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Use of transhepatic intubation in biliary stricture repair
Use of Transhepatic
Intubation
in Biliary
Stricture Repair LEWIS BURROWS, M.D. AND ALLAN E. KARK, M.D., AJew York, New York
From the Defiartment of Surgery, the Mount Sinai Hospit&, New York, New York.
TRICTURE OF THE COMMON DUCT presents a difficult surgical problem when it is situated high in the intrahepatic portion of the common hepatic duct. While the etiologic factors may be neoplastic or inflammatory, trauma is by far the most common cause and unfortunately is usually iatrogenic and secondary to cholecystectomy [1,2]. A variety of procedures have been devised to deal with this complication [Z-6]. It has been noted that the less proximal common duct there is to deal with, the poorer the outlook for ultimate success [2,5,7]. The worst results occur when the strictured portion of the duct is high in the porta hepatis where fibrosis in the hilum of the liver leaves almost no manageable length of epithelial-lined duct, and mucosa to mucosa anastomotic apposition becomes impossible. The sequence then becomes one of restricture, consequent obstruction, and further operation in a progressively more debilitated patient. This train of events can sometimes be avoided if the less than perfect anastomosis can be splinted for long periods of time. New epithelium can grow over the scarred lining of the duct and anastomotic narrowing is prevented by the presence of the indwelling stent IS]. However, where the hepatic portion of the duct is joined to an isoperistaltic limb of small intestine, the prosthesis may move past the anastomosis long before final healing occurs. Smith [6] has devised a method of overcoming this difficulty by means of transhepatic intubation across the anastomotic site. With the tip of the stent placed in the peristaltic stream instead of against it, and with fixation
of its suprahepatic portion at skin level, the tube is kept across and beyond the anastomotic site for long periods by the direction of peristaltic force. The purpose of this report is to illustrate the application of the Smith technic in two patients with benign stricture who were followed up for over two years after surgery.
s
Vol. 113,March 1967
CASE REPORTS CASE I. A forty-live year old Puerto Kican man first entered the Mount Sinai Hospital with a three day history of chills, fever, and bile drainage from an abdominal incision. One year previously he had undergone cholecystectomy at another hospital for chronic cholecystitis and cholelithiasis. On the third postoperative day obstructive jaundice was noted and progressed until the patient was re-explored on the eighth postoperative day. It was then discovered that the common duct had been inadvertently clamped, cut, and tied. Repair was attempted utilizing a jejunal loop anastomosed to the remaining common hepatic duct. A short circuiting jejunojejunostomy was also performed. A catheter stent was placed across the anastomosis and brought out through the abdominal wall via the efferent loop. Two months after discharge, he was readmitted to another hospital for recurrent chills, fever, and mild jaundice. Re-exploration was performed and multiple small liver abscesses were found; the abdomen was closed, and the patient was placed on large doses of antibiotics. Transient improvement followed but readmissions were then necessary for recurrent fever. The patient then sought admission to the Mount Sinai Hospital. Physical examination revealed a chronically ill man with rectal temperatures ranging from 9!I” to 102’~. and without obvious clinical jaundice. Multiple healed abdominal scars were present, and a small amount of bile-stained drainage occurred from the lateral end of a right subcostal incision. The liver and spleen were not enlarged. The stools were 409
Burrows and Kark
410
1
2
FIG. 1. Technic for placing transhepatic catheters. FIG. 2. Position of transhepatic catheters on the abdominal wall. brown and the urine yellow. Pertinent laboratory data revealed the following: hemoglobin, 13.2 gm. per cent; normal white blood cell count with a shift to the left; total bilirubin, 2 mg. per cent with a direct portion of 0.8 mg. per cent; alkaline phosphatase, 65.5 units (King-Armstrong) ; serum glutamic oxalacetic transaminase, 130 units; total protein, 8.3 gm. per cent with a reversed albumin-globulin ratio of 3.1:5.2; urine was positive for bile, with a urobilinogen of 1: 180. Radiologic (intravenous cholangiograms) and other laboratory studies supported the initial impression of recurrent cholangitis secondary to stricture at the anastomotic site. The patient was explored and the operative findings confumed the diagnosis. There was an opening between the common duct and the jejunum which only admitted a narrow probe. The intrahepatic biliary system was dilated proximal to this obstruction and filled with sludge. With irrigation the ducts were cleared of most of this debris. Operative reconstruction consisted of converting the hepaticojejunostomy to a Roux-Y system. Two No. 14 nylon catheters were led via the half-completed anastomosis through the major left and right hepatic ducts across the liver tissue (Fig. 1) to emerge suprahepatically and were led out through the skin by separate stab incisions (Fig. 2). The catheters lay past the anastomosis in the jejunal segment for about 2 inches. Mucosa to mucosa apposition of duct to jejunum was completed with interrupted No. 5-O silk; however, because of the high intrahepatic position of the stricture, total circumferential mucosal apposition was not possible along a short part of the posterior margin. The tubes were left open to bedside suction into sterile bottles. Daily gravity irrigations with normal sterile saline solution were begun on the first postoperative day. A tube cholangiogram obtained prior to discharge
revealed patency of both catheters and an absence of leakage from the anastomosis. The patient had a smooth postoperative course and was discharged to the follow-up clinic with careful instructions regarding daily irrigations at home. Approximately nine months after surgery, the tubes were removed in the outpatient department. A transient episode of fever and pain occurred on the evening of the tube removal and the patient was readmitted for observation and treatment with broad spectrum antibiotics. Culture of the indwelling catheter tip on removal revealed the presence of a variety of gramnegative organisms; blood cultures taken at that time were negative. The patient recovered from this episode within forty-eight hours and was again discharged to the follow-up clinic where he was followed up for an additional seven months. He gained 28 pounds and felt very well. Because of this experience, it has been deemed advisable to remove similar tubes in other patients in the hospital under antibiotic cover. Over the next eleven months the patient was readmitted on three occasions with recurrent chills, fever, and jaundice. Laboratory studies obtained during these admissions revealed leukocytosis and elevated serum bilirubin and alkaline phosphatase levels. Repeated intravenous cholangiography showed a normal intrahepatic ductal system. The patient was discharged after the second readmission on broad spectrum antibiotics. Although the serum bilirubin fell to normal levels with clinical recovery, the alkaline phosphatase remained moderately elevated. A normal sized ductal system on cholangiography suggested the possibility of intrahepatic strictures with a relatively poor prognosis. It was decided to re-establish transhepatic intubation if further attacks occurred. Consequently, with a third admission for recurrent symptoms, exploration was American
Journal of Surgery
411
Biliary Stricture Repair f*nmed. The Roux-Y jejunal segment was opened 2 inches tlistal to the choleductal-jejunal anastomosis revealing a patent anastomosis which admitted a No 4 and 5 Bakes’ dilator with ease. The anastom&s appeared to have narrowed by approximately 50 per cent since the original procedure. The anastomosis was dilated up to a size admitting a No. 8 Rakes’ dilator and the intrahepatic ductal system irrigated and cleared of much sludge and gravel. Transhepatic and transanastomotic drainage was re-established with ease by means of two catheters as before, and the jejunum opening closed in two layers. Postoperatively, the patient did well and was discharged with instructions for home irrigation of the catheter. The serum hilirubin on discharge was 1.1 mg. per cent and the alkaline phosphatase 17.8 Bessey-Lowry units (normal 2.3). At present, five months after surgery, he is doing well clinically with transhepatic tubes in position and daily irrigations. The bilirubin remains at 0.6 mg. per cent, and the alkaline phosphatase is still high at 7.2 BesseyLowry units. CASE II. A thirty-one year old white woman was admitted to the Mount Sinai Hospital for the first time with chief complaints of jaundice, fever, and abdominal pain of three months’ duration. She was in her eighth month of pregnancy, and two previous pregnancies resulted in cesarean sections for cephalopelvic disproportion. Her surgical history went back to the third month of this pregnancy when she underwent elective cholecystectomy at another hospital for chronic cholecystitis and cholelithiasis. Two weeks after this procedure, re-exploration was required for pain and fever and she was told that “an abscess had been drained.” Two weeks later, she first noted jaundice. Fever, pain, and jaundice progressed until her admission at Mount Sinai for this condition. Pertinent laboratory and physical findings were : temperature, 99.6%. ; liver palpable three fingerbreadths below the right costal margin; uterus palpable two fingerbreadths above the umbilicus; fetal heart tones present; healed lower abdominal scar; urine strongly positive for bile; urobilinogen, 1:-10; serum bilirubin, 10.3 mg. per cent with a direct portion of 6.3 mg. per cent; total protein of 7.3gm. per cent with a reversed albuminglobulin ratio of 2.1 :X3; alkaline phosphatase, 78.6 King-_Armstrong units; serum glutamic oxalacetic transaminase , 28 Frankel units; prothrombin time, twentv-seven seconds with a control of thirteen seconds. The patient was treated nonoperatively until cesarean section could be performed to ensure a viable fetus and thereafter undertake a corrective surgical procedure. While awaiting the optimal time for cesarean section, the patient went into spontaneous labor and was delivered of a full term viable
Vol.
113. March 1967
i
FIG. 3. Dissection into liver parenchyma to expose common hepatic duct for mucosa to mucosa apposition.
male infant. Six days after delivery, she was explored for obstructive jaundice. Findings were as follows: beneath an enlarged liver, near the porta hepatis, there was an inflammatory mass consisting of dense fibrous tissue, duodenum, pylorus, and portal tract structures. By careful dissection, the mass was removed from the undersurface of the right lobe of the liver, and the proximal bile duct opening was identified as a pinpoint orifice flush with the liver. The duodenum opposite this point was inspected, and the distal ductal system was identified as a ragged 2 mm. hole on the duodenal wall where the duct entered its intraduodenal pathway. No other portion of the ductal system could be identified, and it was considered impossible to use this distal portion for any reconstructive procedure. White bile emitted freely from the intrahepatic portion of the bile ducts. By sharp dissection upwards along the common hepatic duct, approximately 1.5 cm. of fibrotic duct was freed from the liver. (Fig. 3.) A Roux-k’ hepaticojejunostomy was performed and the anastomosis was made with interrupted No. .5-O silk; two No. 14 nylon catheters were brought transhepatically into the subphrenic space and led out of the abdominal wall. Liver biopsy specimen taken at operation revealed portal tract scarring secondary to extrahepatic biliary tract obstruction. The postoperative course was unremarkable except for a low grade fever which gradually resolved. Prior to discharge, a catheter contrast study revealed a widely patent anastomosis with free drainage into the jejunum without evidence of leakage. The serum biliruhin had fallen to 4.2 mg. per cent and the alkaline phosphatase to 40.8 King-Armstrong units at this time. She has been followed up in the outpatient department and her clinical well being has continued until the present writing, twenty four months after surgery.
Burrows
412 COMMENTS
Both of these cases represent examples of the postoperative sequelae which can unfortunately follow surgical trauma to the common duct. Smith [6] has stressed certain guiding principles when dealing with surgery in the common duct region, which deserve re-emphasis: (1) “These injuries are so difficult to treat that they simply must not be allowed to occur. (2) If, unfortunately, a duct is damaged, every conceivable effort must be made when repairing it to get it right the first time.” Both patients have been followed up for over twenty-four months; one has required reoperation and the other continues to do well. The long asymptomatic interval suggests that at least one patient (case II) will continue to do well [8]. Both patients have shown a gradual return toward normal liver function which is indicative of a good ultimate prognosis [7]. The operative details are readily available in the literature [6], but certain points deserve comment. It is surprisingly easy to pass the transhepatic catheters, especially when use is made of the angled gallstone forceps. The dilated intrahepatic biliary tree is easily traversed, and this dilatation is present all the way into the more terminal radicals near the dome of the liver. By simply passing the forceps into the main hepatic ducts and with gentle manipulation, the surgeon can feel the stonegrasping end on the subphrenic surface of the liver. By gently pushing through the remaining 1 to 2 cm. of liver tissues, bleeding is avoided. Care must be taken that at least three to four catheter holes are present in the liver substance and also in the jejunum distal to the anastomosis. The natural fear on the surgeon’s part of blood and biliary drainage into the subphrenic space with subsequent abscess formation did not materialize in either case and has not been a problem in Smith’s series either. This space must seal rapidly in the postoperative period around the drainage tubes. With the experience of a transient septic episode after removal of the tube in case I, the second patient was admitted for the same procedure and placed on prophylactic antibiotics. Neither patient experienced any difficulty with the home irrigations, a procedure undoubtedly preventing the accumulation of excessive sludge about the indwelling catheters. This technic appears to be a most suitable one for high stricture. The procedure ensures
and Kark satisfactory biliary drainage and is safe; postoperative suction prevents the pooling of infected bile about the anastomotic site; antibiotics can be added to the irrigating solution when indicated; restenosis is prevented by the physical presence of a stent which cannot be moved away from the critical anastomosis by jejunal peristaltic forces. In the event of recurrent stricture, the catheters can be repassed during a relatively simple operative procedure. This is exemplified in case I and offers a much simpler alternative to a tertiary intrahepatic ductal repair. By opening the jejunum the caliber and extent of stricture can be determined accurately and transhepatic catheters passed with surprising eas.e. It is possible, as in case II, to obtain a reasonable amount of intrahepatic bile duct for anastomotic purposes by sharp dissection into the scarred liver surface, thereby “coring out” liver substance surrounding the duct. Minimal bleeding is encountered probably because of the fibrosis which accompanies the stricture. In addition to its use in the two cases of benign extrahepatic biliary obstruction, transhepatic tubes have been used recently to bridge a malignant obstruction high in the common hepatic duct. It is anticipated that bile will drain across these tubes into the duodenum until the tumor obstructs them at which time retrograde external drainage and decompression will still be possible. SUMMARY
Two cases are presented of repair of posttraumatic stricture of the common bile duct using transhepatic intubation. The same technic has been used for palliation of malignant obstruction of the common hepatic duct. The technic seems to be an advance over methods of intubation led externally from the jejunum. REFERENCES 1. COLE, W. H. Strictures
2.
3. 4.
5.
of the common duct. Surg. Gynec. 6 Old., 82: 104, 1946. WALTERS, W., NIXON, J. W., JR., HODGINS, T. E., and RAMSDELL, J. A. Strictures of the common hepatic bile ducts. A study of more than 400 operations with a l-25 year follow-up. Arch. Surg., 78: 908, 1959. CATTEL, R. B. and BRAASH, J. W. Strictures of the bile duct. S. Ckn. North America, 28: 645, 1958. LONGMIRE, J. A., JR. and SANFORD, M. C. Intrahepatic cholangiojejunostomy with partial hepatectomy for biliary obstruction. Surgery, 24: 264, 1948. MAINGOT, R. Postoperative strictures of the bile American
Journal
of Surgery
Biliary
Stricture
ducts. Ann. Roy. Cdl. Surgeons England, 24: 186, 1951. 6. SMITR, 1~. Hepaticojejunostomy with transhepatic intubation; a technique for high strictures of the hepatic ducts. &it. J. Surg., 51: 186, 1964.
Vol. 113. March 1967
Repair
413
J. A., JR. Hepdtocholan~iojcjurloatonly Roux-en-Y: an alternate method of rc,pair of bile duct strictures. Ann. Surg., 151. lZI, 1960. 8. COSMAN, R. and PORTER, M. R. Renign stricture of the bile ducts. Ann. Suug., 152: 1, 1961).
7.
KIRKLEY,
Intubation
in Biliary
Stricture Repair LEWIS BURROWS, M.D. AND ALLAN E. KARK, M.D., AJew York, New York
From the Defiartment of Surgery, the Mount Sinai Hospit&, New York, New York.
TRICTURE OF THE COMMON DUCT presents a difficult surgical problem when it is situated high in the intrahepatic portion of the common hepatic duct. While the etiologic factors may be neoplastic or inflammatory, trauma is by far the most common cause and unfortunately is usually iatrogenic and secondary to cholecystectomy [1,2]. A variety of procedures have been devised to deal with this complication [Z-6]. It has been noted that the less proximal common duct there is to deal with, the poorer the outlook for ultimate success [2,5,7]. The worst results occur when the strictured portion of the duct is high in the porta hepatis where fibrosis in the hilum of the liver leaves almost no manageable length of epithelial-lined duct, and mucosa to mucosa anastomotic apposition becomes impossible. The sequence then becomes one of restricture, consequent obstruction, and further operation in a progressively more debilitated patient. This train of events can sometimes be avoided if the less than perfect anastomosis can be splinted for long periods of time. New epithelium can grow over the scarred lining of the duct and anastomotic narrowing is prevented by the presence of the indwelling stent IS]. However, where the hepatic portion of the duct is joined to an isoperistaltic limb of small intestine, the prosthesis may move past the anastomosis long before final healing occurs. Smith [6] has devised a method of overcoming this difficulty by means of transhepatic intubation across the anastomotic site. With the tip of the stent placed in the peristaltic stream instead of against it, and with fixation
of its suprahepatic portion at skin level, the tube is kept across and beyond the anastomotic site for long periods by the direction of peristaltic force. The purpose of this report is to illustrate the application of the Smith technic in two patients with benign stricture who were followed up for over two years after surgery.
s
Vol. 113,March 1967
CASE REPORTS CASE I. A forty-live year old Puerto Kican man first entered the Mount Sinai Hospital with a three day history of chills, fever, and bile drainage from an abdominal incision. One year previously he had undergone cholecystectomy at another hospital for chronic cholecystitis and cholelithiasis. On the third postoperative day obstructive jaundice was noted and progressed until the patient was re-explored on the eighth postoperative day. It was then discovered that the common duct had been inadvertently clamped, cut, and tied. Repair was attempted utilizing a jejunal loop anastomosed to the remaining common hepatic duct. A short circuiting jejunojejunostomy was also performed. A catheter stent was placed across the anastomosis and brought out through the abdominal wall via the efferent loop. Two months after discharge, he was readmitted to another hospital for recurrent chills, fever, and mild jaundice. Re-exploration was performed and multiple small liver abscesses were found; the abdomen was closed, and the patient was placed on large doses of antibiotics. Transient improvement followed but readmissions were then necessary for recurrent fever. The patient then sought admission to the Mount Sinai Hospital. Physical examination revealed a chronically ill man with rectal temperatures ranging from 9!I” to 102’~. and without obvious clinical jaundice. Multiple healed abdominal scars were present, and a small amount of bile-stained drainage occurred from the lateral end of a right subcostal incision. The liver and spleen were not enlarged. The stools were 409
Burrows and Kark
410
1
2
FIG. 1. Technic for placing transhepatic catheters. FIG. 2. Position of transhepatic catheters on the abdominal wall. brown and the urine yellow. Pertinent laboratory data revealed the following: hemoglobin, 13.2 gm. per cent; normal white blood cell count with a shift to the left; total bilirubin, 2 mg. per cent with a direct portion of 0.8 mg. per cent; alkaline phosphatase, 65.5 units (King-Armstrong) ; serum glutamic oxalacetic transaminase, 130 units; total protein, 8.3 gm. per cent with a reversed albumin-globulin ratio of 3.1:5.2; urine was positive for bile, with a urobilinogen of 1: 180. Radiologic (intravenous cholangiograms) and other laboratory studies supported the initial impression of recurrent cholangitis secondary to stricture at the anastomotic site. The patient was explored and the operative findings confumed the diagnosis. There was an opening between the common duct and the jejunum which only admitted a narrow probe. The intrahepatic biliary system was dilated proximal to this obstruction and filled with sludge. With irrigation the ducts were cleared of most of this debris. Operative reconstruction consisted of converting the hepaticojejunostomy to a Roux-Y system. Two No. 14 nylon catheters were led via the half-completed anastomosis through the major left and right hepatic ducts across the liver tissue (Fig. 1) to emerge suprahepatically and were led out through the skin by separate stab incisions (Fig. 2). The catheters lay past the anastomosis in the jejunal segment for about 2 inches. Mucosa to mucosa apposition of duct to jejunum was completed with interrupted No. 5-O silk; however, because of the high intrahepatic position of the stricture, total circumferential mucosal apposition was not possible along a short part of the posterior margin. The tubes were left open to bedside suction into sterile bottles. Daily gravity irrigations with normal sterile saline solution were begun on the first postoperative day. A tube cholangiogram obtained prior to discharge
revealed patency of both catheters and an absence of leakage from the anastomosis. The patient had a smooth postoperative course and was discharged to the follow-up clinic with careful instructions regarding daily irrigations at home. Approximately nine months after surgery, the tubes were removed in the outpatient department. A transient episode of fever and pain occurred on the evening of the tube removal and the patient was readmitted for observation and treatment with broad spectrum antibiotics. Culture of the indwelling catheter tip on removal revealed the presence of a variety of gramnegative organisms; blood cultures taken at that time were negative. The patient recovered from this episode within forty-eight hours and was again discharged to the follow-up clinic where he was followed up for an additional seven months. He gained 28 pounds and felt very well. Because of this experience, it has been deemed advisable to remove similar tubes in other patients in the hospital under antibiotic cover. Over the next eleven months the patient was readmitted on three occasions with recurrent chills, fever, and jaundice. Laboratory studies obtained during these admissions revealed leukocytosis and elevated serum bilirubin and alkaline phosphatase levels. Repeated intravenous cholangiography showed a normal intrahepatic ductal system. The patient was discharged after the second readmission on broad spectrum antibiotics. Although the serum bilirubin fell to normal levels with clinical recovery, the alkaline phosphatase remained moderately elevated. A normal sized ductal system on cholangiography suggested the possibility of intrahepatic strictures with a relatively poor prognosis. It was decided to re-establish transhepatic intubation if further attacks occurred. Consequently, with a third admission for recurrent symptoms, exploration was American
Journal of Surgery
411
Biliary Stricture Repair f*nmed. The Roux-Y jejunal segment was opened 2 inches tlistal to the choleductal-jejunal anastomosis revealing a patent anastomosis which admitted a No 4 and 5 Bakes’ dilator with ease. The anastom&s appeared to have narrowed by approximately 50 per cent since the original procedure. The anastomosis was dilated up to a size admitting a No. 8 Rakes’ dilator and the intrahepatic ductal system irrigated and cleared of much sludge and gravel. Transhepatic and transanastomotic drainage was re-established with ease by means of two catheters as before, and the jejunum opening closed in two layers. Postoperatively, the patient did well and was discharged with instructions for home irrigation of the catheter. The serum hilirubin on discharge was 1.1 mg. per cent and the alkaline phosphatase 17.8 Bessey-Lowry units (normal 2.3). At present, five months after surgery, he is doing well clinically with transhepatic tubes in position and daily irrigations. The bilirubin remains at 0.6 mg. per cent, and the alkaline phosphatase is still high at 7.2 BesseyLowry units. CASE II. A thirty-one year old white woman was admitted to the Mount Sinai Hospital for the first time with chief complaints of jaundice, fever, and abdominal pain of three months’ duration. She was in her eighth month of pregnancy, and two previous pregnancies resulted in cesarean sections for cephalopelvic disproportion. Her surgical history went back to the third month of this pregnancy when she underwent elective cholecystectomy at another hospital for chronic cholecystitis and cholelithiasis. Two weeks after this procedure, re-exploration was required for pain and fever and she was told that “an abscess had been drained.” Two weeks later, she first noted jaundice. Fever, pain, and jaundice progressed until her admission at Mount Sinai for this condition. Pertinent laboratory and physical findings were : temperature, 99.6%. ; liver palpable three fingerbreadths below the right costal margin; uterus palpable two fingerbreadths above the umbilicus; fetal heart tones present; healed lower abdominal scar; urine strongly positive for bile; urobilinogen, 1:-10; serum bilirubin, 10.3 mg. per cent with a direct portion of 6.3 mg. per cent; total protein of 7.3gm. per cent with a reversed albuminglobulin ratio of 2.1 :X3; alkaline phosphatase, 78.6 King-_Armstrong units; serum glutamic oxalacetic transaminase , 28 Frankel units; prothrombin time, twentv-seven seconds with a control of thirteen seconds. The patient was treated nonoperatively until cesarean section could be performed to ensure a viable fetus and thereafter undertake a corrective surgical procedure. While awaiting the optimal time for cesarean section, the patient went into spontaneous labor and was delivered of a full term viable
Vol.
113. March 1967
i
FIG. 3. Dissection into liver parenchyma to expose common hepatic duct for mucosa to mucosa apposition.
male infant. Six days after delivery, she was explored for obstructive jaundice. Findings were as follows: beneath an enlarged liver, near the porta hepatis, there was an inflammatory mass consisting of dense fibrous tissue, duodenum, pylorus, and portal tract structures. By careful dissection, the mass was removed from the undersurface of the right lobe of the liver, and the proximal bile duct opening was identified as a pinpoint orifice flush with the liver. The duodenum opposite this point was inspected, and the distal ductal system was identified as a ragged 2 mm. hole on the duodenal wall where the duct entered its intraduodenal pathway. No other portion of the ductal system could be identified, and it was considered impossible to use this distal portion for any reconstructive procedure. White bile emitted freely from the intrahepatic portion of the bile ducts. By sharp dissection upwards along the common hepatic duct, approximately 1.5 cm. of fibrotic duct was freed from the liver. (Fig. 3.) A Roux-k’ hepaticojejunostomy was performed and the anastomosis was made with interrupted No. .5-O silk; two No. 14 nylon catheters were brought transhepatically into the subphrenic space and led out of the abdominal wall. Liver biopsy specimen taken at operation revealed portal tract scarring secondary to extrahepatic biliary tract obstruction. The postoperative course was unremarkable except for a low grade fever which gradually resolved. Prior to discharge, a catheter contrast study revealed a widely patent anastomosis with free drainage into the jejunum without evidence of leakage. The serum biliruhin had fallen to 4.2 mg. per cent and the alkaline phosphatase to 40.8 King-Armstrong units at this time. She has been followed up in the outpatient department and her clinical well being has continued until the present writing, twenty four months after surgery.
Burrows
412 COMMENTS
Both of these cases represent examples of the postoperative sequelae which can unfortunately follow surgical trauma to the common duct. Smith [6] has stressed certain guiding principles when dealing with surgery in the common duct region, which deserve re-emphasis: (1) “These injuries are so difficult to treat that they simply must not be allowed to occur. (2) If, unfortunately, a duct is damaged, every conceivable effort must be made when repairing it to get it right the first time.” Both patients have been followed up for over twenty-four months; one has required reoperation and the other continues to do well. The long asymptomatic interval suggests that at least one patient (case II) will continue to do well [8]. Both patients have shown a gradual return toward normal liver function which is indicative of a good ultimate prognosis [7]. The operative details are readily available in the literature [6], but certain points deserve comment. It is surprisingly easy to pass the transhepatic catheters, especially when use is made of the angled gallstone forceps. The dilated intrahepatic biliary tree is easily traversed, and this dilatation is present all the way into the more terminal radicals near the dome of the liver. By simply passing the forceps into the main hepatic ducts and with gentle manipulation, the surgeon can feel the stonegrasping end on the subphrenic surface of the liver. By gently pushing through the remaining 1 to 2 cm. of liver tissues, bleeding is avoided. Care must be taken that at least three to four catheter holes are present in the liver substance and also in the jejunum distal to the anastomosis. The natural fear on the surgeon’s part of blood and biliary drainage into the subphrenic space with subsequent abscess formation did not materialize in either case and has not been a problem in Smith’s series either. This space must seal rapidly in the postoperative period around the drainage tubes. With the experience of a transient septic episode after removal of the tube in case I, the second patient was admitted for the same procedure and placed on prophylactic antibiotics. Neither patient experienced any difficulty with the home irrigations, a procedure undoubtedly preventing the accumulation of excessive sludge about the indwelling catheters. This technic appears to be a most suitable one for high stricture. The procedure ensures
and Kark satisfactory biliary drainage and is safe; postoperative suction prevents the pooling of infected bile about the anastomotic site; antibiotics can be added to the irrigating solution when indicated; restenosis is prevented by the physical presence of a stent which cannot be moved away from the critical anastomosis by jejunal peristaltic forces. In the event of recurrent stricture, the catheters can be repassed during a relatively simple operative procedure. This is exemplified in case I and offers a much simpler alternative to a tertiary intrahepatic ductal repair. By opening the jejunum the caliber and extent of stricture can be determined accurately and transhepatic catheters passed with surprising eas.e. It is possible, as in case II, to obtain a reasonable amount of intrahepatic bile duct for anastomotic purposes by sharp dissection into the scarred liver surface, thereby “coring out” liver substance surrounding the duct. Minimal bleeding is encountered probably because of the fibrosis which accompanies the stricture. In addition to its use in the two cases of benign extrahepatic biliary obstruction, transhepatic tubes have been used recently to bridge a malignant obstruction high in the common hepatic duct. It is anticipated that bile will drain across these tubes into the duodenum until the tumor obstructs them at which time retrograde external drainage and decompression will still be possible. SUMMARY
Two cases are presented of repair of posttraumatic stricture of the common bile duct using transhepatic intubation. The same technic has been used for palliation of malignant obstruction of the common hepatic duct. The technic seems to be an advance over methods of intubation led externally from the jejunum. REFERENCES 1. COLE, W. H. Strictures
2.
3. 4.
5.
of the common duct. Surg. Gynec. 6 Old., 82: 104, 1946. WALTERS, W., NIXON, J. W., JR., HODGINS, T. E., and RAMSDELL, J. A. Strictures of the common hepatic bile ducts. A study of more than 400 operations with a l-25 year follow-up. Arch. Surg., 78: 908, 1959. CATTEL, R. B. and BRAASH, J. W. Strictures of the bile duct. S. Ckn. North America, 28: 645, 1958. LONGMIRE, J. A., JR. and SANFORD, M. C. Intrahepatic cholangiojejunostomy with partial hepatectomy for biliary obstruction. Surgery, 24: 264, 1948. MAINGOT, R. Postoperative strictures of the bile American
Journal
of Surgery
Biliary
Stricture
ducts. Ann. Roy. Cdl. Surgeons England, 24: 186, 1951. 6. SMITR, 1~. Hepaticojejunostomy with transhepatic intubation; a technique for high strictures of the hepatic ducts. &it. J. Surg., 51: 186, 1964.
Vol. 113. March 1967
Repair
413
J. A., JR. Hepdtocholan~iojcjurloatonly Roux-en-Y: an alternate method of rc,pair of bile duct strictures. Ann. Surg., 151. lZI, 1960. 8. COSMAN, R. and PORTER, M. R. Renign stricture of the bile ducts. Ann. Suug., 152: 1, 1961).
7.
KIRKLEY,