 In 15% of patients, cholecystectomy fails to relieve the symptoms for which the operation was performed. ‘post-cholecystectomy’ syndrome.  problems are usually related to the preoperative symptoms and are continuation of those symptoms. Full investigation should be undertaken to confirm the diagnosis  presence of a stone in the common bile duct,  a stone in the cystic duct stump  or operative damage to the biliary tree.

 best DIAGNOSED by  MRCP or ERCP.  The latter has the added advantage that, if a stone is found in the common bile duct, it can be removed.

 Patients with symptoms developing either immediately or delayed after a cholecystectomy, particularly jaundice,need urgent investigation.

 immediate ultrasound scan. whether there is intra- or extrahepatic ductal dilatation.  The anatomy defined by MRCP.  ERCP therapeutic manoeuvres :  removal of an obstructing stone  insertion of a stent across a biliary leak.  If a fluid collection is present in the subhepatic space, drainage catheters may be required. These can be inserted under radiological control or, if this expertise is not available, at open operation.

 Small biliary leaks will usually resolve spontaneously, especially if there is no distal obstruction.  Should the common bile duct be damaged, the patient should be referred to an appropriate expert for reconstruction of the duct.

 About 15% of injuries recognised at the time of operation.  In 85% of cases, the injury declares itself postoperatively by:  (1) a profuse and persistent leakage of bile if drainage has been provided, or bile peritonitis if such drainage has not been provided;  (2) deepening obstructive jaundice.

 When the obstruction is incomplete, jaundice is delayed until subsequent fibrosis renders the lumen of the duct inadequate.  The surgical repair and subsequent outcome is related to the level of injury, which is determined using the Bismuth classification

 Bismuth classification  Type I Low common bile duct; stump > 2 cm  Type II Middle common hepatic duct; stump < 2 cm  Type III Hilar – confluence of right and left ducts intact  Type IV Right and left ducts separated  Type V Involvement of the intrahepatic ducts

 In the debilitated patient,  temporary external biliary drainage by passing a catheter percutaneously into an intrahepatic duct.  stents may be passed through strictures at the time of ERCP and left to drain into the duodenum.  When the general condition improved,  Definitive surgery can be undertaken.  The principles of surgical repair are  maintenance of duct length and restoration of biliary drainage.

 For benign stricture or duct transection, the preferred treatment is immediate Roux-en-Y choledochojejunostomy by an experienced surgeon.  For a stricture of recent onset through which a guidewire can be passed, balloon dilatation with insertion of a stent.  The outcome of such surgery is good, with 90% of patients having no further cholangitis or stricture formation.

 PRIMARY STONES:occure years after a cholecystectomy or development of new pathology, such as infection of the biliary tree or infestation by Ascaris lumbricoides or Clonorchis sinensis.  Secondary stone (missed stone )from gall bladder  Any obstruction to the flow of bile can give rise to stasis with the formation of stones within the duct.  The consequence of duct stones is either obstruction to bile flow or infection.

 Stones in the bile ducts are more often associated with infected bile (80%) than are stones in the gall bladder

 Symptoms  The patient may be asymptomatic  May has bouts of pain,  jaundice and fever. The patient is often ill and feels unwell. The  term ‘cholangitis’ is given to the triad of pain, jaundice and fevers,  sometimes known as ‘Charcot’s triad’.  Signs  Tenderness may be elicited in the epigastrium and the right hypochondrium.  In the jaundiced patient, it is useful to remember  Courvoisier’s law – in obstruction of the common bile duct  due to a stone, distension of the gall bladder seldom occurs; the  organ is usually already shrivelled. In obstruction from other  causes, distension of the gall bladder is common by comparison.

 Management  Full supportive measures are required with rehydration, correction of clotting abnormalities and treatment with appropriate broad-spectrum antibiotics.

 Once the patient has been resuscitated, relief of the obstruction is essential.  Endoscopic papillotomy is the preferred first technique  with a sphincterotomy, removal of the stones using a Dormia basket or the placement of a stent if stone removal is not possible.  If this technique fails, percutaneous transhepatic cholangiography can be performed to provide drainage and subsequent percutaneous choledochoscopy.  Surgery, in the form of choledochotomy, is now rarely used for this situation, as most patients can be managed by minimally invasive techniques

 The aim of this surgery is to drain the common bile duct and remove the stones by a longitudinal incision in the duct.  When the duct is clear of stones, a T-tube is inserted and the duct closed around it;  the long limb of the T-tube is brought out on the right side, and the bile is allowed to drain externally.  When the bile has become clear and the patient has recovered, a cholangiogram is performed, usually 7– 10 days following operation.  If residual stones are found, the T-tube is left in place for 6 weeks so that the track is ‘mature’. The retained stones can be removed percutaneously by an interventional radiologist (Burhenne technique)

 Causes of benign biliary stricture  Congenital  ■ Biliary atresia  Bile duct injury at surgery  ■ Cholecystectomy  ■ Choledochotomy  ■ Gastrectomy  ■ Hepatic resection  ■ Transplantation  Inflammatory  ■ Stones  ■ Cholangitis  ■ Parasitic  ■ Pancreatitis  ■ Sclerosing cholangitis  ■ Radiotherapy  Trauma  Idiopathic

 ■ Ultrasonography  ■ Cholangiography via T-tube, if present  ■ ERCP  ■ MRCP  ■ PTC  ■ Multidetector row CT

 Benign tumours of the bile duct  uncommon  less than 0.1% of biliary tract operations.  clinical presentation may mimic the more common conditions such as cholecystitis, choledocholithiasis,cancer of the bile duct and pancreatic cancer.

 Benign neoplasms classificationas follows:  papilloma and adenoma;  multiple biliary papillomatosis;  granular cell myoblastoma;  neural tumours;  leiomyoma;  endocrine tumours.

 Carcinoma may arise at any point in the biliary tree, from the common bile duct to the small intrahepatic ducts

 Incidence  rare malignancy accounting for 1–2% of new cancers in a western practice.  two-thirds of patients being older than 65 years.  the tumour is usually an adenocarcinoma  (cholangiocarcinoma), predominantly in the extrahepatic biliary system.

 Patients with a history of followings are at increased risk of developing the disease.  ulcerative colitis,  hepatolithiasis,  Choledochal cyst or  sclerosing cholangitis

 longstanding history of sclerosing cholangitis increases the risk of developing biliary tract cancer by 20-fold compared with the normal population.

 liver fluke infestations in the Far East are also associated with cholangiocarcinoma. Opisthorchis viverrini infestation is important in Thailand, Laos and western Malaysia.  These parasites induce DNA changes and mutations through production of  carcinogens and free radicals, which stimulate cellular proliferation in the intrahepatic bile ducts and can ultimately lead to invasive cancer.

 slow-growing tumours that invade locally and metastasise to local lymph nodes.  Distant metastases to the peritoneal cavity, liver and lung may occur.  Jaundice is the most common presenting feature.  Abdominal pain, early satiety and weight loss are also commonly seen.

 On examination,  Jaundice is evident,  cachexia often noticeable  a palpable gall bladder is present if the obstruction is in the distal common bileduct (Courvoisier’s sign).

 Investigations  Biochemical investigations will confirm the presence of obstructive jaundice (elevated bilirubin, alkaline phosphatase and gamma- glutamyl transferase).  The tumour marker CA19-9 may also be elevated.  Non-invasive studies such as ultrasound and CT  scanning define the level of biliary obstruction, the locoregional extent of disease and the presence of metastase

 For proximal tumours, percutaneous transhepatic cholangiography is the most useful modality. PTC  outlines the anatomy of the tumour and the intrahepatic biliary system.  it allows percutaneous biliary drainage,  samples can be obtained for cytology to confirm the diagnosis.

. For distal tumours, an ERCP is preferred  as an endobiliary stent can be placed across the obstructing lesion.  Again, cytology or biopsies can be taken for diagnosis.

 Treatment  depends on the site and extent of disease.  ONLY 10–15% are suitable for surgical resection. . Most patients are inoperable,

 Depending on the site of disease,  resection may involve partial hepatectomy and reconstruction of the biliary tree.  Distal common duct tumours may require a pancreaticoduodenectomy.  The perioperative mortality rate is now less than 5%.  The median survival is 18 months, with 20% of patients surviving 5 years post resection.

 Survival appears to be better for distal tumours compared with those involving the upper third of the biliary tree.  Adjuvant chemotherapy or radiotherapy has a limited role and is not considered standard therapy.

 Bile duct cancer  ■ Rare, but incidence increasing  ■ Presents with jaundice and weight loss  ■ Diagnosis by ultrasound and CT scanning  ■ Jaundice relieved by stenting  ■ Surgical excision possible in 5%  ■ Prognosis poor – 90% mortality in 1 year

 Incidence  This is a rare disease  variable by geographical region and racial/ethnic groups.  The highest incidence is in Chileans, American Indians and in parts of northern India, where it accounts for as much as 9.1% of all biliary tract disease.

. In western practice, gall bladder cancer accounts for less than 1% of new cancer diagnoses.  The patients are usually older, in their sixties or seventies.

 The aetiology is unclear, association with  preexisting gallstone disease.  Calcification of the gall bladder is associated  with cancer in 10–25% cases.  Infection may promote the development of cancer as the risk of carcinoma in typhoid carriers is significantly increased.

 Pathology  The majority of cases are adenocarcinoma (90%).  ; the tumour is most commonly nodular and infiltrative, with thickening of the gall bladder wall, often extending to the whole gall bladder.

 The tumour spreads by direct extension into the liver, seeding of the peritoneal cavity and involvement of the perihilar lymphatics and neural plexuses.  At the time of presentation, the majority of tumours are advanced.

 Clinical features  Patients may be asymptomatic at the time of diagnosis. . If symptoms are present, they are usually indistinguishable from benign gall bladder disease such as biliary colic or cholecystitis, particularly in the older patient.  Jaundice and anorexia are late feature.  A palpable mass is a late sign

 Investigation  Laboratory findings  may be consistent with biliary obstruction  or non-specific findings such as anaemia, leucocytosis, mild elevation in transaminases and increased erythrocyte sedimentation  rate (ESR) or C-reactive protein (CRP).

 The level of serum CA19-9 is elevated in 80% of patients.  The diagnosis is made on ultrasonography  defined by a multidetector row CT scan,  percutaneous biopsy confirming the histological diagnosis.  laparoscopy is useful in staging the disease, as it can detect peritoneal or liver metastases that would preclude further surgical resection.

 Treatment and prognosis  Occasionally, the diagnosis is made by histological examination of a gall bladder removed for ‘benign’ gallstone disease.  For early stage disease confined to the mucosa or muscle of the gall bladder, no further treatment is indicated.  However, for transmural disease, a radical en bloc resection of the gall bladder fossa and surrounding liver along with the regional lymph nodes should be performed.

 The disease has a very poor prognosis with the median survival less than 6 months and a 5-year survival of 5%.  The value of adjuvant therapy is unproven.

 Gall bladder cancer  ■ Rare  ■ Presents as for benign biliary disease (gallstones)  ■ Diagnosis by ultrasound and CT scanning  ■ Excision in less than 10% – remainder palliative treatment  ■ Prognosis poor – 95% mortality in 1 year

1) Correct Anaemia if Present 2) Good Hydration with i.v. fluids to prevent dehydration & maintain the Renal Function 3) Mannitol i.v. infusion to maintain osmotic diuresis and prevent Bilirubin from precipitating in the tubules. 4) Vitamine K injectable to activate important clotting factors (fat soluble vitamines are not absorbed) 5) Add 5% Glucose Water to help build up Liver glycogen 6) Antibiotics Broad Spectrum

 blunt or penetrating abdominal trauma.  Operative trauma is perhaps more frequent than external trauma.  physical signs are those of an acute abdomen.  Management depends on the location and extent of the biliary and associated injury.  In the stable patient, a transected bile duct is best repaired by a Roux-en-Y choledochojejunostomy.  Injuries to the gall bladder can be dealt with by cholecystectomy.