP
have more distinctive value. The two methods can show
whether there are stenosis, dilatation, stones as well as
tumor, and can know state of intrahepatic and pancreatie
duct. Stenotic segment of choledochus due to CP is usu-
ally longer than 34 mm (39 ± 5 mm), and most of them is
smooth, symmetrical and grandually attenuated, a few
unsmooth [7,8]. Diameter of dilatating proximal chole-
dochus generally is within 25 mm. B-ultrasonography
and CT are the first choice of unautmatic examination,
which could be used to measure diameters of bile and
pancreatic duct, and to observe liuminalstate and figure
of liver, bile and pancreatic system. Nomal choledochal
diameter is 5 to 8 mm, over 10 mm, bile duct ditatation
should be highly doubted by radiology. Nagazima et al.
[22] thought if proximal choledochus dilated ≥15 mm, or
in operation, No. 3 Bake’s dilator and No. 10 French
urinary catheter could not be used to insert into duode-
num from choledochal incision diagnosis of choledochal
end-piece stenosis could be identified. Karmal et al. re-
ported 19 cases with chdedochal end-piece stenosis whose
median proximal choledochal diameter was 16 mm. New-
ton et al. [23] thought that choledochal exploration by
Bake’s dilator and/or rubber urinary is common menthod
to judge whether stenosis or not, which is simple and
effective.
4.3. Types
According to exploration and autopsy findings, choledo-
chal end-piece stenosis can be classified into three types.
Type I is the external-pressing annular stricture (59.6%).
The choledochus of the type runs cross pancreas. The
swelling and fibrous panereas due to inflamation crushs
circularly bile duct to stenosis, which only could be,
passed through the Bake’s dilators smaller than No. 3
and the French urinary catheters smaller than No. 10.
And in our choledochal explorations, Bake’s dilator bou-
gies could not be touched at the back of the pancreas.
Type II is the front wall of choledochus being com-
pressed stenosis (31.9%). The common bile duct of the
type walks closely along the back of pancreas. The
swelling and fibrous pancreas due to inflamation com-
presses the anterior wall of choledochus [24], so that it
gets relatively stenosis. However, without pancreatic
tissues covering the posterior wall of common bile duct,
duct wall has better elasticity. So the bake’s dilators
more than No. 4, even No. 8 to No. 11 Bake’s dilators
and more than No. 12 French urinary catheters in few
patients, could be passed gradually through it. It seems
not to be a stenosis. But radiological examinations
showed obvious dilatation in proximal bile duct. And the
authors found in operation that bile ducts had been
pressed flat by pancreas. All these showed that there was
stenosis in the choledochal end-piece. The stenosis of the
type is mainly judged by operation. The procedure to
explorate choledochal end-piece is as follows: first, cut-
ting out part of the duodenal sie peritoneum, secondiy,
turning over the duodenum to observe condition of bile
duct, whether walking along the back of pancreas and
whether being compressed, then, inserting the fore finger
and middle finger of surgeon’s left hand to the back of
the patient’s pancreas, holding Bake’s metal dilator by
right hand which had been crooked to a certain radian,
explorating downward and meanwhile touching dilator
bougies by left hand. The diagnostic foundation of the
stenosis of type II is, on the basis of obvious dilatation of
proximal chledochus (diameter ≥ 15 mm), to eliminate
the other factors, such as stone, tumor as well, and to
prove that pancreas exist really inflammation. The fol-
lowings must be provided: 1) The bougie should clearly
be touched at the the back of the pancreas, or by turning
over the duodenum, the compressed state of the bile duct
in its pancreatic part could be seen; 2) Bake’s dilators
bigger than No.6 and No.14 French urinary acatheter can
be used to pass through the choledochal terminal. By
comparison, above-mentioned conditions is unrequired to
the stenosis of type I.
Type III is pseudocystic oppression stenosis (8.5%).
Pancreatic pseudocysts in the head can construct directly
the bile duct to stricture [25]. According to whether
complicating or not the stenosis of type I or II, the type
can be divided into three subtypes. Type IIIo is the steno-
sis merely due to cystic compression, which is seldorn
seen in clinical, only 1 case in the group. Type IIIa is the
stenosis due to cystic compression with type I, and there
are two cases in the group. Type IIIb is the stenosis due
to cystic compression with type II, and only 1 case in the
group.
As a matter of fact, type III is a mixed type stenosis
caused mainly by pseudocyst, and could be found by

Y. F. LV ET AL. 232
means of B-ultrasoniography and CT. There is more dif-
ficult in preoperative diagnosis of the stenosis of type I
or II. In the light of the principle of hypromechanics, we
know that more serious stenosis in the end-piece biliary
duct is, higher press in the proximal biliary duct is, and
more distinct dilatation in the proximal biliary duct is. In
that stenotic degree of type I is more serious than one of
type II, its dilatation in the proximal bile duct is more
obvious, and there is a notable discrepancy in two types
(P = 0.0018). As is known in the Table 2, it could be
seen that 76.9% of paticents belongs to the stenosis of
type I if proximal choledochus is dilated, and its diameter
is more than 20 mm. And it could identify its stenosis of
type I that its choledochal diameter is more than 23 mm.
57.4% of patients belongs to the stenosis of type II if
proximal choledochal diameter is below 20 mm. Cer-
tainly, it is necessary to take a dynamic observationof
pathologic change. AKP examination is an indictive in-
dex to diagnose the obstruction of biliary tract. And AKP
values of all patients in the group are raised with differ-
ent degree. From the Table 3, it could be seen that there
is notable different AKP value between the stenosis of
type I and II (P = 0.0121). If AKP value is over four
times than the upper limit of normal reference value, it
could be diagnosed the stenosis of type I.
4.4. Treatment
Most of patients with choledochal end-piece stenosis due
to biliogenic CP need surgical management, that is cho-
lecystectomy, besides exploratory operation to clear away
calculi in bile duct, and controlling development of their
diseases as far as possible. In narcosis, we regard habitu-
ally it as safe index that the Bake’s dilators more than No.
4 or/and the French urinary catheters more than No. 12
can get through the choledochal end-piece. If only the
Bake’s dilators smaller than No. 3 and the French uri-
nany catheters smaller than No. 10 can get through, it
shows there is serious stenosis in the choledochal end-
piece [26] that need treatment to avoid occurring acute
cholangitis and biliaty cirrhosis of liver.
Type I should be treated with internal drainage owing
to serious stenosis, simple cholecystojejunostomy or
choledochodedenostomy and with cholangitis, and oddi’s
spnincterotomy and spnincteroplasty is easy to defeat on
account of stenostic segmentofover 30 mm [27]. Frey et
al. [8] had reported that 66% - 100% lf patients with
sphincterotomy to treat choledochal terminal stenosis due
to cp often required to be reoperated so it should be
carefal to choose operation program. Ideal choice is
Roux-en-x-type choledochojejunestomy [28]. If the ste-
nosis is caused byalcholicor idiopathic CP, without pan-
creatic calculi and pseoducysts, it can be replaced inter-
nal by endoscopy treatment [29-36]. Both surgery and
endoscopy are effective methods to cure choledochal
terminal stenosis [37-39].
13 patients of type Ⅱ have only undergone T-tube
drainage owing to slighter stenosis and T-tube drainage
owing to slighter stenosis and clinical symstom. All had
not untoward effect but one had a secondary operation
(internal drainage) after pancreatic surgery whose pan-
creatitis seizure frequently, with jaundice in the stage of
each attack. The case might associate with the following
factors: 1) pathophysiolagic changes had taken place.
85.1% of these patients also had gallalader stones at the
same time all of them had chelecy stitis. 80% of patients’
bacteriod culture of bile extracted inoperation proved to
be positive. These had direct bearing on pathopoiesis and
recurrence of their pancreatitis. Atrer the cholecystec-
tomy was conducted, the pollution. Source from focal
part was elirninated and the bile was purified, which was
favorable to a recovery of pancreatitis. The compression
of the pancreas to its common bile duct was consequently
lightened. 2) By explorating the cornmon bile duct, the
adhesive tissues on the back of the pancreas became
loose and separated, therefore, it could lighten, even
eliminate the pull to the posterior wall of the common
bile duct. 3) Bake’s metal dilator itself had a function of
the mechanical dilatation. These patients after, operations
were routinly given large dose antimicrobials over a
week, and the inflam mation in their pancreta had been
cured. So it is very safe and effective to use T-tube
drainage as a treatment for the stenosis of type II. Since
recurrence of pancreatitis could increase the degree of
stenosis, T-tube drainage is inapplicable to the patients
whose CP have a tendentiousness towards recurrence.
But this kind of patient, after all, is minority, only one in
the group. Stahl [10] reported that in the course of fol-
low-up to 20 patients, who had had non-operative treat-
ment, only one had undergone biliary tract internal
drainage after 3.8 years. Thus it can be inferred that a
patient with the stenosis of type II can be treated with
non-operative ways, without other illness complicated
such as illness of biliary tract, chronic recurrent pan-
creatitis. Pancreatic duct dilatation and pancreatic pseu-
docysts, but he must be subjected regularly to the fol-
lowing examinations B-ultraonography, computer tomo-
graphy and biochemical examinations concerned, besides,
the change of his condition should be observed closely.
The patients with the stenosis of type III should un-
dergo cyst internal drainage. Warshaw [40] considered
that relying merely on internal drainage to reduce pres-
sure due to cyst, the obstruction of choledochus due to
fibrosis formation couldn’t often be relieved, so in opera-
tion, the adhesive tissues on the back of the pancreas
should be freed and relaxed to reduce the pull to the bil-
iary duct. After lysis, the patients with the stenosis of
type IIIo or IIIb can undergo cyst internal drainage at the

Y. F. LV ET AL. 233
same time T-tube placement in choledochus. To the pa-
tients with type IIIa, the internal drainage should be un-
dergone in the pseudocyst as well as expansive choledo-
chus, and double Roux-en-Y anastomosis could be adop-
ted [41]. Cut a section of jejunum with mesentery blood
vessel, about 15 cm length. Its proximal end is occluded,
its lateral wall is anastomosed with cyst, and its distal
end is stitched with former distal jejunum’s end, which is
connected with biliary duct. Then in the lower part of it
(about 50 cm from choledocho-jejunal anastomotic sto-
ma), it is anastomosed with the proximal end of former
jejunum. The procedure takes time and energy, but it can
reduce the reflux of in restinal juice.
The patient, whose pancreatic duct has an expanded
segment more than 7 - 8 mm, should be subjected to
Puestow’s operation program [42]. The patients with
duodenal obstruction, lasting more than 3 - 4 months,
should undergo gastrojejunostomy. Kamal, Prochorov et
al. suggest that the best choice to a patient, who suffers
from choledochal duodena, and pancreatic lesions, is
pancreatoduodenectomy [43,44].
5. Significance
Significance of this research lies in that:
1) This article has originally put forward the theory
that there are three types of choledochal end-piece steno-
sis due to CP. These not only have explained some clini-
cal pictures of CP, but also have instructive significance
to diagnose and treat the choledochal end-piece stenosis.
2) From the aspects of anatorny and pathology, the
authors have demonstrated cause and diagnostic methods
to three types of stenosis.
3) The authors have named three type of stenosis, that
is, the external-pressing annular stricture, the front wall
of choledochus being compressed stenosis and pseudo-
cystic oppression one. Moreover, according to the anat-
omic characters of type III, it has been divided into three
subtypes (IIIo, IIIa, IIIb).
4) As far as the treatment is concerned, the authors
have come up with different methods to treat different
stenoses. Besides, the authors have introduced clearly the
difference between the stenosis due to biliogenic CP and
ones due to non-biliogenic CP, namely, most of the pa-
tients with the former need undergo surgical treatment.
6. Remaining Questions
This research has put forward the theory that there are
three types of choledochal end-piece stenosis due to CP
as well as diagnostic methods, mainly according to ex-
plorations of operation and anatomy of corpses. However,
before operation, how to diagnose and make differential
diagnose better precisely is still a question worthwhile to
be studied.
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