Thursday, July 13, 2006

Obstructive jaundice

Obstructive jaundice

Obstructive jaundice which can be either due to intra-hepatic cholestasis or extra-hepatic biliary obstruction is amenable to surgical treatment. Hence, it is also called surgical jaundice.

It is difficult to diagnose the type and cause of obstruction on clinical grounds alone. But there are certain clinical criterion’s associated with it.
In calculus disease of biliary tract, intermittent or fluctuating jaundice can be seen with chills and rigors. It is progressive and painless and is associated with weight loss and anorexia in malignant obstruction.
In cases of infra-cystic obstruction due to malignant neoplasms, gall bladder may be palpable while in calculus diseases it is not palpable as it gets shrunken because of previous attacks of cholecystitis. This is Courvoisier’s law.

Causes of obstructive jaundice can be broadly classified into benign and malignant diseases.

Diseases causing obstructive jaundice include:
Benign
Common bile duct stone
Biliary stricture
Choledochal cyst
Primary sclerosing cholangitis
Mirizzi’s syndrome
Stenosis of papilla
Extra-hepatic biliary atresia

· Malignant

1) Primary
· Klatskin tumor
· Cholangiocarcinoma
· Carcinoma of the head of the pancreas
· Carcinoma of the duodenum
· Carcinoma of the ampulla of Vater
· Carcinoma of the gall bladder

2) Secondary- lymph nodes at the porta.

Amongst these the commonest causes include CBD stones and peri-ampullary malignancies.

Common bile duct stones:

Common bile duct stones are usually secondary stones that have migrated into the biliary system and the gall bladder. Common duct stones are known to occur in around 15% of patients undergoing standard open cholecystectomy (Mitchell ’93).
Approximately 11% of patients with gall bladder stones will have CBD stones at the time of operation. This incidence may climb to 18% in older patients who have had gallstones for a longer period of time. Between 5%-7% of CBD stones found at operation may be unsuspected by pre-operative evaluation and are discovered by cystic duct cholangiography during the cholecystectomy (Maingot’s ’01)1
Primary duct stones may be encountered in tropics secondary to infestation of biliary tree due to worms. Incidence is around 4 %( Blumgart’s ’88). Primary CBD stones occur in any situation causing prolonged biliary stasis and infection.2, 3
The natural history of choledocholithiasis is varied and unpredictable.
Most frequently CBD stones are an unanticipated finding during routine cholecystectomy. Small stones usually pass on to the duodenum spontaneously. They may induce and episode of pancreatitis by temporarily obstructing the pancreatic duct.
If stones obstruct the CBD in the presence of infected bile, cholangitis ensues. Classic triad of fever, chills and jaundice should always raise a suspicion of CBD stone. If stones obstruct the CBD in absence of infected bile, asymptomatic jaundice that is classically fluctuating ensues. Fluctuation is due to duct dilatation and floating back of the stone into the dilated CBD and reduction in the edema.
Pancreatitis is the second most common complication of a CBD stone. Other complications include choledochoenteric fistula and biliary stricture.
Diagnostic ultrasound, especially the real-time mode, has become the single most valuable screening test in case of jaundiced patients. It is a non-invasive procedure and can detect up to 50% of stones. Plain abdominal films are of very limited value as <15% of stones are radio-opaque. Either percutaneous transhepatic cholangiograms (PTC) or endoscopic retrograde cholangiograms (ERCP) can be asked for depending upon previous ultrasound findings and availability if more precise information is needed. CT or MRI usually is not of any help in the diagnosis or management of patients with cholelithiasis, with or without cholangitis.

CBD EXPLORATION:

Cholecystectomy is accompanied by exploration of common bile duct in 13-26 % of cases (Sheridan ’87).
Exploration of CBD with cholecystectomy raises the mortality of patients operated upon from 1% if the gall bladder alone is removed to 4.5% (Payne’86). Hence, routine CBD exploration has been condemned. Traditional indications for CBD exploration have given way to following absolute indications:
Palpable stones in the CBD
Jaundice with cholangitis
Stone demonstrable in intra-operative cholangiography
Pre-operative radiological demonstration of calculi in CBD.
Hence, routine intra-operative cholangiography4, 5, 6 is strongly recommended whenever choledochoscopy is not available. Intra-operative cholangiography7 is 85-95% sensitive in recognizing CBD stones (Blumgart’s ’88). Its advantages include –
Exclusion of CBD exploration in patients who have dilated CBD don’t have stones
During routine cystic duct cholangiography while doing cholecystectomy, approximately 5-7% of patients will be found to have unsuspected stones in the CBD
Pre-exploratory size and location of stones
To study the anatomy of the biliary tree and ampulla.

The commonest method of approach is supra-duodenal vertical incision (Tompkins ’90).
One of the most controversial aspects of choledocholithotomy is how to conclude the operation. There are three possibilities:
A) Simple closure-
It can only be attempted when one is sure about the patency of the distal duct system as evidenced by passing of dye into duodenum in a post procedure cholangiogram.
B) T-Tube drainage-
Most surgeons will still prefer chledochorraphy to a T-Tube8 in spite of a high incidence of cholangitis and biliary peritonitis. Hence, antibiotic prophylaxis is strongly recommended when T-Tube is in-situ9.
C) Biliary enteric procedures-
There are specific indications for biliary-enteric anastomosis (Blumgart’s ’88). They include-
Multiple primary duct stones with dilated ducts particularly in elderly
Multiple stones in a dilated duct
Irretrievable intrahepatic stones
Proven papillary stenosis
Impacted ampullary stone
Terminal CBD stricture.

Three procedures are in vogue:

1) CHOLEDOCHODUODENOSTOMY10:
It is mainly indicated when CBD is more than 1.5 cms, patient is elderly and high risk. The supra-duodenal choledochoduodenostomy uses vertical CBD and horizontal duodenal incision.
Complications of this procedure include-
Sump syndrome11- the cause of this is accumulation of stones, undigested food matter, or both in the segment of the distal bile duct, which obstructs the anastomotic opening and causes cholangitis and pain.
Biliary stasis
Anastomotic stenosis
Retained or recurrent stones

2) TRANS-DUODENAL SPHINCTEROPLASTY12:
It is indicated in a patient of impacted stone in ampulla or a very low CBD stricture (duct is dilated down to terminal few mms). Though an advantage to examine ampulla directly is got, disadvantages are too many. The complications include pancreatitis and duodenal leak.

3) CHOLEDOCHOJEJUNOSTOMY:
This is done when CBD can be mobilized completely. A roux-en-y loop or a simple loop is used with a entero-enterostomy below. Its advantages are low incidence of cholangitis and reflux of indigestible intestinal contents into the biliary tree. The drawback is that there is increased incidence of post-operative peptic ulcer disease13.

ADVANCES IN BILIARY CALCULOUS DISEASE

1) THERAPEUTIC ENDOSCOPY-
Endoscopic sphincterotomy (EP)
Classen and Demling first did it in 1974. it was first used only in selected patients. Now it is widely used in a variety of situations. It is the procedure of choice for recurrent or retained stones after cholecystectomy (Miller ’87)14, 15. It is also used in older and high-risk patients who wish to avoid surgery. After papillotomy stones can be either retrieved by a dormia basket or allowed to pass spontaneously. Success rates of between 85-95% have been reported. The complication rate ranges from 6.5-8.7% and mortality rate ranges from 0.1-3%. Long term follow up studies have shown that re-stenosis and/or recurrent stones occurred in 7% of patients, usually within 2 years.
Endoscopic retrograde cholangiography (ERC)
This procedure involves cannulation of the ampulla. A cholangiogram will show the exact number, size and location of the stones. Stone extraction can be done with balloon dilatation and basket extraction or they can be crushed using a mechanical lithotripter (Martin ’93). Endoscopic infusion of monooctanoin has been tried recently to dissolve stones and duct clearance of 18-55% have been reported (Stock ’92)16.
A combination of EP and ERC has achieved a duct clearance of 85-90% in a single procedure.

2) LAPAROSCOPIC APPROACH-
Laparoscopic cholecystectomy and trans-cystic CBD exploration17, 18
After cholecystectomy, cystic duct can be dilated laparoscopically and stones can be retrieved using baskets.
Laparoscopic choledochotomy
It is an approach in patients with dilated CBD, calculi 1 cm or more in diameter, multiple calculi or those who require lithotripsy for impacted stones.

3) EXTRA-CORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) 19, 20, 21-
In patients in whom endoscopic sphincterotomy and stone extraction proved to be unsuccessful, the use of ESWL has been proved successful. A multi-institutional study of 42 patients treated at 11 institutions showed that stone fragmentation can be obtained in 95% of the patients. However, 50% of the patients required adjunctive procedures to clear the bile duct stones, including endoscopic extraction, biliary lavage and stenting. Only 2 patients required operation to clear the bile duct stones (Maingot’s 01).

4) PERCUTANEOUS TRANS-HEPATIC ROUTE-
Using a modified dormia basket inserted through a percutaneous trans-hepatic catheter, a Boston group reported successful clearance of CBD stones in 93% of 50 patients treated. All of these patients had contraindications to surgery or had undergone unsuccessful endoscopic attempts at removal. 29 patients in this group required either monooctanoin or methyl-tert-butyl ether infusions to reduce stone size or remove residual debris. The authors reported a 13% morbidity and 4% mortality rate.
The percutaneous transhepatic route has also been used s a method of passing a cholangioscope to visualize and remove the biliary stones.

5) DRUG TREATMENT-
Various drugs like methyl tert-butyl ether, chenodeoxycholic acid and monooctanoin have been used to dissolve stones with variable results.

Many investigative reports on innovative techniques are available22. These include endoscopic introduction of electro hydraulic lithotripters by use of “mother-daughter” endoscopic techniques, endoscopic introduction of intra-corporeal shock-wave lithotripters into the bile duct, percutaneous transhepatic insertion of electro hydraulic lithotripters, and insertion of laser lithotripters via T tube tracts. While these technologic advances are interesting, they remain to be proven effective and economical.
Based on present data, when a patient is less than 65 years of age, open CBD exploration is safer than EP. Patient more then 65 years of age is a candidate for laparoscopic or endoscopic approach23.

Extra hepatic biliary atresia
The incidence throughout the world is approximately 1 in 14,000 live births. The occlusion of the bile ducts is accompanied by a variable degree of intrahepatic damage that can progress to cirrhosis and liver failure, in untreated cases. Historically, cases were classified as correctable or non-correctable, depending on the presence or absence of residual proximal duct segments of bile duct. The introduction of new surgical technique, in the 1960s, invalidated the traditional classification.
The first major review of 49 cases was published by Thompson24 in 1891 and 1892 and concluded that, whatever the etiology of biliary atresia, a progressive, destructive inflammatory lesion of the bile ducts characterized it. Holmes analyzed more than 100 case reports and first suggested that surgical treatment might be effective in biliary atresia. Ladd described 20 more cases. Hays and Synder reported, in 1963, that in most American series, <5% of patients survived beyond early childhood25. In 1959, Kasai and Suzuki described a new radical operation for non-correctable atresia based on the histologic observation that remnants of the extra-hepatic ducts at the porta hepatis frequently contained ductules measuring up to 300 micrometers in diameter26. Approximately 85% of extra-hepatic biliary atresia cases classified as non-correctable now are treated routinely with the Kasai’s portoenterostomy procedure.
The 4-year survival rate in untreated cases of biliary atresia is approximately 2%, but portoenterostomy performed before the age of 7 weeks has resulted in early jaundice-free survival in more than 90% of the cases. Past 7 weeks of life, the long-term results of surgery are very poor.
Although morphology of the extra-hepatic bile ducts varies widely in biliary atresia, the Japanese Society of Pediatric Surgeons identified three principal types, which form the basis of the classification now in general use-
Type 1: atresia of the CBD
Type 2: atresia of the common hepatic duct
Type 3: atresia of the right and left ducts.
In a Japanese survey of 643 cases, 566 (88%) were type 3, 64(10%) were type 1, and only 13(2%) were type 2 lesions.
Surgical treatment consists of pre-operative percutaneous liver biopsy, followed by radical resection of the occluded biliary tract and reconstruction with a Roux-en-y loop of jejunum.
The results of portoenterostomy has gradually improved as illustrated in a report that showed that the number of jaundice-free children rose from 7.6% in the period 1953-1961 to 85% in 1987-8827. The current probability of 5-year survival after portoenterostomy in specialized unit is around 60%.

Choledochal cyst

A choledochal cyst is defined as an isolated or combined congenital dilation of the extra hepatic or intrahepatic biliary tree.
In 1723, Vater and Ezler described the anatomic details of a choledochal cyst, but Douglas is credited with the final description of a case of a choledochal cyst.
McWhorter reported the first excision of a choledochal cyst
Alonso-Lej et al reviewed the literature in 1959 and proposed an early classification system for choledochal cysts. Todani et al modified the Alonso-Lej classification in 1977, to account for the combination of intra and extra hepatic cystic dilation28.
Type I- dilation of extra hepatic biliary tree: Ia-cystic, Ib-focal, and Ic-fusiform
Type II- saccular diverticulum of extra hepatic bile duct
Type III- biliary tree dilation within the duodenum, choledochocele
Type IV a- dilation of intrahepatic and extrahepatic biliary tree
b- multiple extrahepatic cysts
Type V- dilation confined to the intrahepatic ducts (Caroli’s disease)
Once considered a rare congenital lesion of children, choledochal cysts have been reported in over 3300 patients, with many recent repots including adults. More than 2/3rd of all cases have originated in Asia.

Carcinoma of the head of the pancreas

Carcinoma of the pancreas is a disease with poor prognosis considered by many to be one of the deadliest malignancies. Less than 20 % of affected patients survive one year after diagnosis. (Lilimoe 95)
Pancreatic cancer, by far the most common periampullary malignancy, is the ninth most common cancer and is the fourth and fifth leading cause of death in men and women, respectively, in the United States29. The lowest incidence is seen in India and parts of the Middle East. There is a slight male predilection; however the incidence and mortality rate in women has increased. In the last two decades while remaining constant in men. Blacks are more commonly affected than whites.
Approximately 95 % of malignancies arise from exocrine pancreas; of them 75% occur in the head. Carcinoma head of the pancreas presents early due to development of jaundice. Jaundice is progressive and often associated with significant pruritus. Pain of moderate intensity may be present as a result of obstruction of the biliary or pancreatic ducts. Recent studies suggest that less than one third of patients presenting with pancreatic carcinoma describe moderate to severe pain. Duodenal obstruction, with nausea and vomiting, is usually late manifestation of peri-ampullary carcinomas. Duodenal and periampullary carcinomas may bleed intermittently. In many patients physical findings are absent, especially early in the course. The development of jaundice is often the first physical finding that is apparent as the tumor obstructs the biliary tree. An enlarged liver or palpable gallbladder is present in 25 to 30 % of patients.
Both USG and CT scan are useful in diagnosing carcinoma pancreas. Currently the use of intravenous and oral contrast enhanced spiral CT scan offers the best form of imaging of the pancreas. It also provides information about liver metastases and major vascular involvement30. Once biliary obstruction has been confirmed by imaging studies, the next step in the evaluation of a jaundiced patient is cholangiography. Either the endoscopic or percutaneous approach is appropriate with the choice of technique depending on local expertise30.
During ERCP stent can be placed through tumor for biliary drainage. Preoperative biliary drainage is shown to reduce operative mortality and morbidity. (Lygidakis 87)
Percutaneous transhepatic biliary drainage can also be used for the same purpose.
Biopsy of a periampullary mass can be obtained by endoscopic or percutaneous route. The primary indication for percutaneous biopsy is in patients who would appear not to be surgical candidates because of either extent of disease or medical contraindications. Percutaneous biopsy may be useful if the CT picture suggests pancreatic lymphoma, which is best managed non operatively.
In cases of doubt, pre operative visceral angiography with arteries of the celiac and mesenteric arteries with venous phase studies provide the best demonstration of vascular anatomy and major vessel encasement or occlusion.
Endoscopic ultrasonography is a minimally invasive technique to image pancreas. It can detect small pancreatic lesions (< 2 cm) and also lymph node and vascular involvement.
Liver metastases and peritoneal implants are the most common sites of distant spread of pancreatic carcinoma. Several groups, before the patient is subjected to laprotomy, have used the technique of diagnostic laparoscopy, as an additional staging modality for the evaluation of patients with pancreatic and periampullary malignancies.


TREATMENT OF PANCREATIC AND PERIAMPULLARY CARCINOMA

In 1899 Halstead described the local resection of an ampullary carcinoma. Whipple in 1935 first described the technique for excision of periampullary carcinoma, which was done in two stages. He improved upon it and did a one-stage procedure in 1941. However 60 to 80% of these tumors proved unresectable at the time of exploration. The procedure involves two components of exploration: exploration with assessment of tumor respectability and resection followed by reconstruction if tumor is found resectable. Involvement of portal vein and superior mesenteric vessels is the most common cause of unresectability. Head of pancreas, entire duodenum, distal part of stomach and distal end of CBD are removed followed by reconstruction.
Traverse and Longmire modified the procedure by preserving the pylorus in 197831. Currently in most series, pylorus preserving pancreatico-duodenectomy (PPPD) is the procedure of choice32. PPPD shortens operative time, retains entire stomach as reservoir, maintains a more normal gastrointestinal hormonal milieu and decreases post gastrectomy symptoms (Lilimoe).
Another modification has been added by Fortener, which includes regional pancreatectomy. Complications after pancreatico-duodenectomy remain high usually in the excess of 25 to 35 %. Pancreatic fistula remains the most serious complication after the operation, with its incidence ranging from 5 to 20 %.
The most frequent complication following PPPD is delayed gastric emptying with an incidence in the 20 to 50 % range33.
Although a number of factors appear to contribute to the overall improvement in results following pancreatico-duodenectomy, a high volume of procedures concentrated in the hand of experienced surgeons seems to be of primary importance34.
Survival rate of patients with carcinoma pancreas who have undergone resection remains low35. Five-year survival rate is usually between 18 to 21 %. Survival following resection of distal bile duct, ampullary, and duodenal carcinoma has always been significantly longer than that for pancreatic carcinoma, with some series reporting a five-year survival in the range of 30 to 60 %.
The role of adjuvant radiation therapy is emphasized by the pattern of relapse after surgical excision, since over half of the patients resected developed local regional recurrence without evidence of distant metastases.
Many palliative procedures have been devised for the treatment of unresectable malignancies. Non-operative palliation appears to be associated with lower complication rates, lower procedure related mortality rates, and shorter periods of hospitalization. There appears to be no advantage with respect to long-term survival. Advocates of surgical palliation however criticize non-operative palliation in that it is frequently associated with late complications of gastric outlet obstruction and recurrent jaundice, resulting in the need for rehospitalization.surgical palliation offers the only chance for long term palliation of all three major symptoms of pancreatic carcinoma: obstructive jaundice, duodenal obstruction and pain. Biliary bypass can be performed as either cholecystojejunostomy or choledochohepaticojejunostomy. The ability to perform a gastrojejunostomy to treat or prevent gastric outlet obstruction is currently the only palliative procedure that cannot be performed non-operatively. The final major advantage of operative palliation is in the management of pain. Intraoperative celiac axis injection with 50 % alcohol can both successfully relieve pain in patients, and prevent the development of pain in patients without pain at the time of exploration36. The use of percutaneous neurolytic block of the celiac axis, either using fluoroscopic or CT guidance is also successful, in the vast majority of patients, at eliminating pain37. In those rare patients in whom percutaneous techniques are not possible, thoracoscopic splanchnicectomy has been shown to effectively relieve pain38. Finally, although not well demonstrated by objective measures, it appears that external beam radiation therapy has a beneficial effect on pancreatic cancer pain.
Recently endoprostheses have given a chance of non-surgical palliation39.
Although, traditionally pancreatic cancer has been associated with a dismal prognosis, recent advances in diagnosis and management, both surgical and non-surgical, have led to overall improvement in the management of these conditions.
All the other periampullary malignancies, like carcinoma of the ampulla, distal bile duct and duodenum present with the same clinical pattern. Methods of diagnosis and management remain the same. But these tumors are less lethal and give an excellent survival rates.


Carcinoma of the gall bladder

DeStoll first described gall bladder carcinoma in 1977. The first hepatic resection for gall bladder cancer was performed by Keen in 1891, and Mayo made the association between gall bladder cancer and gallstones in 1903. The incidence of carcinoma of the gall bladder increases in frequency throughout life. In autopsy series, gall bladder carcinomas account for up to 5 % of all malignancies with many of these tumors being asymptomatic at the time of demise of the patient. Autopsy data from Chile have suggested that the risk of gall bladder carcinoma is 7 times greater in presence of cholecystitis and cholelithiasis40.
Obstructive jaundice in case of GB carcinoma can be managed with either percutaneous transhepatic biliary stents or biliary endoprostheses. Appropriate narcotic therapy may provide adequate pain control in many patients. In those patients with disabling pain, either external beam radiation therapy or percutaneous celiac ganglion nerve block may be helpful in reducing the need for narcotics. The mean survival for the subset of patients who undergo non-operative palliation for symptomatic GB carcinoma is less than 6 months.
The operative palliation of jaundice is dependent upon the extent of final disease. Various procedures like Roux-en-Y choledochojejunostomy, segment III bypass, intraoperative celiac splanchnicectomy and gastrojejunostomy can be performed.
Current recommendations for surgical therapy for GB carcinoma41 are based on the pathologic staging of the tumor and the historical survival rates for the different tumor stages42.
Chemotherapy and radiation therapy43 in postoperative adjuvant setting has not produced any survival advantage.


Cholangiocarcinoma

Primary carcinoma of the biliary tract is an uncommon cause of obstructive jaundice, but carries a very poor prognosis and majority of patients die within 6 to 12 months of diagnosis.
Like GB cancer, the incidence of bile duct cancer increases with age. Bile duct malignancies have a more even distribution between men and women than do GB malignancies.
Cancer of the bile ducts has been recognized for more than a century. Musser reported 18 cases of primary extrahepatic bile duct cancer in literature in 1889. In 1940, Stewart and associates reviewed 306 cases of extra hepatic bile duct cancer reported in the literature, and two decades later Sako and associates reviewed the literature from 1935 to 1954, ad found 570 additional cases of extra hepatic bile duct cancer. Malignancies of the intra hepatic and peri-hilar bile ducts have been described more recently, with Altemeier and associates reporting 3 cases of primary adenocarcinoma of the major intrahepatic bile ducts in 1957, and Klatskin reporting 13 patients with cancer of hepatic duct bifurcation in 1965.

Two types of cholangiocarcinoma have been described
(A.) Hilar cholangiocarcinoma (Klatskin tumor)
In most series, the overall resectability rate for hilar bile duct cancer averages between 40 and 60 %. Data from selected recent series reviewing potentially curative resection of hilar bile duct carcinoma reveal a mean survival of 22 months44 .The addition of major liver resection to surgery for hilar bile duct cancer des not show any survival advantage. Reconstruction is done by hepaticojejunostomy. Palliative procedures include trans-tubal drainage using U tube and biliary enteric anastomosis. PTC is usually necessary to delineate the duct system45. Segment III is commonly used for bypass. The duct is approached by ligamentum teres approach, and is anastomosed side to side to a Roux-en-Y loop of jejunum.
(B.) Cholangiocarcinoma of the distal CBD
This has been grouped under periampullary tumors and requires pancreatico-duodenectomy. USG is the preferred investigation but PTC or ERC gets precise information. In most series, the resectability rate of distal CBD cancer exceeds 60 %. Data from more than 221 patients reveal an average mean survival of 39 months; nearly double the mean survival following potentially curative resection of hilar bile duct cancer44

Ampullary tumors

Local excision is suitable treatment for certain small tumors (less than 2 cm) arising from the ampulla of Vater or in the pancreatic or biliary duct within 2 cm of the ampulla, if there is suspicion of malignancy frozen section evaluation of the resected specimen is done and if it confirms malignancy pancreatico-duodenectomy should be done46. After local resection of ampullary tumors, follow up endoscopy is performed 6 to 12 months postoperatively to assess local recurrence. Patient who develop pancreatitis or jaundice months to years following local resection of ampullary tumors must be suspected of having local recurrence and should undergo repeat endoscopy with ERCP.

Surgery for choledocholithiasis:

Cholecystectomy + choledocholithotomy + T tube drainage

Procedure:
Various incisions are used but we prefer midline or long right para median incision.
After peritoneum is opened any adhesions if present are divided.
Liver is retracted upwards while small bowel, colon and duodenum are covered with moist towels and retracted downwards
An atraumatic Babcock’s forceps is applied to Hartman’s pouch and pulled to right.
Peritoneal fold over Calot’s triangle is incised. Blunt dissection is done to define the CBD and cystic duct. Cystic and right hepatic arteries are defined. Cystic artery is ligated near gall bladder and cut. (Various anatomical variations should always be kept in mind)
Cystic duct is identified up to the neck of the gall bladder. Intraoperative cholangiography is done through the cystic duct. Then the cystic duct is ligated and cut. GB is dissected from GB fossa and removed.
INTRAOPERATIVE CHOLANGIOGRAPHY
Recent data suggest that selective cholangiography4 is appropriate with indications of a history of jaundice or biliary pancreatititis, abnormal liver function tests suggestive of extra hepatic obstruction, a dilated CBD., or palpable stones
After the exposure of cystic duct, a nick is taken on it and a canula is introduced. It is tied both proximally and distally to prevent leakage of dye and introduction of air bubble which appear as stones.
Dilute 1:1 dye is used as stronger dye may obscure stones.
One film is taken immediately after pushing the dye and one may be repeated after 5 minutes.

Choledochotomy

Procedure:
Exploration of CBD is done after the cholangiogram confirms presence of stones.
CBD is cleared.
2 stay sutures are taken on the anterior surface of duodenum 2 cms above duodenum.
Duct is opened longitudinally between the stays. Bile is sucked away to avoid contamination.
The duct is explored using Desjardin’s forceps and calculi are removed.
Then CBD is irrigate with normal saline and patency of ampulla ensured.
A T Tube is now kept in the CBD and duct is closed around the tube with 3-0 vicryl or 3-0 catgut.
The T Tube should be brought out at the lower end of CBD to avoid pulling on the suture line.
Incision is closed with a drain in Morison’s pouch.
Postoperative T Tube cholangiogram is taken.

Choledochoduodenostomy

Procedure:
Duodenum should be kocherised and 2nd part mobilized completely and thoroughly.
Transverse or longitudinal incision can be taken on the CBD. We prefer longitudinal incision.
Longitudinal incision is taken on the duodenum.
A single layer anastomosis is done with 3-0 vicryl. All sutures are interrupted and on atraumatic needle.
A stent can be kept across the anastomosis, which is brought out of the duodenum to the outside.

Sphincteroplasty

Procedure:
Duodenum is opened longitudinally.
Ampulla is visualized.
An incision is taken at 10’0 clock to avoid injury to the pancreatic duct.
Sutures are taken taking care to include the apex after division by serial clamping.
Duodenum is closed longitudinally.

Surgery for extrahepatic biliary atresia:

Kasai’s portoenterostomy

Procedure:
A right subcostal or a transverse abdominal incision across the right rectus sheath is taken. In the latter, if atresia is confirmed, the incision is extended across the left rectus muscle.
The GB in EHBA is often thick walled, contracted, and hidden within a cleft in the liver parenchyma. In these circumstances, operative cholangiography is usually impossible and aspiration of the GB should produce reveal “Limey (whitish) bile”. However, operative cholangiography is mandatory whenever bile is found in the gall bladder.
Liver is fully mobilized and Cholecystectomy is done.
Dissection of extrahepatic bile duct remnants is performed towards the porta hepatis and CBD remnants up to the duodenum are excised.
Rarely, a long patent segment of proximal duct (correctable atresia) that can be used for a hepaticojejunostomy is discovered. In the majority of cases, however, the dissection proceeds above and behind the bifurcation of the portal vein and hepatic artery, and the tissue is transected at its junction with, and parallel to, the capsule of liver.
A Roux-en-Y loop of jejunum is prepared. One end is closed, a side opening is made and portoenterostomy is performed with interrupted 5-0 or 6-0 vicryl sutures. Jejunojejunostomy is done to establish intestinal continuity. A drain is placed in the supraduodenal area before closure of the abdomen.

Surgery for peri-ampullary malignancies:

They are divided into
A) Radical resection
B) Palliative bypass

Whipple’s procedure (pancreatico-duodenectomy) was the most common radical procedure performed. Traverso Longmire’s PPPD was done in few cases.

Whipple’s pancreaticoduodenectomy

Procedure:
An adequate exploration of the pancreas requires good access and exposure. We preferred a long midline or a long right para-median incision.
On opening the abdomen, metastases, portal vein involvement, and extent of tumor beyond the normal limits of resection should be assessed, all of which indicate inoperability. Hepatic, omental, and peritoneal seedlings also contraindicate resection. Fixity around ligament of Treitz and extension of tumor around superior mesenteric vessels also are contraindications for resection.

TRIAL DISSECTION

A) Mobilization of duodenum and the head of the pancreas
This is called kocherisation of duodenum. The colon is dissected from the hepatic bed and off duodenum. The peritoneal reflection lateral to the 2nd part of the duodenum is incised. The duodenum and the head of the pancreas are mobilized anteriorly and towards the midline. The dissection is continued till aorta and IVC are displayed. The posterior pancreatic and aortocaval group of lymph nodes are mobilized anteriorly with the specimen.
B) Dividing the gastro-colic omentum opens lesser sac and the entire pancreas is examined.
C) Dissection of superior mesenteric vein
Middle colic vein is traced upwards to it’s point of entry into the superior mesenteric vein. There is a safe plane anterior to the portal vein as all the tributaries of portal vein enter it from the lateral aspect.
D) CBD is dissected and hooked out. The left gastric vessels are identified and ligated. The fundus and greater curvature are mobilized.

RESECTION

We prefer cholecystectomy if cholecystostomy has been done previously.
CBD is transected. The neck of the pancreas is then carefully transected to the left of the portal vein. The bleeding vessels are ligated with 4-0 silk sutures. Portal vein tributaries need to be ligated carefully. The stomach is divided between non-crushing clamps at the selected site.
The specimen now remains attached by only uncinate process and the small bowel. The duodenum and the DJ flexure are freed from the transverse mesocolon by dividing the peritoneum around the duodenum. Ligament of Treitz is divided and small bowel transected a small distance away from the DJ flexure.
The uncinate process is then freed. Vessels need careful ligation because troublesome can take place here.

RECONSTRUCTION

The first anastomosis is the pancreaticojejunal anastomosis. It can be done by the invagination method when the pancreatic duct is smaller or by duct to mucosa anastomosis when the duct is bigger. A stent is kept in the duct, which is brought across the anastomosis out of the jejunum on to the abdominal wall. Then bile duct is anastomosed end to side of jejunum10 cms distal to the first anastomosis. Lastly, gastrojejunostomy is done 25 cms from the first anastomosis in 2 layers.
Tube drain is kept in Morrison’s pouch and the abdomen closed in layers.

Palliative procedures47

These are advised when resection is contraindicated due to advanced disease. Various procedures can be done depending on the level of obstruction. The procedures include-
1) Hepaticojejunostomy
2) Cholecystojejunostomy
3) Choledochojejunostomy
4) Choledochoduodenostomy
Gastrojejunostomy is done if there is duodenal obstruction.
Chemical splanchinectomy is done to reduce pain.

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