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Youmay want to know howto insert theFoley catheter into the
gallbladder during a laparoscopic procedure. Well, insert a 5mm
grasperthroughtheepigastricportandbringittoliewithinthetipofthe
lateralsubcostaltrocar.Nowremovethelatterwhile‘pushing’thegrasper
tofollowtheretractingtrocar,throughtheskinincision.LubricateaFoley
catheter (16Fr will do), grasp it with the grasper and pull it into the
abdomen.
With regard to the management of thecholecystostomy tube, a
tube cholangiogram performed a week later will tell you whether the
cysticductispatent;andifsowhetherthebileductisfreeofstones.The
tube can be safely cappedif all is well, andleft as a safety valveuntil
elective surgery; another attack is simply treated by opening the tube.
Whether an interval cholecystectomy is subsequently indicated is
controversial, but is usually performed (see above). Cystic duct
obstructionwouldusuallymandateintervalcholecystectomy.
Otherconsiderations
Intra-operativecholangiogram(IOC)
Without jumping into this never-ending discussion again, anIOC has
beenmentionedasawaytodelineateunclearanatomyincasesofacute
cholecystitis. It may be enough to say that “the authors have not
foundtheneedforthismeasureintheirexperience...”;wealsofindit
difficultto performinacute disease, where thecysticduct is obstructed
and the tissues are edematous and friable. Transcholecystic needle
cholangiographyhasbeendescribed,butrarelyused.Itisbesttodefine
the surgical anatomy by proper dissection, using the above-mentioned
principles,andifyoucan’t—thenavoidthisareaandresorttosubtotal
cholecystectomy.Again: in emergency surgery,simpleis beautiful. Why
complicateyourlife?!
[An] intra-operative cholangiogram is a religion — not
science.
NathanielJ.Soper
Antibiotictreatment
The role of antibiotics in treating acute cholecystitis appears to be
trivial,butitisnot.Itseemsthatover-treatmentistherule,bytypeaswell
as by dosage. The common pathogens are enteric Gram-negative
bacteria, secondarily infecting an obstructed gallbladder. So, as
mentioned above, the early phase of acute cholecystitis is probably
sterile.Noteverycaseof12-hourRUQpainwithsomeultrasonographic
signsofdistensionandwall-thickeningmandatesantibiotics.Andifthey
areprescribed,thecoverageshouldnotautomaticallyincludeanaerobes,
which are not common pathogens. However, we would add antianaerobecoveragewhennecrotizingACissuspectedclinicallyorfound
at operation. If surgery is carried out, the peri-operative antibiotic
coverage for acute cholecystitis should be short, as for ‘resectable
infection’ ( Chapters 7 and 44), and extended only for complicated
casesofempyema,gangreneorperforation.
Acalculouscholecystitis
Webriefly mentioned this condition above asit is relatively rare, and
oftenmistakenly diagnosed when small stones are simply missed. This
entityisa manifestationofdisturbed gallbladdercirculationin acritically
ill patient, usually the outcome of multiple etiologic factors: gallbladder
distensionduetofasting,alow-flowstate,andvasospasmduetotheuse
ofaminevasopressors.Theresultisadistendedgallbladder,withan
ischemic wall and secondary infectionthat risks the patient’s life.
(Havingsaidthis,therehasbeenagrowingnumberofcasesdeveloping
‘out of the blue’ in otherwise healthy individuals, even young patients,
withoutanyoftheknownpredisposingfactors.)
Thediagnosismaybeobscuredbythepatient’sgeneralconditionand
underlyingcritical disease, and clinicalsignsmay not be obviousinthe
sedatedpatient,but bedside US (or a trip to theCT)willquickly reveal
thedistendedgallbladder,surroundedbyfluid,thatwillexplaintheseptic
deterioration and the elevated liver enzymes — if you were suspicious
enoughtoorderthestudy.Questionablecasesandunclearstudiesmay
require the definitive HIDAscan — but this isdifficult to performin the
typicalICUpatient,soyoumayneedtoactempiricallyifsuspicionishigh
enough.
Although this condition may lead to necrosis and perforation, most
cases,despite old beliefs,willrespond to percutaneousdrainage. If the
patientdoes not improve, though, cholecystectomymayberequired. In
non-critically ill patients diagnosed with acalculous cholecystitis,
wewouldproceedwithLC,alongthelinesdiscussedabove.
For an in-depth discussion on the complications of cholecystectomy
readtherelevantchapterinourtwinbook2!
Beware of the easy-looking gallbladder and the
overconfidentsurgeon.
2
Bileductemergencies
DannyRosin
SoastonehaspassedintotheCBD—howdoesitchangeyour
approach?
Asincholecystitis,thesamemechanismisresponsibleformostofthe
problems—obstructionandbuild-upofpressure.Obstructioniscaused
by a stone in most cases, but a stricture or external compression can
resultinasimilaroutcome—whichcanbeoneofthree:
•
Non-infected:obstructivejaundice.
•
Infected:acute(‘ascending’)cholangitis.
•
Acutepancreatitis.
The exact mechanism may vary in different patients — for
example:
•
The young, postpartum patient, who developed stones during
pregnancy (due to the progesterone effect on gallbladder
contractility), now starts to contract her gallbladder, expelling the
smallstonesthroughasomewhatwidecysticduct.
•
The old man, 30 years aftercholecystectomy,with a primary CBD
stone(orachainofthem).
•
The55-year-oldathletewhosuddenlyturnsyellow, due to his notyet diagnosed pancreatic head carcinoma (painless, and usually
non-infectedunlesswestarttointervene).
Ofcourse,thelistofetiologiesdoesn’tstophere,butyougettheidea:
thereisanobstructionofthebileduct,hopefullybenign,andit’syourjob
to treat the resulting complication. The obstruction itself may resolve
spontaneously,andifnot—itneedsaspecificintervention.
We will leave the third scenario to our pancreatic experts (and
anyway, it’s rarely an emergency), and discuss the three stonerelatedentitiesthatarerelevanttousasgeneralsurgeons,namely
—jaundice,cholangitisandpancreatitis.Whileseparatedfordidactic
reasons, ‘mixed’ presentations do occur commonly in real life. The
common denominator for all these emergencies, though, is that
only rarely do they require emergency surgery. Your goal, and
responsibility,istosolvetheacuteproblem,navigatingbetweendifferent
imaging modalities and interventional procedures, and lead the patient
safelytoanelectiveoperation.
Obstructivejaundice
If the gallstones are small enough,and thecystic ductwide enough,
stones can migrate into the CBD. The sphincter of Oddi is the reason
why even small stones may get stuck, at least temporarily, but it is
surprisingtofindevenlargerstonesintheCBD,whichmakeuswonder
howthehelldidthey passthroughthecysticduct… butthe factisthey
did,sometimesafterbeingstuckinthegallbladderoutletfor afewdays
(youmayrememberWinniethePooh,stuckinRabbit’sholeforaweek
— but eventually he popped out). Ofcourse, small stonesthat pass to
theCBDandstaytherecangrowovertime,butthisisaslowprocess.
Primary CBD stones are muchless frequent, and are usually the
resultoflongstanding bilestasis,whichmaybe relatedtoastricture,or
the elusive ‘sphincter of Oddi dysfunction’. We don’t have a good
explanationwhysuchaslowandquietprocesssuddenlyleadstoacute
obstruction of the CBD, but the outcome is the same, like that of a
passingstone:mechanicalblockageoftheflow.
Thepresentationmaybedifferentthough,asacuteobstructionof
a narrow duct by a small passing stone is usually painful
(‘choledochalcolic’),whilewithobstructingstonesinachronically
dilated and hypokinetic CBD, symptoms tend to be ‘gradual’ or
‘minimal’— almost like the ‘silent jaundice’ of malignant
obstruction.
Thepatientwilltellyouabouthisdarkurine,andhislovingwifeabout
his yellow eyes, but obvious jaundice requires a bilirubin of 3mg%
(50μmol/L) or more. The liver function tests are sensitive, with direct
hyperbilirubinemia, moderately elevated transaminases, and the more
specificelevatedalkalinephosphataseandgamma-glutamyltransferase.
Don’tbe surprised toseesome amylase/lipase elevationas well —the
‘commonchannel’bringsalongmany variantsofcombined pathologyof
thebiliaryandpancreaticsystems.
Management
Asopposedtocholangitis(seenext),obstructivejaundiceisnotalifethreateningemergency;butthepatientisstressed,becauseofthepain,if
present,and the altered appearance — withitsfrightening associations
(“yellow patients have cancer”). The mandatory ultrasound will
confirm your diagnosis (gallstones? dilated vs. collapsed
gallbladder — remember Courvoisier’s sign? dilated CBD?
intrahepaticdilatation?pancreatic mass?), although the sensitivity
forCBDstonesisnotmorethan50%.Ifnogallstonesarevisiblein
the gallbladder, you have to investigate further for peri-ampullary
malignancy—andCTisyournextstep.
Benign obstructive jaundice is a fluctuating condition, and
spontaneousresolution iscommon.It usuallymeans that thestone has
passed, but not necessarily so — stonesmay act likea ball-valve with
intermittent obstruction. In these cases you are likely to see that
normalization of the hepatic enzymes is not complete. But even if all
laboratory features normalize, you should still consider specific
CBDimagingtoruleoutaCBDstonebeforedecidingtoremovethe
gallbladder.MRCPavailabilityhassignificantlyincreasedinrecentyears
and is our preferred study, but endoscopic ultrasound (EUS) is also
accurate, albeit more invasive. Endoscopic retrograde
cholangiopancreatography (ERCP) asa diagnostic modalityis not
justifiedinthesecases.
Whenthejaundicefailstoresolve,orifyourinvestigationproved
the presence of a CBD stone — pre-operative ERCP with
sphincterotomy(ERCP+S)isthefavouredapproachinmostplaces.
AftertheCBD has been cleared, in the absenceofinfection, surgery
(laparoscopiccholecystectomy)should not be delayed too much.There
are some claims that pre-operative ERCP does induce some
inflammatory changes, which can make surgery more difficult, but we
havenoevidencethatdelayingsurgeryhasarealadvantage.
We will not conclude without mentioning cholecystectomy with intraoperative cholangiography, bile-duct exploration (transcysticif possible)
and stone removal. The proponents of this approach (laparoscopic, of
course),claimthatthisisthesimplest,one-stagesolution,butthefactis
thattheequipmentandexpertiserequiredarebeyondwhat’scommonly
available,sothisperfectsolutionisnotsoperfect…andthusnotwidely
practiced.
OpenCBDexplorationisstillavalidoptionbutis usually saved for
failed endoscopic attempts — we hope that you, or your mentors,
remember how to do it and are familiar with the management of Ttubes…
Acute(‘ascending’)cholangitis
What is the source of infection in patients with
choledocholithiasis?Isitreally ‘ascending’fromtheduodenum(which
isnotsoheavilycolonizedanyway)?Isitaninfectedstonethatstartsthe
process?Godknows…butcompleteobstruction,likeamalignantone,is
probably ‘protective’ against secondary infection until late into the
diseaseprocess.Biliary intervention is probablythe most common
cause of cholangitis, and once bacteria are introduced into the
system, the risk ofrecurrent infection is highuntilthe problem is
solved.
The most important underlying factor is bile stasis, and the most
importantelementofthetreatmentisrestoringthebileflow.Withoutit—
ductalpressurewillrise,andthe risk of bacterial translocation from the
biletothebloodincreases,resultinginbacteremiaandsepsis.
YouareprobablyfamiliarwithCharcot’striad (JeanMartin Charcotof
Paris,1825-1893— Figure20.4):
•
Rightupperquadrant(RUQ)pain.
•
Fever(andrigors).
•
Jaundice.
Addtothatthe two other elements — confusion and septic shock —
and you get Reynold’s pentad, which is associated with markedly
increased mortality, and should make you move faster. Significant
leukocytosis(orevenworse—leukopenia),andevidenceoforganfailure
(lungs, kidneys, liver) signifies rapid deterioration and mandates
aggressivetreatment.
Management
You already know how to diagnose jaundice in the laboratory, but
pleasedon’tforgettoobtainbloodculturesaswell.
Thetreatmentcomprises:
•
Fluid resuscitation and hemodynamic monitoring (and support, if
needed).
•
Antibiotictreatment.
•
Unpluggingtheduct.
The antibiotic treatment, started empirically, should cover enteric
Gram-negative bacteria (typically E. coli and Klebsiella), and probably,
especially in elderly patients, also anaerobes, which will grow in up to
20% of thecultures. In most cases of acute cholangitis there will be a
relatively prompt response, with defervescence within 24 hours.
Therefore,interventionaltherapiesshouldbeusedselectively,andsaved
for patients with persistent septic signs, deterioration of lab results
(increasing bilirubin), and diagnosis of non-resolving biliary obstruction.
Onlyinahandfulofpatients,presentinginsepticshockasaresult
of pyogenic bile, is emergency ERCP+S at presentation justified.
Makesurethatthe extreme condition is not the result of an associated
condition,likegangrenouscholecystitis.
Figure20.4.“Ohtheurineisdark…whatdoyoucallthattriad?Charcoaltriad?”
ERCP+Sisthe modality of choiceforbiliarydrainage.Ifpossible
the obstructing stone should be removedafter sphincterotomy,but in a
septic patient a shorter drainage procedure may suffice, by inserting a
plasticstent.
Failedorimpossible ERCP (a gastricbypass patient,for example),
will mandate an alternative procedure, like percutaneous transhepatic
drainage. If the gallbladder is distended, a percutaneous
cholecystostomymaydraintheCBDaswell.
Surgical solutions, as in obstructive jaundice, should be on an
electivebasis,aftersolvingtheacutecondition,exceptinrareconditions
that mandate emergency surgery, like gallbladder perforation. Taking a
septic patient for an emergency exploration of theCBD isa rare event
nowadays,butifdeemednecessary(e.g.failedERCP+Storemovelarge
CBDstonesoranimpactedDormia®basket)—itshouldbekepttothe
minimalpossible —like acholedochotomy andT-tubeinsertion. Forget
aboutcomplexbiliaryanastomosesinasepticpatient.
3
Biliarypancreatitis
B.Ramana
You can read about acute pancreatitis in general in Chapter 19.
Here we’ll focus on the approach to patients with gallstone
pancreatitis.
Youshouldsuspectgallstonepancreatitisinpatientswhopresentwith
acute pancreatitis and are found (on US) to harbor stones in the
gallbladder. Suspect italso in non-alcoholic patientseven if stones are
notvisualizedasoccasionally‘idiopathicacutepancreatitis’iscausedby
tinygallbladderstonesorsludge(microlithiasis).
Commonly, in addition to the elevated pancreatic enzymes, there is
some degree of chemical liver dysfunction (similar to that described
aboveinpatientswithascendingcholangitis).Itisbelievedthatbiliary
pancreatitisiscausedbysmallstonesdroppingintotheCBDfrom
thegallbladder,andmigratingdistallythroughthepapilla.Morethan
30yearsagoDr.JohnAcostaestablishedhisnameintheHallofFame
of surgery by sifting through the feces of patients with suspected
gallstonepancreatitis,findingsmallstonesintheirfeceswithin10daysof
their admission ( Figure 20.5). In those patients who underwent a
laparotomy,within48hoursimpactedstonesinthepapillawerefoundin
morethantwo-thirdsofindividuals(andthemorbidity/mortalitywashigh);
in those whounderwent a delayed operation no impacted stones were
found and the M & M was minimal. From John Acosta (and the other
stoolstrainers whoduplicatedhis findingsand added moreinformation)
welearned:
•
The vast majority of CBD stones responsible for pancreatitis pass
spontaneously.
•
Mostoftheso-called‘impactedstones’willpassintotheduodenum
ifyouwaitlongenough.
•
Inmostsuch patients pre-operative ERCP isnegativeforbile duct
stones.
•
Inmostsuchpatients(intra-operative)cholangiographyduringLCis
normal.
•
Siftingthroughpatients’fecesmaychange your life and make you
famous!
Thishastaughtushowtomanagethesepatients…
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