Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1527_Библиотеки_им_академика_М_И_Перельмана.pdf
Bilioenteric Anastomoses
27
Cholecystojejunostomy
Many long-term complications will not be observed in different BEA,
because they are performed in patients with malignant disease. Oishi et al. [77]
reported a morbidity of 32% and late complications in 15% of the cases,
including recurrent biliary stones with obstruction and anastomotic stricture;
however, despite the morbidity, 85% of patients had a successful and durable
biliary decompression during an 8 year follow-up. Cholecystojejunostomy is
not the ideal BEA for benign disease, and it should be limited to malignant
obstruction. Thomson et al. [78] described a series of patients in which all
developed cholangitis and concluded that cholelithiasis and cholangitis are
inevitable when this BEA is used for benign obstruction
Rare complications can occur and have been described as intussusception
(cause of recurrent obstructive jaundice), right upper quadrant pain,
cholangitis, or GI bleeding in patient with this BEA. [79] Bleeding varicose
have been reported as late complications of palliative biliary surgery for
chronic pancreatitis. [80, 81] Salam et al. [82] reported varices through the
cholecystojejunostomy in a patient with concomitant obstruction of the
common bile duct and the portal vein.
Cholecystojejunostomy is not recommended for definitive treatment of
benign disease. When a benign biliary obstruction is suspected, other BEA has
to be considered, due to the survival of these patients and the risk of
cholangitis and malignancy. [77, 78, 83] Gallbladder carcinoma is a possible
late complication of cholecystojejunostomy and should be remembered when
dealing with patients that had this BEA. [83] Cholecystojejunostomy has a risk
of malignancy and is another important reason why this procedure is
abandoned in benign obstruction.
Choledochoduodenostomy (CDD)
Choledochoduodenostomy (CDD) is one of the BEA that has been more
thoroughly described. Riedel was the first to describe them more than a
century ago (1892). CDD is a controversial procedure; with a lot of
complications described in the literature. Ascending cholangitis, sump
syndrome and alkaline reflux gastritis are some of the documented
complications. Although it has good long-term results in some studies, it is not
the best procedure for lower common bile duct obstruction. [84] The most
Miguel Ángel Mercado and Julio Alfaro Varela
28
common complications are intra-abdominal abscess (26%), wound infection
(20%), and biliary leakage (13%). [44]
CDD has a morbidity of 23% and a mortality of 3%. [86] CDD risk for
cholangitis is between 0% to 12%, usually associated with stricture of the
anastomosis and remnant or recurrent stones. [86] The width of CDD
anastomoses has been of debate for some time, considered by some authors to
range between 2-2.5 cm. Stricture of the anastomoses and subsequent
development of cholangitis are the most frequently described long-term
complications, and to avoid it several authors recommend a BEA width of at
least 2. 0 cm. Several authors recommend a stoma size greater than 2.5 cm to
prevent cholangitis. [87]
Sphincter of Oddi regulates the flow of bile and pancreatic juice into the
duodenum preventing reflux of duodenal content back into the biliary tract,
function that is lost with CDD. CDD is associated to pneumobilia,
regurgitation of food debris and duodenal content into the biliary tract. [88]
Although CDD are one of the most physiological BEA allowing bile outflow
into the duodenum, most of its complications are associated to the loss of
sphincter of Oddi function.
Side-to-side CDD has great risk of developing “sump syndrome.” Sump
syndrome is defined as the accumulation of biliary and duodenal contents in a
poorly drained distal stump of the biliary tree. [89] Sump syndrome has been
reported in 0 to 9.6% of the cases. [23, 90, 91] The presence of symptoms
following food accumulation within the bile duct is what characterizes the
syndrome. [92] Complications of sump syndrome are cholangitis, pancreatitis,
hepatic abscesses, and secondary biliary cirrhosis. [92] Sump syndrome has a
low incidence and appears to be related to BEA stricture and not a true sump
syndrome. [89] Limiting the definition of sump syndrome to cholangitis and
hepatic abscess may underreport true incidence of this syndrome. [44] (Figure
23).
Treatment of sump syndrome begins with endoscopic sphincterotomy in
order to decompress the common bile duct, with good results. [93-96]
Sometimes endoscopic treatment fails due to previous heavy or multiple
stones, large food debris accumulated through the stoma that cannot be cleared
with endoscopy. [92] Caroli-Bosc et al. [93] described their experience with
patients with sump syndrome managed endoscopically and found out that 60%
had food debris and 33% biliary calculi. Surgical treatment includes Roux-en-
Y hepaticojejunostomy, with resection of the distal portion of the CBD. [92]
Bilioenteric Anastomoses
29
Figure 23. CT scan with multiple pericholangitic abscesses and mild dilation of
intrahepatic bile ducts, suggestive of BEA stricture and ascending cholangitis.
The incidence of duodenogastric reflux (DGR) after CDD, assessed by
endoscopy and histology, ranges from 11.5% to 70%, even though dyspeptic
symptoms attributable to DGR have been reported in only 15% of patients.
The symptoms related to DGR depend not only the presence but also in the
severity of reflux; the presence of an intact pylorus in these patients could
prevent the severity of DGR. [93] Lujan-Mompean et al. evaluated DGR in
patients with cholecystectomy alone and in patients with cholecystectomy plus
CDD. This last group had higher reflux rates than patients who underwent
simple cholecystectomy, attributing it to unregulated bile flow to the
duodenum following bypass of the sphincter of Oddi and altered motility of
the pyloroduodenum due to surgical manipulation of the duodenum. [94] Most
of the patients with CDD are asymptomatic and the degree of DGR does not
necessarily produce symptoms in all patients. [93]
CDD have been associated to malignant. Reflux of food debris and
substances into the biliary tract cause changes in the biliary epithelium that
may lead to malignant transformation. [64] Eleftheriadis et al. [98] evaluated
duct mucosa in patients who had a CDD performed and found that the mucosa
showed hyperplasia, metaplastic goblet cells, and pyloric like gland formation;
changes that are also found in patients with hepatolithiasis and congenital
choledochal cyst, which have been considered as premalignant disease. [99,
100] Tocchi et al. [63] described an incidence of cholangiocarcinoma of 5.5%
which was higher in patients with CDD, compared with hepaticojejunostomy
Miguel Ángel Mercado and Julio Alfaro Varela
30
or transduodenal sphincteroplasty (7.6% vs. 1.9% vs. 4.8%, respectively).
Patients that underwent this type of BEA are recommended to have close
follow-up in the long-term, especially if they had several episodes of
cholangitis.
Choledochojejunostomy (CJ)
Most surgeons prefer a Roux-en-Y CJ in the management of benign
biliary disease. [85] Postoperative morbidity of CJ is of 20% to 33%, with a
mortality of 0% to 2%. [74, 100, 101] CJ are more complicated and takes
longer; requiring circumferential dissection of the common bile duct and a
Roux-en-Y anastomoses. [44] Hepaticojejunostomy is preferred over this
BEA.
Hepaticojejunostomy
Hepaticojejunostomy has a morbidity rate of 19-49% and a mortality of 0-
6% for benign disease [59, 100, 102-103] The most common complications
include wound infection, cholangitis, bile leak, hemorrhage, pancreatitis,
delayed gastric emptying, cardiopulmonary complications, systemic sepsis,
renal failure, abscess formation, fistula formation, and stenosis. Factors
associated to BEA complications are low serum albumin levels and worse
American Association of Anesthesiologists (ASA) physical status. [59]
Excellent results are expected in 90% of the cases when they are performed
under expert hands.
Stricture following HJ occurs in 5% to 17%. [100, 102-104] Factors
associated to stricture formation are vasculobiliary injuries, multiple repair
attempts, biloma, external or internal biliary fistula, anastomosis in non-dilated
duct, injury at or above the level of the biliary bifurcation, preoperative and
postoperative percutaneous biliary drainage, and patient comorbidities. [74,
102] BEA strictures can be treated with endoscopic dilation, percutaneous
dilation or redo surgery. Kucukay et al. [105] described the efficacy of
percutaneous biliary balloon dilation (PBBD) of benign HJ strictures, and
found a morbidity of 5.6%. Recurrent biliary stricture presents in two thirds of
patients within 2–3 years after reconstruction, 80% of patients within 5 years,
and 90% of patients within 7 years. [60, 106-107] Biliary leakage has been
reported in 2.3% of the cases. [108] Initial management of biliary leakage may
Bilioenteric Anastomoses
31
be with endoscopic treatment, interventional radiology and surgery in more
complex cases. (Figure 24).
Figure 24. Image (a) corresponds to a percutaneous cholangiography through a
previously placed external drainage catheter in which a biliary leakage (arrow) from
the BEA was evident. Image (b) shows a percutaneous transhepatic internal-external
catheter placed through the BEA to control the biliary fistula.
Outcome and Follow-Up
Time Interval and Duration of Follow-up
Time interval for follow-up after a bilioenteric anastomoses is of 3 months
during the first year, every 6 months during the second year and yearly
evaluation is recommended after the third year. The total minimum time
interval for follow-up is of 5 years; when most bilioenteric anastomoses tend
to dysfunction. Some author recommend follow-up for 2 to 5 years and other
groups up to 10 to 20 years. [54, 60, 64, 109-110]
It is important to remember
that most patients with malignancy are not expected to reach this minimum
time interval.
Miguel Ángel Mercado and Julio Alfaro Varela
32
Laboratory Tests and Imaging
Several biochemical parameters and imaging techniques are used during
follow-up to evaluate anastomoses patency:
Liver function tests: Liver function test elevation after bilioenteric
anastomoses is no infrequent. AST/ALT are highly sensible
biomarkers of liver damage. Bilirrubin level is closely related to
biliary obstruction. Alkaline phosphatase (AP) increase before there is
clinical evidence of jaundice. In most cases AP levels return to normal
value after bilioenteric anastomoses. AP persists high but with normal
bilirubin levels when there is partial obstruction of a liver segment.
[111] When total bilirubin and direct bilirubin levels rise, complete
obstruction has to be ruled out. Many patients that undergo
bilioenteric anastomoses never return to normal levels of AP and
don’t represent higher risk of cholangitis in the long-term.
Liver Ultrasound (US): It is an imagine technique easily available.
The disadvantage of this method is its limitation to evaluate liver
hilum due to abundant interposition of structures and gas. It is useful
to detect early complications as fluid collections. During follow-up it
may evidence dilated intrahepatic bile ducts as a sign of BEA
dysfunction.
Computer Tomography (CT): It is useful in the diagnosis of early and
late complications during the postoperative period and during follow-
up.
Magnetic Cholangioresonance: Is an excellent non-invasive method to
evaluate patency of the anastomoses and is the first option for
evaluating BEA. It has the disadvantage of not allowing any
therapeutic action in the presence of obstruction. (Figure 25).
Percutaneous cholangiography: It is used when cholangioresonance is
not available. It has the advantage of allowing direct manipulation of
the BEA if it is required with balloon dilation or drainage catheter
need to be placed to control biliary leakage or progressive dilation of
the BEA. (Figure 26)
Bilioenteric Anastomoses
33
Figure 25. Image (a) corresponds to a T2 coronal magnetic cholangioresonance with a
patent BEA. Image (b) corresponds to a 3D cholangioresonance volumetric
reconstruction of a patent BEA with adequate biliary outflow into the jejunal limb in
which the biliary tract has normal diameter.
Figure 26. Percutaneous trans-hepatic cholangiography in which a stenotic BEA and
dilation of the intrahepatic biliary tract is evident.
Imaging studies are not routinely indicated unless suspicion of early or
late complications exists or stricture of the anastomoses needs to be ruled out
during follow-up. Imaging studies are determined according to biochemical
and clinical symptoms. Biochemical parameters are useful and are evaluated in
every check-up.
Miguel Ángel Mercado and Julio Alfaro Varela
34
Classifications
There are several classifications used to evaluate outcome and patency of
bilioenteric anastomoses. These classifications include laboratory findings and
clinical parameters. The most frequently used classifications are the
Terblanche [110] scale (Table 2) and Mc Donald [65] classification. (Table 3).
Table 2. Terblanche Classification
Grade I
Excellent Results
No biliary symptoms with normal liver
function test.
Grade II
Good Results
Transitory symptoms, currently no
symptoms and normal liver function test.
Grade III
Fair Results
Clearly related symptoms requiring
medical therapy and/or deteriorating
liver function tests.
Grade IV
Poor Results
Recurrent stricture requiring correction
or related death.
Table 3. McDonald Classification
Grade A
No clinical symptoms from the biliary tract, normal
laboratory liver function
tests.
Grade B
No clinical signs, laboratory liver function tests slightly
elevated liver or periodical episodes of pain or fever.
Grade C
Pain, cholangitis with the presence of fever, jaundice and
abnormal laboratory tests.
Grade D
Condition requiring surgical or endoscopic correction.
Patients with Grade A and B are considered as having an excellent
outcome. These patients are amenable to follow-up twice a year to determine
their clinical symptoms and laboratory findings. [65] In the case patients
evolve to Grade C, the presence of cholangitis must be assessed, patency of
the anastomosis and liver parenchyma status through US or
cholangioresonance. The need for hospital stay and endoscopic, radiological or
surgical treatment has to be evaluated. Grade C and D are considered as poor
outcome; therefor, closer follow-up is recommended in this group. Follow-up
is mandatory in all patients that undergo bilioenteric anastomoses because
Bilioenteric Anastomoses
35
60% of therapeutic failure occurred in the first 3 years and 80% during the first
5 years. [106, 107]
Three scenarios may occur in patients with Grade III or Grade C:
1) Recurrent episodes of cholangitis, abnormal liver function tests,
normal liver parenchyma and a patent anastomosis. These cases are
treated with antibiotics and ursodesoxycolic acid.
2) Episodes of cholangitis, abnormal liver function tests, especially AP,
dilated intrahepatic bile ducts and stricture of the anastomosis.
Treatment of choice is ERCP and/or interventional radiology and as
last resource redo surgery.
3) Recurrent episodes of cholangitis, pericholangitic abscesses and
stricture of the anastomosis. Treatment may begin with antibiotics,
ERCP and/or interventional radiology, redo surgery with possible
hepatectomy if less invasive strategies fail.
Good long-term results can be achieved in 70-90% of the cases. [112]
The
John Hopkins group reported a series of 142 patients with a success rate of
90.8% at 5 year follow-up [64] Other authors report successful results between
80-90% of the cases at 5 year follow-up. [113] The authors experience with
355 patients reported success in 94% of the cases (most of them secondary to
iatrogenic bile duct injury). An important factor associated to successful
results is the experience of the surgeon and patients that require complex
biliary surgery and reconstruction should be referred to a specialized center.
Two-third of strictures will appear during the first 2 years and 90% during
the first 5 years. [106] The authors recommendation for treatment of recurrent
strictures is to begin with less invasive measures to dilate the anastomoses.
When strictures occur, endoscocopic or transhepatic balloon dilation with stent
placement is effective. Costamagna et al. [114] proposed progressive
endoscopic dilation of the stenosis with placement of multiple stents. Patients
that will benefit with endoscopic treatment are the ones diagnosed soon after
surgery and have better outcome than those who develop strictures after
surgery. [115] Strictures in the proximal segments of the biliary tract are more
difficult to treat and require surgical treatment. [115] Davids et al. [116]
performed a comparative study between surgery and endoscopic treatment,
reporting similar long-term success with recurrence in 17% of patients.
Percutaneos treatment require multiple sessions of balloon dilation and long-
term placement of stents, [117] with morbidity associated to bleeding and bile
leak up to 40%. Twenty percent of patients may eventually require redo
Miguel Ángel Mercado and Julio Alfaro Varela
36
surgery. [118]Pitt et al. [74] compared surgical repair (choledochojejunostomy
vs. Hepaticojejunostomy) with percutaneous balloon dilation, reporting
patency rates of 88% and 55% at 5 years for the surgical reconstruction group
and percutaneous treatment.
Quality of Life
World Health Organization defines health as “a state of complete physical,
mental, and social well-being, and not merely the absence of disease.”[119]
Scarce information is available in the literature about Quality Of Life (QOL)
after BEA. A general idea exists that patients that have a BEA will have a
worst QOL; but no data is available and most information is related to surgical
outcome after biliary tract reconstruction secondary to iatrogenic bile duct
injury. The John Hopkins group presented a study assessing the QOL between
patients who underwent surgical reconstruction of bile duct injuries and
laparoscopic cholecystectomy. Their study evaluated 3 domains (Physical,
psychological and social) and demonstrated lower scores in the psychological
domain in patients with bile duct reconstruction (p<0.05). [120] Boema et al.
[121] study had reduced QOL scores in the physical and mental domains;
independently from the type of treatment (surgery vs. endoscopic) and the
severity of the injury. De Reuver et al. [122] demonstrated a worse QOL in
patients involved in litigations.
References
[1] Beal JM. Historical perspective of gallstone disease. Surg Gynecol
Obstet 1984; 158: 181-189
[2] Hardy KJ. Carl Langenbuch and the Lazarus Hospital: events and
circumstances surrounding the first cholecystectomy. Aust N Z J Surg
1993; 63: 56-64.
[3] van Gulik TM. Langenbuch's cholecystectomy, once a remarkably
controversial operation. Neth J Surg. 1986; 38: 138-141.
[4] Braasch JW. Historical perspectives of biliary tract injuries. Surg Clin
North Am. 1994; 74: 731-740.
[5] Blumgart LH. Hilar and intrahepatic biliary enteric anastomosis. Surg
Clin North Am. 1994; 74: 845-863