Benign stricture of the common bile duct

BENIGN STRICTURE

OF THE COMMON

HARWELL

WILSON,

BILE DUCT*

M.D.

Memphis, Tennessee

A

HIGH percentage of the strictures of the common bile duct are preceded by biliary tract surgery. Cole’ states that in 75 per cent of the cases of common bile duct stricture treated at the IIIinois Research Hospita1 there was a history of previous bihary tract surgery. Cole cites hgures by Cattell indicating previous operative injury to the duct in 80 per cent of the cases of stricture of the duct treated whiIe Walters reported a reIationship of go per cent of his cases. The occasiona cases of stricture of the common duct not related to operative injury are usuaIIy caused by an inlIammatory process severe enough to produce librosis of the tissues in or about the duct. In rare instances gallstones in the duct with the associated Iong-standing inflammatory condition is the sign&cant factor producing the stricture. A stone impacted in the duct at the ampuIIa of Vater has occasionaIIy resulted in a stricture of the common bile duct. A limited number of these Iesions have resuIted from the severe inflammatory reaction associated with a duodena1 uIcer. However, the case history of a patient suffering from stricture of the common biIe duct most often reveaIs previous biIiary tract surgery. (Figs. I and 2.) PREVENTION

OF

COMMON

DUCT

INJUKIES

The prevention of stricture of the common hiIe duct is dependent in most instances upon proper surgical technic at the time of choIecystectomy. FaiIure to identify accurateIy the junction of the cystic and common duct may result in injury. An extensive inflammatory reaction may obscure the structures and cause d&uIty for the operator in identifying the junction of the cystic and common ducts. In di&uIt cases it is often wise to remove the gaIIbIadder from above downward. There is usually more bIeeding from the Iiver bed when this method is used but often there is Iess risk of surgica1 trauma to the ducts. The anomahes frequentIy present in the duct system present another situation in which identity of the

cystic and common duct junction is diflicult. I1 a practice is made of determining the point where the cystic and common ducts actually join rather than assuming the junction is normaIIy situated, operative injury may he avoided in most cases. Operative records of patients who have strictures of the common duct reveal that one of the chief diffrcuIties encountered during the previous cholecystectomies has been hemorrhage. The necessity of cIamping onIy the bIeeding point in instances in which hemorrhage occurs has been repeatedly stressed. DigitaI compression of the hepatic artery will usuahy contro1 the hemorrhage from the cystic artery, temporariIy enabIing the surgeon to visuaIize the bleeding point and permitting a cIear operative held. This is accompIished by inserting the index finger into the foramen of WinsIow and compressing the hepatic artery between the thumb and index finger. Experienced surgeons have frequentIy caIIed attention to the necessity of adequate exposure, good illumination and proper anesthesia. Injuries are not Iimited to trauma under unfavorabIe circumstances such as difficult> in identifying important structures, puzzling anomalies of the duct system and hemorrhage. In some cases of duct injury reference to the origina record reveaIs that the operation was considered to be technically easy. This may be due to the fact that when traction is appIied to the gallbladder the common duct can easiIy be puIIed up in Iine with the cystic duct and in this position can be bIindIy cIamped without the knowIedge of the operator. (Fig. 3.) OPERATIVE

METHODS

STRICTURE

OF

FOR COMMON

MANAGEMENT BILE

The many different procedures carried out in the reconstruction of the common bile duct actually have been deviations of two general principIes, nameIy, end-to-end suture of the common duct and the impIantation of the proximal end of a strictured duct into some

* From the Department of Surgery of the University of Tennessee, Memphis, Tenn.

December,

rgfo

OF

DUCT

941

942

Wilson-Stricture

of Common

portion of the gastrointestina1 tract. Recently another procedure was introduced by Longmire2 which entails resection of a portion of the Ieft lobe of the liver and anastomosis between the left intrahepatic duct and the jejunum. The end-to-&d anastomosis of the duct is

in that

BiIe Duct it may

be removed

when desired.

(Fig. 4.) The second principIe, implanting the proxima1 end of the duct into some portion of the gastrointestina1 tract, has been used with numerous variations. In many instances cho-

FIG. I. A stone impacted in the common bile duct very occasionally

produces ukeration and fibrosis which is foIIowed by stricture of the duct. FIG. 2. Drawing shows region of posterior waI1 duodenal uker about which the inflammatory reaction might produce a stricture of the common bile duct. FIG. 3. Traction on the gallbtadder may displace the hepatic artery or the common duct during chokcystectomy. Accurate visuatization and demonstration of the structures is necessary to prevent injury.

Iedochoduodenostomy is done. In other cases the best method in cases in which this is posthe anastomosis has been between the proximal sibIe. CatteI13 and Lahey4 have stressed reduct and stomach or jejunum. AIIen5 popuIarfIecting the duodenum mediaIIy and splitting ized the use of the Roux Y Iimb of the jejunum the head of the pancreas in order to expose to the proxima1 end of the common duct which the distal retroduodena1 portion of the duct. appears to invoIve Iess danger of ascending After the duct has been definitely identified, infection. We beIieve this procedure is more the stenosed area of the duct is excised. The satisfactory than choledochoduodenostomy. end-to-end anastomosis is usually accompIished (Fig. 5.) We aIso believe an accurate anasover some type of catheter or supporting tomosis of the mucosa of the duct to the structure. At one time vitaIIium@ was regarded mucosa of the intestine is very important and as somewhat superior fur this purpose. Howthat in genera1 a more satisfactory anastomosis ever, later observations indicated that it offered can be accomplished if it is performed over no advantage over the catheter or rubber tube. some type of catheter which can be brought to It is more advantageous to perform such the outside and can be removed when desired. anastomoses over a catheter or T tube which (Fig. 6.) can be brought to the outside in some manner Intrahepatic choIangiojejunostomy with parto provide adequate drainage of the”common tial hepatectomy as introduced originaIIy by bile duct as Iong as necessary. iCatteI13 has Longmire and as modified by WiIson and emphasized the value of inserting the catheter or T tube in the common duct either above or GiIIespie6 offers a new and radical approach of below the anastomosis and bringing it to the . vaIue in certain diffkuIt cases. The Ieft intrahepatic biIe duct is identified by resecting a outside. The catheter offers another advantage American

Journal of Surgery

WiIson-Stricture

of Common

BiIe Duct

4

FIG. 4. End-to-end anastomosis of the common duct over a T tube after resection of the narrowed portion of the duct. It is usuaIIy wise to bring the catheter out of the duct through an opening either above or below the anastomosis rather than at the site of suture as iIIustrated. FIG. 5. IIIustration of one method of accomplishing choIedochoduodenostomy. In many instances the anastomosis is performed over a short rubber tube which is not brought outside the duodenum as illustrated. Choledochojejunostomy utiIizing the Roux Y principIe as emphasized by AIIen is often preferabIe to the method iIIustrated. FIG. 6. A, stricture of the duct at the amp&a of Vater at times is best treated by a transduodenal approach with division of the stricture under direct vision; B, transverse cIosure of duodenum in order to preserve the lumen of the viscus.

portion of the left lobe of the Iiver and an anastomosis performed between the duct and jejunum. This type of anastomosis is particuIarIy heIpfu1 in cases in which aImost no remnant of the duct remains. (Fig. 7.) Since the introduction of this new procedure two successfu1 cases have been reported upon by WiIson and GiIIespie6 and by Sanders.7 The December,

1950

foIIowing is a resume of a case previousIy reported by WiIson and GiIIespie in which the modified Longmire procedure was utiIized: CASE

REPORT

A forty year old white maIe was admitted to our service in January, 1948, compIaining of jaundice accompanied with recurring fever and

of Common

Wilson-Stricture

chilIs. He was markedIy jaundiced. Tenderness was noted beneath the right costal margin. The stooIs were clay colored and further inquiry reveaIed there had been a Ioss of 40 pounds of weight. The patient’s past history reveaIed he had undergone choIecystectomy sixteen months

J FIG. 7. Illustration of technic used in case in which partiaI hepatectomy and intrahepatic choIangiojejunostomy was done because of inability to demonstrate any Dortion of the common bile duct. Left upper inset shows type of incision used with stab wound shown for drainage. The central drawing ilIustrates anastomosis between a Roux Y Iimb of the jejunum and the left intrahepatic biIe duct; anastomosis performed over a catheter which was brought to the outside by the WitzeI method. Right Iower inset shows method of controlling hemorrhage from Iiver by the use of overlapping __ - mattress sutures tied over a strip of gelfoam. A, ilIustrates smaI1 artery which accomoanies Ieft heoatic duct which is IabeIed (B); smalI pdrtion of Iiver parenchyma adjacent to the duct has been curretted away. ”

L

A

previousIy

and at the time had been toId the gaIIbIadder contained many stones. His postoperative course was uneventfu1 with the exception of an unusuaIIy profuse drainage of hiIe from the wound for severa days. Sometime after the operation he began to experience attacks of jaundice which varied in intensity. An expIoratory Iaparotomy was performed on March 21, 1947, and he was toId no obstruction existed in the biIe duct. On February 3, 1948, an expIoratory Iaparotomy was performed and

BiIe

Duct

a definite common biIe duct couId not be identified. However, when an area was incised in the hilus of the Iiver, a smaI1 amount of biIe couId be seen flowing out; and this area was anastomosed to the duodenum. It soon became apparent that the newIy established communication was not functioning satisfactoriIy. On March 13, 1948, partia1 hepatectomy and choIangiojejunostomy were done. A modified V type incision was made beneath the Costa1 margin. The trianguIar Iigament supporting the Ieft Iobe of the Iiver was divided and the Ieft Iobe of the liver deIivered into the wound. OverIapping mattress sutures were utiIized to control bIeeding whiIe resecting the Ieft Iobe of the liver. Upon accompIishing resection of the IateraI two-thirds of the Ieft Iobe a smaI1 biIe duct was identified and catheterized with a No. 14 French catheter. The Iiver tissue immediately adjacent to the duct was removed and an end-to-end anastomosis between the Roux Y loop of the jejunum and the biIe duct was done. The catheter was brought out of the Roux Y Iimb of jejunum by the WitzeI procedure. Liver tissue removed at operation reveaIed the presence of a rather diffuse hepatitis which was not unexpected in view of the patient’s Iong history of biIiary tract infection. The postoperative course was characterized by fever and some drainage from the abdomina1 wound. BiIe was present in the stoo1 on the third postoperative day. TweIve days after the operation a partia1 wound disruption developed which required secondary cIosure. The patient graduaIIy improved. When Iast seen he was no longer jaundiced, he had gained approximately 20 pounds in weight and had returned to his normal occupation. The serum biIirubin curve was approximateIy normal. The patient was apparentIy in good health eighteen months after the repair. Strictures in some instances deveIop at the site of repair and it is impossibIe to determine whether a patient is permanentIy cured until long periods of time have eIapsed. The abdomina1 surgeon should be thoroughIy famiIiar with the various types of repair which have proved useful in the management of these most difflcuIt and varied Iesions. SUMMARY I.

often

AND

CONCLUSIONS

Stricture of the common biIe duct is most due to operative trauma. However, inAmerican

Journal of Surgery

W&on-Stricture

of Common

llammatory processes in or about the duct may occasionally resuIt in a stricture. 2. The diffkult situations often encountered during biliary tract surgery are pointed out together with surgical technics most heIpfu1 in avoiding operative injury. 3. The method of repair of common duct stricture is dependent on the location and type of stricture. 4. The value of partial hepatectomy and intrahepatic cholangiojejunostomy in diffIcuIt cases is discussed and a case utilizing this method reviewed. REFERENCES I. COLE, WARREN. Strictures

of the common Surg., Gynec. @ Obst., 82: Io4-105, 1946.

duct.

BiIe

Duct

2. LONGMIRE, W. P., JR. and SANFORD, M. C. Intrahepatic cholangiojejunostomy with partial hepatectomy for biIiary obstruction. Surgery, 24: 264. 276, 1948. 3. CATTELL, R. B. Benign stricturesof the biliary ducts. J. A. M. A., 134: 135-240, 1947. 4. LAHEY. F. H. Finding the Iower end of the common duct’ in stricture if the common duct. S. Chin. Nortb America, 23: 714-716, 1943. 5. ALLEN, A. W. A method of re-establishing continuity between the bile ducts and the gastro-intestinal tract. Ann. .%rg., 121: 412-424, 1945. 6. WILSON, HARWELL and GILLESPIE, C. E. Partial hepatectomy with intrahepatic cholangiojejunostOmy. Ann. Surg., 129: 756-765, 1949. 7. SANDERS, R. L. Hemihepatectomy with hepaticojejunostomy for irreparabIe defects of the bile ducts. Arch. Surg., 58: 752-761, 1949. 8. WILSON, HARWELL and C. FRANK YATES. Stricture of the common biIe duct: etioIogy and treatment. South. Surgeon, (in press).

IN a few recent cases of tubercuIosis of the faIIopian tubes in which a tubercuIous peritonitis aIso deveIoped exceIIent resuIts were obtained by the use of streptomycin. This antibiotic can be injected into the peritoneal cavity, especiaIIy after a paracentesis, before removing the trocar-or it can be given parenteraIly. A few surgeons have even injected:streptomycin into the adnexa1 masses. Many of these cases apparentIy are compIeteIy cured by this antibiotic and many an operation may thus be avoided. (Richard A. Leonardo, M.D.)

December,

I 950

945