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_1841_Библиотеки_им_академика_М_И_Перельмана.pdf
GALLSTONES
223
must also focus on the bile duct. An ultrasound examination of these patients
will show either a dilated or non-dilated bile duct. The subsequent management
is shown in Fig. 4.13 .
With a normal bile duct, simple cholecystectomy is performed but with a
dilated bile duct it is important to address this prior to cholecystectomy. MRCP
is invaluable in these patients and will demonstrate other pathologies if stones
are absent (ampullary stenosis, strictures, compressed duct in the pancreatic
head secondary to pancreatitis) (Becker et al ., 1997 ; Vaishali et al ., 2004 ).
With transient abnormalities these are uncommon and only a small percent-
age of patients will be demonstrated to have stones. In this group with a stone
or stones demonstrated preoperatively on MRCP, ERCP is almost always suc-
cessful in removing these stones and clearing the duct and allowing a routine
cholecystectomy to be safely performed (Schumacher et al ., 1998 ).
Known bile duct stones ( Fig. 4.14 )
Patients with confirmed abnormalities in the CBD represent a heterogenous
group. At one extreme is the young female who presents as an emergency
with recent onset of jaundice and signs of sepsis. At the other end of the spec-
trum is the elderly patient who presents with pain or not infrequently minimal
symptoms in whom abnormal liver function tests were incidentally discovered
while they were being investigated for different symptoms. These patients may
have a very dilated bile duct full of stones and the management has to be
specifically planned.
Fig. 4.13 The management of patients with gallstones and abnormal liver function
tests.
Ultrasound
Normal CBD
MRCP
ERCP
laparoscopic/open
exploration CBD
on table ERCP
Cholecystectomy
and OTC
Cholecystectomy +
on table
cholangiogram (OTC)
Dilated CBD
Normal
Stone
GALLBLADDER
224
Before proceeding with treatment in these patients, as much detail as possi-
ble must be obtained. A poor quality ultrasound may need to be repeated and
serial liver function tests may show a trend. An MRCP is invaluable if this has
not already been done and at this stage options for treatment that can be con-
sidered include ERCP, laparoscopic surgery, combinations of endoscopic and
surgical approaches and open surgery with exploration of the bile ducts. The
age of the patient is important when deciding upon the best approach and we
try to avoid sphincterotomy in patients less than 30 years old (Bergman et al .,
1996 ; Hakamada et al ., 1997 ; Tanaka et al ., 1998 ; Cade et al ., 2008 ).
Our present strategy is shown in Fig. 4.14 and summarized here:
◆
Patients over 75 years of age with multiple duct stones and ducts greater
than 15mm are treated endoscopically with stents changed every 6 months.
Only 10–25% of these patients will ever have problems with gallbladder
stones (Davidson et al ., 1988 ; Hill et al ., 1991 ; Kaw et al ., 2002 )
◆
Patients over 75 years of age with ducts less than 15mm and small numbers
of stones have ERCP and duct clearance. Only if problems continue will it
be necessary to proceed to cholecystectomy (Hill et al ., 1991 )
◆
Younger patients with bile duct stones should have an ERCP and duct
clearance followed 6 weeks later by a cholecystectomy. If unable to clear the
ducts at ERCP an on-table ERCP or bile duct exploration will be necessary
◆
Young patients (less than 30 years old) should be considered for cholecys-
tectomy with laparoscopic exploration of the bile duct and an open explo-
ration of the bile duct if this is unsuccessful or not feasible (Bergman et al .,
1996 ; Hakamada et al ., 1997 ; Tanaka et al ., 1998 ).
Occasionally MRCP will reveal unexpected findings related to the
gallstones:
◆
Mirizzi’s syndrome (see ‘Mirizzi’s syndrome’, Fig. 4.25 ) (Mirizzi, 1948 ;
Becker et al ., 1997 ). If elderly, these patients should be managed by endo-
scopic stenting, while young patients require open surgery
◆
Bile duct stricture: this is usually infl ammatory secondary to stone disease.
ERCP with removal of the stones and stenting is the initial treatment of
choice followed by cholecystectomy and subsequent monitoring to ensure
resolution. These patients may require further defi nitive surgery
◆
Compressed CBD in the head of the pancreas: ERCP and stent with removal
of any bile duct stones. Cholecystectomy is performed as soon as possible
and ERCP is repeated after 3 months to reassess the intrapancreatic portion
of the bile duct. At that stage it is usually possible to remove the stent but if
this is not possible due to persistence of the obstructing segment then the
GALLSTONES
225
stent is changed and the following treatment is the same as that for a bile
duct stricture (see Fig. 5.2)
◆
Malignancy: if suspected (and may be seen with stones above) investigate
and treat as described in Section 5
◆
Ampullary stenosis: ERCP and sphincterotomy with removal of any bile
duct stones followed by a cholecystectomy 6 weeks later.
Surgical exploration of the bile duct is becoming less common, but whether
laparoscopic or open is still very valuable. It is definitive and allows removal of
the gallbladder, if still present, and clearance of the duct to be performed at the
same time. In experienced hands it is associated with a very low morbidity. It
is, however, important to be familiar with all the necessary approaches before
deciding on the most appropriate procedure.
Clinicians who attempt laparoscopic explorations must be familiar with the
use of the choledochoscope and also be prepared if necessary to proceed to
open exploration. Frequently in very young patients with CBD stones the
cystic duct is large and an exploration can be performed through it with extrac-
tion of the stones and endoloop closure. The ability to perform synchronous
ERCP in theatre is rather labour intensive and requires an experienced laparo-
scopic surgeon and endoscopist but is very valuable (particularly for units with
considerable ERCP expertise), and offers another approach using techniques
with which they are familiar. It also allows sphincterotomy to be performed if
any doubt remains at the end of the procedure about residual sludge or debris
within the duct.
Laparoscopic bile duct exploration ( Fig. 4.15 – 4.18 )
Once cholangiography during a laparoscopic cholecystectomy has identified
a stone in the bile duct the surgeon has a number of decisions to make (see
Fig. 4.14 ).
Can exploration be safely achieved by laparoscopic techniques or should an
ERCP be performed in the postoperative period? If ERCP with stone extrac-
tion fails, then the patient will need to return to the operating theatre.
If small stones are seen in a non-dilated duct then simple measures such as
flushing the duct and administering IV glucagon should be attempted. The
availability of bile duct exploration kits has greatly simplified the decision to
explore the duct. Most, include Dormia baskets, Fogarty balloon catheters of
sufficient length, and cystic duct introducing systems with dilating balloons
(Verbesey and Birkett, 2008 ). These can be used to manage stones in the CBD
but it is rarely possible to dislodge stones if they are within the common
hepatic duct. If the duct can be cleared, and this is confirmed with completion
GALLBLADDER
226
Fig. 4.14 Stones in the bile duct at laparoscopic cholecystectomy.
Small stones
(3–4mm)
non-dilated duct
Flushing
Successful
Unsuccessful
Large cystic
duct (CD)
Small cystic duct
Large stone
Cystic duct
larger than
stone/s
Laparoscopic
exploration with
Dormia basket
ERCP on table
laparoscopic
exploration
Laproscopic
exploration of
CBD
On table ERCP
if available
Dormia basket
retrieval via CD
Cholecystectomy
Cystic duct
smaller than
stone/s
Open exploration
T-tube
Consider Roux
loop
Very dilated
CBD or elderly
Multiple large
stones, large
duct
Diluted duct
Single small
stone
OTC Reveals
CBD Stones
GALLSTONES
227
Fig. 4.15 Laparoscopic
bile duct exploration via
the cystic duct following
intraoperative cholangiog-
raphy using a small incision
made transversely in the
cystic duct.
Fig. 4.16 A cholangiogram
catheter is introduced and
a fluoroscopic image of
the biliary tract obtained.
GALLBLADDER
228
cholangiography, then an endoloop is used to close the cystic duct and the
operation finished. If stones remain, then an ERCP will need to be organized
postoperatively. If a dilated cystic duct and hepatic duct are present a choledo-
choscope can be used to visualize and retrieve stones ( Figs. 4.17 and 4.18 ).
Fig. 4.17 A choledocho-
scope can be passed
through a dilated cystic
duct giving images of
the dilated common bile
duct.
Fig. 4.18 A Dormia basket
can be passed down the
cystic duct to extract
common bile duct calculi
and a completion cholan-
giogram taken to confirm
clearance.
GALLSTONES
229
If this fails to clear the CBD, or stones are lodged above the cystic duct con-
fluence, then a choledochotomy and laparoscopic exploration is warranted if
the surgeon is appropriately skilled. If all stones can be removed then closure
of the choledochotomy over a T-tube with a drain alongside the bile duct is
safe and associated with a generally uneventful postoperative recovery (Rhodes
et al . 1998 ; Verbesey and Birkett, 2008 ). However, if the duct cannot be cleared
then an open exploration will be required.
Open bile duct exploration ( Figs. 4.19 – 4.24 )
Open exploration of the bile duct is becoming a rare procedure principally
due to advances in interventional endoscopy. Patients with a preoperative
suspicion of bile duct pathology (abnormal liver function tests, dilated CBD
on ultrasound, pancreatitis, or MRCP demonstrated stones) are almost exclu-
sively treated by ERCP. The exception is patients under 30 years of age, with
proven stones where sphincterotomy is not desirable, but even in this group
the vast majority can be managed by laparoscopic duct exploration. There
remains (and is always likely to remain) a small group where other pathology
is suspected, such as strictures not felt to be inflammatory, a failed endoscopic
Fig. 4.19 Longitudinal bile
duct incision.
GALLBLADDER
230
Fig. 4.20 Bile duct
exploration with a Dormia
basket.
Fig. 4.21 Bile duct explora-
tion with Fogarty balloon.
GALLSTONES
231
removal of very large or numerous stones, or problems incidentally discovery
at operative cholangiography which mean that exploration is going to be
required. Unless there are contraindications to laparoscopic exploration
this should be the preferred approach, especially for small numbers of small
stones (less than 5mm) in young patients (Rhodes et al ., 1998 ). Despite
this, open exploration which is well tolerated with a low morbidity is now
probably underused. In addition it tends to be a definitive procedure with few
postoperative problems.
Fig. 4.22 A T-tube is cut to size (a). A small ‘V’ is made at the apex of the T-tube to
aid removal from the bile duct at 2 weeks (b and c). In small bile ducts removal is
further aided by guttering the T-tube (d).
(a) (b)
(c) (d)
GALLBLADDER
232
We employ a small transverse incision as for cholecystectomy and this rarely
needs to be enlarged. Packing is also as for cholecystectomy and the gallblad-
der, if still present, is initially removed. A supraduodenal approach is always
employed and we rely heavily on choledochoscopy to check the duct and
retrieve difficult stones. Unless a recent MRCP is available, we will always per-
form an initial on-table cholangiogram (OTC) (mentioned previously)
through the cystic duct (as described for removal of the gallbladder). This gives
a baseline and will generally indicate how many stones are present and their
position. It is particularly useful in the demonstration of stones high in the
biliary tract which can be difficult to remove with the choledochoscope and
may become impacted by pressure or with instrumentation.
After the OTC, the anterior surface of the bile duct is identified and cleared
for 3–4cm and after identifying the artery to the bile duct, which should be
avoided, the duct is then opened longitudinally with a small scalpel blade.
The choledochotomy ( Fig. 4.19 ) should be just large enough to admit the
choledochoscope (stay sutures are only necessary in smaller ducts to avoid
damage to the back wall). No instrumentation is employed until the choledo-
choscopy has confirmed the OTC findings. We prefer to extract the stones
Fig. 4.23 The T-tube is
placed through the
choledochotomy and
the bile duct closed with
interrupted 4/0 PDS
sutures.