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Chapter 10
especially at the ampulla. This requires skills using
the lithoclast for certain circumstances and laser or
electrohydrolic fragmentation for others. Expertise
in this area renders the transduodenal sphincteroplasty approach obsolete.
For those embarking on laparoscopic exploration,
careful consideration of the strategies to be employed, equipment required and adequacy of assistance will go a long way to simplifying a potentially
complex procedure. When laparoscopic transcystic
exploration fails, the surgeon has three options:
• toligatethecysticduct,completethe
cholecystectomy and rely on postoperative ERCP;
• toperformalaparoscopiccholedochotomy;
• toperformalaparotomyandopenexplorationof
the CBD.
If laparoscopic choledochotomy fails, the options
include: insertion of a T-tube and subsequent extraction of the retained stones via the T-tube track after
6 weeks; postoperative ERCP and sphincterotomy;
or conversion to open exploration CBD. Individual
circumstances will dictate which option is the most
suitable, although this should be discussed carefully
with the patient before a management strategy is
implemented.
It has been suggested that preoperative ERCP is
the most cost-effective management of patients at
high risk for CBD stones.
106
There is evidence accumulating, however, that where transcystic clearance is successful this leads to less morbidity and
more rapid recovery.
83,88
The author believes the
most cost-effective approach is laparoscopic cholecystectomy, IOC and transcystic clearance of
CBD stones, reserving ERCP for retained stones.
Learning the techniques to achieve this seems
worthwhile.
In a recent extensive review of the literature, it
was concluded that laparoscopic CBD exploration
is safe and effective for all patients presenting with
gallstones and may be a better way of removing
CBD stones than ERCP.
107,108
Recurrent or retained CBD stones
Recurrent CBD stones occur in up to 10% of
cases. In a retrospective series of 169 patients
followed for up to 19 years, recurrences were
more common in patients with primary duct
stones, large CBD diameter (around 16 mm) and
periampullary diverticula. Lowest recurrence
rates were found in those patients undergoing
choledochoduodenostomy.
Retained CBD stones found at postoperative
T-tube cholangiography are best dealt with by
ERCP. If ERCP is unsuccessful or not available,
73
exploration of the CBD via the T-tube tract is indicated. It usually takes approximately 6 weeks
for the T-tube track to mature, at which time
percutaneous choledochoscopy or radiologically
guided extraction can be performed. A cholangiogram is obtained immediately prior to the procedure as a proportion of stones will have passed
spontaneously.
The T-tube is removed, a guidewire is left in situ,
and either a steerable catheter or choledochoscope
is advanced down the track and into the CBD. With
choledochoscopy, the remainder of the technique is
identical to that carried out at open operation.
109
With the steerable catheter technique, fluoroscopy
and further cholangiograms are taken as the stones
are retrieved with a stone basket.
110
If there is uncertainty as to the completeness of
clearance, a straight tube may be inserted to keep
the track open for a further attempt a few days
later. Both techniques are successful in more than
95% of cases and carry less risk of complications
such as pancreatitis or haemorrhage than ERCP.
Providing there are no time constraints and the patient is happy to be managed as an outpatient with
a T-tube, the technique is effective.
Transcystic exploration of the common bile
duct at the time of cholecystectomy is an effective
means of managing choledocholithiasis with low
morbidity and cost.
ERCP is effective in managing the remaining
patients in whom this is not achievable and is the
accepted means of managing the patient presenting
with acute cholangitis.
Transhepatic stone retrieval
In a few patients, particularly those who have previously undergone a Pólya gastrectomy, the ampulla
will not be readily accessible for ERCP. Access to
the common duct can be achieved using a percutaneous transhepatic technique. Over a percutaneously inserted guidewire, a series of dilators are
advanced into the biliary tree, so as to develop a
transhepatic tract. Following insertion of a sheath,
a choledochoscope or steerable catheter can be inserted and stones retrieved.
111
Acalculous biliary pain
Given the poor understanding of the mechanisms
of pain production in patients with acalculous
biliary disease, the outcome for patients following
cholecystectomy is uncertain. There is gathering
evidence that some patients have abnormal motility
190
Gallstones
Cholelithiasis
Failure
of the sphincter of Oddi, in addition to the gallbladder. Some authors have reported improvement in
symptoms in as many as 85–95% of patients with
acalculous biliary pain after cholecystectomy,
but it is conceivable that surgery confers a placebo
effect. Controversy exists over the use of cholecystokinin (CCK) provocation tests as a means of reproducing symptoms and predicting which patients
might benefit from cholecystectomy. In one study,
all 26 patients with positive CCK tests showed
improvement after removal of the gallbladder,
whereas 10 of the 16 patients with negative tests
were found to have other pathology accounting for
their pain. Despite these encouraging results, other
investigators have failed to demonstrate differences
112
in outcome in patients with positive CCK tests
when compared to those with negative tests.
Objective criteria on which to base the decision to
recommend cholecystectomy in such patients are
difficult to define. It is clear, however, that despite
the minimally invasive nature of laparoscopic cholecystectomy, there should be no relaxation in the
113
indications for cholecystectomy in patients with
acalculous biliary pain.
Key points
• Asymptomatic gallstones do not require surgical intervention.
• The standard treatment for symptomatic gallstones is now laparoscopic, and there are few
exceptions to a trial of a laparoscopic approach in all comers.
• All surgeons undertaking cholecystectomy, by whatever technique, should be capable of
performing operative cholangiography.
• The use of operative cholangiography appears to be associated with a lower incidence of bile duct
injury.
• Experience is accumulating that transcystic clearance of the CBD at the time of cholecystectomy
is effective, with low morbidity and cost. In the one-third of patients where this is not achievable,
ERCP is probably the best means of clearance.
• An algorithm for the management of common bile duct stones is shown in Fig. 10.9. The
management strategy chosen will depend on personal experience, equipment availability, time and
the availability of other departmental expertise. There is no consensus as to the ideal approach.
114
Suspicion of CBD stones
Routine per-op cholangiogram
CBD stones
Open
exploration
CBD
Failure
Figure10.9 • Algorithm showing the available strategies for management of common bile duct stones.
Laparoscopic
cholecystectomy
Post-op
ERCP
Laparoscopic
exploration
CBD
Failure
Selective per-op cholangiogram
Laparascopic cholecystectomy
No stones
Pre-op ERCP
CBD stones
Endoscopic sphincterotomy
and duct clearance
Success
Open
exploration
CBD
Failure
Laparoscopic
exploration
CBD
191
Chapter 10
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Cholecystokinin cholecystography. Four years evaluation. AJR Am J Roentgenol 1970;110:240–51.
113. Lennard TWJ, Farndon JR, Taylor RMR.
Acalculous biliary pain: diagnosis and selection for
cholecystectomy using the cholecystokinin test for
pain reproduction. Br J Surg 1984;71:368–70.
114. Sunderland GT, Carter DC. Clinical application
of the cholecystokinin provocation test. Br J Surg
1988;75:444–9.
195
11
Benign biliary tract diseases
Benjamin N.J. Thomson
O.James Garden
Introduction
Apart from those disorders related to choledocholithiasis, benign diseases of the biliary tree are relatively uncommon (Box 11.1). The most challenging
issues are in patients who present with symptoms
associated with biliary strictures, which arise more
commonly following iatrogenic injury during cholecystectomy. Congenital abnormalities such as choledochal cysts and biliary atresia are usually in the
domain of the paediatric surgeon, although later presentation of cysts may occur after missed diagnosis
or when revisional surgery is required. Most of the
published literature regarding benign non- gallstone
biliary disease is retrospective or at best prospectively gathered, non-randomised data, but clear
guidelines can be followed based upon observation.
Congenital anomalies
Biliary atresia
Biliary atresia occurs in approximately 1 per 10 000
live births but its aetiology remains unclear. There is
experimental evidence for a primary perinatal infection as well as cellular and humoral autoimmunity.
An inflammatory process before birth may result in
failure of the biliary lumen to develop in all or part
of the extrahepatic biliary tree.
Presentation is usually in the early neonatal period with prolongation of neonatal jaundice. Most
patients are treated in specialist neonatal surgical
units; however, occasionally patients may be referred
to adult units for assessment for liver transplantation following previous unsuccessful treatment.
Management in the neonate is by porto-enterostomy
(Kasai's operation), which involves anastomosis
of a Roux limb of jejunum to the tissue of the hilum. Restoration of bile flow has been reported in
86% of infants treated before 8 weeks of age, but
only 36% in older children.1 Four-year survival is
dependent on the timing of surgery. Of 349 North
American children with biliary atresia, 210 (60%)
required later liver transplantation, with a 4-year
transplantation survival of 82%.2 Recent evidence
has suggested better outcomes following maternal
liver-related liver transplantation, potentially due to
tolerance to non-inherited maternal antigens.
3
Choledochal cysts
The earliest description of a choledochal cyst was by
Douglas in 1952,4 who described a 17-year-old girl
with jaundice, fever and a painful mass in the right
hypochondrium. However, presentation is usually
in childhood and around 25% are diagnosed in the
first year, although prenatal diagnosis is now possible with improvements in antenatal ultrasonography. Adult centres treat a small proportion of those
presenting with delayed diagnosis as well as those
with complications from previous cyst surgery.
The incidence of choledochal cysts in Western countries is around 1 in 200 000 live births but it is much
higher in Asia. There is frequent association with
other hepatobiliary disease such as hepatic fibrosis, as
well as an aberrant pancreatico-biliary duct junction.
5
196
Benign biliary tract diseases
Box11.1 • Benign causes of biliary strictures
Strictures of the extrahepatic biliary tree
Iatrogenic biliary injury
Postcholecystectomy
Trauma
Other
Gallstone related
Mirizzi's syndrome
Inflammatory
Recurrent pyogenic cholangitis
Parasitic infestation
Clonorchis sinensis
Opisthorchis viverrini
Echinococcus
Ascaris
Primary sclerosing cholangitis
Benign strictures imitating malignancy
Pancreatitis
Lymphoplasmacytic pancreatitis
Inflammatory pseudotumour
Idiopathic strictures
HIV cholangiopathy
Magnetic resonance cholangiopancreatography
(MRCP) now allows images that are superior to traditional cholangiography (Fig. 11.1), and it should
be recommended due to its non-invasive nature.
6
Classification
The modified Todani classification is employed to describe the various forms of choledochal cyst7 (Fig. 11.2).
Type I, the most common, represents a solitary cyst
characterised by fusiform dilatation of the common bile
duct. Type II comprises a diverticulum of the common
bile duct, whilst type III cysts are choledochocoeles.
Type IV is the second most common, with extension of
cysts into the intrahepatic ducts. Lastly, type V involves
intrahepatic cystic disease with no choledochal cyst,
which merges into the syndrome of Caroli's disease.
Risk of malignancy
In the Western literature, the incidence of cholangiocarcinoma is reported to be approximately
12% (Fig. 11.1),8 compared to Todani et al.'s
Japanese experience of 16% in 1353 patients.9 The
incidence of malignancy is reported to be 2% at
20 years, increasing to 43% for those in their sixties.10 Cyst drainage without cyst excision does not
prevent later malignant change, and there is continuing debate regarding the precise ongoing risk
following cyst resection. Takeshita et al. reported
180 patients who underwent primary surgery for
a choledochal cyst. Synchronous malignancy was
found in 36 patients (20%), with only one of the
remaining 144 patients developing malignancy
during follow-up.
11
Management
Surgical resection is required to prevent recurrent
episodes of sepsis and pain, to prevent the risk of
pancreatitis from passage of debris and calculi,
and because of the association with cholangiocarcinoma. Complete cyst excision with preservation
of the pancreatic duct is required, with hepaticojejunostomy for reconstruction. Some authors
advocate liver resection for type IV cysts with intrahepatic extension for complete removal of the
cyst, although the advantage is debatable. For those
patients with Caroli's disease, resection may be feasible if the biliary involvement is localised to one
part of the liver. For other patients, endoscopic or
radiological techniques may be required to address
biliary sepsis by improving biliary drainage, while
others may need to be considered for hepatic replacement if liver failure develops.
For extrahepatic cysts, cyst-enterostomy, or drainage of the cyst into the duodenum, should no longer
be performed as the cyst epithelium remains unstable
and malignant potential exists. If previous drainage
has been performed, symptoms of cholangitis generally persist and conversion to a Roux-en-Y hepaticojejunostomy is advisable.
a b
Figure11.1 • MRCP (a) and
macroscopic photograph
(b) demonstrating a type I choledochal
cyst with a distal cholangiocarcinoma
in a 42-year-old Caucasian woman
requiring a pancreaticoduodenectomy.
Gallbladder (GB), tumour (T), pancreatic
duct (single arrow) and aberrant
common channel (double arrow) are
shown. Courtesy of Professor Prithi
S. Bhathal, Pathology Department,
University of Melbourne, Australia.
197
Chapter 11
I II
III IVa
IVb V (Caroli's
Figure11.2 • Modified Todani classification for choledochal cysts.7 Reproduced from Todani T, Watanabe Y, Narusue
M et al. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer
arising from choledochal cyst. Am J Surg 1977; 134:263–9. With permission from Elsevier.
Special operative techniques
During operative exposure, intraoperative ultrasound is very useful to identify the biliary confluence, the intrahepatic extension of the cyst, and the
relationship to the right hepatic artery above and to
the pancreatic duct below (Fig. 11.3). Small aberrant
hepatic ducts may enter the cyst below the biliary
confluence and these are missed frequently on pre-
operative imaging.12 Such aberrant ducts are usually
identified once the cyst has been opened. The cyst is
disease)
198
Benign biliary tract diseases
common with the reduction in ulcer surgery and
increasing specialisation in pancreatico-biliary surgery. Rarely, the injury may be related to abdominal
trauma, injection of scolicidal agents in the management of hydatid cyst, ablation of hepatic tumours or
radiotherapy.
The true incidence of biliary injury following laparoscopic cholecystectomy remains obscure. It has
been suggested that there was a slight increase in
the incidence of injuries following initial introduction of the laparoscopic technique,13 with a reported
incidence of 0.3–0.7%.
said to have a lower incidence of biliary injury, with
a rate of 0.13%.17 Recent variations in technique
such as single-incision laparoscopic surgery (SILS)
cholecystectomy are not immune to biliary injury.
Han et al. recently reported two (1.5%) bile duct injuries in 150 patients having single-port laparoscopic
18
surgery.
14–16
Open cholecystectomy is
Figure11.3 • Operative ultrasound scan of a type I
choledochal cyst. The junction of the undilated proximal
biliary tree with the cyst (long dotted line) is demonstrated.
The right hepatic artery is posterior (two arrows), as is the
right branch of the portal vein (short dotted line).
normally best excised in its entirety and this is facilitated by opening it along its anterior length. This
aids identification of the vessels from which the cyst
is freed. Early identification of the biliary confluence aids the surgeon in planning the incorporation
of any segmental duct into the eventual hepaticojejunal Roux-en-Y anastomosis. Dissection into the
head of the pancreas is made easier by use of bipolar
scissors and the CUSA™ (ultrasonic surgical aspiration system, ValleyLab, Boulder, CO) if the plane of
dissection is obscured by fibrosis or inflammation.
It may be necessary to leave a small oversewn lower
common bile duct stump to avoid compromise to
the pancreatic duct lumen; however, recurrent pancreatitis and possible malignant transformation remain possible complications.
There is an accepted association between
choledochal cyst and cholangiocarcinoma. The cyst
should be excised and the biliary tree reconstructed
by means of a hepatico-jejunostomy Roux-en-Y.
Iatrogenic biliary injury
The commonest cause of an injury to the extrahepatic biliary tree is as a result of an iatrogenic injury at the time of cholecystectomy. Although it is
recognised that injury may also occur during other
gastric or pancreatic procedures, this is much less
Aetiology
Previous reports of injury during laparoscopic cholecystectomy suggested that injury was more likely
to occur when performed for pancreatitis, cholangitis or acute cholecystitis.19 However, in a prospective analysis of patients referred following biliary
injury, 71% occurred in patients in whom the indication for cholecystectomy was biliary colic alone,20
and thus surgeons should always be vigilant regardless of the indication.
In the majority of patients the problem is misinterpretation of the biliary anatomy, with the common bile duct being confused with the cystic duct.
Associated injury to the right hepatic artery often
occurs as it is mistaken for the cystic artery. Partial
injury may occur to the common bile duct after a
diathermy burn or due to rigorous traction on the
cystic duct, leading to its avulsion from the bile duct.
Techniques to avoid injury
Many techniques have been described to decrease
the risk of injury to the common bile duct during cholecystectomy. The main risk factors are
thought to be inexperience, aberrant anatomy and
inflammation.
laparoscopic bile duct injuries, the authors suggested that the primary cause of error was a visual
perceptual illusion in 97% of cases, whilst faults in
technical skill were thought to have been present in
only 3% of injuries.
Correct identification of the biliary anatomy is
essential in avoiding injury to the extrahepatic bile
duct. Dissection of Hartmann's pouch should start
at the junction of the gallbladder and cystic duct
and continue lateral to the cystic lymph node, thus
19,21
However, in an analysis of 252
22
199