The management of benign strictures of the bile duct

THE MANAGEMENT OF BENIGN STRICTURES OF THE BILE DUCT

MANAGEMENT

OF

STHICTUHES

OF

THE

BILE

DUCT

Strictures of the bile ducts, particularly those at the hilus of the liver, present a challenge to the skill of any hepatobiliary surgeon. The continuing incidence of iatrogenic bile duct injury during operation on the biliary tract, and the more frequent preoperative recognition of primary bile duct cancers, have resulted in an increasing number of patients with “high” biliary strictures being referred to specialist surgical units. We herein describe in detail the management of these lesions. The pessimism that is frequently associated with the treatment of “high” bile duct strictures is unjustified. Expert repair of benign bile duct strictures gives excellent long-term results in the large majority of cases. Although many patients with hilar bile duct cancer will have a limited survival, an aggressive surgical policy allows resection of these lesions in approximately 20% of cases and improves the length and quality of survival. Surgical palliation by means of biliary enteric bypass for irresectable lesions also provides good symptomatic relief and is an alternative to nonsurgical intubational techniques. Anatomy There are wide anatomical variations in the extrahepatic biliary tree and adjacent hepatic arterial and portal venous structures. Anomalies of the vessels, in particular of the hepatic artery, are very frequent and occur in more than 20% of patients. The most common is for the right hepatic artery to arise in whole or in part from the superior mesenteric trunk. The anomalous vessel usually runs up to the right of the portal vein and just posterolateral to the bile duct, running close to the cystic duct at the neck of the gallbladder. The important ductal anomalies are nearly all related to the manner of confluence of the right and left hepatic ducts, and of the cysCur-r Probl

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tic duct, with the common hepatic duct. Variations are so frequent that the surgeon must be acquainted with their range and should always expect the unusual. The cystic duct may join the common hepatic duct high, almost at the hilus of the liver. The right hepatic duct as such may be absent, and the major ducts draining the anterior and posterior sectors of the right liver may join the left hepatic duct separately to form the common hepatic duct (Fig 1). In some cases the right anterior or right posterior sectoral duct may run a long extrahepatic course to join the common duct, and the cystic duct may drain directly into such a duct (see Fig 1). However, while these variations are common, the anatomy of the left hepatic duct and its branches is almost always consistent. The right hepatic duct has a short extrahepatic portion, but the left hepatic duct dways has an extrahepatic course, the length of which is reflected by the width of the base of the quadrate lobe. If the quadrate lobe has a broad base then the left hepatic duct has a long, rather transverse course, whereas if the quadrate lobe is pyramidal, with a narrow base, the left hepatic duct has a short, somewhat more oblique course. In the author’s experience these features may be predicted on the basis of the cholangiographic appearances. The left hepatic duct courses to the hilus together with the left branch of the portal vein and hepatic artery, within a peritoneal reflection of the gastrohepatic ligament, which fuses with Glisson’s capsule on the undersurface of the quadrate lobe (Fig 21. The vessels and accompanying left hepatic duct then enter the umbilical fissure of the liver, at the limits of which the vessels divide to supply the

FIG 1. Variations in the anatomy of the confluence of the right and left hepatic ducts. Note the variable site of union of the anterior and posterior right sectoral ducts.

8

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Anterior

FIG 2. Gastro-hepntic

I

Vein

Duct LESSER

Sagittal section showing the anatomy the left hepatic duct, portal vein, and hepatic artery within the gastrohepatic ligament beneath the quadrate lobe (segment IV).

of

\ Artery SAC

left lobe (Fig 3, segments II and III) and the quadrate lobe (segment IV). The left hepatic duct receives a major tributary from each of these segments, which converge in the umbilical fissure dorsocranial to the left portal vein, the segment III tributary running close to the umbilical portion of the vein on its left side. Hepatic ductal tributaries from the quadrate lobe (segment IV) and hepatic arterial and portal venous branches supplying it reculve from the umbilical fissure to the quadrate lobe (see Fig 31. The ligamentum teres in the lower edge of the falciform ligament traverses the umbilical fissure of the liver, which is usuaIly, but not always, bridged in its lowermost part by a tongue of liver tissue joining the left lobe segment III to the base of segment IV. The ligament joins the umbilical portion of the left portal vein as it curves anteriorly, giving off branches to segments II and III of the left lobe. At the base of the ligamentum teres, and on its upper surface, the umbilical portion of the left portal vein branches over the bile ducts to supply the quadrate lobe and segment III (vide infral. The techniques to be described in this contribution rely on these anatomical features. Anastomoses are usually carried out either at the hilus, to the major right or left hepatic ducts or to the segment II or III ducts of the left lobe.

FIG 3. An exploded view of the segmental liver anatomy as described in detail by Bismuth.” (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livingstone, in press. Reproduced by permission.)

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Pathological

Eflects of Bilary Obstruction

FIBROSIS Biliary obstruction is associated with the formation of high local concentrations of bile salts at the canalicular membrane, and these initiate pathologic changes in the biliary system.151 Bile thrombi form within dilated centrilobular bile canaliculi, and secondary changes are seen in adjacent hepatocytes. An inflammatory exudate forms, leading to the deposition of collagen and eventually to fibrosis and scarring around bile ducts and ductules, which ultimately causes mechanical interference with bile flow, and continuing cholestasis. The fibrosis is accompanied by liver cell hyperplasia.*” The lobular structure of the liver is usually well preserved, and the marked fibrosis which occurs in long-standing cases only rarely proceeds to a true cirrhotic pattern. This observation is of importance since such a liver may return to near normality following relief of biliary obstruction.‘g Evidence of liver fibrosis associated with portal hypertension may become evident as early as two years after the onset of obstruction. Major stigmata of hepatocellular dysfunction such as spider nevi, asterixis, and porta systemic encephalopathy are not common in biliary obstruction and should make the clinician suspicious that there may be another cause of liver disease. Liver biopsy may reveal a major component of primary hepatocellular disease (e.g., alcoholic cirrhosis) in association with biliary obstruction. Changes also occur in the extrahepatic ducts, which are subject to fibrosis and upward retraction, especially in the presence of a biliary leak, infection, and perhaps ischemia. This is accompanied by mucosal atrophy and squamous metaplasia. Inflammatory iniiltration and fibrosis are also seen in the subepithelial layers of the ducts, especially in long-standing obstruction. LIVER ATROPHY The distribution of liver mass is regulated by a complex control mechanism in which bile flow, portal venous flow, and hepatic venous flow are the main regulators. Quality and quantity of portal venous inflow are important in maintenance of liver cell size and mass. Segmental or lobar atrophy results from a degree of segmental portal venous occlusion or bile duct occlusion. Unilobar atrophy is associated with hypertrophy of the contralateral lobe and may present diagnostic and operative difficulties. Changes of this nature are frequently found in hilar strictures (Fig 4) and may be associated with asymmetrical involvement of lobar or sectoral hepatic ducts, direct interference with the blood supply, particularly the portal venous branches, or with decreased portal perfusion consequent on drainage of grossly dilated secondary fibrotic changes.50 Although 10

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A CT scan of a patient with cholangiocarcinoma obstructing the hilus, with resultant atrophy of the left lobe of the liver. The dilated left lobe ducts can be clearly seen, and are “crowded” together because of the loss of hepatic parenchyma.

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ducts within an atrophic segment may not be effective in improving hepatic function, particularly in patients with benign strictures. These ducts within the atrophic remnant are frequently filled with infected bile; in these cases continued cholangitis is inevitable unless drainage is obtained. Atrophy occurs more commonly in association with high bile duct tumors and is an important feature to be taken into account in planning treatment. BENIGN

BILIABY

STRICTURES

Benign stenoses and strictures of the bile ducts occur in a number of conditions and may affect the intrahepatic or extrahepatic biliary tree. They may be single or multiple. Table 1 details those causes of benign bile duct strictures discussed in this contribution. The treatment of sclerosing cholangitis and recurrent pyogenic cholangitis are not discussed in detail, although the techniques described may be of use in some of these cases. Bile Duct

Injuries

“Injuries to the bile ducts are unfortunately be tragedies” (Grey-Turner67).

not rare and often turn out to

Injury to the bile ducts may follow damage inflicted during upper abdominal operations, usually cholecystectomy, or may be due to blunt or penetrating abdominal injury. Injuries occurring during TABLE The

1.

Causes

of Benign

Bile Duct

Stricture

Bite duct injuries Postoperative bile duct strictures following: Injuries at cholecystectomy and exploration of the ‘common bile duct Injury after other operative procedures: Biliary enteric anastomosis to previously normal bite ducts Following operations upon the liver or portal vein Pancreatic operations Gastmctomy Following a variety of other operations (I-arely) Stricture after blunt or penetrating injury Postinflammatory strictures Associated with gallstones Associated with chronic duodenal ulcer Granulomatous lymphadenitis Associated with abscess or inflammation in the subhepatic region or in the liver Associated with chronic pancreatins 12

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surgical operations are of importance because they are preventable and because they produce considerable mortality and morbidity far in excess of that recognized for the initial surgical procedure. Repair must be carried out in a precise and expert manner at the Jirst attempt, since repeated operative intervention is associated with less good results. Postoperative

Bile Duct Strictures

The risk of operative injury to the biliary tract varies with the operation being performed and, with the exception of injury at cholecystectomy, there are no studies that reflect the frequency of such damage. Many injuries are not reported at all or are not detected, the patient’s ultimate illness being ascribed to some other cause. While the great majority of injuries to the bile duct occur during cholecystectomy, with or without exploration of the common bile duct, a number also occur in association with other operations, on the stomach, the pancreas, the liver, or for portal hypertension. Stricture of biliary enteric anastomoses occur following reconstructive or bypass procedures in association with other operations, for example, pancreaticoduodenectomy.@’ It is important that such strictures are not misinterpreted as recurrent carcinoma. In addition to injury to a normal biliary tree, damage may also follow operations performed on the diseased biliary tract, as for example after excision of a choledochus cyst, or following operations for sclerosing cholangitis. POSTCHOLECYSTECTOMY INJURIES Cholecystectomy has a high degree of safety, but it is important to remember that it is a major operation and should never be undertaken lightly. While results are good, they are not uniformly so, and some reports suggest that 20% to 25% of patients will have some continuing symptoms.32 Of those with continuing problems only 5% will have severe symptoms such as jaundice, pancreatitis, or cholangitis .25,26 A minority of patients will suffer damage to the biliary tree. Figures are available from surveys carried out in Sweden, Finland, Germany, and France,15’ 6sZ144’ 17’ and all suggest the incidence of biliary injury is roughly two per 1,000 operations for gallstones.ll’ ” Causative Factors and Prevention.-A bile duct injury during cholecystectomy. ANATOMICAL,

duct duct patic also

joins from duct, occur

Cur-r Probl

number

of factors

relate to

vAstKnoNs.-Bile duct injury may occur when the cystic the common hepatic duct at a high level, enters a sectoral the right liver, or is closely adherent to the common herunning together with it in a common sheath. Injury may if the cystic duct is short. In such cases misinterpretation

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of the anatomy and indeed of operative cholangiography can easily occur, especially if a cannula has been advanced so far that it passes into the common bile duct. In this instance, if there is no distal obstruction, the contrast medium passes rapidly down the duct and into the duodenum, there being no display of the proximal ducts. The surgeon can then easily mistake the common bile duct for a long cystic duct, ligate it and remove it along with the attached gallbladder.86 This situation should not be confused with the almost obliterated cystic duct found in long-standing cholelithiasis and chronic cholecystitis.s5 H!3MoRRuAGE.-During attempts to control bleeding encountered during cholecystectomy there may be damage to the bile ducts if clamps are applied blindly.3s The bleeding usually arises from the cystic artery or from the right hepatic artery, although injury to the common hepatic artery also occurs. In a series of 78 postcholecystectomy biliary strictures studied at Hammersmith Hospital, London, selective celiac angiography was performed in 2.5 patients because of a history of vascular damage at operation prior to referral, or because of subsequent hematemesis or melena, the presence of esophagogastric varices seen at endoscopy, or a palpable spleen. Evidence of arterial damage or abnormality was noted in 14, and damage to the portal vein or one of its branches in five cases. In three patients portal venous compromise was accompanied by segmental or lobar liver atrophy. Esophagogastric varices were demonstrated in five patients and splenomegaly in nine.30 On occasion not only is there a bile duct stricture or stenosis, but a hepatic artery aneurysm may form and erode into the biliary tree, producing hemobilia.s7 BILE DUCT tscHEMIA.-The microcirculation of the extrahepatic biliary tree has been investigated by Northover and Terblanche.1zs”30 The blood supply of the bile duct runs in three columns, one posterior and two lateral. It is suggested that damage to these vessels may result in ischemia to the bile duct, with consequent necrosis and stricture. The likelihood of such an event would be increased by dissection of the common bile duct during cholecystectomy, or by undue mobilization prior to choledochotomy. There is no firm evidence for this proposition, but it would seem reasonable not to pursue extensive dissection of the common bile duct during cholecystectomy as is taught in some centers. In addition, transection of the bile duct disturbs the blood supply, in particular arterial flow arising from its lower end. Ischemia occurring in the upper transected duct is undoubtedly responsible for the remarkable scarring and retraction of the stricture toward and into the hilus, so frequently seen. 14

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PATHOLOGIC FAcroas.-Acute cholecystitis may be accompanied by extensive edema in the region of the porta hepatis and Calot’s triangle, and there may be considerable friability during dissection. Under these circumstances damage might more easily occur, and if dissection appears hazardous cholecystostomy or partial cholecystectomy (vide infra) may be a safer option than cholecystectomy.5z Of greater significance is the small contracted fibrotic gallbladder with considerable surrounding scarring which obliterates Calot’s triangle so that the gallbladder lies close against the common hepatic duct. In such instances dissection of &lot’s triangle is impossible. Furthermore, cholecyst-choledochal fistula is not uncommon in long-standing disease, and there may already be a preexisting benign stenosis consequent upon the inflammation.lzl Any patient presenting with gallstones, jaundice, and attacks of cholangitis, who at operation has such a gallbladder should be suspected or harboring a cholecyst-choledochal fistula. In these circumstances it is wiser to remove the greater part of the gallbladder wall, which is easily visible, and to remove the stones. Such a “partial cholecystectomy” is a safe option and allows direct inspection of the depths of the gallbladder. If a fistula is then found it is almost always associated with some narrowing of the bile duct just distal to the fistula and is best managed by mobilizing the duodenum and carrying out a cholecystcholedochoduodenostomy.

TECHNICALFACTORS.-while it is true that some bile duct injuries occur following cholecystectomy performed by surgeons who are inadequately trained or inexperienced,5 many occur after cholecystectomy done by experienced surgeons.67 Injury is much more likely to occur if the surgeon is attempting to operate single-handed and without adequate assistance. The reasons for error are often difficult to determine in a particular case. It is usually assumed that the hepatic duct or common bile duct is mistaken for the cystic duct and is partially excised or ligated. Of 78 cases seen at the Royal Postgraduate Medical Schoo13’ it was possible to incriminate this error in six, and certainly the high nature of the injury in most cases suggests direct damage to or ligation of the common hepatic duct.“l Abdominal incisions must be adequate in length and appropriately sited. Early demonstration of the cystic artery and cystic duct is desirable; the cystic artery should then be ligated close to the gallbladder wall so as to avoid any possible damage to the common hepatic artery or the right hepatic artery. A cystic duct cannula can then be introduced and operative cholangiography performed, which in addition to its advantage of indicating the necessity for bile duct exploration should reveal anatomical abnormalities.*24 Peroper-

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ative cholangiography is important in this respect, but acceptance of poor cholangiographic pictures may betray the surgeon, especially if there is not full demonstration of the biliary tree.86 In jaundiced patients, preoperative cholangiography is advisable and may be obtained by means of percutaneous transhepatic cholangiography or endoscopic retrograde cholangiopancreatography.‘O Dense fibrosis in the area of Mot’s triangle should lead to a change in policy, either resort to a partial cholecystectomy as described previou~ly,~~ or alternatively, dissection of the gallbladder from the fundus cautiously carried out. If difficulty is encountered as the neck of the gallbladder is approached, the attempted total cholecystectomy should be abandoned in favor of a partial procedure. In such densely fibrosed cases the cystic duct is always obliterated and postoperative biliary leakage does not occur. Excessive traction on the gallbladder during cholecystectomy invites tenting of the common bile duct/common hepatic duct junction, and creates a situation likely to result in excision of a segment of common duct. Some authors argue that the precise point of junction of the cystic duct with the common hepatic duct should be clearly demonstrated. This is unnecessary, and indeed such dissection might well lead to injury. Should bleeding occur during operation, its control must be precise. Blood is removed by suction. Arterial hemorrhage can be controlled by pressure with the finger and thumb on the hepatic artery at the free edge of the lesser omentum or by the application of a soft gastrointestinal clamp across this region. The offending vessel is then dissected and deliberately controlled. Should operative cholangiography reveal a small common bile duct with an intraductal filling defect indicating a possible small stone (or stones) in patients with multiple small stones within the gallbladder, some surgeons (including the author1 advocate simple cholecystectomy without exploration of the common duct. Virtually all such stones will pass asymptomatically. Furthermore, operative exploration of such a small duct in pursuit of a tiny stone is difficult, often unrewarding, and more likely to result in damage to the biliary system. Exploration of the common bile duct should involve careful exposure of a sufficient length of duct to allow choledochotomy, without extensive dissection and stripping of the bile duct of its surrounding connective tissue. Gentle exploration is carried out with soft gum elastic bougies, Fogarty-type balloon catheters, and choledochoscopy. There is a danger that, should metal bougies, such as Bakes dilators, be passed downward through the papilla into the duodenum, subsequent secondary postinflammatory stenosis of the papilla of Vater might occur. In addition, false passages may be created. The 16

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dilator may pass into the pancreatic tissue, or through the bile duct wall proximal to the papilla and into the duodenum, creating a choledochoduodenal fistula. Choledochoduodenal fistulae, whether due to passage of an instrument as described above or following an erroneously placed sphincteroplasty, may result in jaundice, cholangitis, and pancreatitis.80 Passage of a dilator into the pancreas may result in postoperative pancreatitis,15’ and a secondary bile duct stricture may result. Stenosis or stricture of the suprapapillary common bile duct may also follow operative sphincteroplasty or endoscopic papillotomy. Exploration of the common bile duct at the time of cholecystectomy should usually be supraduodenal. Sphincteroplasty is reserved by most surgeons for patients with a stone impacted at the papilla of Vater.l” 167 In patients with multiple stones, or primary stasis stones, or where there is distal obstruction as with stenosis of the papilla of Vater, the surgeon may elect to carry out choledochoduodenostomy. If an adequate stoma is created the results are good and late stenosis or cholangitis are rare.112’ 113J153On the other hand, choledochoduodenostomy performed on a narrow common bile duct invites stenosis, perhaps associated with bile duct stricture. After exploration of the common bile duct cholangiography or choledochoscopy is performed. Care must be taken not to damage the duct by repeated suturing. We prefer the method of postexploratory cholangiography described by Gunn and colleagues,127 in which a small Foley catheter (with the tip amputated) is used to occlude the ducts, allowing proximal and distal cholangiography without the necessity of closing the choledochotomy before each x-ray series. Diagnosis.-The diagnosis of benign bile duct stricture requires a precise demonstration of the level and extent of the stricture as well as of damage to adjacent blood vessels. CLINICAL PassaNrAnoN.-Damage to the biliary tree may be recognized at operation, but the evidence of injury is often not appreciated until early in the postoperative period, and sometimes not until months later. Excessive biliary drainage from the wound or drain site in the early postoperative period may indicate a major injury to the bile ducts. In other patients, localized or generalized peritoneal signs become evident, and an intra-abdominal collection of bile is drained at a second operation. In some cases there is a history of postoperative biliary drainage and fever, and perhaps even of a subphrenic or subhepatic abscess, the patient then being free of symptoms for some months before developing recurring bouts of pyrexia, rigors, and jaundice. In other patients, steadily progressive obstructive jaundice may be the first sign that a duct has been injured. CurrProblSurg,

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Jaundice is usually present. Sometimes a bile duct injury associated with fever may present without jaundice; in such cases an internal or external biliary fistula may have been established, or the stricture may involve only one sectoral or lobar duct. In the presence of recurring bouts of cholangitis or an established biliary fistula, weight loss and debility are invariable. The patient may complain of itching, and scratch marks may be evident on the limbs. Hepatomegaly, frequently present, usually indicates long-standing obstruction. Splenomegaly may be the result of secondary hepatic fibrosis with associated portal hypertension, but the possibility of direct damage or thrombosis of the portal vein must be considered. Splenomegaly, esophageal varices, or the presence of frank signs of liver failure such as spider nevi, a liver flap, or ascites, alert the clinician to the possibility of associated hepatocellular disease. Exclusion of this as an additional factor in a patient’s illness is of importance not only in planning management, but also in a medicolegal context. ~ORATORY INVESTIGATIONS.-The liver function tests usually show a cholestatic pattern. The serum bilirubin and alkaline phosphatase levels are raised. With incomplete or sectoral obstruction the serum alkaline phosphatase level is usually elevated, even though the serum bilirubin level may be normal. Serum transaminase levels may be within normal limits or may be elevated, especially if there is cholangitis. In cases of prolonged obstruction the serum albumin level may be depressed. The blood urea concentration should be measured, and it is advisable to record the serum creatinine value as an index of renal function. RADI~L~GI~ IiwEsTIcAnoNs.-On occasion contrast medium can be injected through an external fistula or tube in situ to outline the biliary ductal system. Since biliary infection is inevitably present in such cases, it is wise to protect the patient with antibiotic prophylaxis against the bacteremia that may accompany cholangiography. Ultrasonography, an excellent means of demonstrating dilatation of the intrahepatic ducts, is of less value in a precise demonstration of the extent of stricture. Percutaneous transhepatic cholangiography (PTC) is the key investigation, although some investigators are wary of its use preoperatively because of the risk of cholangitis and leakage of bile.” Performed with the fine needle,13’ the procedure is safe and, provided antibiotic cover is used and the ducts not overfilled, cholangitis and leakage are uncommon. The biliary ductal system is entered in almost 100% of cases, and a successful cholangiogram demonstrates the level and extent of the stricture (Fig 5). Modern surgical technique allows an ordered approach to the selection of a reconstructive operation. Full demonstration of all branches 18

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FIG 5. Percutaneous transhepatic cholangiogram in a patient with a complex benign stricture following three previous attempts at repair. Note the multiple small secondary calculi in the lower right intrahepatic ducts. The vertically running left main hepatic duct suggests a short extrahepatic course.

of the intrahepatic biliary tree is necessary, and in particular a display of the confluence of the bile ducts (if intact) and of the left ductal system and its branches. Endoscopic retrograde cholangiopancreatography (ERCP) is seldom of value in the precise diagnosis of complete high bile duct stricture, since discontinuity of the common bile duct usually prevents display of the intrahepatic ducts. The procedure is of value in demonstrating an incomplete stricture (stenosis). In addition, it is important to carry out ERCP in any patient in whom there is a history of damage to the sphincter at the time of initial exploration of the common bile duct and particularly in the presence of associated unexplained upper abdominal pain, since papillary stenosis and perhaps associated pancreatitis may be demonstrated. The presence of sphincteric incontinence consequent on surgical or endoscopic sphincterotomy or an associated choledochoduodenal fistula25z80 may complicate a biliary stricture and contribute to the occurrence of cholangitis.s4 Curr

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If there has been excessive bleeding at the time of cholecystectomy, or if there is any suspicion either from the history, the presence of a palpable spleen, or endoscopic evidence of varices that the patient has portal hypertension, arteriography and portography are necessary (Fig 6). The latter is usually obtainable by examination of late phase films after splenic arteriography. Occasionally direct percutaneous splenoportography is necessary. Digital subtraction angiographic techniques have facilitated these studies. It is of some importance to recognize that unilateral bile duct and or portal venous obstruction can lead to liver atrophy (vide supra).” The radiologic signs of atrophy include crowding and irregularity of the smaller biliary radicles (Fig 7) and arteries within the affected area. Isotope scanning with HIDA may show a filling defect in the

FIG 6. Selective hepatic arteriogram in a patient with a benign biliary stricture following a cholecystectomy, in the course of which excessive bleeding occurred. The right hepatic artery is completely occluded (arrow) and the right lobe is supplied by multiple collateral vessels. 20

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FIG 7. Percutaneous transhepatic cholangiogram in a patient with a long-standing benign hilar stricture. There is marked right lobe atrophy associated with dilatation and “crowding” of the right intrahepatic ducts. The left lobe has undergone compensatory hypertrophy. The main left hepatic duct in this patient pursues a near-horizontal course (arrow) suggesting a reasonable length of extrahepatic duct available for anastomosis.

atrophic area, and CT scanning may reveal dilated ducts with loss of hepatic parenchyma.50 Despite widely dilated ducts in such atrophic segments, the liver tissue draining into these ducts does not function normally. Isotopic scanning techniques may be of value in the assessment of bile duct strictures, and in particular in the functional assessment of incomplete strictures and of anastomoses carried out at previous reconstructive attempts. Studies at the Royal Postgraduate Medical School, London,ll’ suggest that HIDA scanning may be of particular value in cases of incomplete stricturing, or re-stenosis, and when ultrasonographic examination shows a nondilated ductal system. Similarly, in patients with hepatocellular disease HIDA scanning may be of help in assessing the contribution of restricture to biochemical abnormalities and symptoms as distinct from that due to the priCut-r

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mary liver disease. In some cases with severe stenosis the bilirubin level may be normal but the alkaline phosphatase level raised. PTC is invasive and may be difficult if the liver is fibrous and tough. Endoscopic retrograde cholangiography is impossible in the presence of a Roux loop. HIDA scanning is also valuable during follow-up of patients after surgical repair since it can be repeated and is noninvasive. It is of a special value in demonstrating anastomotic patency and function in patients in whom no tube was left across the anastomosis at the time of repair. Clinical Interpretation.-Discovery at cholangiography of an area of stenosis or incomplete stricture is not necessarily an indication for immediate operation. It is important not “to treat x-rays.” An established internal fistula may provide good long-term biliary drainage, and quite severe degrees of stenosis on cholangiography may be associated with little in the way of symptoms and near-normal liver function tests. Similarly, it may be advisable in selected cases, especially in elderly patients, to accept a degree of obstruction or segmental obstruction if symptoms are minimal and easily controlled (for example, by intermittent administration of antibiotics). In a series of 78 patients the author managed four successfully in this way for periods of nine months to five years without resort to operation and without evidence of progressive illness. In all patients in whom operative treatment is not selected, regular observation is required, since progressive liver damage may be insidious and a persistently elevated alkaline phosphatase level the only index of incomplete obstruction. Similarly, balloon dilatation of benign strictures may be successfu1123’ 154,16’,176,lso, but long-term results are not yet available, and incomplete relief of obstruction may prove to be associated with relief of symptoms while progressive liver damage is occurring (vide infral. Finally, it is important to emphasize that endoscopic examination of the papilla of Vater and of the peripapillary area is advisable in patients with pain as well as cholangitis, since abnormalities in this region may be contributory to or causative of symptoms without regard to the presence of a severe degree of stenosis higher in the biliary tree. Classi$cation and Severity-The ease of management, operative risk, and ultimate prognosis of benign bile duct strictures vary considerably. In a recent review of 34 series published since 1900 totalling 7,643 procedures performed in 5,586 patients, the overall operative mortality was 8.3%.ls6 The factors influencing the outcome are listed in Table 2. Younger patients have a better prognosis than do older ones, and severe coincident disease (e.g., cardiorespiratory disease) is associated with a worse outlook. The presence of hepatocellular disease 22

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TABLE

2.

Prognostic Bile Duct

Factors Stricture

in Patients

With

Benign

General 49 Coincident disease Local Level of stricture Liver fibrosis/cirrhosis Portal hypertension Infection Previous operation Technical experience

of the surgeon

or established secondary liver fibrosis and portal hypertension are important adverse features.‘55 It has long been recognized that strictures involving the common bile duct or low common hepatic duct are easier to repair than higher strictures, which may involve the confluence of the bile ducts. In recognition of this, Bismuth” has proposed an anatomical classification of bile duct strictures into five types, shown in Table 3 and Figure 8. In addition, the presence of infection and in particular, previous attempts at operative repair have a bearing on outcome. The best chance of repair of bile duct injuries is at the first attempt. Morbidity and mortality probably rise at each subsequent effort.ls6 The first repair should be carried out by a surgeon with the experience likely to allow the highest chance of a successful outcome. In a study at Hammersmith Hospital a number of preoperative indices of outcome were defined, based on the history and biochem-

TABLE

3.

Anatomical

Type1 Type2 We3

Type4 Type.5

Classifications

of Bile Duct

Strictures*

Low common hepatic duct stricture Hepatic duct stump > 2 cm Mid-common hepatic duct stricture Hepatic duct stump < 2 cm Hi& stricture (hilar) No hepatic duct Confluence intact Destruction of hilar confluence Ftight and left hepatic ducts separated Involvement of sectoral right branch alone the common duct

*Adapted from Bismuth H: Postoperative strictures gart LH led): The Biliary Tract. Edinburgh, Churchill gery IntemationF& 1982, vd 5, pp 209418.

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or with

of the bile duct, in BlumLivingstone, Clinical our-

23

FIG 8. Classification of bile duct strictures based on the level of the stricture related to the confluence of the hepatic ducts (after Bismuth”). (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livingstone, in press. Reproduced by permission.)

ical assessment of 78 cases of postcholecystectomy stricture. It was found that portal hypertension occurred more often in patients with prolonged duration of obstruction and with frequent episodes of cholangitis. Major infection was significantly more common in patients who had had more than one operation before referral. There ivas a highly significant relationship between the presence of liver fibrosis and a history of major infection, and between depressed levels of serum albumin and postoperative mortality. Similarly, patients with high strictures (Bismuth type 3 and 4) fared worse than patients in whom some part of the common hepatic duct was still intact.30 In essence, patients with multiple previous operations, those with high strictures, and particularly those with liver disease and portal hypertension fared badly, and infection was a major determinant in the progress of disease. Such prognostic indices are of importance in planning therapy and should be taken into account in the assessment of the new interventional radiologic approaches to bile duct stricture. Preoperative Management.-Except in the case of strictures recognized at the time of primary cholecystectomy or in patients in whom emergency operation is dictated by virtue of peritonitis, there is no hurry in proceeding to surgical reconstruction for bile duct stricture. Full investigation should be performed and the patient brought to optimal condition prior to operation. 24

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In the presence of recurrent cholangitis, administration of antibiotics is important as a preliminary to surgical treatment. The correct antibiotic can be selected on the basis of cultures obtained from aspiration of bile at percutaneous transhepatic cholangiography. Antibiotic regimens should take into account the not infrequent presence of anaerobic organisms in the presence of bile duct stricture.17 The most frequently used antibiotic regimen at Hammersmith Hospital is piperacillin and tobramycin commenced immediately preoperatively and maintained for five days in the postoperative period. Anemia should be corrected by blood transfusion and coagulation defects, usually a prolongation of the prothrombin time, by the administration of vitamin K. The nutritional status of patients with bile duct stricture is important. Some patients are anorexic and grossly malnourished. We have found that while feeding through a fine-bore transnasal catheter may be successful in some cases, that enterally administered nutrients are often not tolerated and that parenteral nutrition is frequently necessary. Despite all these measures, weight gain can be difficult to achieve in a patient with biliary tract obstruction, especially in the presence of infection. If there is a significant external biliary fistula the patient will lose electrolytes, and hyponatremia is a particular risk.38, ‘lfi Treatment.-The treatment of patients with benign bile duct stricture often requires the preliminary management of complications such as biliary peritonitis, subphrenic or subhepatic abscess, hematemesis due to erosive gastritis or varices, and of liver failure consequent on liver fibrosis. In general, drainage of abscesses and control of erosive gastritis are carried out before a definitive attempt to repair the stricture. On the other hand, if sepsis arising from the obstructed biliaxy tree is a feature, especially in the causation of erosive gastritis, then immediate biliary drainage is essential. This also applies to patients with bacteremia and renal failure. Drainage may be obtained at operation, but in such desperately ill patients it may be preferable to attempt percutaneous transhepatic biliary drainage as a temporary measure to allow resuscitation. The question of the management of portal hypertension occurring in association with stricture is discussed below. A biliaty fistula should in general be managed conservatively in the first instance (vide infral. The operative management of biliary stricture depends on whether the injury is recognized at the time of original operation, presents in the postoperative period, or occurs as a late event. INJURYRECOGNIZEDAT THE TIME OF OPERATION.-lf injury t0 the extrahepatic biliary tree is recognized at the time of cholecystectomy, then the surgeon should immediately consider his experience and competence to deal with the situation. If a more experienced opercur-rmob/

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2.5

ator is available within the hospital, advice should be sought. There is always time to insert a pack, cover the wound, and wait a short while for another opinion. The damaged area and the bile ducts on either side require careful dissection to define the extent of the injury. The injury may be high, close to the hilus of the liver, or lower in the supraduodenal area, involving the common bile duct/cystic duct confluence. The injury may be partial, with maintenance of mucosal continuity along one wall of the bile duct, or there may be complete transection or even excision of a tubular length of common bile duct/common hepatic duct. Whether the lesion be high and close to the hilus of the liver or low, initial repair of injury recognized at the time ofcholecystectomy should have two basic aims: (1) to maintain duct length and not to sacrifice tissue; and (2) to effect a repair that does not result in postoperative b&at-y leakage. Initial repair may not be the final definitive reconstruction. This is particularly true of injury to a very small duct whose repair may be difficult. The prime aims of preventing fistula and maintaining length should guide the surgeon rather than elaborate attempts at initial reconstruction under difficult circumstances. It is probably preferable to provide external biliary drainage by means of a tube inserted proximally and to refer the patient for treatment by a specialist, than to complicate the situation by an attempted repair that causes further damage to the proximal ducts. Unfortunately the injury is almost always total and involves transection or e,xcision of a length of bile duct. Occasionally only a right sectoral duct is transected or ligated (type 5, Bismuth1 (Fig 9) and there may or may not be involvement of the common hepatic duct or common bile duct as well. Injury is particularly likely to occur if the common biliary channel is small, and in such cases repair is likely to be difficult. Several options are open to the surgeon. Lateral injuries without loss of length are unusual but important to recognize, since repair may be possible by direct suture of the defect over a T-tube. Longer lateral injuries that are not circumferential are much more difficult or impossible to suture transversely. Some authors have suggested on the basis of experimental and clinical evidence that a vein patch may be performed to cover such a defect, and indeed vein grafts have been used to bridge gaps in the bile ducts.8’568120 Others have used flaps of the cystic duct stump or pedicled flaps of jejunum to close such defects.131 We have had no experience with these techniques, and indeed in two cases found the edges of the defect to be ragged and direct patching difficult. In this situation a Roux-en-Y loop of jejunum can be prepared and used as a serosal patch. A Ttube is placed across the defect, its long limb led out through the 26

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FIG 9. Patient with a persistent biliary fistula following cholecystectomy. (A), Tubogram. Only right-sided intrahepatic ducts are seen. Note that the ducts appear to be “Wept” peripherally. This appearance was due to a chronic subphrenic abscess cavity. (B), ERCP in the same patient showing the common duct with filling of the left and part of the right ductal system. There was no filling of the fistula tract or the remaining right intrahepatic ducts. This is an example of a Bismuth type 5 stricture, when a low inserted right SeCtOral duct is damaged at cholecystectomy.

ROUX loop and developed as a transjejunal tube to the skin. Such a repair has three advantages: length is maintained, the serosa of the jejunum is used to bridge the defect, and suture can be carried out with fine interrupted absorbable sutures to the bile duct wall or adjacent connective tissue without attempting direct suture to the ragged edge of a damaged bile duct. Finally, the T-tube decompresses the biliary system across the jejunum, so that when it is removed, a fistula to the adjacent jejunum remains. Two cases managed in this manner have remained well with normal liver function, four and six years after operation. If the bile duct has been transected and the ends can be apposed without tension, an end-to-end anastomosis may be feasible. The duodenum and head of the pancreas should be completely mobilized so as to minimize tension. The end-to-end anastomosis is performed with a single layer of interrupted fine chromic catgut, or other absorbable suture (e.g., Vicryl, Ethicon). The anastomosis is made over a T-tube brought out of the bile duct away from the anastomotic line. It is preferable to avoid direct duct anastomosis for high injuries, in which initial hepaticojejunostomy Roux-en-Y is more likely to give good long-term results.*’ The frequency with which immediate repair of the common bile duct is effective and long lasting is difficult to ascertain. While many CurrProb~Sur~,January

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27

injuries presenting in the late postoperative period are treated by specialists, injuries recognized at the time of operation may never come to the attention of referral centers and may not be documented. Some have suggested that the restricture rate is as high as 50% ,s8 but the evidence for this is not strong, and there is almost certainly a considerable underestimate of the number of bile duct injuries and of immediate repairs done in district hospitals. INJURIES RECOGNIZED IN THE EARLY POSTOPERATIVE PERtoo.-Injuries not recognized at the time of operation present in the early postoperative period in three ways. 1. There may be postoperative drainage of bile from the wound or from a drain site with the formation of a biZiary$stuZa. The essential in management in this situation is not to reoperate rapidly. It is wiser to take stock of the situation, to carry out fistulography, treat infection, nourish the patient, and wait. If fistulography demonstrates any continuity between the biliary system and the gastrointestinal tract, a prolonged period of drainage, if well managed, may result in spontaneous closure of the fistula. Eventual repair may be difficult because the bile ducts may be small, but the patient is not jaundiced and the adverse pathophysiologic features associated with cholestasis are not present. It is a mistake to think that immediate repair of such a fistula is a technically simple matter, since definitive exposure of healthy bile duct mucosa within a duct sufficiently large to permit good anastomosis can be very demanding, and indeed may be impossible. A cautious approach is often preferable, since ultimate closure of the fistula with the development of jaundice is usually associated with proximal ductal dilatation and easier subsequent repair.“j Should fluid loss from the biliary fistula prove too heavy and too prolonged, the external fistula can, alter some weeks or months, be converted to an internal fistula-jejunostomy? Definitive repair, if necessary, can then be carried out at a later date. 2. Presentation in the postoperative period may be as bile peritonitis. This is a serious situation, and the patient is often desperately ill, especially if the bile is infected, although in some patients with sterile bile huge volumes may accumulate within the peritoneal cavity without signs of shock. The management of bile peritonitis demands peritoneal drainage and control of the biliary peritoneal fistula, to save life. Definitive repair is seldom possible, the bile ducts being collapsed and friable and the tissues deeply stained with bile. External drainage is the best initial approach. This may be carried out through a mobilized Roux-en-Y loop of jejunum, the external drainage tube simply being led transjejunally to the exterior. Such a procedure allows initial control. The almost certain necessity for later reoperation for stenosis should be accepted.”

28

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3. Finally, the patient may become progressively jaundiced. case the injury should be managed as outlined below.

In this

INJURIESPRESENTINGATANINTERVALAFTERINITIAL OPERATION.-The principles of management of late biliary stenosis and stricture are as follows: 1. Exposure ofhealthyproximal bile ducts draining all areas ofthe liver. 2. Preparation of a suitable segment lined by normal mucosa, usually a Roux-en-Y loop of jejunum. 3. Mucosa-to-mucosa suture anastomosis of the bile ducts to the intestinal mucosa. Excision of the stricture and end-to-end anastomosis or repair of the damaged bile duct may be carried out in some rare cases. But almost invariably there is loss of length as a result of fibrosis of the common hepatic duct and commonbile duct. A staged procedure maybe necessary because ofanintra-abdominal abscess, hematemesis consequent on erosive gastritis, esophageal varices or other cause, or because ofpoorgeneral condition of the patient. Establishment of external biliary drainage and drainage of the intra-abdominal abscess may allow the patient's clinical condition to improve and the metabolic state to be brought under control before definitive management.40 Percutaneous transhepatic drainage techniques maybe ofvaluein such a staged approach,but there is scant published experience. Similarly, in portal hypertension initial esophageal injection sclerotherapy or even portasystemic shunting may be required to controlvariceal bleeding. Control ofhemorrhage maybe followedby later repair of the stricture. Biliary repair is substantially more difficult in the presence of portal hypertension. The dilated venous collateral channels lying within adhesions in the area of dissection are easily damaged, and intraoperative hemorrhage may be difficult to control. In such patients, interventional radiologic procedures may be used for the management of benign strictures by the introduction oftranshepatic percutaneously placed tubes to drain the biliarytree and simultaneous biliary dilatation of the stricture .lz3,154,16’,ISoThese methods may lead to immediate complications and are difficult to use in the presence of a fibrotic liver with minimally dilated ducts, but some authors report a preference for this approach in patients with portal hypertension.'36 Surgica/ Procedures.-END-To-END ANAsToMosIs-Excision of the stricture and end-to-end anastomosis may be carried out as reported by Cattell and Braasch.40 This establishes repair with a normal anatomical status and biliary drainage. Cattell had reported such anastomosis even for high strictures, but the procedure is now only used when the ends of the bile duct are close enough for anasCurr ProblSurg,

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tomosis to be performed without any undue tension and where there is no appreciable discrepancy in the diameter of the proximal and distal ducts. The quality of the distal duct must also be satisfactory. These conditions are but rarely met in strictures at or near the hepatic hilus. A single row of interrupted fine chromic catgut or Vicry1 sutures is used, the anastomosis being created over a T-tube inserted at a separate point (Fig 10). BILL4RY ENTERIC REPAIR PROCEDURES.-In the V&St majority of Cases a biliary enteric repair procedure must be carried out to establish drainage of bile into the intestinal tract. For strictures of the retropancreatic portion of the common bile duct or of the common bile duct in its immediate supraduodenal portion, a choledochoduodenostomy is an ideal procedure, performed side-to-side or end-to-side. The procedure yields better results if the common bile duct is dilated. Low injuries suitable for treatment in this manner, unusual after cholecystectomy occur more often after gastric operations (vide infra). Strictures involving the common hepatic duct are more difficult, especially close to the hilus of the liver and are best dealt with by hepaticojejunostomy. When the stricture is of the Bismuth type 1 or 2, an approach to the common hepatic duct stump is usually not unduly difficult. When the stricture involves the confluence of the right and left hepatic ducts (type 3) or extends so as to separate

FIG 10. Method of repair of a biliary ductal injury by end-to-end anastomosis over a T-tube. (From Blumgart LH [ed]: Surgery of the Lwer and Mary Tract. London, Churchill Livingstone, in press. Reproduced by permission )

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these ducts (type 41, the problem becomes good results are more difficult to obtain.

much more complex

and

INcisIoN.-Adequate exposure is necessary to allow full visuabzation for good biliary enteric anastomosis. A right subcostal incision may be adequate, but it is usually necessary to extend this incision as a bilateral subcostal (rooftop) incision. A right rectus split incision, advocated by some, does give good exposure in a proportion of cases but is not really adequate for intrahepatic anastomosis or for clear visualization of the base of the ligamentum teres. In cases of right lobe atrophy, exposure is particularly difficult, with the hilar structures rotated posteriorly and to the right (Fig 111, the portal vein is encountered very early during dissection. In such instances a thoraco-abdominal incision through the right seventh intercostal space, either electively or, more often, as an extension of a subcostal incision, may prove valuable.*’ An important early step is division of the ligamentum teres and freeing of the falciform ligament from the abdominal wall as far back as the diaphragm. The liver is freed from the diaphragm if adhesions are present. Adhesions are carefully taken down, to avoid damage to the bowel, particularly the colon. Dissection of adhesions in the subhepatic area is best commenced from the right, mobilizing the colon from the undersurface of the liver. The duodenum, frequently adherent to the base of the liver, may also require separation.

FIG 11.

L Rincipal

L Rinciwd

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Diagrammatic representation of right lobe atrophy associated with left lobe hypertrophy. The normal anatomy (A) becomes distorted with atrophy/hypertrophy The right lobe shrinks and compensatory hypertrophy of the left lobe causes rotational deformity of the liver and hilar structures W.

plane

1987

31

Search for the bile duct distal to the stricture, recommended by some,g8 is often difficult and tedious, may be dangerous, and in any event is unnecessary. The essential and most important point is identification of bile duct mucosa pro)timaZ to the stricture. A systematic, careful, and patient approach is necessary in what may be a difficult and tedious dissection. HEPAnCOJE.IUNosroMY.-The operative approach to be described depends on display of the left hepatic ducts by opening the umbilical fissure, elevating the base of the quadrate lobe and lowering the left hepatic ductal system from the undersurface of the quadrate lobe.24 A firm tie is placed on the divided ligamentum teres so that it may be used as a tractor to elevate the liver so as to display its undersurface. Any bridge of tissue connecting the left lobe of the liver to the quadrate lobe is divided either by fracturing it between finger and thumb or by cutting it with diathermy (Fig 12). This bridge of hepatic parenchyma never contains large vessels, and control of bleeding is easily obtained. Although not essential for an approach to the left hepatic duct, this maneuver is useful in difficult cases. It exposes the umbilical fissure and allows considerably freer access for dissection at the base of the quadrate lobe. The base of the quadrate lobe is identified and dissection proceeds within the plane between Glisson’s capsule and the peritoneal reflection encasing the left portal triad (Figs 2 and 13). This dissection is deepened and the structures of the left portal triad are low-

FIG 12. Division of the bridge of tissue connecting segments III and IV, using cutting diathermy. ligamentum teres is elevated to expose the umbilical fissure.

32

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1987

FIG 13. The initial plate. The at precisely 2). (From ingstone,

line of incision for an approach to the left hepatic duct by lowering of the hilar liver is elevated and the quadrate lobe retracted upwards. The incision is made the point at which Glisson’s capsule reflects to the lesser omentum (see Fig Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livin press. Reproduced by permission.)

ered from the inferior surface of the quadrate lobe and exposed for dissection (lowering of the hilar plate) (Fig 14).‘2’24’76 As this is done dissection proceeds toward the right, and the area at the confluence of the hepatic ducts and the right hepatic duct is exposed. Although a benign stricture may extend to involve the confluence, there is usually a bridge of intact ductal mucosa crossing the upper part of the confluence and extending to the right ductal system. If the right duct cannot be exposed adequately in this way, it is possible to obtain a better length of the right hepatic duct by incising the liver CurrProblSurg,

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FIG 14. The hilar plate has been lowered and the left hepatic duct exposed. carried out medially and to the right to expose the confluence and the A Roux loop of jejunum has been prepared and brought retrocolic to of incision in the left hepatic duct and jejunum are indicated. (From Surgery of the Liver and Biliary Tract. London, Churchill Livingstone, in by permission.)

Exposure has been right hepatic duct. the hilus. The lines Blumgart LH [ed]: press. Reproduced

parenchyma in the line of the gallbladder fossa. This liver split,” together with the opening of the umbilical fissure described above, allows elevation of the entire quadrate lobe.” Occasionally an overhanging lower portion of the quadrate lobe may require excision in order to improve exposure. A curved retractor inserted from above to elevate the quadrate lobe assists exposure. Stay sutures are placed in the left duct, which is then incised longitudinally. Anastomosis is carried out usually to a Roux-en-Y loop of jejunum 34

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(see Fig 141, although some, in an attempt to obviate the subsequent duodenal ulceration that occasionally occurs, have suggested anastomosis to a loop of jejunum interposed between the exposed bile duct (ducts) and the duodenum.l14, 135S 14’ While the vast majority of high strictures can be approached and dealt with as described above,*1’*6824 occasionally it is very difficult to expose the left hepatic duct. This may be due to dense adhesions. Bleeding may be encountered or the quadrate lobe may be large and overhanging the area of the left duct. Sometimes the extrahepatic length of the left duct may be so short as to make the approach difficult. In such instances repair can be effected by dissection of the left hepatic duct within the umbilical fissure (ligamentum teres approach) .166This approach should not be used unless there is continuity at the hilus so that the whole biliary tree will be decompressed. It is more frequently applicable in cases of malignant stricture. TECHNIQUE OF ANAsroMosts.-It is valuable to have an established routine for biliary-enteric anastomosis, since although some anastomoses are low and easily carried out, a technique that regularly allows anastomosis even in cases of difficult high strictures should be developed. The opened bile duct having been prepared, a Roux-en-Y loop of jejunum 70 cm in length is prepared and brought up, preferably retro-colic, for side-to-side anastomosis. If it is considered necessary to splint the anastomosis, the tube is inserted into the hepatic duct before commencement of the anastomosis. It is useful to fix the tube to the duct wall with a single 4/O catgut suture introduced in mattress fashion across the lower duct wall and tied on the outside (Fig 1.5). This fixation holds the tube in a predetermined position and

FIG 15. Manner of fixation of a transanastomotic tube. Note the introduction of the absorbable mattress suture across the ductal wall proximal to the future site of anastomosis. This conveniently secures the tube during suturing of the anastomosis. (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livingstone, in press. Reproduced by permission.)

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avoids the difficulty that occurs if the tube become dislodged later on, during the performance of a difficult anastomosis. Side-to-side anastomosis is performed using the technique described by Voyles and Blumgart,1s2 and Blumgart and Kelley.24 The anterior layer of sutures is placed through the bile duct wall prior to any attempt to place the posterior row. If more than one duct orifice is visible at the hilus, the ducts are best approximated with a row of sutures so that they can be treated as a single duct for anastomotic purposes (Fig 16). If this cannot be done the entire anterior row for all exposed ducts is inserted first so that the separated orifices can be treated as if single. To complete one anastomosis and then another is difficult or impossible. These sutures (3/O Vicryl or other absorbable suture material) are serially introduced starting from the left and working to the right. The needles are passed from the inside outwards so as to allow subsequent tying of the knots within the lumen (Fig 171, in order to produce the best possible mucosa-to-mucosa approximation. The needles on this anterior row of sutures are left in place, and as each suture is passed it is clipped with a shod clamp, and kept in order, for subsequent identification (see Fig 17). The row of sutures so placed is then elevated. These maneuvers not only allow precise placement of the anterior row of sutures, which may be very diflicult if the posterior layer is inserted first and tied, but also facilitate precise placement of the posterior layer, which is now introduced into the jejunum and the bile duct working from left to right, and held taut (see Fig 17). The jejunal loop is then “railroaded” upward and the posterior layer of sutures tied serially on the inside, in reverse order starting from the right and working left (Fig 18). The two corner sutures are held on shod clamps and all the others cut short. The previously placed anterior row of sutures is now completed as follows. First, starting from the right hand side, the needles are picked up and passed through the jejunal wall from outside inward (Fig 19). The entire row is so placed working toward the left, and the

FIG 16. The approximation of separated right and left hepatic ducts at the hilus before hepaticojejunostomy. Ducts must only be approximated if this can be achieved without undue tension. Several ducts may be so approximated, as necessary (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract, London, Churchill Livingstone, in press. Reproduced by permission.)

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FIG 17. The initial steps in the performance of a hepaticojejunostomy. The anterior layer of sutures has first been placed in the anterior wall of the bile duct, starting on the patient’s left and working to the right; the sutures are passed outward from the mucosa. The posterior layer of sutures is then inserted using the anterior layer to elevate the bile duct for improved exposure. These posterior sutures are passed from the jejunal mucosa outward and then through the bile duct wall from outside to inside. Once again sutures are commenced on the patient’s left. (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livingstone, in press. Reproduced by permission.)

needles are now cut from the sutures. The left-hand corner having been reached, the corner stay suture of the posterior layer is cut and the anterior layer then tied serially, working now from the left to the right (Fig 201, each knot being placed on the inside until the right corner of the anastomosis is reached, the extreme right-hand posterior stay suture being cut before the last anterior suture is tied. MUCOSALGRAFT OPERATION.-A method for “sutureless” anastomosis of the jejunum to the bile duct in high bile duct stricture, when exposure of biliary mucosa and consequently sutured hepaticojejunostomy are thought impossible, was introduced by Smith,15’ and subsequently has been recommended as a standard repair for high biliary strictures.162 Advocates of the mucosal graft operation tend to approach the scarred biliary hilus directly, the approach being dictated by an assumption that the stricture and the left hepatic duct Cur-r

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FIG 18. The jejunal loop has been “railroaded” down to the bile duct, and the posterior layer of sutures is now tied, working from the patient’s right to the left. The corner sutures are held, all other sutures cut. (From Blumgart LH [ed]: Surgery of the Liver and Mary Tract. London, Churchill Livingstone, in press. Reproduced by permission.)

are intrahepatic structures. However, this is not so, since the left hepatic duct is in fact extrahepatic and accessible for direct anastomosis even in patients who have had several biliary operations.24 The mucosal graft operation is carried out as follows. The subhepatic area is dissected as described above and the area of the hilus exposed. Dissection at the porta hepatis demonstrates the strictured tract in dense scar tissue. Above the stricture lies the dilated hepatic system, the lining of which is not in view. The scar tissue obscuring the lining of the hepatic ducts is either cut away or split and dilated until the duct system is considered to be seen and the right and left hepatic ducts are thought to be identified. A Roux-en-Y loop of jejunum is now prepared to provide the mucosal graft. A disk of the seromuscular coat is removed. A transhepatic tube is introduced and passed through a hole in the exposed mucosa and secured with sutures. The tube carrying the mucosal graft is now positioned snugly into the orifice at the hilus. A new instrument has been developed to assist the upward passage of 3s

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1987

I

FIG 19. Working from passed through tures within the yet tied. (From Livingstone, in

the patient’s right toward the left, the needles of the anterior layer are the jejunal wall from outside in (so allowing subsequent tying of the sulumen). The entire anterior row of sutures is completed in this way but not Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill press. Reproduced by permission.)

the mucosal graft. If there has been complete obstruction of the common hepatic duct and the right and left hepatic ducts are separated, these are sought and double grafts are inserted, using two transhepatic tubes. The above description is adapted from the detailed illustration of the technique published by Knight and Smith.” LONGMIRE rHocsnuRE.-In 1948 Longmire and Sanford described an approach to the segment II duct of the left lobe of the liver for use when an approach to the hilus was not possible. This procedure remains occasionally valuable, for example, in patients with unilateral left lobe hypertrophy,50 but should not be employed when the left duct can be exposed below the quadrate lobe or within the umbilical fissure (vide supra). The Longmire approach involves removal of liver tissue with greater blood loss and often less effective biliaryenteric anastomosis than can be obtained by other methods. Since approaches to the left duct beneath the quadrate lobe or at the ligamentum teres have been employed at the Royal Postgraduate Medical School, we have reserved the Longmire-Sanford operation for cum

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FIG 20. The left-hand stay suture has been cut and the anterior layer of sutures is now working from the patient’s left side toward the right. (From Blumgart LH [ed]: the Liver and Mary Tract. London, Churchill Livingstone, in press. Reproduced mission.)

being tied, Surgery of by per-

patients with right lobe atrophy accompanied by left lobe hypertrophy, rendering subhepatic dissection of the main left duct or its branches difficult, or for patients in whom the umbilical fissure and the left hepatic duct were involved with malignant disease. The essence of the approach is the removal of a portion of the left lobe of the liver so as to expose the dilated intrahepatic ducts of segment II (and sometimes segment III). One of the great difficulties of the procedure is that the vessels of the portal triad run in close approximation with the ducts so that some bleeding is inevitable and difficult to control without compromising the duct lumina. This is particularly so if the liver is fibrotic and the ducts relatively small. The procedure should thus be used in cases of benign obstruction only with very great caution. 40

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The operation is commenced by mobilizing the left lobe of the liver by division of the left triangular ligament to allow delivery of the left lobe forward into the wound. This maneuver itself may be difficult if the liver is tough and fibrous, or if there is left lobe hypertrophy. It is our preference in the performance of this operation to apply a liver clamp to the left lobe just to the left of the ligamentum teres (Fig 21). The peripheral portion of the left lobe is then simply resected to reveal the exposed ducts and vessels. Slight release of the pressure of the clamp allows identification of the vessels which are then suture ligated. A Roux-en-Y loop of jejunum is prepared and brought up for anastomosis. Identification of a suitable size duct may be ditlicult. In such cases the Roux loop may be opened over a considerable length and sutured to Glisson’s capsule, although this is not easy. Such suture may be carried out utilizing mattress sutures passed through the jejunal wall and through the exposed liver substance (see Fig 21)

FIG 21. The Longmire operation. The left lobe of the liver has been completely mobilized by division of the left triangular ligament. A clamp applied across the mobilized lobe allows control of bleeding during removal of a portion of the left lobe to expose the segment II duct and occasionally the segment Ill duct as well. The jejunal loop may be anastomosed to the surface of the exposed liver as an alternative to direct anastomosis to the duct. (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livingstone, in press. Reproduced by permission.)

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41

SEGMENTIIHEPATICOJEJIJNOSTOMY.-Alt~n~tiVely, exposure ofthe segment II duct, which runs close to the posteroinferior surface of the left lobe of the liver, can also be made by incising the duct longitudinally. The left lobe is mobilized as described previously. The tissue of the left lobe is incised in a cephalocaudal direction posteriorly, and the incision is gradually deepened until the left duct is encountered (Fig 22). The duct is then entered with a probe and incised longitudinally through the liver substance (see Fig 22). Hemostasis is secured and a Roux-en-Y loop of jejunum is brought up for anastomosis. SEGMENTIII HEPATICOJEJLJNOST~MY. -The ligamenturn teres approach to the segment III duct” is ’ usually reserved for malignant hilar obstruction, but may be useful in occasional patients with benign disease. This duct may also rarely be approached by wedge excision of segment III (Fig 23). INTRAHEPATIC HEPATICoJEJurvosToMV.-very rarely the right RIGHT-SIDED hepatic ductal system may be approached by excision of liver tissue on the right side. The tip of segment VM of the right lobe is removed and hepaticojejunostomy carried out in a fashion similar to that described in the left lobe for the Longmire procedure. Similarly, after removal of the gallbladder, incision at the base of the gallbladder

FIG 22. The left lobe of the liver is mobilized and turned upward. A small parenchymal incision is made until the segment II duct is identified. A probe is then passed along its length and the duct opened longitudinally, for anastomosis. (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livingstone. in press. Reproduced by permission.)

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FIG 23. A method of approach to the segment III duct. The left lobe of the liver is mobilized and an anteromedial wedge of liver tissue is removed from segment III. The duct is thus exposed intrahepatically for anastomosis. (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livingstone, in press. Reproduced by permission.)

fossa may expose the underlying segment V duct. The procedure is seldom applicable and is not easy to execute. In rare instances, peripheral hepaticojejunostomy of segmental ducts may be required for segmental obstruction that cannot be otherwise repaired or corrected. Such procedures may be of particular value in cases of segmental atrophy. Some authors”‘43 recommend that in difficult strictures hepaticojejunostomy be carried out over a transjejunal tube which is then brought to the exterior across the blind end of the jejunal Roux loop, which is left long and brought up subcutaneously (Fig 24). This allows easy subsequent interventional radiologic or endoscopic procedures. We have used this technique with success on six occasions. Liver AtrophylHypertrophy-Influence on Approach to Repair.Segmental or lobar liver atrophy accompanied by compensatory hypertrophy and hyperplasia elsewhere in the liver may be encountered in segmental or unilateral ductal obstruction, especially if there is also portal venous obstruction. If an entire half of the liver is affected the combination of ipsilateral atrophy and contralateral hypertrophy leads to anatomical distortion and difficulties in dissection and anastomosis. The most common situation is gross hypertrophy of the left lobe accompanied by right lobe atrophy.50 The approach to such lesions demands drainage of the entire liver substance. If, as is frequently the case, there is discontinuity of the right and left hepatic ducts at the hilus, drainage of the left ductal system via the ligamenturn teres approach or by the Longmire-Sanford operationlo will only drain the left liver. This is usually unsatisfactory. The remaining obstructed portion continues to provide a focus of infection and a source of continued fever. Anastomosis in Cur-r

Probl

Surg,

January

1987

43

FIG 24. A method of hepaticojejunostomy when it is desired to bring the jejunal loop to the anterior abdominal wall so as to allow access for further percutaneous or endoscopic instrumentation. (From Blumgart LH [ed]: Surgery of the Liver and Biliary Tract. London, Churchill Livingstone, in press. Reproduced by permission.)

the region of the hilus is still desirable but is always difficult. Bismuth suggests a thoracoabdominal approach to such strictures in an effort to allow direct appreciation of the anatomy and access for suture repair.15 This approach through the right thorax with division of the diaphragm allows rotation of the liver to the left and facilitates dissection. Recently we have successfully treated three such cases using an initial Longmire approach to the hypertrophied left lobe followed by radiologic interventional dilatation of the hilar structure utilizing the tract of a transanastomotic transjejunal tube for access (Fig 25). Portal Hypertension .-Patients with biliary stricture may develop portal hypertension caused by secondary liver fibrosis or by direct damage to the portal vein. Sometimes there is coincident hepatocellular disease. Few reports specifically stress this problem. Sedgwick et al.‘55 found portal hypertension in about 20% of patients treated at the Lahey Clinic, Boston. Blumgart et aL,3o in a series of 78 patients treated at the Hepatobiliary Surgical Unit, Hammersmith Hospital, found 11 (14%) with portal hypertension at the time of referral. The difficulties encountered in the management of these cases

44

cut-r

Probl

SW-~,

January 1987

FIG 25. Percutaneous transhepatic cholangiogram in a patient with a complex benign bile duct stricture associated with right lobe atrophy and left lobe hypertrophy. The grossly enlarged left hepatic ductal system can be seen. This patient underwent a Longmire operation with intubation of the left hepatic ductal system. Subsequent percutaneous dilatation of his hilar stricture was performed successfully. have

been

detaded.l,

30,55,136.155,188

Collateral venous channels in the subhepatic region and within vascular adhesions make dissection bloody and difficult. The patient who develops portal hypertension is also frequently the patient with a high stricture who has had multiple previous attempts at repair. Percutaneous balloon dilatation of strictures offers new possibilities but will seldom provide a complete solution. In seriously ill patients with jaundice and portal hypertension it may be advisable to pass an initial percutaneous transhepatic tube, or treat the stricture in the first instance at least by balloon dilatation, 123~136,*54,1681176 and then to assess the possibilities of late definitive repair. If hemorrhage is encountered during the course of a stricture repair biliary drainage may be performed initially and a spleno-renal shunt undertaken at a later date. Biliary repair carried out at the time of shunting procedures can be extremely difficult and in any event it is best not performed at a time of severely compromised liver function. Thus, some authors” have recommended that if profuse hemorrhage is encountered during attempted repair a thmestage procedure be carried out-biliary drainage in the first instance, followed by a shunt some three weeks later, then by reconcut-r

mob1

surg,

hnuary

1987

45

struction of the bile duct at a third operation when liver function is at an optimum level. This approach is now seldom necessary if judicious percutaneous drainage is used as a first stage before attempted bile duct repair. If a patient has bleeding esophageal varices and established biliary obstruction, conservative measures should be tried in the first instance to control bleeding. The use of pitressin infusions, the Sengstaken tube, and peresophageal injection of sclerosants into the varices are all reasonable measures. If the bleeding does not stop a twostage operation is recommended-an immediate spleno-renal shunt in the first instance, and bile duct reconstruction at a later date. Again, percutaneous transhepatic drainage or balloon dilatation may be used in association with the above measures. Occasionally patients present without jaundice and with bleeding esophageal varices, the stricture having been adequately repaired at an earlier date. In these instances a portasystemic shunt may be indicated occasionally as an emergency measure, but preferably after initial nonoperative management of the bleed. Alternatively, injection sclerotherapy should be considered. In general the best and most convenient form of portasystemic shunt in these patients is a spleno-renal shunt. Portacaval shunting is technically difficult or impossible because of the previous operations in the hilar area. It is possible, although not proven, that adequate biliary repair in patients with portal hypertension may be followed by a slow improvement in hepatic function with resolution of fibrosis and an eventual fall in portal pressure.ls It is important to obtain a liver biopsy in patients with portal hypertension and a benign bile duct stricture. Parenchymal liver disease, and in particular alcoholic cirrhosis, may coexist with iatrogenie bile duct stricture and be a cause of confusion. Thus, in a series reported by Blumgart et al.,3o two of 11 patients with portal hypertension were found to have hepatocellular disease not consequent upon obstruction. Many of these patients are the subject of medicolegal proceedings, and precise documentation, to afford accurate assessment of the causation of symptoms, is essential. The prognosis of this group of patients is much worse than that in patients without portal hypertension, and a hospital mortality approaching 40% to 80% is to be anticipated.30”55 In a series of 78 patients reported by Blumgart et al.,3o three of 11 patients with portal hypertension died in the hospital, one from uncontrolled variceal hemorrhage before any operation was undertaken. Portal hypertension was associated with prolonged obstruction and recurrent episodes of cholangitis, and these in turn were more frequent in patients who had more than one operation before referral. Results.--“We repairing 46

are still in considerable the common duct and we want

doubt about the best method of someone to analyse carefully the CurrProblSurg,

January1987

records results”

of all the available (Grey-Turne?).

cases to see if we can get guidance

from

the end-

A variety of factors influence the prognosis and outcome of patients admitted to hospital with bile duct strictures. Factors injluencing a satisfactory stricture repair are the number of previous operations, the site of the stricture and the type of repair, while those that influence mortality are the number of previous operations, a history of major infection, the site of the stricture, preoperative serum albumin concentration, and particularly the presence of hepatic fibrosis and portal hypertension.30’ 41Pg5 The adequacy of the operative repair is of great importance in determining ultimate long-term prognosis. While untreated patients have a fatal outcome, an operation that offers only partial relief of the biliary obstruction leads to progressive liver damage and ultimate death. Failure to drain all segments of the liver results in segmental liver atrophy, and usually continued attacks of cholangitis originating within the obstructed ducts. Operative Morbidity and Mortality-The postoperative morbidity of reconstructive operations for bile duct stricture is high. At least one patient in ten is likely to have one or more major nonfatal complication.” More complications are to be expected from series including a high proportion of reoperated cases.3o The common complications encountered are subphrenic, subhepatic, or pelvic infections, wound infections, cholangitis, bacteremic shock, secondary hemorrhage, biliary fistula, and those in the lungs. Mortality is difficult to assess. Some reports do not define operative mortality. Some patients die before operation can be embarked upon and are not included in many surgical series. The failure of some authors to differentiate high from low strictures, to allow for the effects of multiple operations, or to differentiate clearly the mortality of one operative procedure from that of another also makes assessment difficult. as being between 5% and Operative mortality is reported 8% .39,95,187,188 The most common causes of death were uncontrolled hemorrhage, hepatic or renal failure, or a combination of these. Biliary fistula, bacteremia, and pulmonary complications were responsible for the remaining operative deaths. In the recent Hammersmith series of 78 patients, the overall XI-day hospital mortality was 11.5%, which included one death due to bleeding esophageal varices before operation could be undertaken. The operative mortality for all procedures including those for drainage of abscesses, shunt procedures for control of bleeding, and biliary repair was 8.3%. There were no deaths in 58 patients treated by hepaticojejunostomy, nor in three treated

by

choledochoduodenostomy.

high strictures Cum

Probl

Surg,

were treated January1987

Two

by the mucosal

patients

with

graft technique

complex

early in 47

the series. Both died. Thus, of the 63 patients treated solely by repair of the stricture there was an operative mortality of 3.2%. A total of 84 patients have to date been subjected to stricture repair alone, with a 30-day mortality of 2.4% (two patients). There were no deaths in 82 consecutive cases treated by mucosa-to-mucosa sutured anastomosis. There are in fact very few reports on series of patients operated upon for biliary repair by hepaticojejunostomy using the approach to the left hepatic duct system. The zero mortality for 82 cases in the author’s recent experience is comparable to that of Bismuth,” who reports 186 patients operated on by this approach since the introduction of the technique by Hepp and Couinaud in 1956. Seventy percent of these cases had one or more operations before referral and associated lesions that complicated operation and compounded the difficulty of the biliary repair. The associated lesions were mainly intrahepatic stones above the stricture, biliary fistula, hepatic atrophy, and biliary fibrosis. Despite these complications all patients were operated on by a mucosa-to-mucosa sutured anastomosis. The left duct approach was possible in all but four, one of whom was subjected to intrahepatic cholangiojejunostomy. The operative mortality, defined as intraoperative and immediate postoperative mortality, was 0.6%. Smith 1'1,162 reports a review of 451 patients, 413 operated upon by the mucosal graft technique. There were 17 deaths postoperatively in the entire series (3.75%1, but none for those patients submitted to the mucosal graft procedure. It is important that the safety of repair in experienced hands, and particularly in the uncomplicated case, is appreciated. These results should be taken into account in assessing the newer techniques of transhepatic or endoscopic biliary dilatation. Late Results.-The late results of repair of bile duct injury after cholecystectomy are difficult to evaluate given the considerable variation in the criteria chosen to assess long-term outcome. Morbidity and mortality not associated with stricture repair must be taken into account, and the results of stricture repair in uncomplicated cases should be distinguished from those in patients with liver disease, portal hypertension, or lobar atrophy. Similarly, there is scant information on relative mortality and morbidity rates according to the level of stricture. Only one author has proposed a formal classification of severity’* (vide supra). There is also variation in what is accepted as a satisfactory result. Thus, Braasch and colleagues33 accept as a good result a patient without symptoms, or with occasional attacks of cholangitis and jaundice, three years after repair. Others define a satisfactory repair as the absence of symptoms two years after operation.‘“’ Bismuth*l suggests a symptom-free follow48

cur-r

mob1

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January

1987

up of at least five years (and preferably ten years) with normal liver function test results and no restenosis as constituting a good result. In a study reported by Blumgart et a13’ the Bismuth classification was employed. It was found that type 3 and 4 strictures were associated with less good results. Similarly, Warren and Jefferson’85 have reported 958 patients reviewed at the Lahey Clinic of whom 77 had strictures at or proximal to the common hepatic duct. While not differentiating Bismuth type 3 and 4 strictures from Bismuth type 2, this study emphasized the difficulty encountered in the higher strictures. Indeed, in a recent survey186 satisfactory results were found in only approximately 47% of patients with an overall operative mortality of 8.3%. Pitt et al.‘37 examined the factors influencing outcome of repair of benign strictures following cholecystectomy and showed that better results are achieved in patients younger than 30 years, with no previous attempt at stricture repair, by the use of a Rouxen-Y jejunal loop, and with the employment of transhepatic silastic tube splinting for longer than one month-extended in patients with difficult hilar strictures to nine months or more with changeable silastic splints. Way and his colleagues analyzed the course of 50 consecutive patients with recurrent biliary stricture, all of whom had at least one previous repair.136 Presenting features included cholangitis in 40% of patients, jaundice in 30%) and pain in 17%. Seventy-six percent of patients had no further recurrence of symptoms after one operative repair; however, in 11 patients (22%) recurrence developed, although six did well after yet another operation. In four a third recurrence was treated at a fourth operation, successfully in three. The overall operative mortality was 4%. The authors estimated that two thirds of recurrent strictures were evident by two years and 90% by seven years, and that the chance of recurrence was about 25% after retreatment of a first recurrent stricture. They did not outline the methods of repair employed, but emphasized the necessity for hepaticojejunostomy by direct suture. They concluded that prolonged stenting did not contribute to a good result. Blumgart et a13’ reported that, in a series of 78 patients, a satisfactory result was achieved in 90% treated by stricture repair only, over a mean follow-up period of 3.3 years. There were two late deaths within a year of operation-one of liver failure and one in a patient in whom a coincidental cholangiocarcinoma developed. Bismuth, in a series of 186 patients,l’ chose a ten-year follow-up period. Of 186 patients operated on by hepaticojejunostomy to the left duct, 141 (operated on between 1956 and 1972) were recently studied for assessment of late results. Fourteen patients (11%) were lost to follow-up. Seven died from nonbiliary causes, leaving 120 patients for reassessment at between 10 and 20 years. Of these, 88% had an excellent result defined by the absence of any biliary troubles Cur-r

Probl

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January

1987

49

(vide supra). Five percent had transitory trouble shortly after operation, probably related to the procedure itself, but did not require reoperation, and 7% had unsatisfactory results. Three developed recurrent stenosis and required reoperation, and all three had a subsequently good outcome. Five, all with secondary biliary fibrosis, died. These results are essentially similar to those reported by Blumgart et a130 and to the estimate of Kune and Salig8 that 85% of patients who have sustained an operative injury to the bile ducts will be restored to normal health if reconstruction is undertaken by an experienced surgeon. Duodenal ulceration appears to develop in a small proportion of patients after Roux-en-Y biliary enteric repair114, 135,150 and constitutes an additional cause of late morbidity. The majority of cases will respond to the administration of H2 antagonists. Late results for the mucosal graft procedure have been reported by Smith.161 Of 451 patients reviewed, 413 had mucosal graft procedures. At two years 15% of those submitted to mucosal graft had continuing symptoms. In 4% these symptoms were directly attributable to restenosis and the remaining 11% were seriously compromised, having developed either liver disease, secondary sclerosing cholangitis, severe sepsis with stones, or a combination of these. Many patients (indeed one half of the cases reported as having an excellent result) had a persisting elevation of the serum alkaline phosphatase level. This might be due to segmental obstruction associated with the graft operation, and Blumgartlg has shown that such segmental obstruction can occur. The results reported by Smith16’ appear to offer no advantage in the treatment of the complex case. The underlying assumption of advocates of this procedure-namely, that suture anastomosis for high strictures cannot be performed-is open to question. Precise direct anastomosis can be carried out with a very low mortality and excellent long-term followup even in patients with complex strictures previously submitted to mucosal graft operation.30 Techniques offollow-up have varied from simple observation and measurement of liver function tests to the performance of transtubal cholangiography and HIDA scanning.llg It has been noted repeatedly that some patients will remain asymptomatic yet have a persistently raised alkaline phosphatase level.161’ ls8 Studies carried out at the Royal Postgraduate Medical School in which both HIDA scanning and alkaline phosphatase values were measured suggest that persistent elevation of alkaline phosphatase over a prolonged period of time is consequent either on associated hepatocellular disease or on incomplete relief of obstruction.11g It is probably correct to suggest that a result should not be regarded as excellent unless the alkaline phosphatase returns to a normal level. This is important in assessing 50

cur-r

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1987

late results and should be recognized in studying the results of percutaneous transhepatic dilatation. The influence of long-term transanastomotic tubal splinting on long-term patency has been debated. Transanastomotic splinting has been used by many,53857 and a transhepatic tube by Grindlay et al.,68 Goetz,64 Praderi,‘38’ 13’ and subsequently by Smith.“l The length of time that the tube should be left in situ is a subject of controversy. One study” suggested that better long-term results were obtained in anastomoses splinted for longer than 12 months than in those splinted for six months. Three to six months is now generally considered to be the minimum period of splintage with the tube left for 12 months in more difficult cases. The median duration of splinting in a study carried out at Hammersmith Hospital was only four months .30 Some authors’2”6 rarely use transanastomotic stenting and have obtained good results. It may well be that transanastomotic tubes are unnecessary136 in the average patient and indeed we have recently omitted tubes altogether in a series of 25 patients without noticeable problems. Percutaneous transhepatic catheterization and dilatation can be a useful maneuver in patients with recurrent stricture following hepaticojejunostomy, and we have used this approach with success. A planned combined surgical and interventional radiologic approach is also useful, especially if intrahepatic stones cannot be completely retrieved by the surgeon, or if repair is difficult or unsatisfactory, and recurrent stricture is anticipated. A tube is left across the anastomosis and delivered to the exterior, the tract subsequently being used by the radiologists. Percutaneous approaches, which have their own risks, should not be used when anastomosis is easily possible. Conclusions.-Injury to the bile duct during cholecystectomy is a most serious problem. The mortality, both initial and late, is related largely to reoperative procedures, infection, the evolution of secondary biliary fibrosis and to the development of portal hypertension. The following points summarize the problem: 1. Bile duct injury at cholecystectomy is inflicted as a result of imprecise dissection and poor visualization of anatomical structures. 2. Vascular damage to the hepatic artery, portal vein, or both is not uncommon. 3. A prolonged history of high stricture involving the hepatic ducts, multiple attempts at repair, infection, and the development of secondary liver fibrosis together with a low preoperative serum albumin level are adverse prognostic features. 4. Precise diagnosis of the level of the stricture and demonstration of hepatic ducts is desirable prior to operation. 5. Associated complications such as abscess formation, gastroin-

CurrProblSorg,

January1907

51

testinal tract bleeding, fistula, and portal hypertension are probably best treated before stricture repair. 6. There is a place for conservative management or transhepatic percutaneous dilatation in selected high-risk patients, especially in the presence of portal hypertension. However, nonoperative approaches should be used with caution, since incomplete relief of a stricture may be dangerous in the long term and may be associated with development of liver damage. In any event, most strictures can be safely repaired by biliary-enteric anastomosis. 7. Radiologic interventional approaches may be used in an adjunctive manner with surgical repair in selected cases, using either a percutaneous approach or the introduction of catheters along surgically established tubal tracts. 8. The majority of benign bile duct strictures can and should be managed by surgical restoration of biliary-enteric continuity by dissection of the left hepatic ductal system and the confluence, followed by direct mucosa-to-mucosa anastomosis of the bile duct, usually to a Roux-en-Y loop of jejunum. For this approach, and in the absence of liver disease, the operative mortality is probably less than 1%. 9. Mucosal graft techniques, hepatotomy, and left hepaticojejunostomy of the Longmire type have only limited indications. 10. Future investigations of this subject should examine established prognostic indices and classify the level of bile duct strictures so as to allow comparison of results and assessment of new methods of treatment. 11. Repair of bile duct strictures is a specialist procedure and the best results are obtained by a good initial repair. Repeated attempts at anastomosis or intubation are associated with the development of high, complex strictures and late liver disease, both of which are associated with poor long-term results. BILE DUCT INJURY CHOLECYSTBCTOMY

AFTER

OPERATIONS

OTHER

THAN

Bihar-y Operations Operations that involve biliary enteric anastomosis may be complicated by postoperative stricture or fistula. Such procedures may be carried out for reconstruction after primary pancreaticoduodenectomy,42 after deliberate excision of the bile duct for tumors in its middle third, after excision of choledochal cysts with subsequent hepaticoenteric anastomosis, and after choledochoduodenostomy. Late strictures are most likely to occur after bypass procedures to a normal-caliber duct, particularly if the bile duct is itself diseased, as for example after resection or bypass for chronic pancreatitis, 52

Cur-r

Probl

SW-~,

January

1987

when the duct is often involved in the inflammatory process. Where biliary-enteric anastomosis has been carried out for long-standing biliary obstruction, the duct is dilated and thickened, anastomosis is easy and late stenosis rare. Indeed, if such stenosis occurs, as for example following pancreaticoduodenectomy for pancreatic or ampullary cancer, recurrence of disease should be suspected. Postgastrectomy

Biliary

Stricture

Injury to the bile duct can occur during performance of gastrectomy, particularly if during the procedure the pyloric region and first part of the duodenum are found to be grossly distorted or inflamed. The most common situation is biliary injury during the course of Polya gastrectomy. Such cases may present in the postoperative period with jaundice or a biliary fistula, and there may be difficulty in distinguishing the presentation from that of a leaking duodenal stump. We have seen four bile duct strictures after gastrectomy (Table 4). Two were of the nature described but two followed Bilroth I gastrectomy. In these two cases the surgeon carried out what was claimed to be an easy, straightforward, Bilroth I gastrectomy. It was remarked that the duodenal loop was mobile and the procedure not difficult. In one case after completing the anastomosis the surgeon realized that he had removed the entire first and second part of the duodenum from the pancreatic head, thus exposing the bile duct and pancreatic duct. In the second case a precisely similar injury occurred, but the surgeon did not recognize the problem and closed the abdomen. The patient presented in the postoperative period

TABLE

4.

Causes of Benign Biliary Hammersmith Hospital, Postcholecystectomy Penetrating injury Blunt injury I5 with liver Pancmatitis Postgastrectomy Operation for choledochal Periportal inflammation (Including 1 after DXR) Following portal shunt Total

Stricture, 1979 to 1986*

injury)

cyst

101 5 6 9 4 4 4 1 134

*Excludes papillary stenosis, primary localized stricture bzlemsing cholangitisl, and stricture secondary to cholelithiasis or associated tith the Mirizzi syndrome. Corr

Probl

Surg,

January

1987

53

with a b&try-pancreatic fistula. Surgical reexploration revealed the denuded pancreatic head. Repair of the damaged bile duct following Polya gastrectomy is usually not difficult. The stricture frequently lies in close proximity to the duodenal stump, and it is a relatively simple matter to identify the biliary tree and carry out a direct anastomosis at or close to the blind end of the duodenum. Where the entire pancreatic head is denuded, as in the cases described above, a Roux-en-Y loop of jejunum may be developed and brought up retrocolic, the open end being used to envelop the pancreatic head. The two patients described were treated in this way and have been followed up for periods of ten and six years, respectively. Both remain well, with normal liver function and normal pancreatic function. However, during the follow-up period one patient developed a late biliary stenosis in the area of damage and secondary choledochojejunostomy had to be performed at the apex of the previously placed Roux-en-Y loop. Other

Procedures

In a total series of 134 cases of benign bile duct stricture the author has had experience of one patient with late biliary stenosis following portacaval shunt, and a further case in whom bile duct stricture occurred following irradiation of para-aortic glands for testicular malignancy (see Table 4). Liver resection may be complicated by damage to the bile ducts. In cases of liver injury, biliary damage may be associated with the original trauma or be inflicted during the subsequent operative treatment. It may be difficult or impossible to define precisely the cause of a subsequent biliary fistula or stricture. Biliary injury may also occur during liver resection for tumor or cyst and is more likely in patients with lesions involving the hilus, where the biliary tree is liable to damage during dissection. The management of injuries following partial hepatectomy can be extremely difficult,84,164 the problems being similar to those encountered in the atrophy/hypertrophy complex (vide supra). A biliary fistula occurring after partial hepatectomy should be treated expectantly for long periods and operation be proceeded with only if the fistula fails to close or if jaundice or cholangitis supervene. BILE

DUCT

INJURY

The gallbladder or abdominal injury or latter, while common the United Kingdom. 54

DUE

TO

ABDOMINAL

TRAUMA

biliary tree may be damaged following closed by penetrating stab or gunshot wounds. The in some parts of the world, are uncommon in In a total series of 134 bile duct strictures at Curr

ProblSurg,

January1987

the Royal Postgraduate Medical School, Hammersmith Hospital, six occurred in association with blunt injury (five with associated liver injury) and five following stab wounds (see Table 41. Occasionally late problems arise where prolonged fistulization occurs from a segment of the liver isolated from the rest of the liver by ductal injury. Management of such cases is difficult, and even prolonged observation may fail to see closure of the fistula, especially if this is associated with a stricture preventing drainage of the damaged area. Where such a fistula occurs, management may be by one of three methods. First, resection of the isolated segment of liver may be carried out. Such an approach can be difficult and is seldom warranted. In rare instances the fistula may be identified at operation and simply oversewn. Alternatively, a well-developed fibrous fistulous tract can be anastomosed either to a prepared loop of jejunum or to the gallbladder if this is nearby. Such an operation may produce a permanent cure, but late stenosis or stricture may still be a problem for which secondary repair is required.‘@’ POSTINFLAMMATORY

BILIARY

STRICTURES

Bile duct stenosis and stricture may occur in association with any process that causes fibrosis of the common biliary channels or that causes a diffuse sclerotic process within the biliary tree. Such strictures may result from cholelithiasis, chronic duodenal ulceration, granulomatous lymphadenitis, or chronic pancreatitis. Long-Standing

Cholelithiasis

Long-standing cholelithiasis results in repeated attacks of cholecystitis, the gallbladder being progressively fibrosed, shrunken, and surrounded by inflammatory tissue. As this process proceeds and the gallbladder shrinks it may come to obliterate the triangle of Calot so that the gallbladder wall abuts against the common hepatic duct and the inflammatory process spreads to involve the common hepatic duct, causing inflammatory stenosis and stricture. These patients usually present with jaundice and recurrent attacks of cholmay be in association with a history of angitis.12’ The presentation acute or chronic cholecystitis, and a stricture may be present at the time of cholecystectomy. The surgeon, who has proceeded to operation on the jaundiced patient without prior imaging of the biliary tree, may find operative cholangiography difficult and may discover that his attempts to remove the gallbladder have created a bile duct injury. Furthermore, a large stone in the region of Hartmann’s pouch may erode into the common hepatic duct, causing a cholecyst-choledochal fistula. In such instances removal of the gallbladder results Cur-r

l’robl

Surg,

January

1987

55

in an opening into the common hepatic duct or even removal of a portion of the common hepatic duct. This situation should be suspected in any patient with a long history of gallstones who presents with jaundice and cholangitis. Operation in such cases should never be performed without preliminary percutaneous transhepatic or endoscopic retrograde cholangiography. Finally, inflammatory strictures of the common hepatic duct in association with chronic cholelithiasis may present with radiologic features indistinguishable from those of cholangiocarcinoma. This possibility must be borne in mind in any patient suspected of having hilar cholangiocarcinoma in whom there is coincident cholelithiasis. Such stricturing in association with cholelithiasis is rare. Four such cases have been recorded in Hammersmith Hospital. The key to management is preoperative recognition of the possibility of stricture in association with cholelithiasis. Chronic

Duodenal

Ulcer

Rarely, chronic peripapillary duodenal ulcer can erode the entire papillary area,46 resulting in stricture or a choledochoduodenal fistula. Presentation is with jaundice and cholangitis, usually on a background of a prolonged history of duodenal ulcer. Granulomatous

Lymphadenitis

Granulomatous lymphadenitis may also be responsible for stricture of the adjacent common hepatic or common bile duct. This may occur in association with tuberculosis; occasionally this can be proven, although the history is usually a prolonged one and proof may be difficult to obtain. In such cases there has almost always been long-standing obstruction to the bile ducts, and there is usually associated secondary biliary fibrosis and a degree of liver damage. This may occasionally be unilateral, with liver atrophy. Treatment can be difficult, since not only is there compromised liver function, but biliary drainage may be difficult to establish. Subhepatic

Abscess

or Inflammation

Abscess or inflammation in the subhepatic region, particularly as a complication of cholecystitis, may lead to external compression of the common hepatic duct and cholestasis. These lesions, often difficult to distinguish from hilar cholangiocarcinoma or cancer of the gallbladder, usually require only simple surgical drainage of the subhepatic collection without the necessity for biliary reconstruction.

56

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1987

Chronic

Pancreatitis

Chronic pancreatitis may result in bile duct stenosis and stricture. Jaundice occurs in up to one third of patients with chronic pancreatitis,147 due to biliary stenosis or stricture. The characteristic long and narrow stricture occupies the retropancreatic portion of the common bile duct.l@ Other variants of stricture may occur and have been described in detail.147 Although stricture is more common in association with chronic alcoholic pancreatitis, it occasionally occurs in chronic pancreatitis of other etiologies. In addition to jaundice there may be associated pain which is usually intermittent in character. Cholangitis and fever are unusual but can occur.“’ Diagnosis is by endoscopic retrograde cholangiography, or transhepatic percutaneous cholangiography, or sometimes only at the time of operation. The radiologic appearance is of a smooth tapering stenosis in the retropancmatic portion of the common bile duct. Because the fibrotic process associated with pancreatitis may affect the proximal bile duct, and because the development of the stenosis is gradual, there may be very little dilatation of the proximal biliary system. The stenosis may, however, be shorter or may only involve the immediate area of the papilla. Contrast medium usually traverses the stricture and passes into the duodenum, but this is not always the case, and differentiation from carcinomatous obstruction may be difficult. While a long tapering narrow stricture of the bile duct is usually characteristic of chronic pancreatitis, especially when associated with demonstrable abnormality of the pancreatic ducts at ERCP, carcinoma may still very occasionally be present, and caution is necessary to avoid error in these cases. A bile duct stenosis or stricture in association with chronic pancreatitis is in itself not an indication for therapy. Quite severe stenoses may be found in patients who have absolutely normal liver function test results and who have never been jaundiced. Spontaneous resolution of cholestasis may occur in this group of patients with conservative treatment. If cholestasis is persistent, or cholangitis occurs, biliary bypass is necessary. If operation is to be carried out for the management of the chronic pancreatitis itself, and it is known that severe biliary stenosis is present, the surgeon may elect to perform a biliary bypass at the same time. In a series of 240 patients with chronic pancreatitis, 39 of whom came to operation, nine had symptomatic biliary tract obstruction and a total of 13 were subjected to some form of biliary enteric anastomosis, either alone or in association with a pancreatic resection.” While side-to-side choledochoduodenostomy may be employed in some cases, this is usually not the best procedure since the surrounding inflammatory reaction may render the duodenum rigid

curr

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1987

57

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