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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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2 Biliary System
Functional biliary disorders
47
Diagnosis Sphincter of Oddi dysfunction
Functional gallbladder disorder
Numerous pharmacologic agents have been used to treat sphincter of Oddi dysfunction➔no one
agent has demonstrated enough consistent benet
Case Management
Patient with stenosis of ampulla or
elevated basal pressure
Management
Patient with sphincter of Oddi dysfunction
who failed endoscopic management
Patient with sphincter of Oddi dysfunction
who cannot undergo endoscopic
management for anatomic reasons
(Billroth II or Roux-en-Y)
Patient with restenosis of the sphincter of
Oddi after endoscopic sphincterotomy
Patient with biliary pain but no objective
indicator of pathology
➔usually diagnosed years after cholecystectomy
➔sphincter of Oddi manometry (gold
standard)➔elevated sphincter of Oddi basal
pressure (≥40mmHg)
Cholescintigraphy➔assessment of gallbladder
ejection fraction (normal EF is 35–80%)
Endoscopic sphincterotomy
Transduodenal sphincteroplasty
Transduodenal sphincteroplasty
Transduodenal sphincteroplasty
Invasive procedures (such as endoscopic
sphincterotomy) are not recommended
Patient with biliary pain and functional
gallbladder disorder (EF<35, EF>80)
Cholecystectomy
Cholecystostomy Tube Placement
Cholecystostomy tube placement
Indications Patients with acute cholecystitis with very high operative risk
Patients who are critically ill and develop acalculous cholecystitis
Approach
Indications
Transhepatic
cholecystostomy
Most favored approach➔due
to decreased risk of bile leak,
catheter dislodgement, and a
decreased time to catheter track
maturation
Transperitoneal
cholecystostomy
Used in severely coagulopathic patients
to decrease the risk of liver bleeding
associated with the transhepatic
approach and in patients with liver
disease to avoid the liver
Open/
laparoscopic
cholecystostomy
When a percutaneous
approach cannot be
done
48
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Approach
Transhepatic
cholecystostomy
Transperitoneal
cholecystostomy
A. H. Sohail et al.
Open/
laparoscopic
cholecystostomy
Transhepatic
Liver
US probe
Abdominal
wall
Visceral peritoneum
Gallbladder
Key steps Percutaneous placement of
cholecystostomy tube (8F or
US probe
Abdominal
wall
Percutaneous placement of
cholecystostomy tube (8F or 10F)
10F)
Transperitoneal
Transhepatic
Image guided
Image guided
Management of patients with cholecystostomy tube
Transhepatic
Liver
Gallbladder
Visceral peritoneum
A 20F or 24F
catheter may be used
for an open/
laparoscopic
cholecystostomy tube
placement
Purse-string suture is
typically placed in
the fundus of the
gallbladder to secure
the cholecystostomy
tube
Type Management Future cholecystectomy
Acalculous
cholecystitis
Calculous
cholecystitis
Tube to remain in place until tract matures
(3–8weeks)
• Prior to removal, a contrast study must be obtained
to ensure patency of the cystic duct and tract
maturation
➔No need for future cholecystectomy
➔Cholecystectomy in 6–12weeks after
cholecystostomy tube placement
Complications of cholecystostomy tube and their management
Complication Management
Catheter displacement or migration Cholangiography using cholecystostomy tube
Tube blockage Prevent it by ushing daily
Progression to gangrene or perforation Urgent cholecystectomy
No improvement in patient condition
after 24hours of placing
cholecystostomy tube
Check for perforation, gangrene
Check tube position
2 Biliary System
Cholecystectomy withor Without Cholangiography
Cholangiogram
Type Characteristics Radiology
49
Normal
cholangiogram
Obstructing
calculi
Contrast injected into cystic duct➔outlines
CBD➔ows into duodenum
Contrast should ow antegrade into duodenum and
retrograde into both left and right ducts. Filling
defects indicate stones. Care should be taken to
ensure a clear view of the biliary tree with rotation of
the C-arm to an oblique axis if needed
No intra or extrahepatic ductal dilation
Fluoroscopic intraoperative cholangiogram
image demonstrates a patent common bile
duct (arrow) with ow of contrast into the
duodenum (D)
Obstruction of CBD by meniscoid lling defect
above sphincter
Dilation of intrahepatic bile ducts➔suggests distal
obstruction
Cholecystectomy
Elective indications for
cholecystectomy in
asymptomatic patients
Fluoroscopic cholangiogram image with
digital subtraction demonstrates a complete
obstruction (arrow) of the distal CBD with
reux of contrast into the intrahepatic
ducts (arrowhead)
Patients with hemolytic anemias, such as sickle cell anemia
Patients with a calcied gallbladder wall (higher cancer risk)
Patients with large (>2.5cm) gallstones (higher cancer risk)
Patients with a long common channel of bile and pancreatic ducts
Some transplant surgeons recommend prophylactic cholecystectomy before receipt of
an organ transplant
50
Fundus of
gall
Right hepatic
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Cholecystectomy
A. H. Sohail et al.
Elective cholecystectomy Antibiotics not required in low-risk patients
Preoperative preparation
Key steps
Critical view of safety
Antibiotics➔only in high-risk patients
Non-elective
Antibiotics to cover gram-negative and anaerobes
cholecystectomy (for
cholecystitis)
Retract the fundus cephalad
Retract the infundibulum laterally
Begin dissection at the infundibulum
Dissect the bottom third of the gallbladder from the hepatic bed➔to expose the base
of the gallbladder
Establish the critical view of safety
Clip and divide the cystic duct and artery
Remove the gallbladder from the cystic plate
• Complete clearing of the hepatocystic triangle of all fat and brous tissue
• Separation of the lower third of the gallbladder from the cystic plate
• Identication of 2 and only 2 structures (cystic duct and cystic artery) entering the
gallbladder
Critical view of safety should be conrmed before clipping and dividing the cystic
artery and duct
If the critical view of safety cannot be attained➔“bail out” procedures
bladder
Hartmann’s
pouch
artery
Cystic duct
Common bile duct
Lymph node
of Calot
2 Biliary System
Cholecystectomy
Prevention of CBD
injury
Strategies for prevention of CBD injury
Use of an angled scope Use of an angled scope helps prevent CBD injury because
visual misperception accounts for 97% of bile duct injuries
Appropriate traction on
the gallbladder
➔Poorly executed retraction of the gallbladder can lead to
parallel alignment of the cystic and common bile ducts.
Retraction should be dynamic and active to allow optimal
visualization and minimize 2D/3D errors
The fundus is retracted toward the right shoulder➔to
expose the infundibulum
The Hartmann pouch should be retracted laterally➔the
cystic duct no longer lies almost parallel to the common
hepatic duct
51
Intraoperative
cholangiogram
Identication of the
critical view of safety
Early recognition of injury➔improves patients’ long-term outcomes
Data on the effectiveness of IOC in preventing bile duct
injury are mixed, but IOC helps early recognition of injury
➔gold standard to prevent CBD injury
Excessive use of thermal cautery medial to the gallbladder
and inferior to Rouviere’s sulcus should be avoided
Research
Reference Findings
Mattila A, Mrena J, Kellokumpu I.Cost-analysis and
effectiveness of one-stage laparoscopic versus two-stage
endolaparoscopic management of
cholecystocholedocholithiasis: a retrospective cohort study.
BMC Surg. 2017;17(1):79
Single-stage laparoscopic CBD exploration and
cholecystectomy is superior to ERCP and
subsequent laparoscopic cholecystectomy in
terms of length of stay and cost. Morbidity and
mortality appear to be similar
Complications of cholecystectomy and their management
Complications Characteristics Management
Bile duct injury 0.26% to 0.6% of cases See iatrogenic bile injury section
Retained biliary
stones
Bleeding
Intraductal: Can be identied up to 2years
following cholecystectomy
Extraductal (dropped stones): Usually
asymptomatic, potential for delayed
infection, abscess
Incidence 0.1–1.9%
Bleeding usually occurs from the cystic plate
during removal of the gallbladder➔middle
hepatic vein traverse the cystic plate and is
vulnerable
ERCP with sphincterotomy
Antibiotics±percutaneous drainage,
laparoscopic drainage, open drainage
Intraoperative bleeding➔laparoscopic
hemostatic control if it fails➔immediate
conversion to open to control profuse
hemorrhage
Postoperative bleeding➔expedited return to
OR for laparoscopy control of bleeding,
convert to open as necessary
52
Fenestrating
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Bail out procedures when critical view of safety cannot be obtained
Procedure Key steps Complications
A. H. Sohail et al.
Subtotal
cholecystectomy:
Fenestrating
Subtotal
cholecystectomy:
Reconstituting
Involves leaving an open part of the gallbladder
behind±a closed cystic duct
Cystic duct is closed from the inside with a
purse-string suture
Involves leaving a closed part of the gallbladder
behind
Leaving a closed remnant (stapled or sutured)
Higher rate of short term
complications: Postoperative bile
leak, longer hospital stay
May need a second procedure to
control bile leak (ERCP and stent)
Higher rate of long-term risks
choledocholithiasis, gallstone
pancreatitis, recurrent cholecystitis,
and cholangitis
Reconstituted stump becomes a
functional gallbladder
Reconstituting
Laparoscopic fundus:
First cholecystectomy
Laparoscopic tube
cholecystostomy
Dissecting in retrograde manner “top down,” from
the fundus➔infundibulum
Gallbladder hangs from 2 tubular structures
Damage control procedure Must exclude gangrenous
Risk of vasculobiliary injuries by
entering into the wrong dissection
plane due to visual misperception
cholecystitis
Avoidance of injuries to the hepatic
exure
2 Biliary System
Research
53
Reference Findings
Strasberg SM, Brunt LM.The critical
view of safety: Why it is not the only
method of ductal identication within
the standard of care in laparoscopic
cholecystectomy. Ann Surg.
2017;265(3):464–5
van Dijk AH, Donkervoort SC, Lameris
W, etal. Short- and long-term outcomes
after a reconstituting and fenestrating
subtotal cholecystectomy. J Am Coll
Surg. 2017;225(3):371–9
Michael Brunt L, Deziel DJ, Telem DA,
etal. Safe cholecystectomy multi- society
practice guideline and state-of-the-art
consensus conference on prevention of
bile duct injury during cholecystectomy.
Surgical Endoscopy. 2020;34(7):2827–55
Bile Duct Injury-Iatrogenic
Bile duct injury
The critical view of safety conrmed to be the safest technique to
recognize the elements of the Calot triangle and, if correctly
performed, it signicantly impacted on preventing intraoperative
complications
Fenestrating subtotal cholecystectomy had signicantly more bile
leakage, but had lower recurrence rate of biliary events
• Systematic literature search and a panel comprising 25 international
experts, with the aim to prevent bile duct injury during laparoscopic
cholecystectomy
• Consensus on 17 out of 18 key questions with evidence-based
recommendations
• Strong recommendations for (1) use of intraoperative imaging if
uncertain anatomy or suspected biliary injury and (2) referral to
experienced surgeon/team for patients with conrmed or suspected
bile duct injury hepatobiliary team
Incidence The incidence of iatrogenic bile duct injury ranges from 0.2% to 1.5%
Presentation
Obstruction➔jaundice, fever, and elevations in both serum bilirubin and alkaline phosphatase
Symptoms may be related to biliary obstruction, bile leak, or compounded by
cholangitis➔elevation of bilirubin and alkaline phosphatase
Transection/laceration➔bile accumulates in the subhepatic space and forms either a biloma or
biliary ascites➔RUQ pain, fever, peritonitis, abdominal distension, elevations in bilirubin (due
to elevation of bile duct absorption), and leukocytosis
54
E1
E3 E4 E5
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Bile duct injury
A. H. Sohail et al.
Diagnostic work up usually begins with laboratory investigations; ultrasound may provide
additional information. This is followed by CT or MRCP imaging. Finally, ERCP for diagnostic
conrmation with possible intervention (stent ± sphincterotomy) is then performed
Diagnosis
Strasberg
classication of
injuries
Diagnostic modality Characteristics
Ultrasound Initial imaging modality for patient presenting with
symptoms after cholecystectomy
Evaluates for a collection and evaluates the biliary
tree
CT scan of abdomen Allows for assessment of biliary injuries and
concomitant vascular injuries➔help in planning
repair
MRCP Allows clear visualization of hepatobiliary anatomy
and delineation of injury
Hepatobiliary iminodiacetic acid (HIDA)
scan
Conrms presence of obstruction or leak➔if
positive then➔MRCP to ERCP to localize leak
ERCP Assess the biliary anatomy
If injury identied➔can be used to treat pathology
(stenting)
A
BC
D
(>2cm)
E2 (<2cm)
Strasberg classication
A Cystic duct leak or leak from a small duct in the
liver bed
B Occlusion of an aberrant right hepatic duct
C Leak from an aberrant right hepatic duct
D Lateral injury to CBD (<50% of circumference)
E1 CHD stricture, with >2cm of healthy CHD
E2 CHD stricture with <2cm of healthy CHD
E3 Hilar stricture with preserved biliary conuence
E4 Hilar stricture with involvement of conuence
E5 Stricture to an aberrant RHD and to CHD
2 Biliary System
Bile duct injury
55
Immediate resuscitation, initiation of broad-spectrum antibiotics, and sepsis control
Case Management
Management
Patient who presents with worsening right
upper quadrant pain 2days after
laparoscopic cholecystectomy
Intraoperative biliary injury is suspected
(unexpected bile leak or a second bile duct
identied when dissecting the critical view
of safety)
Resuscitation and broad-spectrum antibiotics
➔right upper quadrant ultrasound or CT scan of
abdomen to look for uid collection
MRCP or HIDA scan to dene injury
Drainage of intra-abdominal biloma
ERCP➔to dene the injury and attempt to bridge
it with a stent
Distal injuries➔can be stented or drained
endoscopically
If unable to visualize the proximal tree with
ERCP➔PTC is required for decompression
Proximal injuries➔may benet from placement of
percutaneous stents if not amenable to ERCP
Delayed secondary repair after 6–8weeks
➔start with intraoperative cholangiogram to
delineate anatomy
➔repair by the operative surgeon is generally not
recommended
➔drainage and referral to HPB center
Case scenario Management
Injury to a single duct <3mm Ligation
Injury <50% not caused by thermal energy
(electrocautery)
Injury causing defect <1cm and away from
the bifurcation
Injury or transection >50% circumference
or injury caused by thermal energy
(electrocautery) with inability to perform
primary anastomosis
Injury to distal bile duct >50%
circumference
Surgeon not experienced in repair of CBD Insert drains to control bile leak
Patient with leak from the cystic duct ERCP+stenting
Primary repair over a T tube
End-to-end repair over a T tube
Hepaticojejunostomy
Choledochoduodenostomy
Transfer to HBP center
56
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Research
A. H. Sohail et al.
Reference Findings
Dominguez-Rosado I, Sanford DE, Liu J, Hawkins
WG, Mercado MA.Timing of surgical repair after
bile duct injury impacts postoperative complications
but not anastomotic patency. Ann Surg.
2016;264(3):544–53
Slim K, Martin G.Does routine intra-operative
cholangiography reduce the risk of biliary injury
during laparoscopic cholecystectomy? An evidencebased approach. J Visc Surg. 2013;150(5):321–4
Gallbladder Cancer
Gallbladder cancer
Gallbladder carcinoma is the most common malignancy of the biliary tract
Characteristics
Incidence is higher in females, obesity and patients older than 40years
Cholelithiasis, solitary gallbladder polyp >1cm, porcelain gallbladder, primary sclerosing
Risk factors
cholangitis, anomalous pancreaticobiliary junction, larger gallstones (>2cm increases risk
2.5-fold, >3cm increases risk tenfold), segmental mucosal calcication
Incidental gallbladder cancer found after laparoscopic cholecystectomy➔most common
presentation
Adequate sepsis control and delayed repair of biliary
injuries should be considered for patients presenting
between 8days and 6weeks after injury to prevent
complications if a previous bile duct repair was attempted
This review of literature concluded that routine IOC could
prevent major biliary injuries (one ductal injury per 500
cholecystectomies)
Presentation
Diagnosis
Most often asymptomatic
May present with pain, anorexia, nausea, or vomiting
May also present with obstructive jaundice—When extends into CHD/CBD
Can spread into liver or into peritoneal cavity
Ultrasound ndings suspicious for cancer➔liver protocol CT scan or MRI/MRCP
Cancer antigen (CA) 19-9 and carcinoembryonic antigen (CEA) levels may be elevated in
advanced disease➔not useful for screening
CT of the chest and pelvis➔for staging
Staging laparoscopy is recommended before laparotomy for patients with T2/T3➔high yield
for detection of occult metastatic disease
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