Ch. 54 – Biliary System

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1572 Section X Abdomen biliary reconstruction can be managed nonoperatively, and mortality rates have been less than 1%. 32 Common complications include recurrent cholangitis, external biliary fi stula, bile leak, and hemobilia. Restenosis of a biliary-enteric anastomosis occurs in about 10% of patients, and may manifest up to 20 years later. About two thirds of recurrent strictures become symptomatic within 2 years after repair. The more proximal strictures are associated with a lower success rate than are distal ones. Percutaneous balloon dilation with stenting has a signifi cantly lower success rate (64%) than operative repair. Although most patients are free of jaundice and cholangitis after operative repair of a bile duct injury, there appears to be a signifi cant impact of the injury on the quality of life. 35 Postcholecystectomy Pain Abdominal pain or other symptoms originally attributed to the gallbladder may persist or recur months or years after cholecystectomy. Improvements in imaging have decreased the incidence of this pain, which was once reported to be as high as 20%. Patients presenting with right upper quadrant pain, jaundice, and chills shortly after cholecystectomy should be evaluated for retained stones or biliary leak. Other causes of abdominal pain in patients with normal liver function tests should also be investigated. Another possibility in a small number of patients with persistent pain following cholecystectomy is abnormalities in the sphincter of Oddi such as stenosing papillitis or sphincter dysfunction. Retained Biliary Stones Retained or recurrent stones following cholecystectomy present soon after (
A Recurrent Pyogenic Cholangitis Cholangiohepatitis or intrahepatic stones are endemic in East Asia. It is uncommon in North America except in the Chinese population. It is more common in people with poor economic status and living standards. The infectious aspect of this disease is caused by bacterial contamination, usually biliary pathogens, and biliary parasites, such as Clonorchis sinensis, Opisthorchis viverrini, and Ascaris lumbricoides. Biliary sludge and dead bacterial cell bodies form brown pigment stones formed throughout the biliary tree, which cause partial obstruction. Biliary strictures and repeated episodes of cholangitis are the common clinical course and may lead to hepatic abscesses and cirrhosis. Patients are at risk for cholangiocarcinoma due to persistent biliary infection and irritation from stones and sludge. Presentation Patients with recurrent pyogenic cholangitis (RPC) commonly present with frequent episodes of pain, fever, and jaundice. MRC and PTC are the primary imaging modalities for monitoring of disease progression (Fig. 54-25). They are useful for identifying location and severity of Chapter 54 Biliary System 1573 Figure 54-24 A posteroanterior radiograph obtained during a barium examination of the small bowel shows an irregular collection of barium in the right upper quadrant (A, arrowheads), representing partial fi lling of the cystic duct. Both jejunum and ileum are markedly dilated, with dilution of the barium in a pattern consistent with small bowel obstruction. There is abrupt termination of the barium column at the site of an oval intraluminal fi lling defect (A, arrow). A view of the end of the barium column shows luminal obstruction by a smooth intraluminal mass (B, arrows) with faint calcifi cation of the peripheral rim. Exploratory laparotomy revealed a foreign body in the terminal ileum that was 4 cm by 4 cm and felt hard. (From Kaiser AM, Molmenti EP: Gallstone ileus. N Engl J Med 335:942, 1996.) B stones and strictures and allow decompression of the biliary tree in a septic patient. Management Patients with RPC should be treated with a multidisciplinary approach including endoscopists, interventional radiologists, and surgeons because of the frequency and inaccessibility of strictures and stones. The long-term goal of therapy is to extract stones, remove debris, and relieve strictures. Because clearance of all stones at any one operation is diffi cult, Roux-en-Y hepaticojejunostomy with a subcutaneous afferent limb (Hudson loop) is a safe and effective way to provide access to the biliary tree for stone extractions. 36 Cholangiocarcinoma has been reported in 1% to 10% of patients with RPC; therefore, patients with adequate hepatic reserve and a dominant lobe with stones should undergo extended hepatectomy of the involved side, Roux-en-Y hepaticojejunostomy, and Hudson loop. This would remove the stones and reduce the future risk for cholangiocarcinoma. About 50% of patients require further percutaneous choledochoscopy or balloon dilation to clear any remaining stones or manage persistent strictures.
Page 1 and 2: Biliary System Ravi S. Chari, MD an
Page 3 and 4: Vater, where it empties into the du
Page 5 and 6: Urinary excretion (95% of biliary s
Page 7 and 8: The pain is most commonly triggered
Page 9 and 10: Cholangiography Cholangiography fun
Page 11 and 12: Cholesterol Gallstones The pathogen
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Page 15 and 16: A B After endoscopic sphincterotomy
Page 17 and 18: Surgery for Calculous Biliary Disea
Page 19 and 20: Box 54-4 Indications for Intraopera
Page 21 and 22: transduodenal approach may be feasi
Page 23 and 24: is jaundice with or without abdomin
Page 25: An adequate incision permitting ful
Page 29 and 30: Management IV antibiotics and aggre
Page 31 and 32: Box 54-6 Todani Modifi cation of Al
Page 33 and 34: Figure 54-31 Operative photography
Page 35 and 36: ant abdominal pain. A heterogeneous
Page 37 and 38: Figure 54-35 Bismuth classifi catio
Page 39 and 40: sectable disease; however, intraope
Page 41 and 42: tion and mimic either pancreatic ca

Ch. 54 – Biliary System

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