BILIARY STRICTURE

Anatomy of biliary tree

Definition A biliary stricture is an abnormal narrowing of the common bile duct, the tube that moves bile from the liver to the small intestine. Bile is a substance that helps with digestion.

Pathological effects of biliary obstruction High local concentration of bile salts inflammation

Pathological effects of biliary obstruction (Contd.) Fibrosis and scarring Biliary fistula Biliary stasis Liver atrophy Repeated cholangitis Secondary Biliary cirrhosis and PHTN

Causes of benign stricture Any inflammatory process occurring along the length of the common bile duct can cause a stricture. I. Congenital strictures Biliary atresia II. Bile duct injuries A. Postoperative strictures (1) Cholecystectomy (i) Lap.: MC (0.3-0.85%) (ii) Open: (0.1-0.2%) (2) Biliary-enteric anastomosis (3) Hepatic resection (4) Portocaval shunt (5) Pancreatic & duodenal surgery (6) Gastrectomy (7) Liver transplantation B. Stricture after blunt or penetrating trauma

Causes of benign stricture (Contd.) C. Strictures after endoscopic or percutaneous biliary intubation III. Inflammatory strictures A. Cholelithiasis or choledocholithiasis B. Chronic pancreatitis C. Chronic duodenal ulceration D. Abscess or inflammation of liver or subhepatic space E. Parasitic infection (Ascaris Lumbricoides, Clonorchis Sinensis ) F. Recurrent pyogenic cholangitis (Oriental cholangiohepatitis) IV. Primary sclerosing cholangitis V. Radiation-induced stricture

Causes of malignant stricture Primary tumors Cholangiocarcinoma (MC) GB Cancer Pancreatic adenocarcinoma Ampullary carcinoma Hepatoma Gastric carcinoma Metastatic tumors Colon cancer Breast cancer Lung cancer Melanoma Ovarian cancer

Bile duct injury at cholecystectomy Most benign strictures follow iatrogenic bile duct injury Most commonly during laparoscopic cholecystectomy Incidence 1.open cholecystectomy (0.1 -0.2%) 2.lap cholecystectomy (MC) (0.3-0.85%) Risk factors: Acute or chronic inflammation, Anatomical variation, Obesity, Bleeding Surgical technique with inadequate exposure and failure to identify structures before ligating or dividing them are the most common cause of significant biliary injury. Most common duct injuries occur during attempted dissection of the cystic duct when the CBD is mistaken for cystic duct. If a bile duct injury is suspected during cholecystectomy, a Cholangiogram must be obtained to identify the anatomy. PTC is the imaging method of choice for most post-operative biliary strictures.

Proper exposure –maximum cephalad traction on fundus with concomitant lateral traction on infundibulum

Bismuth`s classification

Strasberg`s classification

The Stewart-Way classification of laparoscopic bile duct injury

Hannover classification (2007) It classifies injuries in relationship to the confluence and also includes vascular injuries. Type A: It refers to cystic and/or gallbladder bed leaks. Type B: is a complete or incomplete stenosis caused by a surgical staple. Type C: represents lateral tangential injuries. Type D: refers to complete section of the common bile duct emphasizing their distance to the confluence as well as the concomitant injuries of hepatic artery and portal vein. Type E: is late bile duct stenosis at different lengths to the confluence.

Hannover`s classification

Clinical Presentation Fever Abdominal Pain (biliary colic) Obstructive Jaundice Bile leakage from incision or in subhepatic drain Features of ascending cholangitis - Charcot’s triad, Reynold’s pentad Subsequent bile peritonitis Overall only 10% of post-op. bile duct strictures are recognized within 1st week and approx. 70% are diagnosed within 6 months of original operation.

Laboratory Tests Complete Blood Count PT with INR Liver Function Test - S. Bilirubin level - S. Alkaline Phosphatase - S. Transaminases - S. GGT Curv law –nontender enlarged gb with mild jaundice ,cause is unlikely to be gall stones,usually pancreatic or gb ca Signs of HCF—ascites,encephalopathy,variceal bleed

Imaging Studies Ultrasound HIDA scan CT scan MRCP ERCP Endoscpic Ultrasound Percutaneous transhepatic cholangiography Intra-operative Cholangiography Triad –pain, jaundice, fever……….pentad –shock, altered mental status Symptoms of obstructive jaundice---itchy skin,clay coloured stool,anorexia,yellowish discolouration of eyes and skin,dark coloured urine,easy bruising,fever

Ultrasound Study of choice for the initial evaluation of jaundice or symptoms of biliary disease Will show dilated bile ducts proximal to the stricture Information about level of stenosis CBD PV

HIDA scan Hepatic Iminodiacetic acid scan To evaluate the physiologic secretion of bile Provides functional assessment of incomplete strictures and surgical anastomosis It will identify obstruction of the biliary tree and bile leaks

CT scan Provides superior anatomic information Used to identify the cause and site of biliary obstruction

MRCP (Magnetic Resonance Cholangiopancreatography) Non-contrast noninvasive method Only diagnostic Provides anatomic information about location and degree of dilatation Delineate the intrahepatic and extrahepatic biliary tree and pancreas CBD PD

ERCP (Endoscopic Retrograde Cholangiopancreatography) Diagnostic and therapeutic Invasive test using endoscopy and fluoroscopy to inject contrast through the ampulla and image the biliary tree Used for dilatation of the biliary stricture

MRCP VERSUS ERCP MR cholangiopancreatography is noninvasive and safe, because it does not require anesthesia or injection of intraductal or intravenous contrast agent. On current MR imaging systems high-quality images can be obtained consistently.  MRCP is useful in patients after incomplete or unsuccessful ERCP In some patients, such as those who have undergone surgery with biliary enteric anastomosis or Billroth II, it may not be possible to perform ERCP, so MRCP is the modality of choice to evaluate these postsurgical patients. Unlike ERCP, MRCP produces images of the ducts in their natural state, because it does not involve distention of the ducts by injected contrast medium. ERCP cannot evaluate extraductal structures directly, whereas MRCP can be combined with conventional MR imaging for the evaluation of extraductal disease, such as tumors.  ERCP has advantages over MRCP, which include direct therapeutic interventional procedures that may be performed concurrent with diagnostic imaging.  ERCP is generally a safe procedure, but still associated with nonnegligible morbidity and mortality rates. Also, technical failures occur in up to 10% of cases because of unsuccessful cannulation of the common bile duct (CBD) or pancreatic duct. In some institutions MRCP is gradually replacing ERCP as a primary diagnostic imaging modality to evaluate the biliary system and pancreatic duct.

Endoscpic Ultrasound (EUS) Valuable in the assessment of distal CBD and ampulla Most useful in assessing tumours for invasion into vascular structures CBD Shadow

PTC (Percutaneous transhepatic cholangiography) It is only undertaken once a bleeding tendency has been excluded and the patient’s prothrombin time is normal. Antibiotics should be given prior to the procedure. Useful in intrahepatic biliary disease In whom ERCP is not technically feasible It will outline proximal biliary tree, define stricture and its location, allow decompression of the biliary tree Method: A needle (Chiba or Okuda needle) is passed directly into the liver to access one of the biliary radicals, and the tract is then used for insertion of transhepatic catheters.

PTC (Percutaneous transhepatic cholangiography) (Contd.) In addition, this technique enables placement of a catheter into the bile ducts to provide external biliary drainage or the insertion of indwelling stents. Bile can be sent for cytology. The scope of this procedure can be further extended by leaving the drainage catheter in situ for a number of days and then dilating the track sufficiently for a fine flexible choledochoscope to be passed into the intrahepatic biliary tree in order to diagnose strictures, take biopsies and remove stones. In general, if a malignant stricture at the level of the confluence of the right and left hepatic ducts or higher is suspected in a jaundiced patient, a PTC is preferred to ERCP as successful drainage is more likely.

PTC (Percutaneous transhepatic cholangiography) (Contd.)

Intra-operative Cholangiography During open or laparoscopic cholecystectomy, a catheter can be placed in the cystic duct and contrast injected directly into the biliary tree. Indications: - Anomalous or confusing biliary anatomy - Inability to perform post-op. ERCP - Dilated biliary tree Any suspicion of choledocholihiasis

MANAGEMENT Depends on the location and cause of the stricture Bile duct injury recognised at the time of operation Bile duct injury recognised after operation (Iatrogenic bile duct injury) Percutaneous or endoscopic dilatation and/or stent placement Surgery - Biliary enteric anastomosis (Roux-en- Y- Hepaticojejunostomy - ideal)

Bile duct injury recognised at the time of operation Conversion to an open operation and use of cholangiography Goals: - Maintainance of ductal length - Elimination of any bile leakage - Creation of tension free repair

Bile duct injury recognised at the time of operation (Contd.) Simple ligation – For ducts < 3 mm Reimplantation- For ducts > 3 mm T tube placement with choledochotomy- For injury to larger duct & involves < 50% of the circumference of the wall Resection of injured segment with biliary enteric anastomosis- Any cautery based injury or injury involving > 50% of the duct circumference If no surgeon with experience in biliary reconstruction is available------ Placement of a drain and immediate referral to an experienced centre is the most appropriate management strategy.

Bile duct injury recognised after operation (Iatrogenic bile duct injury) GOALS: 1. Control of infection limiting inflamation - Parenteral antibiotics - Percutaneous drainage of periportal fluid collections 2. Clear and thorough delineation of entire biliary anatomy - MRCP / PTC - ERCP 3. Re-establishment of biliary enteric continuity - Tension-free, mucosa to mucosa anastomosis - Roux- en-Y hepaticojejunostomy - Long term transanastomotic stents if involving bifurcation or higher

Percutaneous or endoscopic dilatation and/or stent placement ERCP with sphincterotomy, balloon dilatation, and stent placement is generally regarded as primary treatment for benign bile duct strictures. With percutaneous access to a biliary tree, a wire is used to traverse the stricture. Using balloon dilatation techniques, the stricture is dilated and a catheter is left in place to decompress the system, allow healing, document resolution and if necessary guide repeat dilatations.

Treatment of malignant strictures Depends on : Resectability & Staging and general condition Resectable: -Radical resection with biliary enteric anastomosis Palliative: - Endoscopic stenting - Percutaneous transhepatic stenting - Palliative resection with surgical bypass

Surgery (Biliary enteric anastomosis) Choledochoduodenostomy Choledochojejunostomy Roux-en-Y Hepaticojejunostomy (ideal)

Surgery (Biliary enteric anastomosis) To ensure a tension free anastomosis, a generous Kocher maneuver, mobilizing the duodenum and the head of the pancreas out of the retroperitoneum, is necessary. To achieve a successful and durable repair, the anastomosis must be performed between a minimally inflammed bile duct to intestines in a tension free, mucosa to mucosa fashion. Preservation of as much normal biliary tree as possible remains a goal of the reconstruction.

Successful bile duct enteric reconstruction is dependent on several factors: 1. Adequate preoperative assessment of biliary anatomy 2. Exposure of proximal, healthy bile ducts with adequate blood supply 3. The repair must include all injured/strictured ducts to ensure adequate drainage of the entire liver, and control of bile leakage. 4. Use of a healthy segment of intestine that can be brought to the anastomosis without tension (most often a Roux-en-Y jejunal limb) 5. Creation of a tension-free biliary mucosa-to-bowel mucosa anastomosis

Choledochoduodenostomy Commonly used for repair of the benign strictures in the retropancreatic portion Most successful in presence of dilated CBD (>15 mm) For strictures in distal most part of CBD Maitains endoscopic access to the biliary tree The distal common bile duct is opened longitudinally, as is the duodenum. Interrupted sutures are placed between the common bile duct and the duodenum.

Choledochojejunostomy

Choledochojejunostomy The common bile duct and small bowel are divided. A Roux-en-Y limb of jejunum is anastomosed to the choledochus. The most common indication is an obstructing periampullary mass, usually of duodenal or pancreatic origin. Choledochojejunostomy is most often performed to relieve benign or malignant CBD obstruction or to repair benign or iatrogenic biliary strictures.  It also can serve a palliative role as the bypass procedure of choice in unresectable periampullary tumors and in cases of metastatic disease that would otherwise be unresectable.

Roux-en-Y Hepaticojejunostomy (ideal) It is the preferred method of surgical biliary drainage in most instances, and is the standard method of biliary reconstruction following bile duct resection. Proper exposure of healthy well vascularised proximal bile duct. Roux- en –Y Limb of jejunum >60 cm The entire extrahepatic biliary tree has been resected and the reconstruction done with a Roux-en-Y limb of jejunum This is an end-to-side anastomosis of the common hepatic duct onto the jejunum. HEPP- COUINAUD APPROACH: Hilar plate is dissected , left hepatic duct is anastomosed to Roux jejunal loop with creation of proximal ‘access loop’ for future endoscopic approach.

Hepaticojejunostomy.. (a) An incision is made in the Roux loop of jejunum(b) The anterior sutures are only in the bile duct and are used to display the posterior wall of the duct while the posterior sutures are inserted. (c)The posterior sutures are tied. (d) The anterior sutures are completed. (e) The anastomosis is completed as the anterior sutures are tied.

SUMMARY Bile duct injuries and strictures are complex problems requiring a multidisciplinary approach involving surgeons, radiologists, and gastroenterologists. Failure to properly diagnose and/or manage these problems can result in chronic liver disease and/or chronic disabilities. Complete and accurate preoperative imaging is essential to successful outcomes. Appropriate surgical management with careful attention to detail and technique is also imperative.

REFERENCES Bailey And Love’s Short Practice of Surgery 26th Ed sabiston textbook of surgery 19th edition Schwartz s Principles of Surgery 10th ed. SRB's Manual of Surgery, 4E Farquharson's Textbook of Operative General Surgery, 10E Shackelford's Surgery of the Alimentary Tract - 2

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