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
233
with a biliary Fogarty catheter or a Dormia basket ( Figs. 4.20 and 4.21 ) if pos-
sible and the only problems are usually related to impacted stones at the lower
end ( Fig. 4.21 ).
If all stones can be cleared, the number and position is consistent with OTC,
and a good view is obtained of the lower end and sphincter, then no further
procedure is necessary.
If a stone is impacted then it may be impossible to pass the balloon or deploy
the Dormia basket and it will be necessary to extract the stone with forceps.
The choledochotomy is extended to 10mm and Desjardin’s forceps used. These
tend to come in sets of four with one which is slightly curved, one less than
90 degrees, one of 90 degrees, and one significantly more than 90 degrees. The
slightly curved pair or the one with the 90-degree angle are usually most suit-
able. It is important to check that the forceps pivot centrally otherwise when it
is opened to grasp the stone the choledochotomy will be inadvertently torn. If
the stone can be grasped, it is removed, examined to ensure it is complete (and
no fragments have been potentially left in the duct), and then the duct
Fig. 4.24 At the end of the procedure the T-tube is brought out through the
abdominal wall, a tube drain is placed along side the bile duct, and the wound
is closed.
GALLBLADDER
234
rechecked with a choledochoscope. Completion cholangiography is difficult to
interpret and we now use this only very rarely. If the stone cannot be extracted
easily, then the duodenum is Kocherized and frequently this improves the
position and allows extraction with Desjardin’s forceps of the more curved
variety. In the rare event that a stone still cannot be removed, rather than per-
severe and produce a false passage or bile duct injury, a small duodenotomy
should be created to allow a combined approach. Even if this is straightfor-
ward, we prefer to also perform a small sphincteroplasty to prevent problems
secondary to the inflammation and fibrosis which are inevitably going to occur
following removal of the stone (see Section 5).
After the duct has been cleared and checked with the choledochoscope then
a small 10- or 12-French T-tube is inserted ( Fig. 4.22a–c ) after cutting a small
‘V’ from opposite the junction of the long limb with the T section and suturing
it in place (after checking it is patent by flushing, as manufacturing defects
have produced tubes without a lumen) by closing the bile duct with inter-
rupted 4/0 PDS sutures ( Fig. 4.23 ).
If exploration has to be performed in a small duct then we would gutter the
tube (cut along the length of the T-piece opposite to the long arm of the tube),
which further aids its removal ( Fig. 4.22d ). After a washout a small tube drain
is inserted into the subhepatic space and the T-tube brought out through the
abdominal anteriorly. The course of the T-tube should be as straight as pos-
sible to facilitate its later use if necessary but must not be too short. The simple
way to check this is to lift the anterior abdominal wall as far forwards as pos-
sible (mimicking the worst possible postoperative scenario with an ileus which
produces a similar level of distension) and ensure that this would not pull the
T-tube out of the bile duct). The intra-abdominal portion of the T-tube should
be straight when the abdominal wall is maximally distended (held forwards or
retracted by the assistant) otherwise it may be extracted by abdominal wall
traction, secondary to any postoperative problem. The T-tube is then secured
with a stitch and cut (about 20cm) outside the abdominal wall to reduce the
risk of inadvertent kinking ( Fig. 4.24 ). The T-tube must always be flushed at
the end of the procedure to ensure that it has not been kinked or compressed
as it passes through the abdominal wall or at the site of the drain stitch.
Postoperatively fluid and diet is restricted for only 24 hours. The tube drain
is removed if no bile is present at 48 hours and the patient allowed home the
following day. We used to perform T-tube cholangiography at 10 days but now
do this at 14 days or later to prevent premature removal of the T-tube. If the
cholangiogram is normal (non-dilated duct, no filling defects, and free flow
into the duodenum) then the T-tube can be removed and this can be done at
any time from 2–3 weeks. T-tubes ought not be clamped for any reason.
GALLSTONES
235
This practice dates back to a period with more reactive tubes with a rapidly
formed robust tract. The tract remained intact even when the tube was clamped
and as the pressure increased and the bile duct was acutely distended, the
obstruction would produce pain (Ellis, 1985 ). The modern tubes produce a
tract that disrupts more easily and could leak without any immediate symp-
toms if the tube was clamped. If the cholangiogram shows no flow into the
duodenum, it is repeated 2 weeks later and problems at this stage are rare as
oedema and inflammation have generally settled. If stones are identified at
cholangiography at any stage they can be removed at ERCP which is usually
straightforward. If any difficulty is encountered then a wire can be passed
down through the T-tube into the duodenum in a similar fashion to that
employed during a combined percutaneous transhepatic cholangiography
(PTC)/ERCP procedure.
Combined laparoscopic cholecystectomy and ERCP
We consider this valuable when ERCP has been unsuccessful in selectively
cannulating the CBD for technical reasons. In this situation when there is a
strong suspicion of bile duct stones, or they have been demonstrated by other
modalities, then the choice is between laparoscopic exploration of the duct,
laparoscopic cholecystectomy with on-table ERCP, and open exploration.
When there is particular expertise in one area then this should be chosen and
familiarity with ERCP often remains more common than laparoscopic explo-
ration of the bile duct. When considering open surgery we do take into account
the patient’s build. With a high body mass index, results for minimally inva-
sive procedures really are much better and they should always be considered
initially.
The procedure of laparoscopic cholecystectomy and ERCP is similar to that
for laparoscopic cholecystectomy with OTC. When the cystic duct has been
identified (it may be quite large in these cases) a clip is placed on the gallblad-
der side and the cystic duct opened transversely with scissors 5–6mm below.
A catheter is introduced without removing the obturator and a metal clip is
placed across the duct lightly to hold the catheter in place and allow an image
to be taken. The obturator is then removed and screening started while slowly
injecting contrast medium. After ensuring that there are no leaks (extravasation
of contrast around the junction of the cystic duct and CBD makes subsequent
images difficult to interpret), further contrast is injected to outline the biliary
tract. Some tilting of the operating table may be required for this but the whole
of the bile duct must be seen sufficiently clearly to identify stones (and other
pathology), confirm the anatomy, and demonstrate unimpeded flow into the
duodenum. When the number of stones and their position is identified, we
GALLBLADDER
236
will then decide whether to proceed with a laparoscopic exploration or ERCP.
If the cystic duct is large enough to admit the choledochoscope and the stones
are 5mm or less in diameter and sited in the CBD, then we will always initially
attempt a laparoscopic exploration. The choledochoscope is introduced
through the cystic duct and stones retrieved singly with a Dormia basket. If this
is successful, then the cystic duct is closed with an endoloop and the gallblad-
der removed. The disadvantages of this procedure are the lack of a sphinc-
terotomy for any retained debris or small stones. ‘Success’ of the procedure has
to be based on the preoperative MRCP and OTC findings, the demonstration
of the calculi that are consistent with these, and a satisfactory choledochos-
copy which demonstrates a clear ductal system. Completion cholangiograms
cannot be relied upon as they can be difficult to interpret at the end of the
procedure due to the presence of air bubbles and, occasionally after a diffi-
cult exploration, sufficient oedema to inhibit the flow of contrast into the
duodenum.
When there is a large number of stones or the stones are greater than 5mm
in size, laparoscopic exploration is less likely to be successful and this situation
requires either a formal open bile duct exploration with a T-tube left in situ or
performing a synchronous ERCP. This is simplified by having a cholangi-
ogram catheter in place as this allows a long guide wire to be passed down the
catheter in the bile duct until it enters the duodenum. At this stage the proce-
dure is very similar to a combined PTC/ERCP. The ERCP scope is inserted
and, using as little air as possible, the guide wire in the duodenum is grasped
with a snare and drawn through the scope. This overcomes the previous prob-
lem of inability to cannulate the CBD and facilitates a sphincterotomy over
the wire and balloon or basket extraction of the stones by the endoscopist. In
addition, at the completion of the procedure, the ER cholangiogram pictures
are generally of sufficient quality to be confident that there are no retained
stones or debris. Finally, if any doubt remains about the duct, a small stent
can be left in situ and the situation reassessed 6 weeks later.
Mirizzi’s syndrome
Mirizzi originally described his ‘functional hepatic syndrome’ in 1948 (Mirizzi,
1932 , 1937 , 1948 ) and he felt that the symptoms were due to spasm of the
hepatic sphincter secondary to inflammation in the area of the junction of the
cystic duct and common hepatic duct. Subsequent histological studies failed to
identify any sphincter at this point. The syndrome is now attributed to a large
stone in the cystic duct or Hartmann’s pouch which presses (± inflammatory
change) on the bile duct or erodes out of the gallbladder to involve the bile
duct ( Fig. 4.25 ).
GALLSTONES
237
The presentation can be sub-classified but is not helpful clinically (Csendes
et al ., 1989 ).
These patients should either be managed by endoscopic stenting if elderly
or by open surgery if younger. Occasionally it is possible to remove the gall-
bladder with stones impacted in the cystic duct and the bile duct will be
intact. In these cases the obstruction was mechanical due to extrinsic pres-
sure and there should be no long-term sequelae. In some cases it is also pos-
sible to remove the gallbladder and leave only a small defect in the bile duct
wall which can be treated by insertion of a T-tube (Rossi and Tsao, 1994 ;
Zaliekas and Munsen, 2008 ). A minority, however, will be found to have a
very abnormal junction of cystic duct and bile duct and the only option is to
remove the gallbladder and reconstruct the bile duct with a Roux loop as
described in Section 1. This can be technically difficult and particularly the
crucial identification and preservation of the hepatic artery which is fre-
quently involved in the inflammatory process. The bile duct, however, is
always dilated and the bilioenteric anastomosis as a consequence, usually
straightforward.
Postcholecystectomy problems ( Fig. 4.26 )
Postcholecystectomy problems can be divided into immediate, such as persistent
fistulae and problems with unrecognized retained stones, and late, particularly
pain and occasionally infective sequelae from unretrieved stones (Lublin et al .,
2004 ; Editorial, 1974 ; Lum et al ., 2006 ).
Fig. 4.25 Mirizzi’s
syndrome showing a
gallstone eroding through
the gallbladder wall into
the bile duct.
GALLBLADDER
238
Immediate problems
Recovery after a laparoscopic cholecystectomy is usually uneventful and any
unexpected symptoms or signs immediately after surgery generally indicate a
complication. These include pain which is difficult to control, bile from the
drain, and evidence of bleeding. Clinical features occurring after a few days
include peritonitis, jaundice, and evidence of localized collections with fever,
distension, and a raised white cell count.
Pain Pain can result from localized leaks (which may produce no overt drain-
age but cause localized peritonism) and bruising around port sites (which can
be concealed for several days and mimic intra-abdominal problems). Even
where drains are used (and some surgeons do not insert them regularly) these
are not completely reliable and if pain persists we will organize an ultrasound
scan. This often shows nothing more than a small localized collection in the
gallbladder fossa which is to be expected and under these circumstances we
do no more. Occasionally a large fluid collection is detected and percutaneous
drainage is required. The drainage is frequently sufficient to resolve the
problem and also reveals to the clinician the nature of the fluid. If this is bile,
then there is the potential risk of the leak continuing and patient care must be
further considered.
Bile leaks from drains Bile leakage from drains or found by aspiration is gen-
erally small in amount and self-limiting. These are presumed to arise from the
liver and the gallbladder fossa or a small radicle which was not seen when dis-
secting the gallbladder from the liver with diathermy (Kum et al ., 1996 ;
Adamsen et al ., 1997 ). If the bile is not seen in the drain but found at aspiration
of a large collection, the concern is that this will continue and we ask the radi-
ologist to insert a percutaneous drain at the time of drainage. When patients
remain well and the drainage is clearly controlling the leak, we do no more, as
the majority of these will settle spontaneously. If patients are unwell despite
the drainage, then we have a low threshold for re-laparoscopy together with
a thorough washout and the use of tube drains. The source of the bile leak is
frequently from the gallbladder bed, uncommonly from the peritoneal reflec-
tion in the area of the fundus and rarely from the cystic duct stump, usually
when locking clips have not been used.
When patients remain well and the leakage continues for more than a few
days, we will investigate them with a repeat ultrasound and MRCP to see if there
is any evidence of bile duct dilatation or a CBD stone. This may have been pre-
viously unrecognized or actually passed into the CBD at the time of the chole-
cystectomy. We generally then perform ERCP (removing any stones that may
be present) and stenting to reduce the pressure in the bile duct and allow the
GALLSTONES
239
Fig. 4.26 Management of postcholecystectomy problems.
Damage to
hepatic artery
Bile leak
Cholecystectomy
Initial
management
conservative
Obstructive
jaundice
Bleeding
Re-laparoscopy
and control
MRCP
Stone
Continues
Infected
Settles
Resolves
No further
treatment
CT
Percutaneous
drainage
Open exploration
± resection
Removed stent
after 6 weeks
Exploration
No treatment
Continued
problems
Resolved
Continues
Exploration and
repair CBD
Laparoscopic
washout and
drain
ERCP and
biliary stent
ERCP and
extraction
latrogenic
Incidental malignancy
(see cholangiocarcinoma
Section 5)
Conservative
management
Ischaemic/
necrotic liver
Stricture
Continued
abdominal pain
Investigate
• Upper GI endoscopy
CT pancreas
• Faecal elastase
GALLBLADDER
240
leakage to stop. Even if the drainage stops rapidly we leave the stent in situ for
5–6 weeks. It is exceptionally uncommon after stenting in the presence of an
otherwise normal bile duct that any further treatment is necessary.
Evidence of bleeding Laparoscopic cholecystectomy is a very safe procedure
and the excellent view afforded means that operative bleeding tends to be mag-
nified and obvious and consequently difficult to overlook. Nevertheless, in the
postoperative setting, reactionary or true secondary haemorrhage is always
possible as with any surgical procedure. As bleeding which is catastrophic is
rare, patients tend to be diagnosed either because of local or generalized pain
with an ultrasound showing fluid which is not bile, or a significant anaemia
which implies a more serious bleed than that seen with a haematoma in the
gallbladder bed or abdomen wall. Secondary haemorrhage will be heralded by
the sudden onset of pain after the patient had initially settled postoperatively
and is usually very obvious clinically. Most of these patients can be managed
conservatively and laparoscopy in this situation while revealing blood often
does not define the source. Bleeding requiring open surgery is rare.
Delayed postoperative problems
Patients developing symptoms after a few days, including those referred for a
specialist opinion, are a more difficult group to manage. Although the major-
ity of referred patients have a persistent bile leak or obstructive jaundice, the
problem by this stage can be confused by complications secondary to local or
generalized sepsis and, in extreme cases, multiorgan failure.
Jaundice Fortunately bile duct injuries remain uncommon after gallbladder sur-
gery. In the cases we see, about half occur after laparoscopic procedure and
about half after open procedures. It should be remembered, however, that the
vast majority of cholecystectomies are now done laparoscopically, many of the
injuries at open procedures were after conversion of difficult cases, and it is
always difficult to know at what stage an injury occurred. Consequently it is
difficult to be dogmatic about the relative risks of different approaches and the
exact mechanism of the injuries.
When jaundice develops postoperatively, the operating surgeon always nat-
urally fears that the problem must be a bile duct injury and although this does
occur it is more commonly due to a small bile leak secondary to retained
stones, and occasionally due to cholestatic jaundice from the anaesthetic agent
or antibiotics. Fortunately the cause can be rapidly clarified by the use of ultra-
sound and MRCP. Stones are treated by endoscopic extraction and drugs
inducing jaundice are withheld or not prescribed again (cholestatic jaundice
can take 6–12 weeks to settle after withdrawing the responsible drug). Bile duct
injuries, depending on their nature, are managed as discussed in Section 5.
GALLSTONES
241
Abdominal sepsis Patients who develop signs of intra-abdominal sepsis who are
treated conservatively and do not settle may become very unwell. It is usually clear
that the source of the problem is intra-abdominal but generally less clear as to the
exact aetiology and it is important in these patients to exclude pancreatitis.
CT scanning is extremely useful and may reveal, in addition to any postop-
erative pancreatitis, unexplained free fluid or evidence of infection with free
air. This is occasionally due to inadvertent bowel injuries during laparoscopic
procedures and these patients will all need a formal laparotomy. At laparotomy
one may find very large volumes of infected bile. Leaks postoperatively cause
surprisingly few problems unless the collection becomes infected. A clue to
non-infected bile is the presence of a previously unrecorded elevation of
bilirubin with the other liver function tests being normal. We have seen
patients with several litres of non-infected bile who, apart from abdominal
distension, are clinically well and some argue that it is one of the principal
reasons for the routine use of a drain at cholecystectomy. When large volumes
of bile are found, the cause is usually leakage from the cystic duct or, less com-
monly, a large radicle in the gallbladder bed. These patients almost never have
unrecognized bile or hepatic duct injuries as in those patients presentation
tends to be much earlier.
Late presentations and postcholecystectomy syndrome
Problems which occur many months or years after cholecystectomy are those
associated with any surgical procedure, such as adhesions and wound pain,
and those specifically related to the cholecystectomy procedures; these include
bile duct strictures, chronic infection due to unrecovered stones, and postch-
olecystectomy syndrome (Lublin et al ., 2004 ).
Strictures Late strictures do occur and must be differentiated from primary
duct stone formation, particularly in elderly patients. This may happen several
years after the procedure but generally at less than a year (Bismuth, 1982a ; Pitt
et al ., 1982 ; Chapman WC et al ., 1995 ; Lillemoe et al ., 1997 ). The symptoms
are a low grade (often intermittent) fever, mildly abnormal liver function tests
(which fluctuate with a worsening trend), and finally jaundice and its associated
pruritus. When investigated, these patients can either have relatively short
benign-looking stricture or a long tight stricture, often mistaken for a malignant
process. We believe that the former probably arises from a combination of
clips placed too close to the bile duct (often seen on MRCP) and a small amount
of leakage which may have become infected and caused some additional fibrosis.
Some authors recommend balloon dilatation for these but we have not found
this helpful. If the patient is sufficiently fit, we recommend a biliary reconstruc-
tion with a Roux loop. If they are elderly, or not fit for a major surgical procedure,
GALLBLADDER
242
then endoscopic stenting is chosen. Prevarication with these patients intro-
duces the risk of biliary cirrhosis and attributing symptoms to cholangitis or
sludge and the use of long-term treatment with antibiotics are inappropriate.
We believe the majority of long strictures, which may be several centimetres
in length and end just below the hilum, are diathermy injuries produced by
conduction. These are more difficult to manage and even when successfully
treated by Roux-en-Y reconstruction often re-present with further strictures.
The subsequent strictures usually involve the main hepatic duct and some-
times the proximal left and right hepatic ducts and repair of these can be com-
plex, often requiring extensive procedures with liver resections, and are assisted
by constructing an access limb (see Section 5).
Pain Right-sided pain out of proportion to that which would be expected from
adhesions or the wounds are occasionally due to spilled stones. At the advent of
laparoscopic cholecystectomy, this was not uncommon as it was believed that
spilled stones rarely caused problems. In 50% of patients with gallstones the
bile is infected and while many stones probably do not cause problems, in the
case of an unusual presentation this should always considered.
Postcholecystectomy syndrome Pain after cholecystectomy has been
described in up to 10% of patients. In half of these, the cause is unrelated to the
gallstones (peptic ulceration, reflux oesophagitis, irritable bowel syndrome)
and occasionally no cause can be found (Luman et al . 1996 ; Weinert et al .,
2000 ; Lublin et al ., 2004 ). The patients are generally adamant that the proce-
dure did not alter their pain. Frequently they describe it as worsened.
Investigation of these patients should be aimed at excluding biliary tract and
pancreatic pathology. Some bile duct dilatation normally occurs after cholecys-
tectomy even without mechanical bile duct pathology. CT scanning and MRI
will largely exclude more sinister pathologies and we always estimate
faecal elastase as some patients will have chronic pancreatitis. In these patients,
MRCP frequently shows that the duct is narrowed and smoothly tapered for
several centimetres in its intrapancreatic course and this is very suggestive
of pancreatitis. When this is not the case and no stones are detected, then a
diagnosis of biliary dyskinesia must be entertained. As described in Section 5,
these patients frequently have a slightly dilated bile duct and can be improved
by ERCP and a small stent across the ampulla. Only if this is not effective would
we recommend a formal sphincterotomy as many of these patients are young.
Acalculous disease of the gallbladder
Gallbladders without stones may cause problems and acalculous cholecystitis
is felt to be responsible for problems in up to 5–15% of patients presenting