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Biliary stricture: A continuing study
Biliary Stricture: A Continuing Study A. James McAllister, MD, Salt Lake City, Utah
N. Frederick Hicken, MD, Salt Lake City, Utah
Benign stricture of bile ducts, although becoming less frequent, remains the most serious benign disease of the biliary tract. More than 90 per cent of strictures result from surgery for gallstones [Z-3], be it cholelithiasis or choledocholithiasis. All experienced surgeons have, for at least one generation, emphasized causes of ductal or vascular damage, but many patients still require repair of such injuries. Better training of surgeons has decreased experience with stricture but methods of adequate repair have changed little in the past twenty years. The only truly satisfactory management of stricture is prevention. Females are afflicted in a ratio of 3 or 4 to 1 over males and it is directly related to the number of cholecystectomies performed. Our experience covers a period of twenty-five years; but statistical material consists of patients seen in our area over two periods of five years separated by a decade. Material and Methods
The cases of all biliary operations in the five major hospitals in the Salt Lake City area during the five year period from 1952 to 1957 were reviewed. During this interval 3,748 biliary operations were performed with ninety-seven procedures carried out for benign ductal stricture. Ampullary stricture and malignancy were excluded. During that period 2.4 per cent of operations were for ductal injuries. At the Latter-Day Saints Hospital specifically, there were 2,122 biliary procedures (1,902 cholecystectomies, 361 choledochostomies, 101 cholecystostomies), of which fifty-eight (2.6 per cent) were for stricture. Appallingly, one in every forty biliary operations were for repair of injured ducts. A similar study was undertaken at the Latter-Day Saints Hospital for the years 1962 to 1967, during which seventeen ductal strictures or injuries occurred out of 2,402 biliary procedures (2,060 cholecystectomies, 615 choledochostomies, 72 cholecystostomies). Five injuries were recognized and handled at primary operation. Five were reoperations on patients from a previous period. Thus, there were acFrom the Departments of Surgery. LDS Hospital. and University of Utah college of Medicine, salt we city, Utah. Repint reqwsts should be addressed to A. James McAllister. MD. 511 MedICal Arts Building, Salt Lake City, Utah 84111.
Vohmo 132. Novnnkr
1978
tually only seven new strictures (0.3 per cent). This great improvement can only be explained by better training of surgeons now operating and the almost universal use of operative cholangiography in our area. Causes of strictures almost universally result from one or a combination of four major factors: (1) inadequate exposure; (2) anatomic variations not familiar to the surgeon; (3) hemorrhage difficult to control; (4) inability to identify structures due to existing inflammatory changes. Adequate exposure requires: complete relaxation by a capable anesthesiologist in an operating theater with excellent illumination; adequate assistance to retain a dry, well retracted field; and cholangiographic facilities, which are mandatory for ideal biliary work. Incision should be generous and placed to allow extension if needed. Anatomic variations are so frequent in the ductal and vascular patterns of the extrahepatic system that fully one third of patients will exhibit an anatomy other than that shown in the textbook. Surgeons must familiarize themselves with the work of Nicholas Michaels [4] if injury is to be avoided. Cholangiography via the gallbladder or cystic duct near the gallbladder, early in the operative procedure, provides a blueprint of the ductal structures, thus helping avoid injury to the common hepatic duct in handling the crossover cystic duct, which may pass anterior or posterior to the common duct to join it from the left to form the choledochus. (Figure 1, left.) At times a single septum separates the two ducta and safe removal is impossible without injury to a duct or ita blood supply. The long parallel cystic duct (Figure 1, middle) with a single septum between it and the hepatic duct can also be demonstrated and protected, as can the duct which enters a hepatic duct, be it right or left. (Figure 1, right.) Arterial variations need cause no problem if the surgeon is aware of possible deviation and not only identifies the cystic artery in the triangle of Calot but also sees the artery enter the gallbladder before it is clamped or ligated. Hemorrhage should not occur, but when it does, retraction must be maintained, keeping the hepatoduodenal ligament taut by pulling the duodenum downward and to the left so that the tubular structures within the ligament can be seen. The surgeon can easily control bleeding by compression of the portal vein and the hepatic artery by placing the index finger in the foramen of Winslow and compressing the porta hepatis between the thumb and forefinger until the area can be lavaged, aspirated, and the vessel clearly seen and safely controlled.
567
McAllister and Hicken
Figure 1. Left, crossover cystic duct passes anterior or posterior to common hepatic duct to form choiedochus. Mkkfie, iong parallel cystfc may pass parallel to hepatic duct even to papilla of Vater. Right, cystic duct joins right or left hepatic duct (here joins right hepatic duct).
Figure 2. Mass ligature engages tissues not desired in iigation.
Mass ligation of tissue is never justified in the subhepatic area. (Figure 2.) More strictures, and more severe strictures, have resulted from this procedure than any other in our experience. This is concurred by the reports of Braasch and Warren [I], who experienced 51 per cent of strictures in their series from ligation to control bleeding, which injured the separate hepatic ducts or common hepatic duct.
568
Mass clamping must likewise be condemned, for if the major bile ducts are crushed, it may be weeks before resulting necrosis allows leakage of bile into the abdomen or fibrosis with obstruction as heralded by chills, fever, jaundice, and pain of stricture. (Figure 3.) Usually it is possible to place gallbladder forceps from posterior to. anterior after dissection of the cystic duct or cystic artery whereby both tips can be clearly in view of the surgeon before the clamp is locked. Inflammatory changes, which make visualization of necessary structures impossible, preclude removal of the gallbladder, and cholecystostomy should be performed. (It is true another operation will be required, but cholecystectomy later is far better than stricture repair.) The frequency of cholecystostomy may vary according to the facilities available, the assistance present, and the skill and judgment of the surgeon performing the procedure. But, in general, approximately 3 to 5 per cent of the patients undergoing operation for acute cholecystitis are best handled by cholecystostomy and drainage. Chronic inflammatory changes must be managed at operation in the contracted gallbladder or the gallbladder containing impacted stones in Hartmann’s pouch. At times the fibrosis between the gallbladder and common duct produces a single fused layer requiring sharp dissection. When separating Hartmann’s pouch from the common duct in this instance, to avoid ductal injury we should err on the side of the gallbladder in dissection. Should a small defect in the duct occur or a small cholecystocholedochal fistula be encountered, a small catheter or T tube may be inserted with little problem. But if the defect is large or made up of scar tissue, anastomosis of the duct primarily or choledochal enteric anastomosis must be carried out in a nonscarred area. Gentle blunt dissection will usually free the adherent cystic duct from the common hepatic duct and allow ac-
The American Journal 04 Surowy
Biliary Stricture
Figure 3. Tips of instruments should point toward surgeon to avoid crushing important structures.
Figure 4. Tension on cystic duct may distort common duct resutting in partial obstruction.
curate ligation near the choledochus. All traction must be released from the cystic duct, with the hepatic and common ducts clearly seen before ligation, if tenting is to be avoided. This injury (tenting) usually occurs in the thin, ptotic pa-
terrupted sutures is the ideal technic, especially if carried out at a secondary operation. If the common duct is transected during cholecystectomy and primary repair is done at the time of injury, ischemic fibrosis may result in the upper segment, since at that time the only blood supply to the common hepatic bile duct may be a single artery up the posterior wall of the choledochus, arising from the retroduodenal artery of Wilkie [4]. Roux-en-Y choledochojejunostomy is our preferred procedure when hepaticoenterostomy is needed, since it diverts the intestinal stream and the incidence of cholangitis seems low in our experience. Several methods of providing a wide anastomosis may be tried, such as incision of the duct wall or division of the hepatic ductal septum, as shown by Warren. (Figure 5.) We have found it possible to incise a rather long stricture longitudinally and anastomose the open end of the jejunum to the incised duct, allowing the bile to pass into the jejunum or down the duct, actually making a living graft into the defect. (Figure 6.) This provides a most satisfactory anastomosis. Hepaticoduodenostomy is the most frequent procedure used because most patients had longstanding disease and a degree of portal hypertension that made movement in the abdomen especially hazardous. The operation can be performed quickly
tient with the so-called easy gallbladder in which the hepatic and common bile ducts are pulled up and the cystic duct is ligated too closely with partial or complete obstruction to the normal flow of bile. (Figure 4.) Comments
Deciding the operative approach to take and what to do when encountering a stricture are difficult problems. The surgeon performs the best operation possible based upon the condition of the patient, the structures that can be found and used, and the ease of developing satisfactory tissues for anastomosis. At times, the operation must be staged, and simple drainage of major bile duct or periductal abscess as well as bile duct to decompress the liver allows the patient to improve, the liver to become smaller, blood coagulation factors to improve, total obstruction to be relieved, and a definitive surgical procedure to be carried out when the patient can tolerate it. Primary duct repair by longitudinal incision and transverse closure is usually impossible in our experience. End-to-end anastomosis of the duct, when it can be accomplished free of scar tissue, providing a mucosa-to-mucosa anastomosis by fine catgut in-
Volume 132, November 1876
569
McAllister and Hicken
Figure 5. After Warren and Braasch [ 11, a larger lumen may be developed by excising septum between right and left hepatic ducts.
and provides a very satisfactory result in many people. Careful follow-up, particularly in the first two years, is necessary to treat any cholangitis when it occurs. Early exploration is also necessary should response to antibiotics not be prompt or prolonged. Air cholangiograms will almost always be present in the upright abdominal film and contrast medium enters the biliary tree on gastrointestinal x-ray studies after hepaticoduodenostomy. If the opening is adequate and not obstructive, function is good and may be permanent. Anastomosis of the choledochus or the hepatic duct to the duodenal stump in a patient who has had gastric resection and Billroth II anastomosis is very satisfactory and in our hands has been an excellent procedure. (Figure 7.) Fifty procedures were performed on thirty patients first seen in the years 1952 to 1957, with none lost to follow-up. Sixteen of the thirty patients (53.2 per cent) are alive and well seventeen years or more since initial presentation; none have been symptomatic in the past five years. Two patients were reoperated on five and seven years ago. Since 1967 two patients have expired of esophageal varices despite portacaval shunts, and each showed cholestatic jaundice and cholangiolytic hepatitis with biliary cirrhosis as a result of repeated obstruction and infection over a long period of time. There were four operative deaths (13.3 per cent of patients); however, this represents only 8 per cent of the fifty operative procedures. Five patients have died of late biliary complications. Thus, the total operative and late biliary mortality consist of nine
570
Figure 6. A long stricture may be incised w/th end-to-side Roux-en- Y anastomosis of bo we/ to choledochus.
people, or 29.9 per cent as a result of the disease or attempts to control the disease, truly a high mortality and morbidity for a benign illness. Actual morbidity and mortality rates are, of course, not yet known. We hope to maintain contact with the survivors throughout their lifetime and know our absolute statistics with this disease. Hopefully our more recent patients may show better results than those treated earlier since we are seeing them earlier after injury and more often before irreversible complications have occurred. Toward this end we are now attempting to direct our teabhing. Stents are usually not needed in repair of stricture and although long-term drainage has been recommended by some, other observers believe that drainage tubes are not necessary and that they act as a foreign body and should be avoided or used for only short-term decompression. We agree with this and use fine, soft, pliable tubes primarily to facilitate follow-up cholangiograms for clinical evaluation and teaching. When one cannot bypass scar tissue and no other method of drainage and anastomosis is possible, firm stents of metal or firm rubber material may prolong life and may be the only applicable method to form a bile conduit. These stents must be accepted as compromise therapy with the knowledge that they will obstruct, although survival with a tube in place for as long as twenty-five years has been reported. As
The American Journal of Surgery
Biliary
Stricture
Figure 7. Anastomosb of choiedochus or common hepatic duct is very satisfactory in a patient with Billroth II gastric resection.
advocated by Saypol and Kurian [5], replaceable stents that can be replaced without surgery may be used in such patients, as was shown in eight patients treated by Stone et al in 1973 [6]. (Figure 8.) The subject of railroad or replaceable stents probably justifies a newer more critical review in view of recent profusion technics to dissolve incrustations of stones within tubes. Combined therapy may offer better, longer relief in patients with severe fibrosis than we have heretofore accomplished in the high hepatic strictures where mucosa-to-mucosa repair is impossible.
Figure 8. After Saypol and Kurtan [ 51, railroad stents percutaneous across anastomo& back through hepatic tissue to skin can be replaced without open surgery.
Summary
References
Fortunately, benign stricture is becoming a much less frequently encountered problem in biliary surgery. This must be largely explained by repetitious warnings in the literature and by teachers during the past thirty years. Our efforts now perhaps should be directed toward early recognition and treatment of ductal injuries before irreversible liver injury has occurred. Use of solutions to flush ducts and stents warrants further study, and the use of percutaneous replaceable stents along with biliary solvents in the
1. Warren KW, Braasch JW: Common duct stricture prevention and repair. Surg C/in North Am 45: 3, 1965. 2. Warren KW, Mountain JC, Midell Al: Management of strictures of the biliary tract. Surg C/in North Am 51: 3, 1971. 3. Way LW, Dunphy JE: Biliary stricture. Am J Surg 124: 287, 1972. 4. Michaels NA: Blood Supply and Anatomy of Upper Abdominal Organs. Philadelphia, JB Lippincott, 1945. 5. Saypol GM, Kurian G: A technique of repair of stricture of the bile duct. Surg Gynecol Obsfet 128: 1071, 1969. 6. Stone RM, Cohen 2, Taylor BR, et al: Bile duct injury. Results of repair using a changeable stent. Am J Surg 125: 253, 1973.
Volume 132, November 1976
hope that better prognosis of such fibrosed ducts is justified. The true morbidity and mortality of biliary stricture cannot be accurately known unless a group of patients can be accurately followed throughout their entire lifetime when a final appraisal can be made.
571
N. Frederick Hicken, MD, Salt Lake City, Utah
Benign stricture of bile ducts, although becoming less frequent, remains the most serious benign disease of the biliary tract. More than 90 per cent of strictures result from surgery for gallstones [Z-3], be it cholelithiasis or choledocholithiasis. All experienced surgeons have, for at least one generation, emphasized causes of ductal or vascular damage, but many patients still require repair of such injuries. Better training of surgeons has decreased experience with stricture but methods of adequate repair have changed little in the past twenty years. The only truly satisfactory management of stricture is prevention. Females are afflicted in a ratio of 3 or 4 to 1 over males and it is directly related to the number of cholecystectomies performed. Our experience covers a period of twenty-five years; but statistical material consists of patients seen in our area over two periods of five years separated by a decade. Material and Methods
The cases of all biliary operations in the five major hospitals in the Salt Lake City area during the five year period from 1952 to 1957 were reviewed. During this interval 3,748 biliary operations were performed with ninety-seven procedures carried out for benign ductal stricture. Ampullary stricture and malignancy were excluded. During that period 2.4 per cent of operations were for ductal injuries. At the Latter-Day Saints Hospital specifically, there were 2,122 biliary procedures (1,902 cholecystectomies, 361 choledochostomies, 101 cholecystostomies), of which fifty-eight (2.6 per cent) were for stricture. Appallingly, one in every forty biliary operations were for repair of injured ducts. A similar study was undertaken at the Latter-Day Saints Hospital for the years 1962 to 1967, during which seventeen ductal strictures or injuries occurred out of 2,402 biliary procedures (2,060 cholecystectomies, 615 choledochostomies, 72 cholecystostomies). Five injuries were recognized and handled at primary operation. Five were reoperations on patients from a previous period. Thus, there were acFrom the Departments of Surgery. LDS Hospital. and University of Utah college of Medicine, salt we city, Utah. Repint reqwsts should be addressed to A. James McAllister. MD. 511 MedICal Arts Building, Salt Lake City, Utah 84111.
Vohmo 132. Novnnkr
1978
tually only seven new strictures (0.3 per cent). This great improvement can only be explained by better training of surgeons now operating and the almost universal use of operative cholangiography in our area. Causes of strictures almost universally result from one or a combination of four major factors: (1) inadequate exposure; (2) anatomic variations not familiar to the surgeon; (3) hemorrhage difficult to control; (4) inability to identify structures due to existing inflammatory changes. Adequate exposure requires: complete relaxation by a capable anesthesiologist in an operating theater with excellent illumination; adequate assistance to retain a dry, well retracted field; and cholangiographic facilities, which are mandatory for ideal biliary work. Incision should be generous and placed to allow extension if needed. Anatomic variations are so frequent in the ductal and vascular patterns of the extrahepatic system that fully one third of patients will exhibit an anatomy other than that shown in the textbook. Surgeons must familiarize themselves with the work of Nicholas Michaels [4] if injury is to be avoided. Cholangiography via the gallbladder or cystic duct near the gallbladder, early in the operative procedure, provides a blueprint of the ductal structures, thus helping avoid injury to the common hepatic duct in handling the crossover cystic duct, which may pass anterior or posterior to the common duct to join it from the left to form the choledochus. (Figure 1, left.) At times a single septum separates the two ducta and safe removal is impossible without injury to a duct or ita blood supply. The long parallel cystic duct (Figure 1, middle) with a single septum between it and the hepatic duct can also be demonstrated and protected, as can the duct which enters a hepatic duct, be it right or left. (Figure 1, right.) Arterial variations need cause no problem if the surgeon is aware of possible deviation and not only identifies the cystic artery in the triangle of Calot but also sees the artery enter the gallbladder before it is clamped or ligated. Hemorrhage should not occur, but when it does, retraction must be maintained, keeping the hepatoduodenal ligament taut by pulling the duodenum downward and to the left so that the tubular structures within the ligament can be seen. The surgeon can easily control bleeding by compression of the portal vein and the hepatic artery by placing the index finger in the foramen of Winslow and compressing the porta hepatis between the thumb and forefinger until the area can be lavaged, aspirated, and the vessel clearly seen and safely controlled.
567
McAllister and Hicken
Figure 1. Left, crossover cystic duct passes anterior or posterior to common hepatic duct to form choiedochus. Mkkfie, iong parallel cystfc may pass parallel to hepatic duct even to papilla of Vater. Right, cystic duct joins right or left hepatic duct (here joins right hepatic duct).
Figure 2. Mass ligature engages tissues not desired in iigation.
Mass ligation of tissue is never justified in the subhepatic area. (Figure 2.) More strictures, and more severe strictures, have resulted from this procedure than any other in our experience. This is concurred by the reports of Braasch and Warren [I], who experienced 51 per cent of strictures in their series from ligation to control bleeding, which injured the separate hepatic ducts or common hepatic duct.
568
Mass clamping must likewise be condemned, for if the major bile ducts are crushed, it may be weeks before resulting necrosis allows leakage of bile into the abdomen or fibrosis with obstruction as heralded by chills, fever, jaundice, and pain of stricture. (Figure 3.) Usually it is possible to place gallbladder forceps from posterior to. anterior after dissection of the cystic duct or cystic artery whereby both tips can be clearly in view of the surgeon before the clamp is locked. Inflammatory changes, which make visualization of necessary structures impossible, preclude removal of the gallbladder, and cholecystostomy should be performed. (It is true another operation will be required, but cholecystectomy later is far better than stricture repair.) The frequency of cholecystostomy may vary according to the facilities available, the assistance present, and the skill and judgment of the surgeon performing the procedure. But, in general, approximately 3 to 5 per cent of the patients undergoing operation for acute cholecystitis are best handled by cholecystostomy and drainage. Chronic inflammatory changes must be managed at operation in the contracted gallbladder or the gallbladder containing impacted stones in Hartmann’s pouch. At times the fibrosis between the gallbladder and common duct produces a single fused layer requiring sharp dissection. When separating Hartmann’s pouch from the common duct in this instance, to avoid ductal injury we should err on the side of the gallbladder in dissection. Should a small defect in the duct occur or a small cholecystocholedochal fistula be encountered, a small catheter or T tube may be inserted with little problem. But if the defect is large or made up of scar tissue, anastomosis of the duct primarily or choledochal enteric anastomosis must be carried out in a nonscarred area. Gentle blunt dissection will usually free the adherent cystic duct from the common hepatic duct and allow ac-
The American Journal 04 Surowy
Biliary Stricture
Figure 3. Tips of instruments should point toward surgeon to avoid crushing important structures.
Figure 4. Tension on cystic duct may distort common duct resutting in partial obstruction.
curate ligation near the choledochus. All traction must be released from the cystic duct, with the hepatic and common ducts clearly seen before ligation, if tenting is to be avoided. This injury (tenting) usually occurs in the thin, ptotic pa-
terrupted sutures is the ideal technic, especially if carried out at a secondary operation. If the common duct is transected during cholecystectomy and primary repair is done at the time of injury, ischemic fibrosis may result in the upper segment, since at that time the only blood supply to the common hepatic bile duct may be a single artery up the posterior wall of the choledochus, arising from the retroduodenal artery of Wilkie [4]. Roux-en-Y choledochojejunostomy is our preferred procedure when hepaticoenterostomy is needed, since it diverts the intestinal stream and the incidence of cholangitis seems low in our experience. Several methods of providing a wide anastomosis may be tried, such as incision of the duct wall or division of the hepatic ductal septum, as shown by Warren. (Figure 5.) We have found it possible to incise a rather long stricture longitudinally and anastomose the open end of the jejunum to the incised duct, allowing the bile to pass into the jejunum or down the duct, actually making a living graft into the defect. (Figure 6.) This provides a most satisfactory anastomosis. Hepaticoduodenostomy is the most frequent procedure used because most patients had longstanding disease and a degree of portal hypertension that made movement in the abdomen especially hazardous. The operation can be performed quickly
tient with the so-called easy gallbladder in which the hepatic and common bile ducts are pulled up and the cystic duct is ligated too closely with partial or complete obstruction to the normal flow of bile. (Figure 4.) Comments
Deciding the operative approach to take and what to do when encountering a stricture are difficult problems. The surgeon performs the best operation possible based upon the condition of the patient, the structures that can be found and used, and the ease of developing satisfactory tissues for anastomosis. At times, the operation must be staged, and simple drainage of major bile duct or periductal abscess as well as bile duct to decompress the liver allows the patient to improve, the liver to become smaller, blood coagulation factors to improve, total obstruction to be relieved, and a definitive surgical procedure to be carried out when the patient can tolerate it. Primary duct repair by longitudinal incision and transverse closure is usually impossible in our experience. End-to-end anastomosis of the duct, when it can be accomplished free of scar tissue, providing a mucosa-to-mucosa anastomosis by fine catgut in-
Volume 132, November 1876
569
McAllister and Hicken
Figure 5. After Warren and Braasch [ 11, a larger lumen may be developed by excising septum between right and left hepatic ducts.
and provides a very satisfactory result in many people. Careful follow-up, particularly in the first two years, is necessary to treat any cholangitis when it occurs. Early exploration is also necessary should response to antibiotics not be prompt or prolonged. Air cholangiograms will almost always be present in the upright abdominal film and contrast medium enters the biliary tree on gastrointestinal x-ray studies after hepaticoduodenostomy. If the opening is adequate and not obstructive, function is good and may be permanent. Anastomosis of the choledochus or the hepatic duct to the duodenal stump in a patient who has had gastric resection and Billroth II anastomosis is very satisfactory and in our hands has been an excellent procedure. (Figure 7.) Fifty procedures were performed on thirty patients first seen in the years 1952 to 1957, with none lost to follow-up. Sixteen of the thirty patients (53.2 per cent) are alive and well seventeen years or more since initial presentation; none have been symptomatic in the past five years. Two patients were reoperated on five and seven years ago. Since 1967 two patients have expired of esophageal varices despite portacaval shunts, and each showed cholestatic jaundice and cholangiolytic hepatitis with biliary cirrhosis as a result of repeated obstruction and infection over a long period of time. There were four operative deaths (13.3 per cent of patients); however, this represents only 8 per cent of the fifty operative procedures. Five patients have died of late biliary complications. Thus, the total operative and late biliary mortality consist of nine
570
Figure 6. A long stricture may be incised w/th end-to-side Roux-en- Y anastomosis of bo we/ to choledochus.
people, or 29.9 per cent as a result of the disease or attempts to control the disease, truly a high mortality and morbidity for a benign illness. Actual morbidity and mortality rates are, of course, not yet known. We hope to maintain contact with the survivors throughout their lifetime and know our absolute statistics with this disease. Hopefully our more recent patients may show better results than those treated earlier since we are seeing them earlier after injury and more often before irreversible complications have occurred. Toward this end we are now attempting to direct our teabhing. Stents are usually not needed in repair of stricture and although long-term drainage has been recommended by some, other observers believe that drainage tubes are not necessary and that they act as a foreign body and should be avoided or used for only short-term decompression. We agree with this and use fine, soft, pliable tubes primarily to facilitate follow-up cholangiograms for clinical evaluation and teaching. When one cannot bypass scar tissue and no other method of drainage and anastomosis is possible, firm stents of metal or firm rubber material may prolong life and may be the only applicable method to form a bile conduit. These stents must be accepted as compromise therapy with the knowledge that they will obstruct, although survival with a tube in place for as long as twenty-five years has been reported. As
The American Journal of Surgery
Biliary
Stricture
Figure 7. Anastomosb of choiedochus or common hepatic duct is very satisfactory in a patient with Billroth II gastric resection.
advocated by Saypol and Kurian [5], replaceable stents that can be replaced without surgery may be used in such patients, as was shown in eight patients treated by Stone et al in 1973 [6]. (Figure 8.) The subject of railroad or replaceable stents probably justifies a newer more critical review in view of recent profusion technics to dissolve incrustations of stones within tubes. Combined therapy may offer better, longer relief in patients with severe fibrosis than we have heretofore accomplished in the high hepatic strictures where mucosa-to-mucosa repair is impossible.
Figure 8. After Saypol and Kurtan [ 51, railroad stents percutaneous across anastomo& back through hepatic tissue to skin can be replaced without open surgery.
Summary
References
Fortunately, benign stricture is becoming a much less frequently encountered problem in biliary surgery. This must be largely explained by repetitious warnings in the literature and by teachers during the past thirty years. Our efforts now perhaps should be directed toward early recognition and treatment of ductal injuries before irreversible liver injury has occurred. Use of solutions to flush ducts and stents warrants further study, and the use of percutaneous replaceable stents along with biliary solvents in the
1. Warren KW, Braasch JW: Common duct stricture prevention and repair. Surg C/in North Am 45: 3, 1965. 2. Warren KW, Mountain JC, Midell Al: Management of strictures of the biliary tract. Surg C/in North Am 51: 3, 1971. 3. Way LW, Dunphy JE: Biliary stricture. Am J Surg 124: 287, 1972. 4. Michaels NA: Blood Supply and Anatomy of Upper Abdominal Organs. Philadelphia, JB Lippincott, 1945. 5. Saypol GM, Kurian G: A technique of repair of stricture of the bile duct. Surg Gynecol Obsfet 128: 1071, 1969. 6. Stone RM, Cohen 2, Taylor BR, et al: Bile duct injury. Results of repair using a changeable stent. Am J Surg 125: 253, 1973.
Volume 132, November 1976
hope that better prognosis of such fibrosed ducts is justified. The true morbidity and mortality of biliary stricture cannot be accurately known unless a group of patients can be accurately followed throughout their entire lifetime when a final appraisal can be made.
571