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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1841_Библиотеки_им_академика_М_И_Перельмана.pdf
LONG-TERM MANAGEMENT OF BENIGN STRICTURES
263
In patients with acute pancreatitis and biliary obstruction, ERCP with clear-
ance of the duct should be performed and it is generally safer to leave a short
stent (to just above the intrapancreatic portion of the bile duct). This is par-
ticularly so with attacks that are recurrent or are failing to settle (Neoptolemos
et al ., 1988b ; Fan et al ., 1993 ). The majority of these patients will then improve
clinically and the compression of the duct in its intrapancreatic course will
resolve and the stent can be removed.
Biliary dyskinesia
Biliary dyskinesia is a term that is generally used to cover a number of disease
entities including gallbladder and bile duct dyskinesia, sphincter of Oddi dys-
function, and sphincter of Oddi dyskinesia (Canfield et al ., 1998 ). Patients
with biliary dyskinesia are a difficult group to manage and achieving a good
long-term result is difficult. There is a suggestion that some of these patients
will improve with laparoscopic cholecystectomy (Patel ND et al ., 2004 ) and
while this has not been our experience, there are many patients with gallstones
who had their gallbladder removed with symptomatic improvement. In some
of them the pain may have been due to their dyskinesia. In the patients who
have had a previous cholecystectomy, there are some who will be significantly
improved by a formal endoscopic sphincterotomy but this will not improve or
may even worsen symptoms in a small group. Manometry is popular in some
centres but it is rare in our experience to be able to proceed straight to an irre-
versible sphincterotomy with confidence on the basis of these results and we
would still insert a stent initially. We place a short (5cm) 7-French stent across
the ampulla and only proceed to a formal sphincterotomy if symptoms improve
signifi cantly . Many of these patients are improved and generally no further
treatment is needed (Geenen et al ., 1989 ).
If stenting is not helpful further procedures are rarely successful, and non-
surgical options should be pursued.
Long-term management of benign strictures
Benign strictures that occur in the biliary tree are a serious challenge and often
coexist with stones that cannot be removed endoscopically (Soomers et al .,
1990 ). Cholangitis is common and if not effectively managed can have a fatal
outcome (Gigot et al ., 1989 ; Angus and Wax, 2001 ). The use of liver function
tests to monitor increasing reduction in liver drainage is useful and a rising
alkaline phosphatase after a period of stability indicates the need for interven-
tion. Initially radiological or endoscopic approaches are always preferred espe-
cially in the older or less fit patients and, not infrequently, are all that is required
BILIARY TRACT
264
(although stents may need to be changed in the long term) (Foutch et al ., 1989 ;
Soomers et al ., 1990 ). Antibiotic prophylaxis is vital for any procedures
attempting to instrument the area, particularly if the instrumentation reaches
above the stricture.
If the narrowing is at an anastomosis, surgical revision is the preferred option
and because of the frequency of recurrent problems, surgical access limbs can
prove invaluable. Patients may not be fit for a formal surgical procedure and
endoscopic access is impossible due to the previous surgery (e.g. a very long
Roux loop) and under these circumstances the only option may be a percuta-
neous antegrade stent. The main problem with the use of expanding metal
stents in the patient with benign disease (even if very unfit) is their limited pat-
ency. They are also impossible to remove (apart from some very recent designs
where the stent is a spiral) and this produces significant problems when they
begin to block. Second stents can be inserted inside the original stent but this
clearly cannot be done repeatedly. Every attempt must be made to manage
these patients conservatively before this is considered.
Patients with benign strictures may require long-term low-dose antibiotics to
protect them from sepsis (Muller et al ., 1987 ; Mazuski et al ., 2002 ; Metcalf et al .,
2004 ). Usually tetracyclines are used as, although only bacteriostatic, they are
excreted in the bile and achieve very high concentrations. If more potent anti-
biotics are required, ‘cycling’ is useful in retarding the development of antibi-
otic resistance. Generally we use Ciproxin® (ciprofloxacin), Augmentin®
(amoxycillin/clavulinic acid), and Septrin® (trimethoprin/sulfamethoxazole)
for 2 weeks each and then repeat the 6-week cycle.
Trauma
Iatrogenic
Gallbladder surgery
Gallbladder surgery may lead to minor or major duct damage (Blumgart et al .,
1984 ; Chapman WC et al ., 1995 ; Stewart and Way, 1995 ; Savader et al ., 1997 ).
The most frequently quoted definition for a major injury is one associated with
the removal of a segment involving more than 50% of the circumference of
the wall of the bile duct (in addition there may of course be unrecognized
diathermy damage) (Blumgart et al ., 1984 ). Small tears and lesser injuries
can either be directly closed or a T-tube placed and the duct repaired over it
( Fig. 5.7 ).
As a rule, if the duct can not easily be closed over the T-tube then the trauma
should be considered major. Such an injury may be worsened with the addi-
tion of diathermy injury. The temptation with bile duct injuries identified at
TRAUMA
265
the time of surgery is to underestimate the damage and attempt a ‘quick fix’.
This is rarely successful and can worsen the problem. Once an injury has been
detected it is necessary to perform a cholangiogram and call for experienced
assistance (Fig. 5.8). The cholangiogram will define the anatomy and the site of
injury (not always the CBD) and enable reflection on the potential options for
repair. A right sectoral duct injury may be ligated and no repair attempted.
A total transection of the right hepatic duct will require a Roux-en-Y loop
anastomosis. Major CBD injuries also require a bilioenteric anastomosis (see
Section 1). If appropriate imaging or assistance is not possible, cannulation of
the lumens and drainage should be instituted and transfer arranged.
Late presentation
Late indicators of a bile duct injury include a persistent bile leak or biliary
peritonitis, or the onset of jaundice (Brooks et al ., 1993 ; Strasberg et al ., 1995 ).
When the injury is identified, ideally it is best managed by an experienced col-
league rather than the original surgeon. This helps provide an objective view of
what has occurred and provides a fresh approach to the problem. Good preop-
erative imaging and assistance is vital for effective management. MRCP, CT,
and ERCP may all be useful in defining the clinical situation while the patient’s
condition is optimized, electrolytes and sepsis managed, and surgery planned
as soon as practical. In the case of a minor injury, ERCP and stenting may be
all that is required (with or without laparoscopic washout of the abdomen)
(Binmoeller et al ., 1991 ; Davids et al ., 1992a ). If open surgery is required for
major injury then usually a bilioenteric anastomosis to either the CBD or the
Fig. 5.7 For a small defect in the wall of the bile duct T-tube insertion is satisfactory.
BILIARY TRACT
266
right and left hepatic ducts will be required. These patients are at risk of devel-
oping an anastomotic stricture as a late complication, and will require close
follow-up with ultrasound and liver function tests for 10 years. For this reason,
we routinely place an access limb to aid in managing any subsequent biliary
anastomotic strictures (see ‘Access limbs’, Figs. 5.12 and 5.13 ).
Avoidance of injury
Much has been written about the aetiological factors associated with bile duct
injury. Routine cholangiography is not protective and a selective approach is
reasonable once confidence and experience has been gained (Kelly and
Blumgart, 1985 ; Talamini, 2003 ). Biliary anatomy may be misinterpreted and
complacency should be guarded against. Extensive inflammation or fibrosis
(especially when, despite adequate assistance, doubt exists about the anatomy),
should be considered an indication for early conversion to open surgery with
cholangiography.
Endoscopic trauma
Endoscopic sphincterotomy
All endoscopic procedures, and particularly ERCP, will cause either perfora-
tion or bleeding from time to time (Freeman et al ., 1996 ; Masci et al ., 2001 ;
Vandervoort et al . 2002 ). Small perforations can be managed conservatively
with nasogastric suction, IV antibiotics, and fluids. Indeed such injury proba-
bly occurs far more frequently than is appreciated and resolves spontaneously
without any action being taken. Bleeding after ERCP is more challenging and
when it does not settle with conservative measures and repeat ERCP and local
treatment, it is possible either laparoscopically or at open surgery to place a
Fogarty balloon down a T-tube or through the cystic duct and inflate the bal-
loon in the duodenum. When gentle traction is applied the pressure from the
balloon will tamponade the bleeding ( Fig. 5.9 and 5.10 ).
The bleeding site can then be reassessed endoscopically 12 hours later. If the
bleeding has settled the balloon is removed (Bardaxoglue et al ., 1994 ). If this
fails, open surgery with a duodenotomy and direct suture of the sphincter in a
fashion similar to that used for the management of periampullary tumours can
be used (see Section 2).
Balloon dilatation
Perforation of the duct by balloon dilatation, if recognized at the time, can be
endoscopically stented (Foutch and Sivak, 1985 ). Late presentations may be
suitable for stenting but are more likely to require at least a laparoscopy to clear
out the peritoneal contamination (Johnson et al ., 1991 ; Davids et al ., 1992b ).
TRAUMA
267
Fig. 5.8 The management of a bile duct injury.
Bile duct injury
Surgery not
recent
MRCP
ERCP and
stent
Roux loop
reconstruction
Unfit
Fit
Peritonitis
Laparoscopy
washout and
drain
Conservative
treatment
MRCP
ERCP
ERCP
Surgery
Stricture
Transection
High grade
Low grade
Bile leak
Well
In the
postoperative
period
Obstructive
jaundice
Settles
No further
treatment
No further
treatment
No treatment
Exploration
Settles
Continues
Continued
problems
Settles
Doesn’t settle
BILIARY TRACT
268
It may also need a bile duct repair depending on the magnitude and position
of the injury.
Impacted baskets ( Fig. 5.11 )
This is uncommon and the incidence is decreasing due to recent design devel-
opments and baskets are now usually intended to fracture at the tip if sufficient
force is applied, thus allowing the basket to be removed (Matsushita et al .,
2004 ).
Nevertheless, it remains a rare and awkward complication of the use of either
the retrieval or the crushing basket. If the skills are available, an initial laparo-
scopic attempt may be made, planning to proceed to open removal if neces-
sary. Laparoscopic access to the bile duct is often more straightforward than
anticipated due to the fact that the bile duct is always very dilated. There will
be some periductal inflammation but it is important to isolate a reasonable
segment of the duct so that a large enough choledochotomy can be created to
remove the two halves of the basket. After ensuring the basket lies underneath
the proposed choledochotomy site (it is usually obvious due to the shape but
ultrasound and even on-table ERCP are occasionally required), the duct is
opened for about 2cm and the basket visualized. The wire of the basket can be
cut with endoscopic scissors but it is important to do this as near to the distal
end of the basket as possible. This makes the removal of the more difficult
Fig. 5.9 Fogarty balloon
passed down a T-tube into
the duodenum, inflated,
and gentle traction
applied to stop the
bleeding.
TRAUMA
269
Fig. 5.10 Indications and complications of ERCP.
Obstructive
jaundice
Dilated ducts
ERCP
Overall mortality from
all complications is
approximately 0.1%
Non-dilated ducts
After biliary tract surgery
• Fistulae
• Post cholecystectomy
syndrome
• Recurrent jaundice
Pancreatic disease
• Large duct pancreatitis
• Pancreatic fistulae
Communicating pseudocyst
Complications
• Pancreatitis - <5%
• Necrotizing pancreatitis - 0.1%
• Cholangitis - 5%
• Perforation - 1%
• Pancreatitis - 7%
• Cholangitis -10%
Successful study
Failed study
Outcome
• CBD for malignancy 85%
• Pancreatic duct 65%
• Failed cannulation 5–10%
Successful stenting
Successful stone removal - 85–90%
BILIARY TRACT
270
distal fragment easier (it is like an open umbrella in a chimney). The proximal
fragment is simply removed by pulling on the wire. Wires which are posteri-
orly placed in the duct may be hidden by the stone. Careful manipulation of
the stone will eventually make extraction possible but this requires considera-
ble patience. Obstructing stones are often delivered during extraction of the
basket. If not it must be dealt with and then, after irrigation, the duct is closed
around a T-tube.
If laparoscopic removal is unsuccessful or not feasible, an open procedure
will be necessary. The simplest method is a duodenotomy and direct traction
on the basket. Failure will require a choledochotomy and the basket wires are
either cut or retrieved through the duct. If this ensues after a laparoscopic
exploration, there will already be a choledochotomy.
Penetrating or blunt injury
The subdivision into major and minor biliary injuries applies as for iatrogenic
injuries and the operative approach is identical. Other structures may also be
involved and it is important to exclude damage to the portal vein, duodenum,
pancreas, or any major artery.
Cholangitis
Following ERCP
This is uncommon following successful ERCP and will usually settle with anti-
biotics and systemic support. Failed ERCP when contrast is introduced into an
Fig. 5.11 Endoscopic
basket has grasped the
stone, which cannot be
removed and the basket
will not release.
CHOLANGITIS
271
obstructive system which is not then drained by removal of the stone or inser-
tion of a stent, is more dangerous and in these patients urgent decompression
is required. A percutaneous biliary drain should be inserted as soon as possible
and this has the added advantage of providing access to the biliary tract for
subsequent treatment, often by a combined radiological and endoscopic
approach. Surgery has no role in the management of these patients apart from
very rare cases where it is decided to proceed with definitive treatment of
another pathology (cholecystectomy for stones usually) and the bile duct is
approached surgically at the same time.
Bile duct stones
Once infected bile and stones coexist, ERCP or surgery should be promptly
organized as this scenario can rapidly lead to a dramatic clinical deterioration.
Postsurgical cholangitis
Antibiotic and supportive measures will usually lead to a prompt response in
the early postoperative period. If later postoperative cholangitis occurs, the
possibility of stricture or stones needs to be considered.
Postsurgical stricture
This typically occurs at either the site of a bilioenteric anastomosis or follow-
ing a cholecystectomy with unrecognized damage to, or infection around,
the CBD.
Bilioenteric anastomoses
Hepatobiliary imino-diacetic acid scan (HIDA) or cholescintigraphy can be
useful in showing delayed biliary excretion and can also sometimes indicate
the likely site of hold up. The anastomosis itself, however, can only be accessed
by PTC, using an access limb or at open surgery. Dilatation and stent place-
ment is possible percutaneously and may be successful. Refashioning the
anastomosis is difficult and should be considered only when other approaches
have failed. An access limb can provide relatively easy entry on a recurrent
basis but for it to be useful it should be easy to locate with ultrasound.
Combined radiological approaches will then be able to access the stricture and
dilate it repeatedly on a long-term basis.
Access limbs ( Figs. 5.12 and 5.13 )
Access limbs are useful when there is a high likelihood of recurrent postopera-
tive problems in the medium and long term and allow for an initial radiologi-
cal approach. This circumstance arises usually with benign conditions and
malignancies with a good outlook associated with a bilioenteric anastomosis.
BILIARY TRACT
272
There is a recognized stricture rate in these patients which is often difficult to
predict. Repair of an iatrogenic bile duct injury following cholecystectomy in a
young patient (where the duct may only be a few millimetres in size) has a
higher chance of stricture formation than a hepaticojejunostomy for stone
disease in an older patient where the duct may be 2cm in diameter. Sometimes,
however, lengthy strictures occur postoperatively and the presumed cause is a
diathermy injury. In these patients, recurrent problems are common and often
Fig. 5.12 Creation of an
access limb. The afferent
loop is left long, sutured
to the underside of the
abdominal wall, and
marked with metal clips.
Fig. 5.13 A modification of the traditional access loop to aid radiological access.
The proximal end of the loop is marked with two silicone covered metal loops at
right angles to each other.