Biliary Tract

From the 74th Annual University of Minnesota Surgery Course: Advances in Hepatic, Biliary, and Pancreatic Surgery

Educational Objectives

The purpose of this program is to improve outcomes of cholecystectomy and management of primary sclerosing chol­angitis (PSC). After hearing and assimilating this program, the clinician will be better able to:

1.   List the most common causes of bile duct injury during laparoscopic cholecystectomy.

2.   Manage injuries to the bile duct that occur during laparoscopic cholecystectomy.

3.   Diagnose PSC.

4.   Identify patients at risk for cholangiocarcinoma, based on findings of fluorescent in-situ hybridization (FISH).

5.   Recognize indications for conversion to open surgery during a complicated laparoscopic cholecystectomy.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Soper is on the scientific advisory board for TransEnterix. Drs. Lillemoe and Nagorney and the planning committee reported nothing to disclose.

Acknowledgements

This program was recorded at 74th Annual University of Minnesota Surgery Course: Advances in Hepatic, Biliary, and Pan­creatic Surgery, held June 2-5, 2010, in Minneapolis, MN, and sponsored by the University of Minnesota Medical School. The Audio-Digest Foundation thanks the speakers and the University of Minnesota Medical School for their cooperation in the production of this program.

Management of Biliary Tract Injuries in the Era of Laparoscopic Cholecystectomies

Keith D. Lillemoe, MD, Jay L. Grosfeld Professor of Surgery and Chair, Department of Surgery, Indiana Uni­versity School of Medicine, Indianapolis

Incidence of bile duct injuries: 1 to 2 per 1000 in prelaparoscopic cholecystectomy era; current incidence 3 to 4 times higher; has remained stable since laparoscopic cholecystectomy introduced »20 yr ago; injuries associated with 3-fold increase in risk for death among Medicare beneficiaries; risk factors include advancing age, comorbidi­ties, and surgeon inexperience; has third highest costs among lawsuits related to general surgery

Causes of injuries: misidentification of common bile duct (CBD) as cystic duct, which leads to clipping of CBD; right hepatic artery and hepatic duct may be injured as well; patients present postoperatively with bile duct leak; injury recognized at time of laparoscopic cholecystectomy in only approximately one-third of cases

Red flags for CBD injuries: atypical anatomy; encountering “second duct” (actually hepatic duct); unsuspected bile leakage (hepatic bile appears golden, unlike bile from gallbladder); on cholangiography, good gallbladder func­tion without filling of intrahepatic biliary radicals should raise suspicions; early identification of injury helps avoid serious complications

Management: call more experienced surgeon if necessary; Roux-en-Y hepaticojejunostomy best choice for repair; if immediate repair not possible, control bile leak in anticipation of subsequent elective repair; delay repair if sur­geon or facility lacks appropriate experience or resources

Delayed presentation: patient calls 3 to 5 days after surgery complaining of nausea, distention, discomfort, and low-grade fever; see patient immediately and suspect CBD injury; measuring serum bilirubin may not be helpful (pa­tient may not be jaundiced and may not show biliary obstruction); radiologic imaging most important diagnostic tool; speaker recommends starting with computed tomography (CT), although ultrasonography (US) may yield same information; usual findings loculated bile or biloma, or diffuse ascites from bile filling entire peritoneal cavity; immediate surgery not indicated due to presence of extensive inflammation and tissue distortion from bile leak; instead, next step should be cholangiography; endoscopic retrograde cholangiopancreatography (ERCP) does not fill intrahepatic biliary tree (does not show transection or portion of liver to be used for reconstruction); transhepatic percutaneous cholangiography indicated instead; biliary leak usually controlled with catheter in place; drainage not always necessary (bile resorbs once leakage stops); magnetic resonance cholangiopancrea­tography (MRCP) identifies problem noninvasively; if reconstruction performed later, catheters may help with identification of biliary tree

Outcomes of repairs: in series of 200 patients transferred to Johns Hopkins, median time between injury and repair 10 wk; almost all patients underwent Roux-en-Y hepaticojejunostomy; 3 deaths among 175 patients undergoing surgery; complications frequent “but relatively simple and easy to manage”; no reoperations required; overall hospital length of stay 9 days; outcome not influenced by timing of surgery or patient presentation (bile leak, jaundice, or history of previous repair); waiting reduces risks

Long-term results: in studies conducted before era of laparoscopic cholecystectomy, success rate 75% to 80%; in study of 142 patients undergoing CBD reconstruction at Johns Hopkins during 1990s and followed for 5 yr, ini­tial success rate 94%; overall success rate 98%

Quality of life: questionnaires sent to 89 patients undergoing successful CBD repair during 1990s (54 patients re­sponded); also sent to 100 patients undergoing uncomplicated laparoscopic cholecystectomy, and to 100 healthy control subjects; reconstructed patients reported significant decrease in quality of life in psychologic domain (but not in physical or social domains), compared to other groups; 17 of 37 patients sued surgeon; plaintiffs had expe­rienced significant decrease in quality of life in all 3 domains

Current Management of Patients With Sclerosing Cholangitis

David M. Nagorney, MD, Professor of Surgery, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN

Primary sclerosing cholangitis (PSC): chronic, progressive, cholestatic, and (putatively) autoimmune liver disease; characterized by segmental fibrosing inflammation of intra- or extrahepatic bile ducts; eventually results in fibrous obliterative cholangitis leading to ductopenia, interface hepatitis, biliary cirrhosis, and portal hypertension; pre­malignant condition associated with increased risk for cholangiocarcinoma, carcinoma of gallbladder, hepatocel­lular carcinoma (when cirrhosis exists), and colorectal carcinoma associated with ulcerative colitis or inflammatory bowel disease; usually detected incidentally on cholestatic biochemical profile; confirmed through cholangiographic evidence of multifocal biliary strictures and segmental dilatations; exclude secondary causes of cholangitis (biliary trauma and choledocholithiasis most common)

Symptoms: most patients asymptomatic; some report right upper quadrant discomfort; fatigue, pruritus, and weight loss occur as condition progresses; clinical cholangitis uncommon unless bile duct violated; jaundice and hepato­splenomegaly seen only in cirrhotic stage of disease

Diagnosis: obtain cholestatic biochemical profile; rule out obvious obstruction with US; exclude primary biliary cirrhosis; image biliary tree with magnetic resonance cholangiography (MRC); strictures and dilatations on MRC confirm diagnosis of large duct PSC; if MRC not diagnostic, proceed with ERCP with appropriate anti­biotic prophylaxis (strictures confirm large duct PSC); if ERCP normal, some experts believe liver biopsy indi­cated to exclude small duct or intrahepatic PSC

Imaging: cholangiographic evidence key for diagnosing sclerosing cholangitis or PSC; ERCP used most com­monly, but MRC now imaging modality of choice (noninvasive, involves no irradiation, cost effective, and can be repeated frequently); typical findings include alternating areas of dilatation and strictures throughout bile ducts; outpatchings of main bile ducts often seen in PSC; similar findings on ERCP

Liver biopsy: role evolving; currently used to diagnose small duct PSC; may help determine prognosis and with counseling patients about need for liver transplantation; may help exclude other diseases; in setting of inflam­matory bowel disease, can help exclude small-duct PSC

Natural history: inevitably progresses; median survival 12 to 17 yr; in multivariate analysis of »500 patients, 8-yr survival 65% to 70%; prediction models  —  applicability for counseling individual patients still unproven

Treatment: no definitive or evidence-based medical therapy has changed overall survival or disease progression

Medical management of complications: pruritus  —cholestyramine (bile salt binder); rifampin or ursodiol (at high doses, both may exacerbate liver disease and portal hypertension); opioid antagonists (eg, naltrexone); if these options fail, plasma charcoal hemoperfusion can provide temporary relief; hepatic osteodystrophy  —assess se­rum vitamin D levels, perform bone mineral densitometry, and supplement with calcium and vitamin D; if inef­fective, prescribe bisphosphonates (administered parenterally in patients with esophageal varices); fat-soluble vitamin deficiencies  —  correct with appropriate oral vitamin supplements or monthly injections

Surgical management: dominant stricture defined as stenosis of common duct <1.5 mm or of hepatic duct <1 mm; confirmed by proximal dilatation; lifetime frequency 50% in patients with PSC; dominant location in hilus; al­ways suspect cholangiocarcinoma; manage endoscopically with brush cytology and biopsy, fluorescent in situ hybridization (FISH) and digital imaging analysis; administer periprocedural prophylaxis; initiate with balloon dilation alone; add stent if necessary; in 2001 study of 63 patients, dilation alone associated with 5-yr survival rate of 85%; when surgery necessary, options include intrahepatic cholangiojejunostomy or extrahepatic bile duct re­section and Roux-en-Y hepaticojejunostomy (contraindicated in patients with cirrhosis)

Gallbladder disease: 25% to 33% of PSC patients have gallstones; 10% of patients have polyps, 50% harboring cancer; cholecystectomy indicated for any patient with PSC and gallstones or polyps; other patients should un­dergo annual surveillance for polypoid lesions of gallbladder; annually, 1% of patients develop cholangiocarci­noma (50% detected when PSC detected)

Diagnosis of strictures: using polyploidy and trisomy combined, FISH has higher sensitivity but slightly lower specificity than cytology alone; helps in diagnosis of cholangiocarcinoma, especially in patients with PSC; extent of abnormalities in FISH or cytology findings negatively correlates with time to presentation of cancer; algorithm  —  if cytology positive, FISH polysomy present, or tetraploidy seen on digital imaging analysis in non-PSC patient, treat as with diagnosis of cancer; no other specific findings (eg, trisomy, aneuploidy) found to have high correlation with cancer; polysomy on FISH more sensitive and specific than other findings for cholangiocar­cinoma; positive predictive value of polysomy little better than random

Liver transplantation: definitive treatment for PSC; indications include portal hypertension, impaired quality of life, and chronic liver failure; indications unique to PSC  —  intractable pruritus, recurrent bacterial cholangitis, and cholangiocarcinoma; 5-yr survival »80% at Mayo; »25% of patients develop recurrent PSC in transplanted or­gan

The Difficult Laparoscopic Cholecystectomy

Nathaniel J. Soper, MD, Loyal and Edith Davis Professor of Surgery and Director, Minimally Invasive Surgery, Northwestern University, Feinberg School of Medicine, and Chief of Surgery, Northwestern Memorial Hospital, Chicago, IL

Difficult operations: severe acute cholecystitis  —  acute inflammation distorts anatomy and image seen on laparo­scope; increases risk for bile duct injury; procedure should be performed by experienced surgeon, with low threshold for conversion to open operation; laparoscopic surgery associated with lower rate of morbidity and shorter hospital stays than open surgery; perform during first hospitalization whenever possible; “golden period” refers to 72 hr after symptom onset (speaker attempts laparoscopic cholecystectomy if patient capable of tolerat­ing conversion to open surgery); with contraindicating comorbidities or factors, treat nonoperatively initially (percutaneous cholecystostomy); allows optimization of comorbidities; may change urgent surgery to elective surgery (conversion rate still »15%); fibrotic or scleroatrophic gallbladder  —  chronic inflammation may com­plicate removal; other difficult cases  —  patients with Mirizzi syndrome, gastrointestinal fistula, cirrhosis or por­tal hypertension, perforated or porcelain gallbladder, xanthogranulomatous cholecystitis, or previous cholecystostomy (remove tube halfway through procedure; sometimes helps locate gallbladder)

Technical problems: grasping and manipulating gallbladder; dissecting and identifying hilar structures; bleeding; limitations of laparoscopic technology (eg, 2-dimensional vision, difficulties in controlling hemorrhage, limited haptic sensation)

Approach: find and stay on gallbladder wall during dissection; speaker usually starts part-way up gallbladder and works back toward hilum; dissect gallbladder neck away from bed; widely open hepatocystic triangle; move in­fundibulum back and forth to appreciate 3-dimensional anatomy; place lateral traction on gallbladder to dysalign cystic and common ducts; display “critical view of safety” before clipping or dividing structures; angled laparo­scope mandatory; add another port if necessary; when in doubt, ask colleague’s opinion; puncture or decompress fundus of tense gallbladder; can perform fundus-first removal or start at midpoint; back wall of gallbladder can be left in situ, if necessary; US helps distinguish cystic duct from CBD; use of cholangiography through gallblad­der also an option; if cystic duct inflamed, ligate with detachable snare (eg, Endoloop); leave drain if necessary; if deep into gallbladder bed, leave suction catheter postoperatively (in case of damage to superficial bile duct)

Imaging of CBD: indicated if uncertain of anatomy; early cholangiography helps define location, length, and width of cystic duct, and presence of impacted stones; may provide road map to unusual segmental ducts; early US identifies junction of cystic duct and CBD

Alternative strategies: laparoscopic cholecystostomy; fundus-first cholecystectomy; subtotal cholecystectomy; con­version to open surgery

Indications for converting to open surgery: unclear anatomy; complication not reparable laparoscopically; severe disease; technical problems with equipment; failure to make progress

Top-down cholecystectomy: cannot elevate liver along with gallbladder; grasp gallbladder near liver bed and pull away; use traction and countertraction; divide mesentery while coming down (stay on gallbladder wall); when low on cystic duct or infundibulum, control bleeding with detachable snare; surgical clips may be used to ligate cystic duct; remember that bile duct injuries may still occur

Subtotal cholecystectomy: indications include severe inflammation, intrahepatic gallbladder, portal hypertension or coagulopathy, large, impacted stones in gallbladder neck or cystic duct, or gangrenous or perforated gall­bladder; may help prevent bleeding or bile duct injury in patients with cirrhosis or portal hypertension, but may also result in bile leak or biliary fistula (drainage necessary); stones may be left behind

Suggested Reading

Baluyut AR et al: Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis. Gastroin­test Endosc 2001 Mar;53(3):308-12; Bambha K et al: Incidence, clinical spectrum, and outcomes of primary sclerosing cholangitis in a United States community. Gastroenterology 2003 Nov;125(5):1364-9; Chapman R et al: Diagnosis and management of primary sclerosing cholangitis. Hepatology 2010 Feb;5(12):660-78; Flum DR et al: Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA 2003 Oct 22;290(16):2168-73; Kelly MD: Laparoscopic ret­rograde (fundus first) cholecystectomy. BMC Surg 2009 Dec 11;9:19; Kim WR et al: A revised natural history model for primary sclerosing cholangitis. Mayo Clin Proc 2000 Jul;75(7):688-94; Machi J et al: The routine use of laparoscopic ul­trasound decreases bile duct injury: a multicenter study. Surg Endosc 2009 Feb;23(2):384-8; Phillips EH et al: Treatment of common bile duct stones discovered during cholecystectomy. J Gastrointest Surg 2008 Apr;12(4):624-8; Sicklick JK et al: Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy. Ann Surg 2005;241:786-95; Singhal T et al: Laparoscopic subtotal cholecystectomy: initial experience with laparoscopic management of difficult cho­lecystitis. Surgeon 2009 Oct;7(5):263-8; Soleimani M et al: Partial cholecystectomy as a safe and viable option in the emergency treatment of complex acute cholecystitis: a case series and review of the literature. Ann Surg 2007 May;73(5):498-507; Stewart L, Way LW: Laparoscopic bile duct injuries: timing of surgical repair does not influence suc­cess rate. A multivariate analysis of factors influencing surgical outcomes. HPB 2009;11:516-22.