Surgical Management of Benign
and Malignant conditions of Biliary
Tree
Houssam G. Osman, M.D.
HPB surgery
Associate Director, HPB Fellowship
Methodist Dallas Medical Center, Dallas
ACOS: In-Depth Review - 2014
Kansas city, MO
CHOLECYSTITIS
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Acute cholecystitis
Achalculous cholecystitis
Gangrenous cholecystitis
Emphysematous cholecystitis
Imaging: US
Treatment options:
 Antibiotics
 Cholecystectomy
 Percutaneous cholecystotomy tube
CHOLEDOCHOLITHIASIS
• Secondary 85%
• Primary 15%
- benign biliary strictures
- sclerosing cholangitis
- choledochal cysts.
- parasitic infections
CHOLEDOCHOLITHIASIS
Conditions
• Painful jaundice
• Cholangitis
• Gallstone pancreatitis
• Silent CBD stone
CHOLEDOCHOLITHIASIS
• Probability of CBD stone
American Society of Gastrointestinal Endoscopy Standards of Practice Committee Maple JT, et al.: The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 71 (1):1-9 2010
CHOLEDOCOLITHIASIS
Imaging
Ultrasound
• 1st line
• Jaundice + CBD > 10 mm -> stone in 90% of cases
• Maybe able to visualize stone
MRCP
• Most sensitive non invasive study (decreased sensitivity for stones < 5 mm)
• Intermediate probability or when ERCP is not feasible
CHOLEDOCOLITHIASIS
ERCP
• ? Therapeutic more than diagnostic?
EUS
• Comparable efficacy to ERCP but ? less complication
I.O.C
• Routine Vs selective
CHOLEDOCOLITHIASIS
Treatment approaches
 ERCP
 PTC
 CBDE
BILE DUCT INJURY
• Incidence during open cholecystectomy 0.2 – 0.3 %
• Incidence during laparoscopic cholecystectomy 0.3 – 0.6%
BILE DUCT INJURY
Causes of laparoscopic biliary injury
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Misidentification of the bile ducts as the cystic duct
Misidentification of the CBD as the cystic duct
Misidentification of the aberrant right sectoral hepatic duct as the cystic duct
Improper techniques of ductal exploration
Failure to occlude the cystic duct securely
Plane of dissection away of gallbladder wall into liver bed
Excessive retraction of cystic duct with tenting of CBD
Injudicious use of electrocautery
Injudicious use of clips
Modified from Strasberg SM et al, 1995: An analysis of problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180: 101-125
William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition
BILE DUCT INJURY
Classification of laparoscopic biliary injury
William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition
BILE DUCT INJURY
Injury recognized at time of surgery
• Stop!
• Consider your expertise and ask for help
• Leave a drain and transfer to HPB surgeon
What is HPB surgeon going to do?
• Quick return to OR - open approach (likely)
• Identify injury and assess concomitant vascular injury
• Cholangiogram
• Repair:
-Roux en Y hepatojejunostomy
-Direct repair over T tube
BILE DUCT INJURY
You are doing a tough laparoscopic cholecystectomy and suspect Mirizzi syndrome, what do you do?
 Proceed with subtotal cholecystectomy
Or
 Place cholecystotomy tube
BILE DUCT INJURY
Hold on a second! How can suspect Mirizzi syndrome??
• Long standing gallstone disease
• Contracted gallbladder
• Jaundice or cholangitis
BILE DUCT INJURY
You are doing a tough laparoscopic cholecystectomy and suspect Mirizzi syndrome and you perform
partial cholecystectomy. You encounter a gush of bile!
what is going on?
• Mirizzi syndrome type 2: cholecystocholedochal fistula
What do you do?
• Cholecystocholedochoduodenostomy, or
• Hepatojejunostomy
William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and
Biliary Tract, 5th Edition
BILE DUCT INJURY
Injury recognized postoperatively
• Bile leak
• Biloma and infection
• Juandice
Workup
• ERCP - diagnostic and therapeutic
• MRCP
• CT – assess vascular injury and fluid collection
• PTC if needed
BILE DUCT INJURY
Injury recognized postoperatively
 Control bile leak
 Drain fluid collection
 Treat infection
 Volume resuscitation
 Electrolyte replacement
 Delayed repair
BILE DUCT CYST
Classification
Chijiiwa K, Koga A: Surgical management and long-term follow-up of patients with choledochal cysts. Am J Surg 165:238-242, 1993
BILE DUCT CYST
Presentation – Adulthood
• Asymptomatic (majority)
• Biliary colic like symptoms and mild jaundice
• Pancreatitis
• Liver cirrhosis
• Malignancy ( weight loss)
Incidence of malignancy 2.5 – 28 %
BILE DUCT CYST
Treatment
 Type I : Excision + Roux en Y hepatojejunostomy vs. hepatoduodenostomy
 Type II: Excision
 Type III: Trans-duodenal excision vs. endoscopic sphinterotomy
 Type IV A: Bile duct and hepatic resection and hepatojejunostomy
 Type IV B: Excision + Roux en Y hepatojejunostomy vs. hepatoduodenostomy +/- sphincteroplasty
 Type V: Liver resection vs. transplant
Cyst excision does not eliminate risk of malignancy
PRIMARY SCLEROSING CHOLANGITIS
• Associated with IBD mainly UC
• Risk of cholangiocarcionoma 1% per year
Presentation
• Asymptomatic
• Liver cirrhosis
• Cholangitis – uncommon
PRIMARY SCLEROSING CHOLANGITIS
Diagnosis
• Cholangiography / MRCP
• Multifocal strictures
Treatment
 Asymptomatic : Observe
 Stricture : ERCP vs resection
 Liver cirrhosis: Transplant
 Cholangiocarcinoma: Resection
EXTRA-HEPATIC CHOLANGIOCARCINOMA
Risk factors
• Primary sclerosing cholangitis
• Bile duct cysts
• Biliary parasites; Clonorchis sinensis, Opisthorchis viverrini
• ?? sphincterotomy
EXTRA-HEPATIC CHOLANGIOCARCINOMA
Classification
• Perihilar
• Mid bile duct
- hepatic confluence to cystic duct
- rare
• Distal bile ducy
- distal to cystic duct confluence
William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and
Biliary Tract, 5th Edition
EXTRA-HEPATIC CHOLANGIOCARCINOMA
Presentation
• Jaundice and pruritus
• Abnormal LFT
• Non specific symptoms and weight loss
EXTRA-HEPATIC CHOLANGIOCARCINOMA
 Distal cholangiocarcinoma
- treat like periampullary tumor
- whipple
 Mid duct cholangiocarcinoma
- very rare
- ? Gallbladder / cystic duct base cancer
- bile duct resection and cholecystectomy
- assess need to treat like GB cancer; segment 4,5 liver resection
EXTRA-HEPATIC CHOLANGIOCARCINOMA
 Perihilar cholangiocarcinoma - Classification
William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition
EXTRA-HEPATIC CHOLANGIOCARCINOMA
 Perihilar cholangiocarcinoma – Work up
- CT
- MRCP
- ERCP
- PTC
Tissue diagnosis is not required in patient with potentially resectable
EXTRA-HEPATIC CHOLANGIOCARCINOMA
 Perihilar cholangiocarcinoma – Treatment
 Resectable
- bile duct resection
- achieving R0 resection almost always require partial hepatectomy
- hepatojejunostomy
- adjuvant treatment
 Unresectable
- palliative
- transplant in selected cases preceded by neoadjuvanet chemotherapy (Mayo
clinic)