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A direct approach to the differential diagnosis of jaundice
A Direct Approach to the Differential Diagnosis of Jaundice Laparoscopy with Transhepatic Cholecystocholangiography
George Berci, MD, Los Angeles, California Leon Morgenstern, MD, FACS, Los Angeles, California J. Manny Shore, MD, FACS, Los Angeles, California Stephen Shapiro, MD, Los Angeles, California
In the majority of patients presenting with jaundice, thediagnosis can bd,established by the usual clinical~,, laboratory, radiologic, and radioisotope investigations. In approximately 20 per Cent, however, jatindice cannot be diagnosed by these methods' [1]. The critical differentiation of "medical" from "surgical" jaundice has traditionally been resolved in our group by exploratory laparotomy after a judicious period, of observ~itibn....Thi~a~pproach necessarily subjects a certain'i)ercentage of patients-with-hepatocellular disease to the increased morbidity a~ndniortality of diagnostic~laparotomy[2]. In recent years a number of new.diagnostic tools have become availabl~ewhich-'can-be used for the preoperativetevalfi'ation ,of jaundiced patients. (Tjable-I.~'These special procedures are all based on the principle of direct cholangiography. Using a variety of approaches, radi0paque material is introd(Iced dir~ctlY-into~some portion~of the biliary system so t~hat it taxi; be v-~isu-~lized despite the presence of-Jaundice. With the exception of retrograde ch01angiography via t h e duodenoscope, these methods generally depend on the presence of dilatation within intrahepatic bile ducts, and' thus possess inherent limita'tions. This disadvantage can be overcome by selecting the gallbladder ks. the injection Site. Guidance is From the DIvisiofl of Surgical Endoscopy, Cedars of Lebanon Hospi•tal, Los Angeles, California. Reprint requests sh0pld Meaddressed to Dr BercL Cedars of Lebll* non Hospital, 4833 Fouktaln Avenue,.Los Angeles, California 90029.
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readily provided by means of the laparoscope. Direct injection into the gallbladder fundus, as advocated by Kalk [3] and Royer, Mazure, and Kohan [4], presents the hazard of bile leak; this is of significance when laparotomy is not necessary after the diagnost!c study. The same information can be obtained by a transhepatic approach to the g~llbladder, as advocated by Rosenbaum [5]. This has the advantage of tamponade of the gallbladder puncture by the liver, preventing the problem of bile extravasation. These considerations led to the development of a direct diagnostic approach to the "difficult" jaundice problem. A perc~taneous transhepatic cholecystocholangiogram is obtained using double guidance by laparoscopy and x-ray image amplification (television-fluoroscopy). This paper will describe the technic evolved at this institution and present its application in three successive cases. The potential of this diagitostic* approach will be discussed and compared with other modalities currently available. Technk: This procedure is reserved for those jaundiced patients in whom a diagnosis cannot, be established after a seven to ten day period of. hospital observation and inv~tigation. The patien~ are prepared for possible laparotomy should a Surgical lesion~be dem0nstrat~ed. Appropriate systemic antibiotics are administered prior to the procedure.
The Ammticm J u m a l ~
Peritoneoscopic Cholanglography in Diagnosis of Jaundice
The study is performed i n the operating room using a special operating table equipped with a radiolucent coordinate-movement tabletop.* (Figure 1.) A ceiling-suspended x-ray tube is employed. A large field (10. inch) mobile image amplifier with a television link-up is placed beneath the operating table.t (Figure 2 . ) T h e fluoroscopic image is displayed on a 14 inch television monitor. Simultaneous display in the x-ray department is possible. Roentgenograms are readily obtained at the appropriate time as indicated by the fluoroscopic views [611 Balanced general anesthesia w i t h controlled ventilation is preferred. The patient is tx)sitioned obliquely with the left side elevated 15 degrees by sheets placed beneath the left scapula. After the induction Of pneumoperitoneum with carbon dioxide, the Hopkins-Storz laparoscope~ is inserted through an infraumbilical midline trocar (7 m m outside diameter). The new image-transmitting system [7] of this laparoscope greatly~enhances visualization and has given impetus to the ree v a l u a t i o n of laparoseopic cholangiography in jaundiced patients. After laparoscopic ~urvey of the abdominal cavity, special attention is paid to the right upper quadrant. The k~ss appearance of the liver and gallbladder is noted. On occasion the diagnosis will be readily recognized, as in liver metastases or carcinomatosis. In the majority of instances, the diagnosis may be inferred by the appearance of the liver and the gallbladder; however, definitive diagnosis requires supplementation of the endoscopic examination with direct cholangiography. Under visual control, an accessory trocar (5 m m outside diameter) is inserted in the right upper quadrant. Through this trocar a palpation probe is advanced for elevation of the righ t lobe 0~ the liver. This permits observation of t h e undersurface of the liver and facilitates inspection of the gallbladder. It also provides stabilization of the liver during cholangiography. Witl~ this technic~ t h e gallbladder can be Visualized in most p a l l e t s . A site is then chosen for the percutaneous puncture. Under visual guidance a n u m b e r 20 gauge, 8 inch Longdwel• needle§ is inserted t h r o u g h ~ h e *lt'lFA Surgical O. R. Table Company, Solna 1, Stockholm, Sweden; distributed by Affilia'ted Hospital Products, Inc, Mdryland Heights, Missouri. tSlemens X-ray Corporation of America, 1329 Grand Centml Aueru~, Glendale ~ Cali~orrda91201. ~Storz Endoscopy America, lnc, 650 South San Vicente Boulevard, Los A nleles/ ~alifornio 90048. |Becton. Dickinson and Company, Rutherford, New Jersey.
VMmlw1No IlelNm~NmrIIWS
Figure 1. The flat radiolucent tabletop can be moved in a coordinate fashion during the procedure, No r e alignment of x.ray apparatus is needed. With this appo. ratus the now of dye can be followed during injection over a 10 inch a r e a .
abdominal wall or appropriate intercostal space in the midclavicular line. The needle is directed towards the hepatic Surface of the gallbladder by traversing the right lobe of the liver. (Figure 3.) An appropriate angle is chosen so that the liver is entered approximately 2 t o 4 c m from the anteroinferior margin. Once the !iver parenchyma is entered, the stylet is withdrawn and the needle is advanced until the gallbladder is entered and bile
Figure 2. The tabletop and patient are eccentrically placed a n d the patient is prepared for operative cl~langiogra~hy. The overhead ce#ing.suspended x-ray tube is lowered, A 10 inch mobile image amplifier coupled t o a television camera (fluoroscopy) witt~ 70 by ?0 mm spot film camera is in position underneath the table. S~andard radiographs can also he employed. Fluoroscopic observation of the ducts during filing permNs appropriately timed spot films.
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is aspirated. The needle is then withdrawn from the system and the Teflon @ catheter is left in position in the gallbladder. T h e catheter issthen ancl~ored to the skin at the exit site with a suture. A bile specimen is sent to the.laboratory for bacteriologic and cytologic'studies. A n air-free system of 50 per cent Hypaque ® in a 50 ml syringe attached to a venous extension tube is prepared. Tlie~contrast m e d i u m is injected slowlyunder fluoroscopic control. As soon as dye appears in the gallbladder, the first film is exposed. Serial films are obtained as the entire biliary system is outlined by continued injection. Rapid ,runoff into the duodenum, readily recognized by fluoroscopy, permits adjustment of the table position for fillingof the hepatic ducts. A videotape can be added to the television system and replayed for immediate review while the x-ray films are being processed. After satisfactory x-ray interpretation, the biliary system is decompressed through the indwelling catheter. The catheter is then withdrawn and the puncture site in the liver is observed through the laparoscope. Bleeding or bile leak is immediately recognized and controlled by a special suction-coagulation probe introduced through the accessory trocar. • (Figure 4.) A follow-up survey film of the abdom e n is taken two hours later to exclude leakage of contrast material from the gallbladder. Liver bi"opsy under visual control is obtained by forceps or needle when indicated. "The abdomen is deflated and the stab wounds are closed with skin clips. T h e patients are usually able to walk on the day of the procedure. Oral in-
Figure 3. Drawing illustrating the Longdwol needle approaching the hepallc surface of the gallbladder by traversing the right lobe of the liver • and entering the gallbladder through its posterior;wail. When bile is aspirated, the needle iswithdrawn aixl the Teflon calhetar is leff in posl@on wHh/n fhe gallbladder.
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take is instituted on the first postoperative day. In the majority of instances discharge from the hospital is possible within forty-eight hours after the procedure. Should a surgical lesion be demonstrated by these diagnostic studies, the abdomen is re-prepared for immediate laparotomy and the appropriate surgical procedure is promptly undertaken.
Case Repods Case I. The patient, a fifty-fouryear old Caucasian man, was admitted with a three month history of painless progressive jaundice and a 40 pound weight loss. Drug ingestion, alcohol intake, gastrointestinal disturbance, and acholic stools were denied. The patient had previously undergone thoracoplasty for tuberculdsis. Physical examination revealed an icteric, wasted m a n without ascites, hepatomegaly~ or palpable abdominal mass. During a ten day period of observation the serum bilirubin rose from 8 to 13 m g per cent. The alkaline phosphatase was 53 King-Armstrong units. Serum glutamic oxalacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), lactic dehydrogenase, prothrombin time, alpha-feto-globulin, serum amylase, Au-antigen, and smooth muscle antibody titers were all within normal limits. X-ray evaluation including barium enema, intravenous urogram, upper gastrointestinal series, and celiac arteriography were of no diagnostic assistance. The clinical impression of malignant biliary obstruction was strongly entertained. Laparoscopy and percutaneous transhepatic cholecystocholangiography were performed, displaying a normal gallbladder and a nonobstructed extrahepatic biliary tree. (Figure 5.) The appearance of the liver was not diagnostic and a liver biopsy revealed cholestasis.
Figure 4. With this insulaled suction-coagulation probe (botlom) introduced through the accessory trocar with sli/eite (top) under visual control, the puncture site of the liver can be coagulated to avoid bile leakage.
The American Jourmd of Surgery
Perltoneoscoplc Cholangiography tn Diagnosis of Jaundice
Figure 5. Case L A, early filling stage. ~Teflon tub'e is in gallbladder, and accessory trocar is seen on left. Paravertebral shadow (arrow) represents air.contrast o f falciform l i g a m e n t . N o stones w e r e detected in the gallbladder. B, late filling stage. Normal sized~ common bile and h e p a t i c ducts are seen. There i s f r e e drainage into the duodenum. A t o t a l of eight films were taken i n this PaUent.
C a s e I I . Tbe patient, a forty-eight year old Caucasian man, presented with a two week history of painless jaundice. Ingestion of hepatotoxic drugs could not be established.: H e denied exposure to hepatitis, injections, or transfilsions, but admitted to heavy alcohol intake and a recent 7 pound weight loss. Serum hilirubin levels during a two week period of observation ranged from 15 to 18 mg per cent. Alkaline phosphatase varied between 4 0 and 60 King-Armstrongunits. S G O T and S G P T levels were slightly elevated. Extens i v e biochemical and roentgenographic investigations, a s in the previous case, were inconclusive. Needle biopsy of the liver revealed cholestasis. The patient w a s scheduled for explorat0ry laparotomy but a drop i n t h e serum bilirubin level prompted reassessment. After a three m o n t h anicteric period, jaundice recurred, the serum bilirubin level rising to 17.9 mg per cent~ Differentiation between ampullary carcinoma and hepatocelhilar disease could not be established clinically. The p a t i e n t was then transferred to the surgical service. Laparosc0py and transhepatic cholecystocholangi0graphy revealed extrinsic obstruction of the distal common bile duct. (Figure 6.) I m m e d i a t e laparotomy confirmed the presence of pancreatic carcinoma. Roux-enY cholecystojejunostomy was performed. C a s e I I I . The patient, a thirty-seven year old Caucasian m a n , presented with a history of biliary colic one •month prior to admission~ A double dose oral cholecystogram a t t h a t time failed to visualize the gallbladder. Painless jaundice and dark urine were noted two days before hospitalization: Heavy ethanol intake was admitted. T h e p a t i e n t was also receiving Dilantin ® and Prolixin® ( a phenothiazide derivative). On physical examination generalized i c t e r u s a n d t e n d e r moderate hepatomegaly were found. Serum bilirubin rose from 7 t o 33 mg per cent within ten days. Alkaline ph0sphatase peaked at 46King-Armstrong units. S G O T and S G P T fell from 524 and 368 units to 184 and 124 units,
Volume 126, September 1973
respectively. Since the patient presented with strong evidence of both biliary lithiasis and parenchymal liver disease, a firm diagnosis could not be established. LaparosCopy revealed an enlarged dark green liver with an undistended opaque gallbladder. A transhepatic cholecystocholangiogram under visual control demonstrated cholelithiasis; however, the cystic duct and extrahepatic biliary tree were normal with free drainage into t h e duodenum. (Figure 7.) A liver biopsy showed cholestasis. The diagnostic procedure thus demonstrated the coincident occurrence of two distinct clinical entities. Cholecystectomy could then be safely deferred until restoration of normal liver function. It was performed two months later when liver function had returned t o normal. The postoperative course was uneventful.
jr
Figure 6. C a s e I1. Late filling stage. There is signific a n t dilatation of the extrahepatic biliary system with extrinsic narrowit;g of the distal third of the common bile duct. Exploration revealed pancreatic carcinoma.
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Bercl et al
Figure 7. Case 111..4, calculi a r e seen in gallbladder, and the common bile duct is normal sized with free drainage into t h e duodenum. Accessory and examining trocars are visible. B, by changing ( h e p 8 tienrs #osition, the normal sized hepatic duct system is observed. This patient had coincident occurfence of two distinct clinical e n fities, phenothiazide-induced jaundice and nonobstrucflve cholelithiasis. Cholecystectomy was performed two months later when liver function had returned to normal The postoperative course was uneventful.
Comments
These cases illustrate the application of a direct diagnostic approach to the "problematic" jaundiced patient: Demonstration 0f the extrahepatic biliary tree by peritoneoscopic cholecystocholangiography precisely differentiates mechanical obstructive lesions from parenchymatous liver disease. Radiologic visualization of the biliary system in the jaundiced patient has been recently achieved by a variety of direct approaches. (Table I.) Percutaneous transhepatic cholangiography has enjoyed the widest usage. Satisfactory visualization of the bile d u c t s b y this method is achieved in only 70 to 85 per cent of cases since this depends on the presence of some degree of dilatation of the intrahepatic bile ducts. Only one investigator has reported 100 per cent accuracy [8]; he utilized general anesthesia, image amplification, and a lateral transthoracic approach. Unfortunately; the presence of a Surgical lesion cannot b e excluded when d u c t a l visualization is not achieved. (Table I[.) Furthermore, complicat.ions such,-as bile leak or hemorrhage cannot be promPtlY recognized due to the blind nature of the procedure. Transjugular transhepatic cholangiography, recently advocated by Weiner and Hanafeei[9], has t h e s a m e limitations a s percutaneous transhepatic cholangiography Since,duct dilatation i s a l s o required for visualization. To date, ~.only a limited experience h a s been ' reported: , The additional complication iof septicemia , h a s b e e n eiacountered after this procedure, but pretreatment with antibi0tics appears to have eliminated this problem.
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"Mini" laparotomy with open transhepatic cholangiography, recently advocated by Strack et al [!0], appears to provide a higher diagnostic accuracy than that Obtained by percutaneous transhepatic cholangiography. Direct inspection of the liver with open biopsy, control of bile leak or hemorrhage, and omentoportography a r e additional advantages offered by this method. Also, t h e procedure can be performed using local anesthesia. Since this examination is carried out~ in the x:ray department, transfer of t h e patien t to thelpperat: ing room is required i f a surgical lesionis defined. This-could be avoided by scheduling the procedure for a suitably equipped operating room. As in the other types of transhepatic cholangiography described, failure to obtain visualization of t h e duct does not exclude the presence of:a surgical
iesion. Duodenoscopy with retrograde cholangiography Pr0Yides the only "noninvasiv~i~avenue of direct ch01angi0graphy. Documented experience with this approach iscurrently limited. Diagnostic accuracy in jaundiced patients ranges between 60 and 77 percent [M-!3]: Here also,failure to obtain duct Visualizationleaves the diagnostic problem unresolVed. Laparoscopy with transhepatic cholecystocholangiography assures demonstration of the biliary tract S i n c e the: gallbladder: is used a s t h e e n t r y site: Unlike the other methods of cholangiography,
the presence of dilatation of the ductal system is not aprerequisite for ,visualization. The problem Of bile leak :from t h e gallbladder puncture site is avoided b y Selecting : a transhepatic: approach. T h i s permits hepatic tamponade :of the p u n c t u r e
rhe American doumnl o! Surgery
r
Peritoneoscoptc Cholanglography in Diagnosis of Jaundice
TABLE !
Methods of Direct Cholangiography in Jaundiced Patients
Invasive Technics Percutaneous transhepattc chola.nglography Transjugular transhepatlc cholanglography Open transhepatic cholangiography ("mini" laparotomy) Perltoneoscoplc cholangiography: 1, Cholecystocholangiography 2. Transhepatic cholecystoqholangiography 3. Transhepatic cholangiography Nonlnvasive Technics Duodenoscopy with retrograde cholanglography
and direct coagulation of the hepatic entry. This is particularly valuable when laparotomy does not result. The use of peritoneoscopy adds further dimensions. At times the gross visual findings, supported by "aimed" biopsy, m a y be diagnostic. In addition, liver biopsy under visual control can be safely performed. (The cholecystectomized patient cannot, of course, undergo this diagnostic procedure, but he can undergo percutaneous transhepatic cholangiography under laparoscopic control.) While this preliminary study has been carried out using general anesthesia, the use of local anesthesia is contemplated as further experience is acquired. The alternatives in the diagnostic approaches to the jaundiced patient are thus either noninvasive or invasive procedures. Duodenoscopy with retrograde cholangiography (noninvasive) would appear preferable as an initial step. The reports available indicate that the endoscopic instrumentation is stillin its developmental stage, and complex x-ray facilities are required. The economic aspects must be taken into consideration in view of the limited diagnostic accuracy reported by a TABLE II
A c c u r a c y of Percutaneous Cholangiography
Author
Date
Seldinger Evens Richie Shei'iock Blake (collective study) Flemma Kaplan Wiechel
1962 1966 ~969 1965 1965 1966 1964 1964
VOlume 129, September 1973
Percentage with Surgical Lesion in Number Nonvisuof Icteric alized Patients Cases 70 140 54 137 559 107 40 60
70 60 50 43 24 20 20 0
handful of highly skilled endoscopists after extensive experience [14]. Of the invasive methods, laparoscopy with percutaneous transhepatic cholecystocholangiography offers the greatest advantages to the surgeon. It can be readily mastered with a minimum of training and experience. Since duct visualization via the gallbladder does not depend on the presence of dilated ducts, the diagnostic accuracy is potentially greater than that of the other forms of direct cholangiography. Finally, the use of a properly equipped operating room facilitates immediate laparotomy when a surgical lesion is demonstrated. This is usually the case in the xnajority of jaundiced patients subjected to direct cholangiography for diagnosis. (Table II.)
Summary I. Preliminary experience with laparoscopic transhepatic cholecystocholangiography for the diagnosis of the "problematic" jaundiced patient is presented. 2. The instrumentation and technic of this procedure are described and illustrated by case presentations. 3. This procedure is compared with other available methods of direct cholangiography, such as percutaneous transhepatic cholangiography, transjugular cholangiography, open transhepatic cholangiography, and duodenoscopy with retrograde cholangiography. 4. The advantages of laparoscopic transhepatic cholecystocholangrography are as follows: (1) direct visual diagnosis; (2) biopsy under visual control; (3) radiographic demonstration of the biliary tract in the absence of duct dilatation; (4) immediate laparotomy when a surgical lesion is demonstrated; (5) control of bile leak and/or bleeding under direct vision. Addendum
Since this report was completed percutaneous transhepatic cholecystocholangiography has been used successfully to rule out cholelithiasis in a patient with portal cirrhosis and attacks of right upper quadrant pain. References 1. Berkowitz D: Pitfalls in the differential diagnosis of jaundice. Am J Gastroentero141: 488, 1964. 2. Anderson JR, Dockerty MB, Waugh JM: Symposium on Abdominal Surgery: Peritoneoscopy evaluation of 396 examinations. Surg C/in North Am 30: 1045. 1950. 3. Katk H: Leitfaden der Laparoscopy. Stuttgard, Thieme, 1951.
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4. Royer M, Mazure P, Kohan S: BIllary dysklnesla studied by means of the "perltoneoscoplc cholanglography." Gastroenterology 16: 83, 1950. 5. Rosenbaum FJ: Die Laparoskoplsche Cholanglography. Kiln Wochenschr 33: 39, 1955. 6. Bercl G, Steckel R: Modern radiology in the operatln9 room. Arch Surg in press. 7. Beroi G, Kont LA: A new optical system in endoscopy with special reference to cystoscopy, Br J Urol 41: 564, 1969. 8. Wetchel K-L: Percutaneous transhepatic cholangtography. Acta Chit Stand (Suppl) 330: 1, 1964. 9. Weiner M, Hanafee WN: A review of transjugular cholanglography. Radio/C/In North Am S: 53, 1970. 10. Strack PR, Newman HK, Lerner AG, Green SH, Meng C-H, Del Guerclo LRM, State D: An integrated proce-
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11.
12. 13.
14.
dure for the rhpld diagnosis of blliary obstruction, portal hypertension and liver disease of uncertain etiology. N Engl J Med 285: 1225, 1971. Deyhle P, Fumagalll J, Paez C, Jenny S, Preter B, Jenny M, Ammann R: KIInlscher Wert der endoskoplschen retrograden Pankreato-Chotangiographle. Dtsch Med Wo~henschr 97:1139, 1972. Vennes JA, Stlvls SE: Endoscopic visualization of bile and pancreatic duct. Gastrolntest Endosc 18: 149, 1972. Blumgart LH, Cotton PB, Burwood R, Lade B, Salmon P, Davies GT, Beales JSM, Sklrving A: Endoscopy and retrograde choledochopancreatography In the diagnosis of the jaundiced patient. Lancet 2: 1269, 1972. Morrlssey JF: To cannulate or not to cannulate. Gastroenterology 53:351, 1972.
T I ~ Am4fftcam J4~rnM of Svq~ry
George Berci, MD, Los Angeles, California Leon Morgenstern, MD, FACS, Los Angeles, California J. Manny Shore, MD, FACS, Los Angeles, California Stephen Shapiro, MD, Los Angeles, California
In the majority of patients presenting with jaundice, thediagnosis can bd,established by the usual clinical~,, laboratory, radiologic, and radioisotope investigations. In approximately 20 per Cent, however, jatindice cannot be diagnosed by these methods' [1]. The critical differentiation of "medical" from "surgical" jaundice has traditionally been resolved in our group by exploratory laparotomy after a judicious period, of observ~itibn....Thi~a~pproach necessarily subjects a certain'i)ercentage of patients-with-hepatocellular disease to the increased morbidity a~ndniortality of diagnostic~laparotomy[2]. In recent years a number of new.diagnostic tools have become availabl~ewhich-'can-be used for the preoperativetevalfi'ation ,of jaundiced patients. (Tjable-I.~'These special procedures are all based on the principle of direct cholangiography. Using a variety of approaches, radi0paque material is introd(Iced dir~ctlY-into~some portion~of the biliary system so t~hat it taxi; be v-~isu-~lized despite the presence of-Jaundice. With the exception of retrograde ch01angiography via t h e duodenoscope, these methods generally depend on the presence of dilatation within intrahepatic bile ducts, and' thus possess inherent limita'tions. This disadvantage can be overcome by selecting the gallbladder ks. the injection Site. Guidance is From the DIvisiofl of Surgical Endoscopy, Cedars of Lebanon Hospi•tal, Los Angeles, California. Reprint requests sh0pld Meaddressed to Dr BercL Cedars of Lebll* non Hospital, 4833 Fouktaln Avenue,.Los Angeles, California 90029.
372
readily provided by means of the laparoscope. Direct injection into the gallbladder fundus, as advocated by Kalk [3] and Royer, Mazure, and Kohan [4], presents the hazard of bile leak; this is of significance when laparotomy is not necessary after the diagnost!c study. The same information can be obtained by a transhepatic approach to the g~llbladder, as advocated by Rosenbaum [5]. This has the advantage of tamponade of the gallbladder puncture by the liver, preventing the problem of bile extravasation. These considerations led to the development of a direct diagnostic approach to the "difficult" jaundice problem. A perc~taneous transhepatic cholecystocholangiogram is obtained using double guidance by laparoscopy and x-ray image amplification (television-fluoroscopy). This paper will describe the technic evolved at this institution and present its application in three successive cases. The potential of this diagitostic* approach will be discussed and compared with other modalities currently available. Technk: This procedure is reserved for those jaundiced patients in whom a diagnosis cannot, be established after a seven to ten day period of. hospital observation and inv~tigation. The patien~ are prepared for possible laparotomy should a Surgical lesion~be dem0nstrat~ed. Appropriate systemic antibiotics are administered prior to the procedure.
The Ammticm J u m a l ~
Peritoneoscopic Cholanglography in Diagnosis of Jaundice
The study is performed i n the operating room using a special operating table equipped with a radiolucent coordinate-movement tabletop.* (Figure 1.) A ceiling-suspended x-ray tube is employed. A large field (10. inch) mobile image amplifier with a television link-up is placed beneath the operating table.t (Figure 2 . ) T h e fluoroscopic image is displayed on a 14 inch television monitor. Simultaneous display in the x-ray department is possible. Roentgenograms are readily obtained at the appropriate time as indicated by the fluoroscopic views [611 Balanced general anesthesia w i t h controlled ventilation is preferred. The patient is tx)sitioned obliquely with the left side elevated 15 degrees by sheets placed beneath the left scapula. After the induction Of pneumoperitoneum with carbon dioxide, the Hopkins-Storz laparoscope~ is inserted through an infraumbilical midline trocar (7 m m outside diameter). The new image-transmitting system [7] of this laparoscope greatly~enhances visualization and has given impetus to the ree v a l u a t i o n of laparoseopic cholangiography in jaundiced patients. After laparoscopic ~urvey of the abdominal cavity, special attention is paid to the right upper quadrant. The k~ss appearance of the liver and gallbladder is noted. On occasion the diagnosis will be readily recognized, as in liver metastases or carcinomatosis. In the majority of instances, the diagnosis may be inferred by the appearance of the liver and the gallbladder; however, definitive diagnosis requires supplementation of the endoscopic examination with direct cholangiography. Under visual control, an accessory trocar (5 m m outside diameter) is inserted in the right upper quadrant. Through this trocar a palpation probe is advanced for elevation of the righ t lobe 0~ the liver. This permits observation of t h e undersurface of the liver and facilitates inspection of the gallbladder. It also provides stabilization of the liver during cholangiography. Witl~ this technic~ t h e gallbladder can be Visualized in most p a l l e t s . A site is then chosen for the percutaneous puncture. Under visual guidance a n u m b e r 20 gauge, 8 inch Longdwel• needle§ is inserted t h r o u g h ~ h e *lt'lFA Surgical O. R. Table Company, Solna 1, Stockholm, Sweden; distributed by Affilia'ted Hospital Products, Inc, Mdryland Heights, Missouri. tSlemens X-ray Corporation of America, 1329 Grand Centml Aueru~, Glendale ~ Cali~orrda91201. ~Storz Endoscopy America, lnc, 650 South San Vicente Boulevard, Los A nleles/ ~alifornio 90048. |Becton. Dickinson and Company, Rutherford, New Jersey.
VMmlw1No IlelNm~NmrIIWS
Figure 1. The flat radiolucent tabletop can be moved in a coordinate fashion during the procedure, No r e alignment of x.ray apparatus is needed. With this appo. ratus the now of dye can be followed during injection over a 10 inch a r e a .
abdominal wall or appropriate intercostal space in the midclavicular line. The needle is directed towards the hepatic Surface of the gallbladder by traversing the right lobe of the liver. (Figure 3.) An appropriate angle is chosen so that the liver is entered approximately 2 t o 4 c m from the anteroinferior margin. Once the !iver parenchyma is entered, the stylet is withdrawn and the needle is advanced until the gallbladder is entered and bile
Figure 2. The tabletop and patient are eccentrically placed a n d the patient is prepared for operative cl~langiogra~hy. The overhead ce#ing.suspended x-ray tube is lowered, A 10 inch mobile image amplifier coupled t o a television camera (fluoroscopy) witt~ 70 by ?0 mm spot film camera is in position underneath the table. S~andard radiographs can also he employed. Fluoroscopic observation of the ducts during filing permNs appropriately timed spot films.
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Berci et al
is aspirated. The needle is then withdrawn from the system and the Teflon @ catheter is left in position in the gallbladder. T h e catheter issthen ancl~ored to the skin at the exit site with a suture. A bile specimen is sent to the.laboratory for bacteriologic and cytologic'studies. A n air-free system of 50 per cent Hypaque ® in a 50 ml syringe attached to a venous extension tube is prepared. Tlie~contrast m e d i u m is injected slowlyunder fluoroscopic control. As soon as dye appears in the gallbladder, the first film is exposed. Serial films are obtained as the entire biliary system is outlined by continued injection. Rapid ,runoff into the duodenum, readily recognized by fluoroscopy, permits adjustment of the table position for fillingof the hepatic ducts. A videotape can be added to the television system and replayed for immediate review while the x-ray films are being processed. After satisfactory x-ray interpretation, the biliary system is decompressed through the indwelling catheter. The catheter is then withdrawn and the puncture site in the liver is observed through the laparoscope. Bleeding or bile leak is immediately recognized and controlled by a special suction-coagulation probe introduced through the accessory trocar. • (Figure 4.) A follow-up survey film of the abdom e n is taken two hours later to exclude leakage of contrast material from the gallbladder. Liver bi"opsy under visual control is obtained by forceps or needle when indicated. "The abdomen is deflated and the stab wounds are closed with skin clips. T h e patients are usually able to walk on the day of the procedure. Oral in-
Figure 3. Drawing illustrating the Longdwol needle approaching the hepallc surface of the gallbladder by traversing the right lobe of the liver • and entering the gallbladder through its posterior;wail. When bile is aspirated, the needle iswithdrawn aixl the Teflon calhetar is leff in posl@on wHh/n fhe gallbladder.
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take is instituted on the first postoperative day. In the majority of instances discharge from the hospital is possible within forty-eight hours after the procedure. Should a surgical lesion be demonstrated by these diagnostic studies, the abdomen is re-prepared for immediate laparotomy and the appropriate surgical procedure is promptly undertaken.
Case Repods Case I. The patient, a fifty-fouryear old Caucasian man, was admitted with a three month history of painless progressive jaundice and a 40 pound weight loss. Drug ingestion, alcohol intake, gastrointestinal disturbance, and acholic stools were denied. The patient had previously undergone thoracoplasty for tuberculdsis. Physical examination revealed an icteric, wasted m a n without ascites, hepatomegaly~ or palpable abdominal mass. During a ten day period of observation the serum bilirubin rose from 8 to 13 m g per cent. The alkaline phosphatase was 53 King-Armstrong units. Serum glutamic oxalacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), lactic dehydrogenase, prothrombin time, alpha-feto-globulin, serum amylase, Au-antigen, and smooth muscle antibody titers were all within normal limits. X-ray evaluation including barium enema, intravenous urogram, upper gastrointestinal series, and celiac arteriography were of no diagnostic assistance. The clinical impression of malignant biliary obstruction was strongly entertained. Laparoscopy and percutaneous transhepatic cholecystocholangiography were performed, displaying a normal gallbladder and a nonobstructed extrahepatic biliary tree. (Figure 5.) The appearance of the liver was not diagnostic and a liver biopsy revealed cholestasis.
Figure 4. With this insulaled suction-coagulation probe (botlom) introduced through the accessory trocar with sli/eite (top) under visual control, the puncture site of the liver can be coagulated to avoid bile leakage.
The American Jourmd of Surgery
Perltoneoscoplc Cholangiography tn Diagnosis of Jaundice
Figure 5. Case L A, early filling stage. ~Teflon tub'e is in gallbladder, and accessory trocar is seen on left. Paravertebral shadow (arrow) represents air.contrast o f falciform l i g a m e n t . N o stones w e r e detected in the gallbladder. B, late filling stage. Normal sized~ common bile and h e p a t i c ducts are seen. There i s f r e e drainage into the duodenum. A t o t a l of eight films were taken i n this PaUent.
C a s e I I . Tbe patient, a forty-eight year old Caucasian man, presented with a two week history of painless jaundice. Ingestion of hepatotoxic drugs could not be established.: H e denied exposure to hepatitis, injections, or transfilsions, but admitted to heavy alcohol intake and a recent 7 pound weight loss. Serum hilirubin levels during a two week period of observation ranged from 15 to 18 mg per cent. Alkaline phosphatase varied between 4 0 and 60 King-Armstrongunits. S G O T and S G P T levels were slightly elevated. Extens i v e biochemical and roentgenographic investigations, a s in the previous case, were inconclusive. Needle biopsy of the liver revealed cholestasis. The patient w a s scheduled for explorat0ry laparotomy but a drop i n t h e serum bilirubin level prompted reassessment. After a three m o n t h anicteric period, jaundice recurred, the serum bilirubin level rising to 17.9 mg per cent~ Differentiation between ampullary carcinoma and hepatocelhilar disease could not be established clinically. The p a t i e n t was then transferred to the surgical service. Laparosc0py and transhepatic cholecystocholangi0graphy revealed extrinsic obstruction of the distal common bile duct. (Figure 6.) I m m e d i a t e laparotomy confirmed the presence of pancreatic carcinoma. Roux-enY cholecystojejunostomy was performed. C a s e I I I . The patient, a thirty-seven year old Caucasian m a n , presented with a history of biliary colic one •month prior to admission~ A double dose oral cholecystogram a t t h a t time failed to visualize the gallbladder. Painless jaundice and dark urine were noted two days before hospitalization: Heavy ethanol intake was admitted. T h e p a t i e n t was also receiving Dilantin ® and Prolixin® ( a phenothiazide derivative). On physical examination generalized i c t e r u s a n d t e n d e r moderate hepatomegaly were found. Serum bilirubin rose from 7 t o 33 mg per cent within ten days. Alkaline ph0sphatase peaked at 46King-Armstrong units. S G O T and S G P T fell from 524 and 368 units to 184 and 124 units,
Volume 126, September 1973
respectively. Since the patient presented with strong evidence of both biliary lithiasis and parenchymal liver disease, a firm diagnosis could not be established. LaparosCopy revealed an enlarged dark green liver with an undistended opaque gallbladder. A transhepatic cholecystocholangiogram under visual control demonstrated cholelithiasis; however, the cystic duct and extrahepatic biliary tree were normal with free drainage into t h e duodenum. (Figure 7.) A liver biopsy showed cholestasis. The diagnostic procedure thus demonstrated the coincident occurrence of two distinct clinical entities. Cholecystectomy could then be safely deferred until restoration of normal liver function. It was performed two months later when liver function had returned t o normal. The postoperative course was uneventful.
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Figure 6. C a s e I1. Late filling stage. There is signific a n t dilatation of the extrahepatic biliary system with extrinsic narrowit;g of the distal third of the common bile duct. Exploration revealed pancreatic carcinoma.
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Figure 7. Case 111..4, calculi a r e seen in gallbladder, and the common bile duct is normal sized with free drainage into t h e duodenum. Accessory and examining trocars are visible. B, by changing ( h e p 8 tienrs #osition, the normal sized hepatic duct system is observed. This patient had coincident occurfence of two distinct clinical e n fities, phenothiazide-induced jaundice and nonobstrucflve cholelithiasis. Cholecystectomy was performed two months later when liver function had returned to normal The postoperative course was uneventful.
Comments
These cases illustrate the application of a direct diagnostic approach to the "problematic" jaundiced patient: Demonstration 0f the extrahepatic biliary tree by peritoneoscopic cholecystocholangiography precisely differentiates mechanical obstructive lesions from parenchymatous liver disease. Radiologic visualization of the biliary system in the jaundiced patient has been recently achieved by a variety of direct approaches. (Table I.) Percutaneous transhepatic cholangiography has enjoyed the widest usage. Satisfactory visualization of the bile d u c t s b y this method is achieved in only 70 to 85 per cent of cases since this depends on the presence of some degree of dilatation of the intrahepatic bile ducts. Only one investigator has reported 100 per cent accuracy [8]; he utilized general anesthesia, image amplification, and a lateral transthoracic approach. Unfortunately; the presence of a Surgical lesion cannot b e excluded when d u c t a l visualization is not achieved. (Table I[.) Furthermore, complicat.ions such,-as bile leak or hemorrhage cannot be promPtlY recognized due to the blind nature of the procedure. Transjugular transhepatic cholangiography, recently advocated by Weiner and Hanafeei[9], has t h e s a m e limitations a s percutaneous transhepatic cholangiography Since,duct dilatation i s a l s o required for visualization. To date, ~.only a limited experience h a s been ' reported: , The additional complication iof septicemia , h a s b e e n eiacountered after this procedure, but pretreatment with antibi0tics appears to have eliminated this problem.
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"Mini" laparotomy with open transhepatic cholangiography, recently advocated by Strack et al [!0], appears to provide a higher diagnostic accuracy than that Obtained by percutaneous transhepatic cholangiography. Direct inspection of the liver with open biopsy, control of bile leak or hemorrhage, and omentoportography a r e additional advantages offered by this method. Also, t h e procedure can be performed using local anesthesia. Since this examination is carried out~ in the x:ray department, transfer of t h e patien t to thelpperat: ing room is required i f a surgical lesionis defined. This-could be avoided by scheduling the procedure for a suitably equipped operating room. As in the other types of transhepatic cholangiography described, failure to obtain visualization of t h e duct does not exclude the presence of:a surgical
iesion. Duodenoscopy with retrograde cholangiography Pr0Yides the only "noninvasiv~i~avenue of direct ch01angi0graphy. Documented experience with this approach iscurrently limited. Diagnostic accuracy in jaundiced patients ranges between 60 and 77 percent [M-!3]: Here also,failure to obtain duct Visualizationleaves the diagnostic problem unresolVed. Laparoscopy with transhepatic cholecystocholangiography assures demonstration of the biliary tract S i n c e the: gallbladder: is used a s t h e e n t r y site: Unlike the other methods of cholangiography,
the presence of dilatation of the ductal system is not aprerequisite for ,visualization. The problem Of bile leak :from t h e gallbladder puncture site is avoided b y Selecting : a transhepatic: approach. T h i s permits hepatic tamponade :of the p u n c t u r e
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Peritoneoscoptc Cholanglography in Diagnosis of Jaundice
TABLE !
Methods of Direct Cholangiography in Jaundiced Patients
Invasive Technics Percutaneous transhepattc chola.nglography Transjugular transhepatlc cholanglography Open transhepatic cholangiography ("mini" laparotomy) Perltoneoscoplc cholangiography: 1, Cholecystocholangiography 2. Transhepatic cholecystoqholangiography 3. Transhepatic cholangiography Nonlnvasive Technics Duodenoscopy with retrograde cholanglography
and direct coagulation of the hepatic entry. This is particularly valuable when laparotomy does not result. The use of peritoneoscopy adds further dimensions. At times the gross visual findings, supported by "aimed" biopsy, m a y be diagnostic. In addition, liver biopsy under visual control can be safely performed. (The cholecystectomized patient cannot, of course, undergo this diagnostic procedure, but he can undergo percutaneous transhepatic cholangiography under laparoscopic control.) While this preliminary study has been carried out using general anesthesia, the use of local anesthesia is contemplated as further experience is acquired. The alternatives in the diagnostic approaches to the jaundiced patient are thus either noninvasive or invasive procedures. Duodenoscopy with retrograde cholangiography (noninvasive) would appear preferable as an initial step. The reports available indicate that the endoscopic instrumentation is stillin its developmental stage, and complex x-ray facilities are required. The economic aspects must be taken into consideration in view of the limited diagnostic accuracy reported by a TABLE II
A c c u r a c y of Percutaneous Cholangiography
Author
Date
Seldinger Evens Richie Shei'iock Blake (collective study) Flemma Kaplan Wiechel
1962 1966 ~969 1965 1965 1966 1964 1964
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Percentage with Surgical Lesion in Number Nonvisuof Icteric alized Patients Cases 70 140 54 137 559 107 40 60
70 60 50 43 24 20 20 0
handful of highly skilled endoscopists after extensive experience [14]. Of the invasive methods, laparoscopy with percutaneous transhepatic cholecystocholangiography offers the greatest advantages to the surgeon. It can be readily mastered with a minimum of training and experience. Since duct visualization via the gallbladder does not depend on the presence of dilated ducts, the diagnostic accuracy is potentially greater than that of the other forms of direct cholangiography. Finally, the use of a properly equipped operating room facilitates immediate laparotomy when a surgical lesion is demonstrated. This is usually the case in the xnajority of jaundiced patients subjected to direct cholangiography for diagnosis. (Table II.)
Summary I. Preliminary experience with laparoscopic transhepatic cholecystocholangiography for the diagnosis of the "problematic" jaundiced patient is presented. 2. The instrumentation and technic of this procedure are described and illustrated by case presentations. 3. This procedure is compared with other available methods of direct cholangiography, such as percutaneous transhepatic cholangiography, transjugular cholangiography, open transhepatic cholangiography, and duodenoscopy with retrograde cholangiography. 4. The advantages of laparoscopic transhepatic cholecystocholangrography are as follows: (1) direct visual diagnosis; (2) biopsy under visual control; (3) radiographic demonstration of the biliary tract in the absence of duct dilatation; (4) immediate laparotomy when a surgical lesion is demonstrated; (5) control of bile leak and/or bleeding under direct vision. Addendum
Since this report was completed percutaneous transhepatic cholecystocholangiography has been used successfully to rule out cholelithiasis in a patient with portal cirrhosis and attacks of right upper quadrant pain. References 1. Berkowitz D: Pitfalls in the differential diagnosis of jaundice. Am J Gastroentero141: 488, 1964. 2. Anderson JR, Dockerty MB, Waugh JM: Symposium on Abdominal Surgery: Peritoneoscopy evaluation of 396 examinations. Surg C/in North Am 30: 1045. 1950. 3. Katk H: Leitfaden der Laparoscopy. Stuttgard, Thieme, 1951.
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4. Royer M, Mazure P, Kohan S: BIllary dysklnesla studied by means of the "perltoneoscoplc cholanglography." Gastroenterology 16: 83, 1950. 5. Rosenbaum FJ: Die Laparoskoplsche Cholanglography. Kiln Wochenschr 33: 39, 1955. 6. Bercl G, Steckel R: Modern radiology in the operatln9 room. Arch Surg in press. 7. Beroi G, Kont LA: A new optical system in endoscopy with special reference to cystoscopy, Br J Urol 41: 564, 1969. 8. Wetchel K-L: Percutaneous transhepatic cholangtography. Acta Chit Stand (Suppl) 330: 1, 1964. 9. Weiner M, Hanafee WN: A review of transjugular cholanglography. Radio/C/In North Am S: 53, 1970. 10. Strack PR, Newman HK, Lerner AG, Green SH, Meng C-H, Del Guerclo LRM, State D: An integrated proce-
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11.
12. 13.
14.
dure for the rhpld diagnosis of blliary obstruction, portal hypertension and liver disease of uncertain etiology. N Engl J Med 285: 1225, 1971. Deyhle P, Fumagalll J, Paez C, Jenny S, Preter B, Jenny M, Ammann R: KIInlscher Wert der endoskoplschen retrograden Pankreato-Chotangiographle. Dtsch Med Wo~henschr 97:1139, 1972. Vennes JA, Stlvls SE: Endoscopic visualization of bile and pancreatic duct. Gastrolntest Endosc 18: 149, 1972. Blumgart LH, Cotton PB, Burwood R, Lade B, Salmon P, Davies GT, Beales JSM, Sklrving A: Endoscopy and retrograde choledochopancreatography In the diagnosis of the jaundiced patient. Lancet 2: 1269, 1972. Morrlssey JF: To cannulate or not to cannulate. Gastroenterology 53:351, 1972.
T I ~ Am4fftcam J4~rnM of Svq~ry