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Surgery_Schwartz_9302 | Surgery_Schwartz | radiates to the right upper back or between the scapulae (Fig. 32-15). The pain is severe and comes on abruptly, typically during the night or after a fatty meal. It often is associated with nausea and sometimes vomiting. Patients generally suffer discrete, recurrent attacks of pain, between which they feel well. Physical examination may reveal mild right upper quadrant tenderness during an episode of pain. If the patient is pain free, the physical examination is usually unremarkable. Labora-tory values, such as WBC count and liver function tests, are usu-ally normal in patients with uncomplicated gallstones.Atypical presentations of gallstone disease are common and a high index of suspicion for biliary disease must be main-tained when evaluating patients with abdominal complaints. Association with meals is present in only about 50% of patients. Some patients report milder attacks of pain but relate it to meals. The pain may be located primarily in the back or the left upper or right | Surgery_Schwartz. radiates to the right upper back or between the scapulae (Fig. 32-15). The pain is severe and comes on abruptly, typically during the night or after a fatty meal. It often is associated with nausea and sometimes vomiting. Patients generally suffer discrete, recurrent attacks of pain, between which they feel well. Physical examination may reveal mild right upper quadrant tenderness during an episode of pain. If the patient is pain free, the physical examination is usually unremarkable. Labora-tory values, such as WBC count and liver function tests, are usu-ally normal in patients with uncomplicated gallstones.Atypical presentations of gallstone disease are common and a high index of suspicion for biliary disease must be main-tained when evaluating patients with abdominal complaints. Association with meals is present in only about 50% of patients. Some patients report milder attacks of pain but relate it to meals. The pain may be located primarily in the back or the left upper or right |
Surgery_Schwartz_9303 | Surgery_Schwartz | with meals is present in only about 50% of patients. Some patients report milder attacks of pain but relate it to meals. The pain may be located primarily in the back or the left upper or right lower quadrant. Bloating and belching may be present and associated with the attacks of pain. In patients with atypi-cal presentations, other conditions that may be causing upper abdominal pain should be ruled out, even in the presence of gallstones. These include but are not limited to peptic ulcer dis-ease, gastroesophageal reflux disease, herpes zoster, abdominal wall hernias, inflammatory bowel disease, diverticular disease, pancreatitis, liver disease, renal calculi, pleuritic pain, and car-diac pain.When the pain lasts >24 hours without resolving, an impacted stone in the cystic duct or acute cholecystitis (see later “Acute Cholecystitis” section) should be suspected. An impacted stone without cholecystitis will result in what is called hydrops of the gallbladder. Bile will be unable to | Surgery_Schwartz. with meals is present in only about 50% of patients. Some patients report milder attacks of pain but relate it to meals. The pain may be located primarily in the back or the left upper or right lower quadrant. Bloating and belching may be present and associated with the attacks of pain. In patients with atypi-cal presentations, other conditions that may be causing upper abdominal pain should be ruled out, even in the presence of gallstones. These include but are not limited to peptic ulcer dis-ease, gastroesophageal reflux disease, herpes zoster, abdominal wall hernias, inflammatory bowel disease, diverticular disease, pancreatitis, liver disease, renal calculi, pleuritic pain, and car-diac pain.When the pain lasts >24 hours without resolving, an impacted stone in the cystic duct or acute cholecystitis (see later “Acute Cholecystitis” section) should be suspected. An impacted stone without cholecystitis will result in what is called hydrops of the gallbladder. Bile will be unable to |
Surgery_Schwartz_9304 | Surgery_Schwartz | cholecystitis (see later “Acute Cholecystitis” section) should be suspected. An impacted stone without cholecystitis will result in what is called hydrops of the gallbladder. Bile will be unable to enter the gall-bladder due to the obstructed cystic duct, but the gallbladder epithelium will continue to secrete mucus, and the gallbladder will become distended with clear-white mucinous material. The gallbladder may be palpable but usually is not tender. Hydrops of the gallbladder may result in edema of the gallbladder wall, inflammation, infection, and perforation. Although hydrops may persist with few consequences, early cholecystectomy is generally indicated to avoid complications.Diagnosis The diagnosis of symptomatic cholelithiasis or chronic cholecystitis depends on the presence of typical symp-toms and the demonstration of stones on diagnostic imaging. An abdominal ultrasound is the standard diagnostic test for gallstones as it is noninvasive and highly sensitive (see earlier | Surgery_Schwartz. cholecystitis (see later “Acute Cholecystitis” section) should be suspected. An impacted stone without cholecystitis will result in what is called hydrops of the gallbladder. Bile will be unable to enter the gall-bladder due to the obstructed cystic duct, but the gallbladder epithelium will continue to secrete mucus, and the gallbladder will become distended with clear-white mucinous material. The gallbladder may be palpable but usually is not tender. Hydrops of the gallbladder may result in edema of the gallbladder wall, inflammation, infection, and perforation. Although hydrops may persist with few consequences, early cholecystectomy is generally indicated to avoid complications.Diagnosis The diagnosis of symptomatic cholelithiasis or chronic cholecystitis depends on the presence of typical symp-toms and the demonstration of stones on diagnostic imaging. An abdominal ultrasound is the standard diagnostic test for gallstones as it is noninvasive and highly sensitive (see earlier |
Surgery_Schwartz_9305 | Surgery_Schwartz | typical symp-toms and the demonstration of stones on diagnostic imaging. An abdominal ultrasound is the standard diagnostic test for gallstones as it is noninvasive and highly sensitive (see earlier “Ultrasonography” section).28 Gallstones are occasionally iden-tified on abdominal CT scans that were obtained as part of a broader workup of abdominal pain. In these cases, if the patient has typical symptoms, it is reasonable to proceed with interven-tion. Stones diagnosed incidentally on CT or plain radiographs in patients without symptoms should be left in place. Occasion-ally, patients with typical attacks of biliary pain have no evi-dence of stones on ultrasound but have evidence of sludge in the gallbladder. If a patient has attacks of typical biliary pain and sludge is detected, cholecystectomy is warranted.In addition to sludge and stones, cholesterolosis and adeno-myomatosis of the gallbladder may cause typical biliary symp-toms and may be detected on ultrasound or CT. | Surgery_Schwartz. typical symp-toms and the demonstration of stones on diagnostic imaging. An abdominal ultrasound is the standard diagnostic test for gallstones as it is noninvasive and highly sensitive (see earlier “Ultrasonography” section).28 Gallstones are occasionally iden-tified on abdominal CT scans that were obtained as part of a broader workup of abdominal pain. In these cases, if the patient has typical symptoms, it is reasonable to proceed with interven-tion. Stones diagnosed incidentally on CT or plain radiographs in patients without symptoms should be left in place. Occasion-ally, patients with typical attacks of biliary pain have no evi-dence of stones on ultrasound but have evidence of sludge in the gallbladder. If a patient has attacks of typical biliary pain and sludge is detected, cholecystectomy is warranted.In addition to sludge and stones, cholesterolosis and adeno-myomatosis of the gallbladder may cause typical biliary symp-toms and may be detected on ultrasound or CT. |
Surgery_Schwartz_9306 | Surgery_Schwartz | cholecystectomy is warranted.In addition to sludge and stones, cholesterolosis and adeno-myomatosis of the gallbladder may cause typical biliary symp-toms and may be detected on ultrasound or CT. Cholesterolosis is caused by the accumulation of cholesterol in macrophages in the 221514764501352441429614396322151911252311353323ABFigure 32-15. A. Sites of the most severe pain during an episode of biliary colic in 107 patients with gallstones (% values add up to >100% because of multiple responses). The subxiphoid and right subcostal areas were the most common sites; note that the left sub-costal area was not an unusual site of pain. B. Sites of pain radiation (%) during an episode of biliary colic in the same group of patients.Brunicardi_Ch32_p1393-p1428.indd 140411/02/19 2:43 PM 1405GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32gallbladder lamina propria, either locally or as polyps. It produces the classic studded macroscopic appearance of a “strawberry gallbladder.” | Surgery_Schwartz. cholecystectomy is warranted.In addition to sludge and stones, cholesterolosis and adeno-myomatosis of the gallbladder may cause typical biliary symp-toms and may be detected on ultrasound or CT. Cholesterolosis is caused by the accumulation of cholesterol in macrophages in the 221514764501352441429614396322151911252311353323ABFigure 32-15. A. Sites of the most severe pain during an episode of biliary colic in 107 patients with gallstones (% values add up to >100% because of multiple responses). The subxiphoid and right subcostal areas were the most common sites; note that the left sub-costal area was not an unusual site of pain. B. Sites of pain radiation (%) during an episode of biliary colic in the same group of patients.Brunicardi_Ch32_p1393-p1428.indd 140411/02/19 2:43 PM 1405GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32gallbladder lamina propria, either locally or as polyps. It produces the classic studded macroscopic appearance of a “strawberry gallbladder.” |
Surgery_Schwartz_9307 | Surgery_Schwartz | AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32gallbladder lamina propria, either locally or as polyps. It produces the classic studded macroscopic appearance of a “strawberry gallbladder.” Adenomyomatosis (cholecystitis glandularis prolif-erans) is characterized on microscopy by hypertrophic smooth muscle bundles and by the ingrowths of mucosal glands into the muscle layer (epithelial sinus formation). Granulomatous polyps develop in the lumen at the fundus, and the gallbladder wall is thickened. Septae or strictures may be seen within the gallblad-der. In symptomatic patients, cholecystectomy is the treatment of choice for patients with these conditions.29Treatment Nonsurgical management of gallstone disease using medications or lithotripsy has had disappointing long-term results. These modalities are not considered to be part of the primary treatment algorithm for gallstone disease.30 Surgi-cal cholecystectomy offers the best long-term results for patients with symptomatic | Surgery_Schwartz. AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32gallbladder lamina propria, either locally or as polyps. It produces the classic studded macroscopic appearance of a “strawberry gallbladder.” Adenomyomatosis (cholecystitis glandularis prolif-erans) is characterized on microscopy by hypertrophic smooth muscle bundles and by the ingrowths of mucosal glands into the muscle layer (epithelial sinus formation). Granulomatous polyps develop in the lumen at the fundus, and the gallbladder wall is thickened. Septae or strictures may be seen within the gallblad-der. In symptomatic patients, cholecystectomy is the treatment of choice for patients with these conditions.29Treatment Nonsurgical management of gallstone disease using medications or lithotripsy has had disappointing long-term results. These modalities are not considered to be part of the primary treatment algorithm for gallstone disease.30 Surgi-cal cholecystectomy offers the best long-term results for patients with symptomatic |
Surgery_Schwartz_9308 | Surgery_Schwartz | These modalities are not considered to be part of the primary treatment algorithm for gallstone disease.30 Surgi-cal cholecystectomy offers the best long-term results for patients with symptomatic gallstones. About 90% of patients with typical biliary symptoms and stones are rendered symp-tom free after cholecystectomy. For patients with atypical symptoms such as dyspepsia, flatulence, belching, bloating, and dietary fat intolerance, the results are not as favorable. The laparoscopic approach has been proven to be safe and effective and has become the standard of care for symptomatic gallstone disease, replacing open cholecystectomy in routine cases.29,31 3Due to the possibility of developing complications related to gallstone disease, patients with symptomatic choleli-thiasis should be offered elective cholecystectomy. While wait-ing for surgery, or if surgery has to be postponed, the patient should be advised to avoid dietary fats and large meals. Dia-betic patients with symptomatic | Surgery_Schwartz. These modalities are not considered to be part of the primary treatment algorithm for gallstone disease.30 Surgi-cal cholecystectomy offers the best long-term results for patients with symptomatic gallstones. About 90% of patients with typical biliary symptoms and stones are rendered symp-tom free after cholecystectomy. For patients with atypical symptoms such as dyspepsia, flatulence, belching, bloating, and dietary fat intolerance, the results are not as favorable. The laparoscopic approach has been proven to be safe and effective and has become the standard of care for symptomatic gallstone disease, replacing open cholecystectomy in routine cases.29,31 3Due to the possibility of developing complications related to gallstone disease, patients with symptomatic choleli-thiasis should be offered elective cholecystectomy. While wait-ing for surgery, or if surgery has to be postponed, the patient should be advised to avoid dietary fats and large meals. Dia-betic patients with symptomatic |
Surgery_Schwartz_9309 | Surgery_Schwartz | elective cholecystectomy. While wait-ing for surgery, or if surgery has to be postponed, the patient should be advised to avoid dietary fats and large meals. Dia-betic patients with symptomatic gallstones should be encour-aged to have a cholecystectomy promptly, as they are more prone to developing severe acute cholecystitis. Pregnant women with symptomatic gallstones who cannot be managed expectantly with diet modifications can safely undergo laparo-scopic cholecystectomy. The operation should be performed during the second trimester if possible.Acute Cholecystitis. Acute cholecystitis, or infection of the gallbladder, is associated with gallstones in 90% to 95% of cases. Rarely, acalculous cholecystitis can occur, usually in patients with other acute systemic diseases (see later “Acalculous Chole-cystitis” section). Obstruction of the cystic duct by a gall-stone is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall. In <1% of | Surgery_Schwartz. elective cholecystectomy. While wait-ing for surgery, or if surgery has to be postponed, the patient should be advised to avoid dietary fats and large meals. Dia-betic patients with symptomatic gallstones should be encour-aged to have a cholecystectomy promptly, as they are more prone to developing severe acute cholecystitis. Pregnant women with symptomatic gallstones who cannot be managed expectantly with diet modifications can safely undergo laparo-scopic cholecystectomy. The operation should be performed during the second trimester if possible.Acute Cholecystitis. Acute cholecystitis, or infection of the gallbladder, is associated with gallstones in 90% to 95% of cases. Rarely, acalculous cholecystitis can occur, usually in patients with other acute systemic diseases (see later “Acalculous Chole-cystitis” section). Obstruction of the cystic duct by a gall-stone is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall. In <1% of |
Surgery_Schwartz_9310 | Surgery_Schwartz | Chole-cystitis” section). Obstruction of the cystic duct by a gall-stone is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall. In <1% of acute cholecystitis, the cause is a tumor obstructing the cystic duct. Why inflammation develops only occasionally with cystic duct obstruction is unknown, but it is probably related to the duration of obstruction. Initially, acute cholecystitis is an inflammatory process, probably mediated by the mucosal toxin lysolecithin, a product of lecithin, as well as bile salts and platelet-activat-ing factor. An increase in prostaglandin synthesis amplifies the inflammatory response. In acute cholecystitis, the gallbladder wall becomes grossly thickened and reddish with subserosal hemorrhages. Pericholecystic fluid often is present. The mucosa may show hyperemia and patchy necrosis. In severe cases, about 5% to 10%, the inflammatory process progresses and leads to ischemia and necrosis of the | Surgery_Schwartz. Chole-cystitis” section). Obstruction of the cystic duct by a gall-stone is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall. In <1% of acute cholecystitis, the cause is a tumor obstructing the cystic duct. Why inflammation develops only occasionally with cystic duct obstruction is unknown, but it is probably related to the duration of obstruction. Initially, acute cholecystitis is an inflammatory process, probably mediated by the mucosal toxin lysolecithin, a product of lecithin, as well as bile salts and platelet-activat-ing factor. An increase in prostaglandin synthesis amplifies the inflammatory response. In acute cholecystitis, the gallbladder wall becomes grossly thickened and reddish with subserosal hemorrhages. Pericholecystic fluid often is present. The mucosa may show hyperemia and patchy necrosis. In severe cases, about 5% to 10%, the inflammatory process progresses and leads to ischemia and necrosis of the |
Surgery_Schwartz_9311 | Surgery_Schwartz | fluid often is present. The mucosa may show hyperemia and patchy necrosis. In severe cases, about 5% to 10%, the inflammatory process progresses and leads to ischemia and necrosis of the gallbladder wall. More frequently, the gallstone is dislodged and the inflammation resolves.Not all episodes of uncomplicated acute cholecystitis involve infection. Secondary bacterial contamination is thought to occur in only 15% to 30% of patients. With some severe infections, gangrenous cholecystitis can develop, and an abscess or perforation may occur. When they happen, perforations are usually contained in the subhepatic space by the omentum and adjacent organs. However, free perforation with peritonitis, intrahepatic perforation with intrahepatic abscesses, and per-foration into adjacent organs (duodenum or colon) with cho-lecystoenteric fistula have been described. When gas-forming organisms are part of the secondary bacterial infection, gas may be seen in the gallbladder lumen and in the wall | Surgery_Schwartz. fluid often is present. The mucosa may show hyperemia and patchy necrosis. In severe cases, about 5% to 10%, the inflammatory process progresses and leads to ischemia and necrosis of the gallbladder wall. More frequently, the gallstone is dislodged and the inflammation resolves.Not all episodes of uncomplicated acute cholecystitis involve infection. Secondary bacterial contamination is thought to occur in only 15% to 30% of patients. With some severe infections, gangrenous cholecystitis can develop, and an abscess or perforation may occur. When they happen, perforations are usually contained in the subhepatic space by the omentum and adjacent organs. However, free perforation with peritonitis, intrahepatic perforation with intrahepatic abscesses, and per-foration into adjacent organs (duodenum or colon) with cho-lecystoenteric fistula have been described. When gas-forming organisms are part of the secondary bacterial infection, gas may be seen in the gallbladder lumen and in the wall |
Surgery_Schwartz_9312 | Surgery_Schwartz | or colon) with cho-lecystoenteric fistula have been described. When gas-forming organisms are part of the secondary bacterial infection, gas may be seen in the gallbladder lumen and in the wall of the gallblad-der on abdominal radiographs and CT scans, an entity called emphysematous cholecystitis.Clinical Manifestations About 80% of patients with acute cholecystitis give a history compatible with chronic cholecysti-tis. Acute cholecystitis often begins as an attack of biliary colic with relapsing and remitting pain in the right upper quadrant or epigastrium that may radiate to the right back or interscapular area. In contrast to biliary colic, the pain of acute cholecystitis does not subside. It is unremitting, may persist for several days, and is usually more severe than the pain associated with uncom-plicated gallstone disease. The patient is often febrile, complains of anorexia, nausea, and vomiting, and may be reluctant to move as the inflammatory process creates focal | Surgery_Schwartz. or colon) with cho-lecystoenteric fistula have been described. When gas-forming organisms are part of the secondary bacterial infection, gas may be seen in the gallbladder lumen and in the wall of the gallblad-der on abdominal radiographs and CT scans, an entity called emphysematous cholecystitis.Clinical Manifestations About 80% of patients with acute cholecystitis give a history compatible with chronic cholecysti-tis. Acute cholecystitis often begins as an attack of biliary colic with relapsing and remitting pain in the right upper quadrant or epigastrium that may radiate to the right back or interscapular area. In contrast to biliary colic, the pain of acute cholecystitis does not subside. It is unremitting, may persist for several days, and is usually more severe than the pain associated with uncom-plicated gallstone disease. The patient is often febrile, complains of anorexia, nausea, and vomiting, and may be reluctant to move as the inflammatory process creates focal |
Surgery_Schwartz_9313 | Surgery_Schwartz | associated with uncom-plicated gallstone disease. The patient is often febrile, complains of anorexia, nausea, and vomiting, and may be reluctant to move as the inflammatory process creates focal peritonitis. On physi-cal examination, tenderness and guarding are usually present in the right upper quadrant. A mass, the gallbladder and adherent omentum, is occasionally palpable; however, guarding may pre-vent identification of this. Murphy’s sign, an inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute cholecystitis.Laboratory evaluation commonly reveals a mild to mod-erate leukocytosis (12,000–15,000 cells/mm3). However, a normal WBC does not rule out the diagnosis. An unusually high WBC count (>20,000 cells/mm3) suggests a complicated form of cholecystitis such as gangrenous cholecystitis, perfo-ration, or associated cholangitis. In uncomplicated acute cho-lecystitis, serum liver chemistries are usually normal, but a mild elevation of serum | Surgery_Schwartz. associated with uncom-plicated gallstone disease. The patient is often febrile, complains of anorexia, nausea, and vomiting, and may be reluctant to move as the inflammatory process creates focal peritonitis. On physi-cal examination, tenderness and guarding are usually present in the right upper quadrant. A mass, the gallbladder and adherent omentum, is occasionally palpable; however, guarding may pre-vent identification of this. Murphy’s sign, an inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute cholecystitis.Laboratory evaluation commonly reveals a mild to mod-erate leukocytosis (12,000–15,000 cells/mm3). However, a normal WBC does not rule out the diagnosis. An unusually high WBC count (>20,000 cells/mm3) suggests a complicated form of cholecystitis such as gangrenous cholecystitis, perfo-ration, or associated cholangitis. In uncomplicated acute cho-lecystitis, serum liver chemistries are usually normal, but a mild elevation of serum |
Surgery_Schwartz_9314 | Surgery_Schwartz | such as gangrenous cholecystitis, perfo-ration, or associated cholangitis. In uncomplicated acute cho-lecystitis, serum liver chemistries are usually normal, but a mild elevation of serum bilirubin (<4 mg/mL) may be present along with mild elevation of alkaline phosphatase, transami-nases, and amylase.28 Severe jaundice is suggestive of obstruc-tion of the bile ducts. This can be a result of common bile duct stones or severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallblad-der that mechanically obstructs the bile duct, known as Mir-izzi’s syndrome (Fig. 32-16). In elderly patients and in those with diabetes mellitus, acute cholecystitis may have a subtle Figure 32-16. Mirizzi’s syndrome. Impaction of a large stone in the neck of the gallbladder causing obstruction at the level of the confluence of the cystic duct and common hepatic duct.Brunicardi_Ch32_p1393-p1428.indd 140511/02/19 2:43 PM 1406SPECIFIC | Surgery_Schwartz. such as gangrenous cholecystitis, perfo-ration, or associated cholangitis. In uncomplicated acute cho-lecystitis, serum liver chemistries are usually normal, but a mild elevation of serum bilirubin (<4 mg/mL) may be present along with mild elevation of alkaline phosphatase, transami-nases, and amylase.28 Severe jaundice is suggestive of obstruc-tion of the bile ducts. This can be a result of common bile duct stones or severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallblad-der that mechanically obstructs the bile duct, known as Mir-izzi’s syndrome (Fig. 32-16). In elderly patients and in those with diabetes mellitus, acute cholecystitis may have a subtle Figure 32-16. Mirizzi’s syndrome. Impaction of a large stone in the neck of the gallbladder causing obstruction at the level of the confluence of the cystic duct and common hepatic duct.Brunicardi_Ch32_p1393-p1428.indd 140511/02/19 2:43 PM 1406SPECIFIC |
Surgery_Schwartz_9315 | Surgery_Schwartz | in the neck of the gallbladder causing obstruction at the level of the confluence of the cystic duct and common hepatic duct.Brunicardi_Ch32_p1393-p1428.indd 140511/02/19 2:43 PM 1406SPECIFIC CONSIDERATIONSPART IIpresentation resulting in a delay in diagnosis. These patients may also have higher rates of treatment related morbidity com-pared to younger and healthier patients.The differential diagnosis for acute cholecystitis includes but is not limited to peptic ulcer disease, pancreatitis, appen-dicitis, hepatitis, perihepatitis (Fitz-Hugh–Curtis syndrome), myocardial ischemia, pneumonia, pleuritis, and herpes zoster involving the intercostal nerve.Diagnosis Ultrasonography is considered the most useful ini-tial radiologic test for diagnosing acute cholecystitis, with a sen-sitivity and specificity of 70% to 90%. Ultrasound is effective at documenting the presence or absence of stones, and it can show gallbladder wall thickening and pericholecystic fluid, both of which are highly | Surgery_Schwartz. in the neck of the gallbladder causing obstruction at the level of the confluence of the cystic duct and common hepatic duct.Brunicardi_Ch32_p1393-p1428.indd 140511/02/19 2:43 PM 1406SPECIFIC CONSIDERATIONSPART IIpresentation resulting in a delay in diagnosis. These patients may also have higher rates of treatment related morbidity com-pared to younger and healthier patients.The differential diagnosis for acute cholecystitis includes but is not limited to peptic ulcer disease, pancreatitis, appen-dicitis, hepatitis, perihepatitis (Fitz-Hugh–Curtis syndrome), myocardial ischemia, pneumonia, pleuritis, and herpes zoster involving the intercostal nerve.Diagnosis Ultrasonography is considered the most useful ini-tial radiologic test for diagnosing acute cholecystitis, with a sen-sitivity and specificity of 70% to 90%. Ultrasound is effective at documenting the presence or absence of stones, and it can show gallbladder wall thickening and pericholecystic fluid, both of which are highly |
Surgery_Schwartz_9316 | Surgery_Schwartz | specificity of 70% to 90%. Ultrasound is effective at documenting the presence or absence of stones, and it can show gallbladder wall thickening and pericholecystic fluid, both of which are highly suggestive of acute cholecystitis (Fig. 32-17). Focal tenderness over the gallbladder when compressed by the sonographic probe (sonographic Murphy’s sign) also supports the diagnosis of acute cholecystitis. Biliary scintigraphy (HIDA scanning) may be of help in atypical cases if the diagnosis remains in question after initial workup. Lack of filling of the gallbladder after 4 hours indicates an obstructed cystic duct and, in the clinical setting of suspected acute cholecystitis, confirms the diagnosis with a reported sensitivity above 90%.32 Con-versely, a normal HIDA scan with clear filling of the gallblad-der rules out the diagnosis of acute cholecystitis. CT scans are frequently performed on patients with acute abdominal pain of unknown etiology, as they can evaluate for a number of | Surgery_Schwartz. specificity of 70% to 90%. Ultrasound is effective at documenting the presence or absence of stones, and it can show gallbladder wall thickening and pericholecystic fluid, both of which are highly suggestive of acute cholecystitis (Fig. 32-17). Focal tenderness over the gallbladder when compressed by the sonographic probe (sonographic Murphy’s sign) also supports the diagnosis of acute cholecystitis. Biliary scintigraphy (HIDA scanning) may be of help in atypical cases if the diagnosis remains in question after initial workup. Lack of filling of the gallbladder after 4 hours indicates an obstructed cystic duct and, in the clinical setting of suspected acute cholecystitis, confirms the diagnosis with a reported sensitivity above 90%.32 Con-versely, a normal HIDA scan with clear filling of the gallblad-der rules out the diagnosis of acute cholecystitis. CT scans are frequently performed on patients with acute abdominal pain of unknown etiology, as they can evaluate for a number of |
Surgery_Schwartz_9317 | Surgery_Schwartz | of the gallblad-der rules out the diagnosis of acute cholecystitis. CT scans are frequently performed on patients with acute abdominal pain of unknown etiology, as they can evaluate for a number of poten-tial pathologic processes at once. In patients with acute chole-cystitis, a CT scan can demonstrate thickening of the gallbladder wall, pericholecystic fluid, and the presence of gallstones, but it is somewhat less sensitive than ultrasonography.Treatment Patients who present with acute cholecystitis should receive IV fluids, broad-spectrum antibiotics, and anal-gesia. The antibiotics should cover gram-negative enteric organ-isms as well as anaerobes. Although the inflammation in acute cholecystitis may be sterile in some patients, it is difficult to know who is secondarily infected. Therefore, antibiotics have become a standard part of the initial management of acute cho-lecystitis in most centers.Cholecystectomy is the definitive treatment for acute cho-lecystitis. In the past, the | Surgery_Schwartz. of the gallblad-der rules out the diagnosis of acute cholecystitis. CT scans are frequently performed on patients with acute abdominal pain of unknown etiology, as they can evaluate for a number of poten-tial pathologic processes at once. In patients with acute chole-cystitis, a CT scan can demonstrate thickening of the gallbladder wall, pericholecystic fluid, and the presence of gallstones, but it is somewhat less sensitive than ultrasonography.Treatment Patients who present with acute cholecystitis should receive IV fluids, broad-spectrum antibiotics, and anal-gesia. The antibiotics should cover gram-negative enteric organ-isms as well as anaerobes. Although the inflammation in acute cholecystitis may be sterile in some patients, it is difficult to know who is secondarily infected. Therefore, antibiotics have become a standard part of the initial management of acute cho-lecystitis in most centers.Cholecystectomy is the definitive treatment for acute cho-lecystitis. In the past, the |
Surgery_Schwartz_9318 | Surgery_Schwartz | antibiotics have become a standard part of the initial management of acute cho-lecystitis in most centers.Cholecystectomy is the definitive treatment for acute cho-lecystitis. In the past, the timing of cholecystectomy has been a matter of debate. Early cholecystectomy performed within 72 hours of the onset of the illness is preferred over delayed cholecystectomy that is performed 6 to 10 weeks after initial medical treatment and recuperation. Several studies have shown that unless the patient is unfit for surgery, early cholecystectomy should be recommended as soon as possible, as it offers the patient a definitive solution in one hospital admission, quicker recovery times, similar complication rates, and an earlier return to work.33,34Laparoscopic cholecystectomy is the procedure of choice for acute cholecystitis. The conversion rate to an open cholecys-tectomy has fallen in recent years to less than 5% as laparoscopic equipment and experience has improved.35 While laparoscopic | Surgery_Schwartz. antibiotics have become a standard part of the initial management of acute cho-lecystitis in most centers.Cholecystectomy is the definitive treatment for acute cho-lecystitis. In the past, the timing of cholecystectomy has been a matter of debate. Early cholecystectomy performed within 72 hours of the onset of the illness is preferred over delayed cholecystectomy that is performed 6 to 10 weeks after initial medical treatment and recuperation. Several studies have shown that unless the patient is unfit for surgery, early cholecystectomy should be recommended as soon as possible, as it offers the patient a definitive solution in one hospital admission, quicker recovery times, similar complication rates, and an earlier return to work.33,34Laparoscopic cholecystectomy is the procedure of choice for acute cholecystitis. The conversion rate to an open cholecys-tectomy has fallen in recent years to less than 5% as laparoscopic equipment and experience has improved.35 While laparoscopic |
Surgery_Schwartz_9319 | Surgery_Schwartz | choice for acute cholecystitis. The conversion rate to an open cholecys-tectomy has fallen in recent years to less than 5% as laparoscopic equipment and experience has improved.35 While laparoscopic cholecystectomy for acute cholecystitis may be more tedious and take longer than an elective cholecystectomy for symp-tomatic cholelithiasis, the laparoscopic approach remains safe and effective, even in the setting of acute and sometimes severe inflammation. Open cholecystectomy must remain an option in particularly difficult cases, or in patients suspected of having prohibitive intraabdominal adhesions, but it is rarely the primary treatment choice.When patients are medically unfit for surgery due to the severity of their illness or medical comorbidities, they can be treated with antibiotics and biliary decompression with cho-lecystostomy tube placement, which is usually effective in stabilizing the patient.36 For those who do recover after chole-cystostomy, the tube can be removed once | Surgery_Schwartz. choice for acute cholecystitis. The conversion rate to an open cholecys-tectomy has fallen in recent years to less than 5% as laparoscopic equipment and experience has improved.35 While laparoscopic cholecystectomy for acute cholecystitis may be more tedious and take longer than an elective cholecystectomy for symp-tomatic cholelithiasis, the laparoscopic approach remains safe and effective, even in the setting of acute and sometimes severe inflammation. Open cholecystectomy must remain an option in particularly difficult cases, or in patients suspected of having prohibitive intraabdominal adhesions, but it is rarely the primary treatment choice.When patients are medically unfit for surgery due to the severity of their illness or medical comorbidities, they can be treated with antibiotics and biliary decompression with cho-lecystostomy tube placement, which is usually effective in stabilizing the patient.36 For those who do recover after chole-cystostomy, the tube can be removed once |
Surgery_Schwartz_9320 | Surgery_Schwartz | and biliary decompression with cho-lecystostomy tube placement, which is usually effective in stabilizing the patient.36 For those who do recover after chole-cystostomy, the tube can be removed once the track is mature (approximately 4 weeks) and cholangiography through it shows a patent cystic duct. Elective laparoscopic cholecystectomy can be scheduled within approximately 6 to 8 weeks, assum-ing their medical fitness recovers.37 Failure to improve after cholecystostomy may be due to gangrene of the gallbladder or perforation, in which case, damage control surgery may be unavoidable.Choledocholithiasis. Common bile duct (CBD) stones may be small or large, single or multiple, and are found in 6% to 12% of patients with stones in the gallbladder. The incidence increases with age. About 20% to 25% of patients above the age of 60 with symptomatic gallstones have stones in the common bile duct as well as in the gallbladder.38 The vast majority of ductal stones in Figure | Surgery_Schwartz. and biliary decompression with cho-lecystostomy tube placement, which is usually effective in stabilizing the patient.36 For those who do recover after chole-cystostomy, the tube can be removed once the track is mature (approximately 4 weeks) and cholangiography through it shows a patent cystic duct. Elective laparoscopic cholecystectomy can be scheduled within approximately 6 to 8 weeks, assum-ing their medical fitness recovers.37 Failure to improve after cholecystostomy may be due to gangrene of the gallbladder or perforation, in which case, damage control surgery may be unavoidable.Choledocholithiasis. Common bile duct (CBD) stones may be small or large, single or multiple, and are found in 6% to 12% of patients with stones in the gallbladder. The incidence increases with age. About 20% to 25% of patients above the age of 60 with symptomatic gallstones have stones in the common bile duct as well as in the gallbladder.38 The vast majority of ductal stones in Figure |
Surgery_Schwartz_9321 | Surgery_Schwartz | age. About 20% to 25% of patients above the age of 60 with symptomatic gallstones have stones in the common bile duct as well as in the gallbladder.38 The vast majority of ductal stones in Figure 32-17. Ultrasonography from a patient with acute cholecystitis. The white arrowheads indicate the thickened gallbladder wall. There are several stones in the gallbladder (white arrows) throwing acoustic shadows (black arrowheads). Trace pericholecystic fluid can be seen surrounding the gallbladder (black arrows).Brunicardi_Ch32_p1393-p1428.indd 140611/02/19 2:43 PM 1407GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32Western countries are formed within the gallbladder and migrate down the cystic duct into the common bile duct. These are clas-sified as secondary CBD stones, in contrast to the primary CBD stones that form in the bile duct itself. Secondary stones are usu-ally cholesterol stones, whereas primary stones are usually of the brown pigment type. The primary stones are | Surgery_Schwartz. age. About 20% to 25% of patients above the age of 60 with symptomatic gallstones have stones in the common bile duct as well as in the gallbladder.38 The vast majority of ductal stones in Figure 32-17. Ultrasonography from a patient with acute cholecystitis. The white arrowheads indicate the thickened gallbladder wall. There are several stones in the gallbladder (white arrows) throwing acoustic shadows (black arrowheads). Trace pericholecystic fluid can be seen surrounding the gallbladder (black arrows).Brunicardi_Ch32_p1393-p1428.indd 140611/02/19 2:43 PM 1407GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32Western countries are formed within the gallbladder and migrate down the cystic duct into the common bile duct. These are clas-sified as secondary CBD stones, in contrast to the primary CBD stones that form in the bile duct itself. Secondary stones are usu-ally cholesterol stones, whereas primary stones are usually of the brown pigment type. The primary stones are |
Surgery_Schwartz_9322 | Surgery_Schwartz | to the primary CBD stones that form in the bile duct itself. Secondary stones are usu-ally cholesterol stones, whereas primary stones are usually of the brown pigment type. The primary stones are associated with biliary stasis and infection, and they are more commonly seen in Asian populations. Biliary stasis leading to the development of primary CBD stones can be caused by biliary strictures, papillary stenosis, tumors, or other (secondary) stones.Clinical Manifestations Choledochal stones may be silent and often are discovered incidentally. They may cause complete or incomplete obstruction, or they may manifest with cholangitis or gallstone pancreatitis. The typical pain caused by a stone in the bile duct is very similar to that of biliary colic caused by impaction of a stone in the cystic duct. Nausea and vomiting are common. Physical examination may be normal, but mild epigas-tric or right upper quadrant tenderness as well as mild icterus are common. The symptoms may also be | Surgery_Schwartz. to the primary CBD stones that form in the bile duct itself. Secondary stones are usu-ally cholesterol stones, whereas primary stones are usually of the brown pigment type. The primary stones are associated with biliary stasis and infection, and they are more commonly seen in Asian populations. Biliary stasis leading to the development of primary CBD stones can be caused by biliary strictures, papillary stenosis, tumors, or other (secondary) stones.Clinical Manifestations Choledochal stones may be silent and often are discovered incidentally. They may cause complete or incomplete obstruction, or they may manifest with cholangitis or gallstone pancreatitis. The typical pain caused by a stone in the bile duct is very similar to that of biliary colic caused by impaction of a stone in the cystic duct. Nausea and vomiting are common. Physical examination may be normal, but mild epigas-tric or right upper quadrant tenderness as well as mild icterus are common. The symptoms may also be |
Surgery_Schwartz_9323 | Surgery_Schwartz | cystic duct. Nausea and vomiting are common. Physical examination may be normal, but mild epigas-tric or right upper quadrant tenderness as well as mild icterus are common. The symptoms may also be intermittent, such as pain and transient jaundice caused by a stone that temporar-ily impacts the ampulla but subsequently moves away, acting as a ball valve. A small stone may pass through the ampulla spontaneously with resolution of symptoms. Finally, the stones may become completely impacted, causing severe progressive jaundice. Elevation of serum bilirubin, alkaline phosphatase, and transaminases are commonly seen in patients with bile duct stones. However, in about one-third of patients with common bile duct stones, the liver chemistries are normal, particularly if the obstruction is incomplete or intermittent.Diagnosis Ultrasonography is useful for documenting stones in the gallbladder (if still present), as well as determining the size of the common bile duct. As stones in the bile | Surgery_Schwartz. cystic duct. Nausea and vomiting are common. Physical examination may be normal, but mild epigas-tric or right upper quadrant tenderness as well as mild icterus are common. The symptoms may also be intermittent, such as pain and transient jaundice caused by a stone that temporar-ily impacts the ampulla but subsequently moves away, acting as a ball valve. A small stone may pass through the ampulla spontaneously with resolution of symptoms. Finally, the stones may become completely impacted, causing severe progressive jaundice. Elevation of serum bilirubin, alkaline phosphatase, and transaminases are commonly seen in patients with bile duct stones. However, in about one-third of patients with common bile duct stones, the liver chemistries are normal, particularly if the obstruction is incomplete or intermittent.Diagnosis Ultrasonography is useful for documenting stones in the gallbladder (if still present), as well as determining the size of the common bile duct. As stones in the bile |
Surgery_Schwartz_9324 | Surgery_Schwartz | or intermittent.Diagnosis Ultrasonography is useful for documenting stones in the gallbladder (if still present), as well as determining the size of the common bile duct. As stones in the bile ducts tend to move down to the distal part of the common duct behind the duodenum, bowel gas can preclude their detection on ultraso-nography. A dilated common bile duct (>8 mm in diameter) on ultrasonography in a patient with gallstones, jaundice, and bili-ary pain is highly suggestive of common bile duct stones. If the presence of bile duct stones is in question, magnetic resonance cholangiopancreatography (MRCP) provides excellent anatomic detail and has a sensitivity and specificity of 95% and 89%, respectively, for detecting choledocholithiasis.14 Endoscopic retrograde cholangiopancreatography (ERCP) is highly effec-tive at diagnosing choledocholithiasis and in experienced hands, cannulation of the ampulla of Vater and diagnostic cholangiog-raphy are achieved in >90% of cases. However, due | Surgery_Schwartz. or intermittent.Diagnosis Ultrasonography is useful for documenting stones in the gallbladder (if still present), as well as determining the size of the common bile duct. As stones in the bile ducts tend to move down to the distal part of the common duct behind the duodenum, bowel gas can preclude their detection on ultraso-nography. A dilated common bile duct (>8 mm in diameter) on ultrasonography in a patient with gallstones, jaundice, and bili-ary pain is highly suggestive of common bile duct stones. If the presence of bile duct stones is in question, magnetic resonance cholangiopancreatography (MRCP) provides excellent anatomic detail and has a sensitivity and specificity of 95% and 89%, respectively, for detecting choledocholithiasis.14 Endoscopic retrograde cholangiopancreatography (ERCP) is highly effec-tive at diagnosing choledocholithiasis and in experienced hands, cannulation of the ampulla of Vater and diagnostic cholangiog-raphy are achieved in >90% of cases. However, due |
Surgery_Schwartz_9325 | Surgery_Schwartz | (ERCP) is highly effec-tive at diagnosing choledocholithiasis and in experienced hands, cannulation of the ampulla of Vater and diagnostic cholangiog-raphy are achieved in >90% of cases. However, due to the risks associated with the procedure, it is rarely used as a purely diag-nostic modality, rather being reserved for cases in which a thera-peutic intervention such as stone extraction or sphincterotomy is planned. Endoscopic ultrasound has been demonstrated to be as good as ERCP for detecting common bile duct stones (sensitivity of 95% and specificity of 97%). However, EUS has fewer thera-peutic capabilities and requires endoscopic expertise, making it less desirable except in specific clinical senarios.39 Percutaneous transhepatic cholangiography (PTC) is rarely needed in patients with common bile duct stones but can be performed for both diagnostic and therapeutic reasons in patients with contraindica-tions to endoscopic or surgical approaches.Treatment For patients with | Surgery_Schwartz. (ERCP) is highly effec-tive at diagnosing choledocholithiasis and in experienced hands, cannulation of the ampulla of Vater and diagnostic cholangiog-raphy are achieved in >90% of cases. However, due to the risks associated with the procedure, it is rarely used as a purely diag-nostic modality, rather being reserved for cases in which a thera-peutic intervention such as stone extraction or sphincterotomy is planned. Endoscopic ultrasound has been demonstrated to be as good as ERCP for detecting common bile duct stones (sensitivity of 95% and specificity of 97%). However, EUS has fewer thera-peutic capabilities and requires endoscopic expertise, making it less desirable except in specific clinical senarios.39 Percutaneous transhepatic cholangiography (PTC) is rarely needed in patients with common bile duct stones but can be performed for both diagnostic and therapeutic reasons in patients with contraindica-tions to endoscopic or surgical approaches.Treatment For patients with |
Surgery_Schwartz_9326 | Surgery_Schwartz | with common bile duct stones but can be performed for both diagnostic and therapeutic reasons in patients with contraindica-tions to endoscopic or surgical approaches.Treatment For patients with symptomatic gallstones and sus-pected common bile duct stones, bile duct clearance and cho-lecystectomy are indicated. This may be safely achieved either with preoperative ERCP followed by surgery or by going directly to surgery with intraoperative cholangiogram and common bile duct exploration to address retained stones. Both approaches are considered safe and effective, and no formal recommendation exists to definitively support one over the other.40,41If upfront laparoscopic cholecystectomy is pursued, the surgery should include an intraoperative cholangiogram to doc-ument the presence or absence of bile duct stones. If stones are identified, laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting (see | Surgery_Schwartz. with common bile duct stones but can be performed for both diagnostic and therapeutic reasons in patients with contraindica-tions to endoscopic or surgical approaches.Treatment For patients with symptomatic gallstones and sus-pected common bile duct stones, bile duct clearance and cho-lecystectomy are indicated. This may be safely achieved either with preoperative ERCP followed by surgery or by going directly to surgery with intraoperative cholangiogram and common bile duct exploration to address retained stones. Both approaches are considered safe and effective, and no formal recommendation exists to definitively support one over the other.40,41If upfront laparoscopic cholecystectomy is pursued, the surgery should include an intraoperative cholangiogram to doc-ument the presence or absence of bile duct stones. If stones are identified, laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting (see |
Surgery_Schwartz_9327 | Surgery_Schwartz | of bile duct stones. If stones are identified, laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting (see “Choledochal Explora-tion” section). If the expertise and/or instrumentation for lapa-roscopic common bile duct exploration are not available, the patient can be awoken and scheduled for ERCP with sphincter-otomy the following day. An open common bile duct explora-tion is an option if the endoscopic and laparoscopic methods are not feasible. If a choledochotomy is performed, primary repair can be considered in large ducts, while smaller ducts should be repaired over a T-tube. To do this, a standard T-tube should be modified by cutting the ends short enough to allow placement within the duct and dividing the T longitudinally to facilitate easy removal from the duct later on (Fig. 32-18). If a common Figure 32-18. T-tube placement. A. A standard T-tube that has been cut and modified for use | Surgery_Schwartz. of bile duct stones. If stones are identified, laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting (see “Choledochal Explora-tion” section). If the expertise and/or instrumentation for lapa-roscopic common bile duct exploration are not available, the patient can be awoken and scheduled for ERCP with sphincter-otomy the following day. An open common bile duct explora-tion is an option if the endoscopic and laparoscopic methods are not feasible. If a choledochotomy is performed, primary repair can be considered in large ducts, while smaller ducts should be repaired over a T-tube. To do this, a standard T-tube should be modified by cutting the ends short enough to allow placement within the duct and dividing the T longitudinally to facilitate easy removal from the duct later on (Fig. 32-18). If a common Figure 32-18. T-tube placement. A. A standard T-tube that has been cut and modified for use |
Surgery_Schwartz_9328 | Surgery_Schwartz | dividing the T longitudinally to facilitate easy removal from the duct later on (Fig. 32-18). If a common Figure 32-18. T-tube placement. A. A standard T-tube that has been cut and modified for use in the biliary tract. B. The T-tube is placed through a ductotomy in the common bile duct with the defect closed over the tube. The opposite end is brought out through the abdominal wall for decompression of the bile ducts.ABBrunicardi_Ch32_p1393-p1428.indd 140711/02/19 2:43 PM 1408SPECIFIC CONSIDERATIONSPART IIbile duct exploration was performed and a T tube left in place, a T-tube cholangiogram should be obtained before its removal, at least several weeks after its placement.In very severe cases, stones impacted in the ampulla may be unable to be cleared by endoscopic approaches or common bile duct exploration (open or laparoscopic). In these cases, transduodenal sphincterotomy can be considered. If one is entirely unable to disimpact the duct, choledochoduodenostomy or Roux-en-Y | Surgery_Schwartz. dividing the T longitudinally to facilitate easy removal from the duct later on (Fig. 32-18). If a common Figure 32-18. T-tube placement. A. A standard T-tube that has been cut and modified for use in the biliary tract. B. The T-tube is placed through a ductotomy in the common bile duct with the defect closed over the tube. The opposite end is brought out through the abdominal wall for decompression of the bile ducts.ABBrunicardi_Ch32_p1393-p1428.indd 140711/02/19 2:43 PM 1408SPECIFIC CONSIDERATIONSPART IIbile duct exploration was performed and a T tube left in place, a T-tube cholangiogram should be obtained before its removal, at least several weeks after its placement.In very severe cases, stones impacted in the ampulla may be unable to be cleared by endoscopic approaches or common bile duct exploration (open or laparoscopic). In these cases, transduodenal sphincterotomy can be considered. If one is entirely unable to disimpact the duct, choledochoduodenostomy or Roux-en-Y |
Surgery_Schwartz_9329 | Surgery_Schwartz | bile duct exploration (open or laparoscopic). In these cases, transduodenal sphincterotomy can be considered. If one is entirely unable to disimpact the duct, choledochoduodenostomy or Roux-en-Y choledochojejunostomy may be the only option to restore biliary continuity.42If the stones were left in place at the time of surgery or diagnosed shortly after the cholecystectomy, they are classified as retained. Those diagnosed months or years later are termed recurrent (Fig. 32-19). Retained or recurrent stones following cholecystectomy are best treated endoscopically. A generous sphincterotomy will allow for stone retrieval as well as spon-taneous passage of stones. Alternately, retained stones can be cleared via a mature T-tube tract (4 weeks) if one was placed at the time of surgery. To do this, the T-tube is removed and a catheter passed through the tract into the common bile duct. Under fluoroscopic guidance, the stones can be retrieved with baskets or balloons. A similar approach will | Surgery_Schwartz. bile duct exploration (open or laparoscopic). In these cases, transduodenal sphincterotomy can be considered. If one is entirely unable to disimpact the duct, choledochoduodenostomy or Roux-en-Y choledochojejunostomy may be the only option to restore biliary continuity.42If the stones were left in place at the time of surgery or diagnosed shortly after the cholecystectomy, they are classified as retained. Those diagnosed months or years later are termed recurrent (Fig. 32-19). Retained or recurrent stones following cholecystectomy are best treated endoscopically. A generous sphincterotomy will allow for stone retrieval as well as spon-taneous passage of stones. Alternately, retained stones can be cleared via a mature T-tube tract (4 weeks) if one was placed at the time of surgery. To do this, the T-tube is removed and a catheter passed through the tract into the common bile duct. Under fluoroscopic guidance, the stones can be retrieved with baskets or balloons. A similar approach will |
Surgery_Schwartz_9330 | Surgery_Schwartz | the T-tube is removed and a catheter passed through the tract into the common bile duct. Under fluoroscopic guidance, the stones can be retrieved with baskets or balloons. A similar approach will allow for stone clearance by percutaneous transhepatic cholecystostomy (PTC) if there is no other way to reach the duct. Repeat surgery should be a last resort if other interventions have failed.Cholangitis. Cholangitis is one of the main complications of choledochal stones. Acute cholangitis is an ascending bac-terial infection associated with partial or complete obstruc-tion of the bile ducts.43 Hepatic bile is sterile, and bile in the bile ducts is kept sterile by continuous antegrade bile flow and by the presence of antibacterial substances in bile, such as immunoglobulin. Mechanical hindrance to bile flow facilitates ascending bacterial contamination from the bowel. Positive bile cultures are common in the presence of bile duct stones as well as with other causes of obstruction. Biliary | Surgery_Schwartz. the T-tube is removed and a catheter passed through the tract into the common bile duct. Under fluoroscopic guidance, the stones can be retrieved with baskets or balloons. A similar approach will allow for stone clearance by percutaneous transhepatic cholecystostomy (PTC) if there is no other way to reach the duct. Repeat surgery should be a last resort if other interventions have failed.Cholangitis. Cholangitis is one of the main complications of choledochal stones. Acute cholangitis is an ascending bac-terial infection associated with partial or complete obstruc-tion of the bile ducts.43 Hepatic bile is sterile, and bile in the bile ducts is kept sterile by continuous antegrade bile flow and by the presence of antibacterial substances in bile, such as immunoglobulin. Mechanical hindrance to bile flow facilitates ascending bacterial contamination from the bowel. Positive bile cultures are common in the presence of bile duct stones as well as with other causes of obstruction. Biliary |
Surgery_Schwartz_9331 | Surgery_Schwartz | to bile flow facilitates ascending bacterial contamination from the bowel. Positive bile cultures are common in the presence of bile duct stones as well as with other causes of obstruction. Biliary bacterial contamination alone does not lead to clinical cholangitis; the combination of both significant bacterial contamination and biliary obstruction is required for its development. Gallstones are the most common cause of obstruction in cholangitis. Other causes include primary sclerosing cholangitis, benign and malignant strictures, parasites, instrumentation of the ducts, and indwelling stents, as well as partially obstructed biliary-enteric anastomoses. The most common organisms cultured from bile in patients with cholangitis include E coli, Klebsiella pneumoniae, Streptococcus faecalis, Enterobacter, and Bacteroides fragilis.43Clinical Manifestations Cholangitis may present as anything from a mild, self-limited episode to a fulminant, potentially life-threatening septicemia. | Surgery_Schwartz. to bile flow facilitates ascending bacterial contamination from the bowel. Positive bile cultures are common in the presence of bile duct stones as well as with other causes of obstruction. Biliary bacterial contamination alone does not lead to clinical cholangitis; the combination of both significant bacterial contamination and biliary obstruction is required for its development. Gallstones are the most common cause of obstruction in cholangitis. Other causes include primary sclerosing cholangitis, benign and malignant strictures, parasites, instrumentation of the ducts, and indwelling stents, as well as partially obstructed biliary-enteric anastomoses. The most common organisms cultured from bile in patients with cholangitis include E coli, Klebsiella pneumoniae, Streptococcus faecalis, Enterobacter, and Bacteroides fragilis.43Clinical Manifestations Cholangitis may present as anything from a mild, self-limited episode to a fulminant, potentially life-threatening septicemia. |
Surgery_Schwartz_9332 | Surgery_Schwartz | Enterobacter, and Bacteroides fragilis.43Clinical Manifestations Cholangitis may present as anything from a mild, self-limited episode to a fulminant, potentially life-threatening septicemia. Patients with gallstone-induced cholangitis are most commonly older and female. The most common presentation is fever, epigastric or right upper quad-rant pain, and jaundice. These classic symptoms, known as Charcot’s triad, are present in about two-thirds of patients. The illness can progress rapidly with the development of shock and altered mental status, known as Reynolds’ pentad (e.g., fever, jaundice, right upper quadrant pain, septic shock, and mental status changes). However, the presentation may be atypical, with little if any fever, jaundice, or pain. This occurs most commonly in the elderly, who may have unremarkable symptoms until the process is already quite advanced. Patients with indwelling stents are at particularly high risk for cholan-gitis, though rarely become jaundiced as a | Surgery_Schwartz. Enterobacter, and Bacteroides fragilis.43Clinical Manifestations Cholangitis may present as anything from a mild, self-limited episode to a fulminant, potentially life-threatening septicemia. Patients with gallstone-induced cholangitis are most commonly older and female. The most common presentation is fever, epigastric or right upper quad-rant pain, and jaundice. These classic symptoms, known as Charcot’s triad, are present in about two-thirds of patients. The illness can progress rapidly with the development of shock and altered mental status, known as Reynolds’ pentad (e.g., fever, jaundice, right upper quadrant pain, septic shock, and mental status changes). However, the presentation may be atypical, with little if any fever, jaundice, or pain. This occurs most commonly in the elderly, who may have unremarkable symptoms until the process is already quite advanced. Patients with indwelling stents are at particularly high risk for cholan-gitis, though rarely become jaundiced as a |
Surgery_Schwartz_9333 | Surgery_Schwartz | who may have unremarkable symptoms until the process is already quite advanced. Patients with indwelling stents are at particularly high risk for cholan-gitis, though rarely become jaundiced as a patent stent will prevent the obstruction of bile flow. On abdominal examina-tion, the findings are indistinguishable from those of acute cholecystitis.44Diagnosis Leukocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases are common and, when present, support the clinical diagnosis of cholangitis. Ultraso-nography is helpful, as it will document the presence of gall-bladder stones, demonstrate dilated ducts, and possibly pinpoint a site of obstruction. CT scanning and MRI can show pancreatic and periampullary masses, if present, in addition to the ductal dilatation. However, abdominal imaging will rarely elucidate the exact cause of cholangitis, and the initial diagnosis is gener-ally made clinically.Treatment The initial treatment of patients with cholangi-tis | Surgery_Schwartz. who may have unremarkable symptoms until the process is already quite advanced. Patients with indwelling stents are at particularly high risk for cholan-gitis, though rarely become jaundiced as a patent stent will prevent the obstruction of bile flow. On abdominal examina-tion, the findings are indistinguishable from those of acute cholecystitis.44Diagnosis Leukocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases are common and, when present, support the clinical diagnosis of cholangitis. Ultraso-nography is helpful, as it will document the presence of gall-bladder stones, demonstrate dilated ducts, and possibly pinpoint a site of obstruction. CT scanning and MRI can show pancreatic and periampullary masses, if present, in addition to the ductal dilatation. However, abdominal imaging will rarely elucidate the exact cause of cholangitis, and the initial diagnosis is gener-ally made clinically.Treatment The initial treatment of patients with cholangi-tis |
Surgery_Schwartz_9334 | Surgery_Schwartz | However, abdominal imaging will rarely elucidate the exact cause of cholangitis, and the initial diagnosis is gener-ally made clinically.Treatment The initial treatment of patients with cholangi-tis includes broad-spectrum IV antibiotics to cover enteric organisms and anaerobes, fluid resuscitation, and rapid biliary ABFigure 32-19. Retained common bile duct stones. The patient pre-sented 3 weeks after laparoscopic cholecystectomy. A. An ultra-sound shows a normal or mildly dilated common bile duct with a stone. Note the location of the right hepatic artery anterior to the common hepatic duct (an anatomic variation). B. An endoscopic retrograde cholangiography from the same patient shows multiple stones in the common bile duct. Only the top one showed on ultra-sound as the other stones lie in the distal common bile duct behind the duodenum.Brunicardi_Ch32_p1393-p1428.indd 140811/02/19 2:43 PM 1409GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32decompression. This is most | Surgery_Schwartz. However, abdominal imaging will rarely elucidate the exact cause of cholangitis, and the initial diagnosis is gener-ally made clinically.Treatment The initial treatment of patients with cholangi-tis includes broad-spectrum IV antibiotics to cover enteric organisms and anaerobes, fluid resuscitation, and rapid biliary ABFigure 32-19. Retained common bile duct stones. The patient pre-sented 3 weeks after laparoscopic cholecystectomy. A. An ultra-sound shows a normal or mildly dilated common bile duct with a stone. Note the location of the right hepatic artery anterior to the common hepatic duct (an anatomic variation). B. An endoscopic retrograde cholangiography from the same patient shows multiple stones in the common bile duct. Only the top one showed on ultra-sound as the other stones lie in the distal common bile duct behind the duodenum.Brunicardi_Ch32_p1393-p1428.indd 140811/02/19 2:43 PM 1409GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32decompression. This is most |
Surgery_Schwartz_9335 | Surgery_Schwartz | in the distal common bile duct behind the duodenum.Brunicardi_Ch32_p1393-p1428.indd 140811/02/19 2:43 PM 1409GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32decompression. This is most often accomplished through ERCP and sphincterotomy. ERCP will show the level and the reason for the obstruction, allow for culture of the bile, permit the removal of stones if present, and accomplish drainage of the bile ducts. Placement of drainage catheters or stents can also be performed if needed. In cases in which ERCP is not available, PTC, EUS, or surgical drainage can be utilized. The selection of the appropriate approach will depend on the type and location of the suspected obstruction as well as the avail-ability of local resources and expertise. Cholecystostomy tubes are not indicated in the acute management of cholangitis as the primary source of the infection is extrinsic to the gallbladder.Patients with cholangitis can deteriorate rapidly and may require intensive care unit | Surgery_Schwartz. in the distal common bile duct behind the duodenum.Brunicardi_Ch32_p1393-p1428.indd 140811/02/19 2:43 PM 1409GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32decompression. This is most often accomplished through ERCP and sphincterotomy. ERCP will show the level and the reason for the obstruction, allow for culture of the bile, permit the removal of stones if present, and accomplish drainage of the bile ducts. Placement of drainage catheters or stents can also be performed if needed. In cases in which ERCP is not available, PTC, EUS, or surgical drainage can be utilized. The selection of the appropriate approach will depend on the type and location of the suspected obstruction as well as the avail-ability of local resources and expertise. Cholecystostomy tubes are not indicated in the acute management of cholangitis as the primary source of the infection is extrinsic to the gallbladder.Patients with cholangitis can deteriorate rapidly and may require intensive care unit |
Surgery_Schwartz_9336 | Surgery_Schwartz | in the acute management of cholangitis as the primary source of the infection is extrinsic to the gallbladder.Patients with cholangitis can deteriorate rapidly and may require intensive care unit monitoring and vasopressor support. However, most patients will respond to biliary decompression and supportive measures. In the current era, acute cholangitis is associated with an overall mortality rate of approximately 5%. When associated with renal failure, cardiac impairment, hepatic abscesses, and malignancies, the morbidity and mortal-ity rates are much higher. Patients who have suffered an episode of acute cholangitis related to gallstone disease should be rec-ommended to undergo elective cholecystectomy approximately 6 weeks after the resolution of their cholangitis.45 Those whose cholangitis was related to another cause of biliary obstruction should be followed and treated for the specific etiology of their obstruction but do not necessarily require cholecystectomy if gallstones | Surgery_Schwartz. in the acute management of cholangitis as the primary source of the infection is extrinsic to the gallbladder.Patients with cholangitis can deteriorate rapidly and may require intensive care unit monitoring and vasopressor support. However, most patients will respond to biliary decompression and supportive measures. In the current era, acute cholangitis is associated with an overall mortality rate of approximately 5%. When associated with renal failure, cardiac impairment, hepatic abscesses, and malignancies, the morbidity and mortal-ity rates are much higher. Patients who have suffered an episode of acute cholangitis related to gallstone disease should be rec-ommended to undergo elective cholecystectomy approximately 6 weeks after the resolution of their cholangitis.45 Those whose cholangitis was related to another cause of biliary obstruction should be followed and treated for the specific etiology of their obstruction but do not necessarily require cholecystectomy if gallstones |
Surgery_Schwartz_9337 | Surgery_Schwartz | was related to another cause of biliary obstruction should be followed and treated for the specific etiology of their obstruction but do not necessarily require cholecystectomy if gallstones were not the causative etiology of their cholangitis. Patients with indwelling stents and cholangitis usually require repeated imaging and stent exchange to mitigate the risk of recurrent infections.Gallstone Pancreatitis. Gallstones in the common bile duct can provoke attacks of acute pancreatitis through transient or persistent obstruction of the pancreatic duct by a stone passing through or impacted in the ampulla. The exact mechanism by which obstruction of the pancreatic duct leads to pancreatitis is unclear, but it may be related to increased ductal pressures causing leakage of pancreatic enzymes into the glandular tissue. The initial management of gallstone pancreatitis is supportive, including admission for bowel rest, IV hydration, and pain control. Antibiotics are not indicated in the | Surgery_Schwartz. was related to another cause of biliary obstruction should be followed and treated for the specific etiology of their obstruction but do not necessarily require cholecystectomy if gallstones were not the causative etiology of their cholangitis. Patients with indwelling stents and cholangitis usually require repeated imaging and stent exchange to mitigate the risk of recurrent infections.Gallstone Pancreatitis. Gallstones in the common bile duct can provoke attacks of acute pancreatitis through transient or persistent obstruction of the pancreatic duct by a stone passing through or impacted in the ampulla. The exact mechanism by which obstruction of the pancreatic duct leads to pancreatitis is unclear, but it may be related to increased ductal pressures causing leakage of pancreatic enzymes into the glandular tissue. The initial management of gallstone pancreatitis is supportive, including admission for bowel rest, IV hydration, and pain control. Antibiotics are not indicated in the |
Surgery_Schwartz_9338 | Surgery_Schwartz | into the glandular tissue. The initial management of gallstone pancreatitis is supportive, including admission for bowel rest, IV hydration, and pain control. Antibiotics are not indicated in the absence of signs of infected pancreatic necrosis. Imaging of the biliary tree with ultrasound, CT, or MRCP is essential to confirm the diagnosis. When gallstones are present and the pancreatitis is mild and self-limited, the stone has probably passed. For these patients, a cholecystectomy with intraoperative cholangiogram is indi-cated as soon as the pancreatitis has clinically resolved. It is strongly recommended that cholecystectomy be performed dur-ing the same admission whenever possible due to the high rate of recurrence and increased morbidity of subsequent attacks of pancreatitis.46 If gallstones are present obstructing the duct and the pancreatitis is severe, an ERCP with sphincterotomy and stone extraction may be necessary. This must be balanced with the risk of ERCP-induced | Surgery_Schwartz. into the glandular tissue. The initial management of gallstone pancreatitis is supportive, including admission for bowel rest, IV hydration, and pain control. Antibiotics are not indicated in the absence of signs of infected pancreatic necrosis. Imaging of the biliary tree with ultrasound, CT, or MRCP is essential to confirm the diagnosis. When gallstones are present and the pancreatitis is mild and self-limited, the stone has probably passed. For these patients, a cholecystectomy with intraoperative cholangiogram is indi-cated as soon as the pancreatitis has clinically resolved. It is strongly recommended that cholecystectomy be performed dur-ing the same admission whenever possible due to the high rate of recurrence and increased morbidity of subsequent attacks of pancreatitis.46 If gallstones are present obstructing the duct and the pancreatitis is severe, an ERCP with sphincterotomy and stone extraction may be necessary. This must be balanced with the risk of ERCP-induced |
Surgery_Schwartz_9339 | Surgery_Schwartz | If gallstones are present obstructing the duct and the pancreatitis is severe, an ERCP with sphincterotomy and stone extraction may be necessary. This must be balanced with the risk of ERCP-induced pancreatitis and thus is usually only employed if supportive measures are failing.Gallstone Ileus. Gallstone ileus can occur when a large gall-stone erodes through the wall of the gallbladder directly into the intestine via a choledochoenteric fistula (Fig. 32-20A). These stones can then pass through the intestinal tract until they reach an area of fixed obstruction. Proximal stones can become impacted in the pylorus or proximal duodenum causing gastric outlet obstruction (Bouveret syndrome). Those that travel dis-tally may become lodged at surgical anastomoses or the ileoce-cal valve, where they can become impacted and cause small bowel obstruction. Gallstone ileus is responsible for less than 1% of all intestinal obstructions.47 These patients present with symptoms of obstipation, nausea, | Surgery_Schwartz. If gallstones are present obstructing the duct and the pancreatitis is severe, an ERCP with sphincterotomy and stone extraction may be necessary. This must be balanced with the risk of ERCP-induced pancreatitis and thus is usually only employed if supportive measures are failing.Gallstone Ileus. Gallstone ileus can occur when a large gall-stone erodes through the wall of the gallbladder directly into the intestine via a choledochoenteric fistula (Fig. 32-20A). These stones can then pass through the intestinal tract until they reach an area of fixed obstruction. Proximal stones can become impacted in the pylorus or proximal duodenum causing gastric outlet obstruction (Bouveret syndrome). Those that travel dis-tally may become lodged at surgical anastomoses or the ileoce-cal valve, where they can become impacted and cause small bowel obstruction. Gallstone ileus is responsible for less than 1% of all intestinal obstructions.47 These patients present with symptoms of obstipation, nausea, |
Surgery_Schwartz_9340 | Surgery_Schwartz | can become impacted and cause small bowel obstruction. Gallstone ileus is responsible for less than 1% of all intestinal obstructions.47 These patients present with symptoms of obstipation, nausea, and abdominal pain. Plain films may show an obstructive bowel gas pattern but may fail to identify a radiolucent stone. Ultrasound evaluation may be lim-ited by extensive bowel gas. CT is highly sensitive and specific for gallstone ileus and will help to determine the location of the obstruction. Management of gallstone ileus focuses on relieving the intestinal obstruction and removing the stone. In cases of very proximal obstructions in the stomach or duodenum, endo-scopic retrieval can be effective. For more distal stones, surgical enterolithotomy can be accomplished either laparoscopically or open. This procedure entails the removal of the stone through ABFigure 32-20. Gallstone Ileus. A. A choledochoenteric fistula has formed between the gallbladder and the duodenum, allowing a | Surgery_Schwartz. can become impacted and cause small bowel obstruction. Gallstone ileus is responsible for less than 1% of all intestinal obstructions.47 These patients present with symptoms of obstipation, nausea, and abdominal pain. Plain films may show an obstructive bowel gas pattern but may fail to identify a radiolucent stone. Ultrasound evaluation may be lim-ited by extensive bowel gas. CT is highly sensitive and specific for gallstone ileus and will help to determine the location of the obstruction. Management of gallstone ileus focuses on relieving the intestinal obstruction and removing the stone. In cases of very proximal obstructions in the stomach or duodenum, endo-scopic retrieval can be effective. For more distal stones, surgical enterolithotomy can be accomplished either laparoscopically or open. This procedure entails the removal of the stone through ABFigure 32-20. Gallstone Ileus. A. A choledochoenteric fistula has formed between the gallbladder and the duodenum, allowing a |
Surgery_Schwartz_9341 | Surgery_Schwartz | or open. This procedure entails the removal of the stone through ABFigure 32-20. Gallstone Ileus. A. A choledochoenteric fistula has formed between the gallbladder and the duodenum, allowing a gallstone to pass into the intestinal tract. B. Intraoperative photo showing a longitudinal enterotomy and extraction of an impacted stone from the distal small bowel.Brunicardi_Ch32_p1393-p1428.indd 140911/02/19 2:43 PM 1410SPECIFIC CONSIDERATIONSPART IIan enterotomy that is then either repaired or resected depend-ing on its size (Fig. 32-20B). Stones that have successfully traversed the ileocecal valve are likely to pass without further intervention. The role of pursuing cholecystectomy and/or cho-ledochoenteric fistula closure at the time of enterolithotomy or addressing it at a later time remains a topic of debate, but it should be considered to reduce the risk of recurrence.47CholangiohepatitisCholangiohepatitis, also known as recurrent pyogenic cholan-gitis, is endemic to the Orient. | Surgery_Schwartz. or open. This procedure entails the removal of the stone through ABFigure 32-20. Gallstone Ileus. A. A choledochoenteric fistula has formed between the gallbladder and the duodenum, allowing a gallstone to pass into the intestinal tract. B. Intraoperative photo showing a longitudinal enterotomy and extraction of an impacted stone from the distal small bowel.Brunicardi_Ch32_p1393-p1428.indd 140911/02/19 2:43 PM 1410SPECIFIC CONSIDERATIONSPART IIan enterotomy that is then either repaired or resected depend-ing on its size (Fig. 32-20B). Stones that have successfully traversed the ileocecal valve are likely to pass without further intervention. The role of pursuing cholecystectomy and/or cho-ledochoenteric fistula closure at the time of enterolithotomy or addressing it at a later time remains a topic of debate, but it should be considered to reduce the risk of recurrence.47CholangiohepatitisCholangiohepatitis, also known as recurrent pyogenic cholan-gitis, is endemic to the Orient. |
Surgery_Schwartz_9342 | Surgery_Schwartz | a topic of debate, but it should be considered to reduce the risk of recurrence.47CholangiohepatitisCholangiohepatitis, also known as recurrent pyogenic cholan-gitis, is endemic to the Orient. It also has been encountered in Asian population in the United States, Europe, and Australia. It affects both sexes equally and occurs most frequently in the third and fourth decades of life. Cholangiohepatitis is caused by bacterial contamination (commonly E coli, Klebsiella spe-cies, Bacteroides species, or Enterococcus faecalis) of the bili-ary tree, and often it is associated with biliary parasites such as Clonorchis sinensis, Opisthorchis viverrini, and A lumbri-coides. Bacterial enzymes cause deconjugation of bilirubin, which precipitates as bile sludge. The sludge and dead bacterial cell bodies form brown pigment stones, the nucleus of which may contain an adult Clonorchis worm, an ovum, or an ascarid. These stones can form throughout the biliary tree and cause par-tial obstructions that | Surgery_Schwartz. a topic of debate, but it should be considered to reduce the risk of recurrence.47CholangiohepatitisCholangiohepatitis, also known as recurrent pyogenic cholan-gitis, is endemic to the Orient. It also has been encountered in Asian population in the United States, Europe, and Australia. It affects both sexes equally and occurs most frequently in the third and fourth decades of life. Cholangiohepatitis is caused by bacterial contamination (commonly E coli, Klebsiella spe-cies, Bacteroides species, or Enterococcus faecalis) of the bili-ary tree, and often it is associated with biliary parasites such as Clonorchis sinensis, Opisthorchis viverrini, and A lumbri-coides. Bacterial enzymes cause deconjugation of bilirubin, which precipitates as bile sludge. The sludge and dead bacterial cell bodies form brown pigment stones, the nucleus of which may contain an adult Clonorchis worm, an ovum, or an ascarid. These stones can form throughout the biliary tree and cause par-tial obstructions that |
Surgery_Schwartz_9343 | Surgery_Schwartz | form brown pigment stones, the nucleus of which may contain an adult Clonorchis worm, an ovum, or an ascarid. These stones can form throughout the biliary tree and cause par-tial obstructions that contribute to repeated bouts of cholangi-tis, biliary strictures, further stone formation, infection, hepatic abscesses, or liver failure (secondary biliary cirrhosis).48Patients with cholangiohepatitis usually present with pain in the right upper quadrant or epigastrium, fever, and jaundice. Relapsing symptoms are one of the most characteristic features of the disease. The episodes may vary in severity but, without intervention, will gradually lead to malnutrition and hepatic insufficiency. An ultrasound may detect stones in the biliary tree, pneumobilia from infection by gas-forming organisms, liver abscesses, and, occasionally, strictures. The gallbladder may be thickened and inflamed in about 20% of patients but rarely contains gallstones. ERCP or MRCP can be utilized for biliary imaging | Surgery_Schwartz. form brown pigment stones, the nucleus of which may contain an adult Clonorchis worm, an ovum, or an ascarid. These stones can form throughout the biliary tree and cause par-tial obstructions that contribute to repeated bouts of cholangi-tis, biliary strictures, further stone formation, infection, hepatic abscesses, or liver failure (secondary biliary cirrhosis).48Patients with cholangiohepatitis usually present with pain in the right upper quadrant or epigastrium, fever, and jaundice. Relapsing symptoms are one of the most characteristic features of the disease. The episodes may vary in severity but, without intervention, will gradually lead to malnutrition and hepatic insufficiency. An ultrasound may detect stones in the biliary tree, pneumobilia from infection by gas-forming organisms, liver abscesses, and, occasionally, strictures. The gallbladder may be thickened and inflamed in about 20% of patients but rarely contains gallstones. ERCP or MRCP can be utilized for biliary imaging |
Surgery_Schwartz_9344 | Surgery_Schwartz | liver abscesses, and, occasionally, strictures. The gallbladder may be thickened and inflamed in about 20% of patients but rarely contains gallstones. ERCP or MRCP can be utilized for biliary imaging for cholangiohepatitis. They can detect obstruc-tions and define strictures and stones. ERCP (or PTC if nec-essary) has the additional benefit of allowing for emergent decompression of the biliary tree in the septic patient. Hepatic abscesses may be drained percutaneously. The long-term goal of therapy is to extract stones and debris and relieve strictures. It may take several procedures, and in severe, refractory cases in which stones and strictures cannot be relieved, it may require a hepaticojejunostomy to reestablish biliary–enteric continuity. Occasionally, resection of involved areas of the liver may offer the best form of treatment. Recurrences are common, and the prognosis is poor once hepatic insufficiency has developed.49PROCEDURAL INTERVENTIONS FOR GALLSTONE | Surgery_Schwartz. liver abscesses, and, occasionally, strictures. The gallbladder may be thickened and inflamed in about 20% of patients but rarely contains gallstones. ERCP or MRCP can be utilized for biliary imaging for cholangiohepatitis. They can detect obstruc-tions and define strictures and stones. ERCP (or PTC if nec-essary) has the additional benefit of allowing for emergent decompression of the biliary tree in the septic patient. Hepatic abscesses may be drained percutaneously. The long-term goal of therapy is to extract stones and debris and relieve strictures. It may take several procedures, and in severe, refractory cases in which stones and strictures cannot be relieved, it may require a hepaticojejunostomy to reestablish biliary–enteric continuity. Occasionally, resection of involved areas of the liver may offer the best form of treatment. Recurrences are common, and the prognosis is poor once hepatic insufficiency has developed.49PROCEDURAL INTERVENTIONS FOR GALLSTONE |
Surgery_Schwartz_9345 | Surgery_Schwartz | involved areas of the liver may offer the best form of treatment. Recurrences are common, and the prognosis is poor once hepatic insufficiency has developed.49PROCEDURAL INTERVENTIONS FOR GALLSTONE DISEASEPercutaneous Transhepatic Cholecystostomy TubesIn cases in which a patient with cholecystitis is deemed to be too ill to safely undergo cholecystectomy, a cholecystostomy tube may be placed into the gallbladder to decompress and drain a distended, inflamed, hydropic, or purulent gallbladder.36 Surgi-cal cholecystostomy with a large catheter placed under local anesthesia is rarely required today. Rather, percutaneous tran-shepatic cholecystostomy (PTC) tubes are most often pigtail catheters inserted percutaneously under ultrasound guidance.50 The catheter is inserted over a guidewire that has been passed through the abdominal wall, the liver, and into the gallblad-der (Fig. 32-21). By passing the catheter through the liver, the risk of uncontrolled bile leak around the catheter and | Surgery_Schwartz. involved areas of the liver may offer the best form of treatment. Recurrences are common, and the prognosis is poor once hepatic insufficiency has developed.49PROCEDURAL INTERVENTIONS FOR GALLSTONE DISEASEPercutaneous Transhepatic Cholecystostomy TubesIn cases in which a patient with cholecystitis is deemed to be too ill to safely undergo cholecystectomy, a cholecystostomy tube may be placed into the gallbladder to decompress and drain a distended, inflamed, hydropic, or purulent gallbladder.36 Surgi-cal cholecystostomy with a large catheter placed under local anesthesia is rarely required today. Rather, percutaneous tran-shepatic cholecystostomy (PTC) tubes are most often pigtail catheters inserted percutaneously under ultrasound guidance.50 The catheter is inserted over a guidewire that has been passed through the abdominal wall, the liver, and into the gallblad-der (Fig. 32-21). By passing the catheter through the liver, the risk of uncontrolled bile leak around the catheter and |
Surgery_Schwartz_9346 | Surgery_Schwartz | has been passed through the abdominal wall, the liver, and into the gallblad-der (Fig. 32-21). By passing the catheter through the liver, the risk of uncontrolled bile leak around the catheter and into the peritoneal cavity is minimized. The catheter can be removed when the inflammation has resolved and the patient’s condition has improved. A patent cystic duct should be confirmed by a tube cholangiogram prior to its removal. Interval cholecystec-tomy should be considered if the patient’s fitness has improved, particularly in individuals whose etiology of cholecystitis was gallstones.Endoscopic InterventionsEndoscopic advances in the last few decades have made endos-copy and ERCP a valuable therapeutic tool in the management of gallstone disease, particularly in the setting of common bile duct stones or abnormalities. Using a 90-degree side-viewing endoscope, the duodenum can be entered and the ampulla of Vater on the medial wall of the second portion of the duode-num visualized. This | Surgery_Schwartz. has been passed through the abdominal wall, the liver, and into the gallblad-der (Fig. 32-21). By passing the catheter through the liver, the risk of uncontrolled bile leak around the catheter and into the peritoneal cavity is minimized. The catheter can be removed when the inflammation has resolved and the patient’s condition has improved. A patent cystic duct should be confirmed by a tube cholangiogram prior to its removal. Interval cholecystec-tomy should be considered if the patient’s fitness has improved, particularly in individuals whose etiology of cholecystitis was gallstones.Endoscopic InterventionsEndoscopic advances in the last few decades have made endos-copy and ERCP a valuable therapeutic tool in the management of gallstone disease, particularly in the setting of common bile duct stones or abnormalities. Using a 90-degree side-viewing endoscope, the duodenum can be entered and the ampulla of Vater on the medial wall of the second portion of the duode-num visualized. This |
Surgery_Schwartz_9347 | Surgery_Schwartz | duct stones or abnormalities. Using a 90-degree side-viewing endoscope, the duodenum can be entered and the ampulla of Vater on the medial wall of the second portion of the duode-num visualized. This can then be cannulated to allow wire and catheter access to the biliary tree, facilitating retrograde chol-angiogram, diagnostic brushings, stenting, dilations, or fluoro-scopically guided basket or balloon retrieval of common bile duct stones. When CBD stones are present, endoscopic sphinc-terotomy should be performed, which will allow for passage of larger stones both at the time of bile duct clearance and in the case of any ongoing choledocholithiasis (Fig. 32-22). In the hands of experts, ERCP has high rates of successful cannulation and bile duct clearance, and it is a safe and tolerable procedure. Debate remains when comparing ERCP to surgical common bile duct exploration in terms of timing and outcomes for choledo-cholithiasis, but both are considered acceptable treatments.41 In | Surgery_Schwartz. duct stones or abnormalities. Using a 90-degree side-viewing endoscope, the duodenum can be entered and the ampulla of Vater on the medial wall of the second portion of the duode-num visualized. This can then be cannulated to allow wire and catheter access to the biliary tree, facilitating retrograde chol-angiogram, diagnostic brushings, stenting, dilations, or fluoro-scopically guided basket or balloon retrieval of common bile duct stones. When CBD stones are present, endoscopic sphinc-terotomy should be performed, which will allow for passage of larger stones both at the time of bile duct clearance and in the case of any ongoing choledocholithiasis (Fig. 32-22). In the hands of experts, ERCP has high rates of successful cannulation and bile duct clearance, and it is a safe and tolerable procedure. Debate remains when comparing ERCP to surgical common bile duct exploration in terms of timing and outcomes for choledo-cholithiasis, but both are considered acceptable treatments.41 In |
Surgery_Schwartz_9348 | Surgery_Schwartz | procedure. Debate remains when comparing ERCP to surgical common bile duct exploration in terms of timing and outcomes for choledo-cholithiasis, but both are considered acceptable treatments.41 In special cases, such as the presence of Roux-en-Y anatomy or a previous hepaticojejunostomy, ERCP can be difficult. How-ever, such anatomy does not preclude the option for endoscopic intervention. Laparoscopic-assisted ERCP (in which the rem-nant stomach is accessed surgically and the endoscope passed into the duodenum) or double-balloon ERCP can be utilized to reach the biliary tree.CholecystectomyCholecystectomy is one of the most common abdominal sur-geries performed in Western countries, with over 750,000 Figure 32-21. Percutaneous cholecystostomy. A pigtail catheter has been placed through the abdominal wall, the right lobe of the liver, and into the gallbladder.Brunicardi_Ch32_p1393-p1428.indd 141011/02/19 2:43 PM 1411GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32being | Surgery_Schwartz. procedure. Debate remains when comparing ERCP to surgical common bile duct exploration in terms of timing and outcomes for choledo-cholithiasis, but both are considered acceptable treatments.41 In special cases, such as the presence of Roux-en-Y anatomy or a previous hepaticojejunostomy, ERCP can be difficult. How-ever, such anatomy does not preclude the option for endoscopic intervention. Laparoscopic-assisted ERCP (in which the rem-nant stomach is accessed surgically and the endoscope passed into the duodenum) or double-balloon ERCP can be utilized to reach the biliary tree.CholecystectomyCholecystectomy is one of the most common abdominal sur-geries performed in Western countries, with over 750,000 Figure 32-21. Percutaneous cholecystostomy. A pigtail catheter has been placed through the abdominal wall, the right lobe of the liver, and into the gallbladder.Brunicardi_Ch32_p1393-p1428.indd 141011/02/19 2:43 PM 1411GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32being |
Surgery_Schwartz_9349 | Surgery_Schwartz | the abdominal wall, the right lobe of the liver, and into the gallbladder.Brunicardi_Ch32_p1393-p1428.indd 141011/02/19 2:43 PM 1411GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32being performed each year in the United States alone.51 Carl Langenbuch performed the first successful open cholecystectomy in 1882, and for >100 years, it was the standard treatment for symptomatic gallbladder stones. In 1987, laparoscopic chole-cystectomy was introduced by Philippe Mouret in France and quickly revolutionized the treatment of gallstone disease. It not only supplanted open cholecystectomy, but it also more or less ended attempts for noninvasive management of gallstones (such as extracorporeal shock wave or cholangioscopic lithotripsy) or medical therapies (such as bile salts). Laparoscopic cholecystec-tomy offers a cure for gallstones with a minimally invasive pro-cedure, minor pain and scarring, and early return to full activity. Today, laparoscopic cholecystectomy is the | Surgery_Schwartz. the abdominal wall, the right lobe of the liver, and into the gallbladder.Brunicardi_Ch32_p1393-p1428.indd 141011/02/19 2:43 PM 1411GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32being performed each year in the United States alone.51 Carl Langenbuch performed the first successful open cholecystectomy in 1882, and for >100 years, it was the standard treatment for symptomatic gallbladder stones. In 1987, laparoscopic chole-cystectomy was introduced by Philippe Mouret in France and quickly revolutionized the treatment of gallstone disease. It not only supplanted open cholecystectomy, but it also more or less ended attempts for noninvasive management of gallstones (such as extracorporeal shock wave or cholangioscopic lithotripsy) or medical therapies (such as bile salts). Laparoscopic cholecystec-tomy offers a cure for gallstones with a minimally invasive pro-cedure, minor pain and scarring, and early return to full activity. Today, laparoscopic cholecystectomy is the |
Surgery_Schwartz_9350 | Surgery_Schwartz | Laparoscopic cholecystec-tomy offers a cure for gallstones with a minimally invasive pro-cedure, minor pain and scarring, and early return to full activity. Today, laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones and the complications of gallstone disease.Few absolute contraindications exist to laparoscopic cholecystectomy, but they include hemodynamic instability, uncontrolled coagulopathy, or frank peritonitis. In addition, patients with severe obstructive pulmonary disease (COPD) or congestive heart failure (e.g., cardiac ejection fraction <20%) might not tolerate the increased intraabdominal pressures of pneumoperitoneum with carbon dioxide and may require open cholecystectomy. Conditions formerly believed to be relative contraindications such as acute cholecystitis, gangrene and empyema of the gallbladder, biliary-enteric fistulae, obesity, pregnancy, ventriculoperitoneal shunts, cirrhosis, and previous upper abdominal procedures are now | Surgery_Schwartz. Laparoscopic cholecystec-tomy offers a cure for gallstones with a minimally invasive pro-cedure, minor pain and scarring, and early return to full activity. Today, laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones and the complications of gallstone disease.Few absolute contraindications exist to laparoscopic cholecystectomy, but they include hemodynamic instability, uncontrolled coagulopathy, or frank peritonitis. In addition, patients with severe obstructive pulmonary disease (COPD) or congestive heart failure (e.g., cardiac ejection fraction <20%) might not tolerate the increased intraabdominal pressures of pneumoperitoneum with carbon dioxide and may require open cholecystectomy. Conditions formerly believed to be relative contraindications such as acute cholecystitis, gangrene and empyema of the gallbladder, biliary-enteric fistulae, obesity, pregnancy, ventriculoperitoneal shunts, cirrhosis, and previous upper abdominal procedures are now |
Surgery_Schwartz_9351 | Surgery_Schwartz | as acute cholecystitis, gangrene and empyema of the gallbladder, biliary-enteric fistulae, obesity, pregnancy, ventriculoperitoneal shunts, cirrhosis, and previous upper abdominal procedures are now considered risk factors for a potentially difficult cholecystectomy, but they do not preclude an attempt at laparoscopy. While laparoscopic outcomes have steadily improved and laparoscopic cholecystectomy has been shown multiple times to be safe and feasible, conversion to an open operation should always remain an option, and it is not a failure. Conversion to open may be necessary if the patient is unable to tolerate pneumoperitoneum, a complication occurs that cannot be fixed laparoscopically, important anatomic struc-tures cannot be clearly identified, or when no progress is made over a set period of time. In the elective setting, conversion to an open procedure is needed in about 5% of patients.51 Emer-gent procedures or patients with complicated gallstone disease can be more | Surgery_Schwartz. as acute cholecystitis, gangrene and empyema of the gallbladder, biliary-enteric fistulae, obesity, pregnancy, ventriculoperitoneal shunts, cirrhosis, and previous upper abdominal procedures are now considered risk factors for a potentially difficult cholecystectomy, but they do not preclude an attempt at laparoscopy. While laparoscopic outcomes have steadily improved and laparoscopic cholecystectomy has been shown multiple times to be safe and feasible, conversion to an open operation should always remain an option, and it is not a failure. Conversion to open may be necessary if the patient is unable to tolerate pneumoperitoneum, a complication occurs that cannot be fixed laparoscopically, important anatomic struc-tures cannot be clearly identified, or when no progress is made over a set period of time. In the elective setting, conversion to an open procedure is needed in about 5% of patients.51 Emer-gent procedures or patients with complicated gallstone disease can be more |
Surgery_Schwartz_9352 | Surgery_Schwartz | a set period of time. In the elective setting, conversion to an open procedure is needed in about 5% of patients.51 Emer-gent procedures or patients with complicated gallstone disease can be more challenging, and the incidence of conversion has been reported to be between 10% and 30%. The possibility of conversion to open should always be discussed with the patient preoperatively.Serious complications of cholecystectomy are rare. The mortality rate for laparoscopic cholecystectomy is about 0.1%. Wound infection and cardiopulmonary complication rates are considerably lower following laparoscopic cholecystectomy than are those for an open procedure.52 While laparoscopic cho-lecystectomy has historically been associated with a higher rate of injury to the bile ducts than the open approach, modern data appears to show this trend disappearing as familiarity with lapa-roscopic techniques and technologies have improved.53Patients undergoing cholecystectomy should have a complete blood count | Surgery_Schwartz. a set period of time. In the elective setting, conversion to an open procedure is needed in about 5% of patients.51 Emer-gent procedures or patients with complicated gallstone disease can be more challenging, and the incidence of conversion has been reported to be between 10% and 30%. The possibility of conversion to open should always be discussed with the patient preoperatively.Serious complications of cholecystectomy are rare. The mortality rate for laparoscopic cholecystectomy is about 0.1%. Wound infection and cardiopulmonary complication rates are considerably lower following laparoscopic cholecystectomy than are those for an open procedure.52 While laparoscopic cho-lecystectomy has historically been associated with a higher rate of injury to the bile ducts than the open approach, modern data appears to show this trend disappearing as familiarity with lapa-roscopic techniques and technologies have improved.53Patients undergoing cholecystectomy should have a complete blood count |
Surgery_Schwartz_9353 | Surgery_Schwartz | data appears to show this trend disappearing as familiarity with lapa-roscopic techniques and technologies have improved.53Patients undergoing cholecystectomy should have a complete blood count and liver function tests preoperatively. Prophylaxis against deep venous thrombosis with either low molecular weight heparin or compression stockings is indicated. ABCFigure 32-22. An endoscopic sphincterotomy. A. The sphincterotome in place. B. Completed sphincterotomy. C. Endoscopic picture of ampulla before and after sphincterotomy.Brunicardi_Ch32_p1393-p1428.indd 141111/02/19 2:43 PM 1412SPECIFIC CONSIDERATIONSPART IIThe patient should be instructed to empty their bladder before coming to the operating room to avoid the need for urinary cath-eterization. An orogastric tube can be placed if the stomach is distended with gas, but it is generally removed at the end of the operation.Laparoscopic Cholecystectomy. The patient is typically positioned supine with the operating surgeon standing | Surgery_Schwartz. data appears to show this trend disappearing as familiarity with lapa-roscopic techniques and technologies have improved.53Patients undergoing cholecystectomy should have a complete blood count and liver function tests preoperatively. Prophylaxis against deep venous thrombosis with either low molecular weight heparin or compression stockings is indicated. ABCFigure 32-22. An endoscopic sphincterotomy. A. The sphincterotome in place. B. Completed sphincterotomy. C. Endoscopic picture of ampulla before and after sphincterotomy.Brunicardi_Ch32_p1393-p1428.indd 141111/02/19 2:43 PM 1412SPECIFIC CONSIDERATIONSPART IIThe patient should be instructed to empty their bladder before coming to the operating room to avoid the need for urinary cath-eterization. An orogastric tube can be placed if the stomach is distended with gas, but it is generally removed at the end of the operation.Laparoscopic Cholecystectomy. The patient is typically positioned supine with the operating surgeon standing |
Surgery_Schwartz_9354 | Surgery_Schwartz | the stomach is distended with gas, but it is generally removed at the end of the operation.Laparoscopic Cholecystectomy. The patient is typically positioned supine with the operating surgeon standing at the patient’s left side. Split-leg positioning with the surgeon stand-ing between the patient’s legs can also provide ergonomic access to the right upper quadrant. Tucking one arm can be helpful if a cholangiogram is planned to allow easier maneu-vering of the fluoroscopy machine around the patient. Pneu-moperitoneum is established with carbon dioxide gas, either with an open technique (Hasson), optical viewing trocar, or closed-needle technique (Veress). Typical access is at the supra-umbilical region, though in the case of previous surgery or scars, alternate access sites should be considered. Once an adequate pneumoperitoneum is established, a 5or 10-mm trocar is inserted through the supraumbilical incision, through which a 5or 10-mm 30° laparoscope is introduced. Traditionally, | Surgery_Schwartz. the stomach is distended with gas, but it is generally removed at the end of the operation.Laparoscopic Cholecystectomy. The patient is typically positioned supine with the operating surgeon standing at the patient’s left side. Split-leg positioning with the surgeon stand-ing between the patient’s legs can also provide ergonomic access to the right upper quadrant. Tucking one arm can be helpful if a cholangiogram is planned to allow easier maneu-vering of the fluoroscopy machine around the patient. Pneu-moperitoneum is established with carbon dioxide gas, either with an open technique (Hasson), optical viewing trocar, or closed-needle technique (Veress). Typical access is at the supra-umbilical region, though in the case of previous surgery or scars, alternate access sites should be considered. Once an adequate pneumoperitoneum is established, a 5or 10-mm trocar is inserted through the supraumbilical incision, through which a 5or 10-mm 30° laparoscope is introduced. Traditionally, |
Surgery_Schwartz_9355 | Surgery_Schwartz | Once an adequate pneumoperitoneum is established, a 5or 10-mm trocar is inserted through the supraumbilical incision, through which a 5or 10-mm 30° laparoscope is introduced. Traditionally, three additional ports are then placed with a 10or 12-mm port in the epigastrium, a 5-mm port in the right midclavicular line, and a 5-mm port in the right flank (Fig. 32-23). Additional ports may be placed as needed to aid with retraction in difficult cases.Through the lateral-most port, the assistant uses a locking instrument to grasp the gallbladder fundus and retract it over the liver edge and upward towards the patient’s right shoulder. This will help visualize the body of the gallbladder and the hilar area. Exposure may be facilitated by placing the patient ABFCEDFigure 32-23. Laparoscopic cholecystectomy. A. The trocar placement. B. The fundus has been grasped and retracted cephalad to expose the proximal gallbladder and the hepatoduodenal ligament. Another grasper retracts the gallbladder | Surgery_Schwartz. Once an adequate pneumoperitoneum is established, a 5or 10-mm trocar is inserted through the supraumbilical incision, through which a 5or 10-mm 30° laparoscope is introduced. Traditionally, three additional ports are then placed with a 10or 12-mm port in the epigastrium, a 5-mm port in the right midclavicular line, and a 5-mm port in the right flank (Fig. 32-23). Additional ports may be placed as needed to aid with retraction in difficult cases.Through the lateral-most port, the assistant uses a locking instrument to grasp the gallbladder fundus and retract it over the liver edge and upward towards the patient’s right shoulder. This will help visualize the body of the gallbladder and the hilar area. Exposure may be facilitated by placing the patient ABFCEDFigure 32-23. Laparoscopic cholecystectomy. A. The trocar placement. B. The fundus has been grasped and retracted cephalad to expose the proximal gallbladder and the hepatoduodenal ligament. Another grasper retracts the gallbladder |
Surgery_Schwartz_9356 | Surgery_Schwartz | A. The trocar placement. B. The fundus has been grasped and retracted cephalad to expose the proximal gallbladder and the hepatoduodenal ligament. Another grasper retracts the gallbladder infundibulum posterolaterally to better expose the triangle of Calot (hepatocystic triangle bound by the common hepatic duct, cystic duct, and liver margin). C. Intraoperative photo of the critical view of safety. The hepatocystic triangle has been cleared of fat and fibrous tissue, the lower one-third of the gallbladder is separated from the liver to expose the cystic plate, and two and only two structures are seen entering the gallbladder. D. A clip is being placed on the cystic duct–gallbladder junction. E. A small opening has been made in the cystic duct, and a cholangiogram catheter is being inserted. F. Additional clips have been placed, the cystic duct has been divided, and the cystic artery is being divided.Brunicardi_Ch32_p1393-p1428.indd 141211/02/19 2:43 PM 1413GALLBLADDER AND THE | Surgery_Schwartz. A. The trocar placement. B. The fundus has been grasped and retracted cephalad to expose the proximal gallbladder and the hepatoduodenal ligament. Another grasper retracts the gallbladder infundibulum posterolaterally to better expose the triangle of Calot (hepatocystic triangle bound by the common hepatic duct, cystic duct, and liver margin). C. Intraoperative photo of the critical view of safety. The hepatocystic triangle has been cleared of fat and fibrous tissue, the lower one-third of the gallbladder is separated from the liver to expose the cystic plate, and two and only two structures are seen entering the gallbladder. D. A clip is being placed on the cystic duct–gallbladder junction. E. A small opening has been made in the cystic duct, and a cholangiogram catheter is being inserted. F. Additional clips have been placed, the cystic duct has been divided, and the cystic artery is being divided.Brunicardi_Ch32_p1393-p1428.indd 141211/02/19 2:43 PM 1413GALLBLADDER AND THE |
Surgery_Schwartz_9357 | Surgery_Schwartz | F. Additional clips have been placed, the cystic duct has been divided, and the cystic artery is being divided.Brunicardi_Ch32_p1393-p1428.indd 141211/02/19 2:43 PM 1413GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32in reverse Trendelenburg position with slight tilting of the table to bring the right side up. Through the midclavicular port, the surgeon uses a grasper in the left hand to retract the gallbladder infundibulum laterally and expose the neck of the gallbladder and hepatoduodenal ligament. It may be necessary to take down any adhesions between the omentum, duodenum, or colon to the gallbladder in order to reach the infundibulum. The majority of the dissection can then be performed with the right hand through the epigastric port, utilizing a combination of electrocautery and sharp and blunt dissection.Dissection starts at the infundibulum of the gallbladder, just above the takeoff of the cystic duct. The peritoneum, fat, and loose areolar tissue around the | Surgery_Schwartz. F. Additional clips have been placed, the cystic duct has been divided, and the cystic artery is being divided.Brunicardi_Ch32_p1393-p1428.indd 141211/02/19 2:43 PM 1413GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32in reverse Trendelenburg position with slight tilting of the table to bring the right side up. Through the midclavicular port, the surgeon uses a grasper in the left hand to retract the gallbladder infundibulum laterally and expose the neck of the gallbladder and hepatoduodenal ligament. It may be necessary to take down any adhesions between the omentum, duodenum, or colon to the gallbladder in order to reach the infundibulum. The majority of the dissection can then be performed with the right hand through the epigastric port, utilizing a combination of electrocautery and sharp and blunt dissection.Dissection starts at the infundibulum of the gallbladder, just above the takeoff of the cystic duct. The peritoneum, fat, and loose areolar tissue around the |
Surgery_Schwartz_9358 | Surgery_Schwartz | and sharp and blunt dissection.Dissection starts at the infundibulum of the gallbladder, just above the takeoff of the cystic duct. The peritoneum, fat, and loose areolar tissue around the gallbladder and the cystic duct–gallbladder junction is dissected off and reflected inferi-orly toward the bile duct. This is continued until the gallbladder neck and the proximal cystic duct are clearly identified. The next step is the identification of the cystic artery, which usually runs parallel to and somewhat behind the cystic duct, and often lies behind a prominent lymph node (Lund’s node, often called Calot’s node). At this point, a critical view of safety should be obtained. This requires that the hepatocystic triangle is cleared of fat and fibrous tissue, the lower third of the gallbladder is separated from the liver to expose the cystic plate, and two and only two structures (cystic duct and cystic artery) are going into the gallbladder (see Fig. 32-19).54 At this point, an | Surgery_Schwartz. and sharp and blunt dissection.Dissection starts at the infundibulum of the gallbladder, just above the takeoff of the cystic duct. The peritoneum, fat, and loose areolar tissue around the gallbladder and the cystic duct–gallbladder junction is dissected off and reflected inferi-orly toward the bile duct. This is continued until the gallbladder neck and the proximal cystic duct are clearly identified. The next step is the identification of the cystic artery, which usually runs parallel to and somewhat behind the cystic duct, and often lies behind a prominent lymph node (Lund’s node, often called Calot’s node). At this point, a critical view of safety should be obtained. This requires that the hepatocystic triangle is cleared of fat and fibrous tissue, the lower third of the gallbladder is separated from the liver to expose the cystic plate, and two and only two structures (cystic duct and cystic artery) are going into the gallbladder (see Fig. 32-19).54 At this point, an |
Surgery_Schwartz_9359 | Surgery_Schwartz | is separated from the liver to expose the cystic plate, and two and only two structures (cystic duct and cystic artery) are going into the gallbladder (see Fig. 32-19).54 At this point, an intraopera-tive cholangiogram can be performed if indicated (see “Intraop-erative Cholangiogram” section).With a critical view of safety obtained, the cystic duct and artery are clipped with two clips at the base and one clip on the gallbladder side. They can then be safely divided. Sometimes, a very dilated cystic duct may be too large for clips. Such ducts can be successfully managed by ligation with an endoloop, lapa-roscopic stapler, or suture closure. Finally, the gallbladder is dissected off the liver bed using electrocautery while watching for potential abnormal posterior branches of ducts or arteries. Before the gallbladder is completely removed from the liver edge, it can be used as a retractor for a final evaluation of the operative field. The surgeon should be sure to evaluate for | Surgery_Schwartz. is separated from the liver to expose the cystic plate, and two and only two structures (cystic duct and cystic artery) are going into the gallbladder (see Fig. 32-19).54 At this point, an intraopera-tive cholangiogram can be performed if indicated (see “Intraop-erative Cholangiogram” section).With a critical view of safety obtained, the cystic duct and artery are clipped with two clips at the base and one clip on the gallbladder side. They can then be safely divided. Sometimes, a very dilated cystic duct may be too large for clips. Such ducts can be successfully managed by ligation with an endoloop, lapa-roscopic stapler, or suture closure. Finally, the gallbladder is dissected off the liver bed using electrocautery while watching for potential abnormal posterior branches of ducts or arteries. Before the gallbladder is completely removed from the liver edge, it can be used as a retractor for a final evaluation of the operative field. The surgeon should be sure to evaluate for |
Surgery_Schwartz_9360 | Surgery_Schwartz | or arteries. Before the gallbladder is completely removed from the liver edge, it can be used as a retractor for a final evaluation of the operative field. The surgeon should be sure to evaluate for bleed-ing points or bile staining, and confirm placement of the clips on the cystic duct and artery. The gallbladder is then divided from its final attachments and removed either through the epigastric or umbilical incision, often with the aid of a retrieval bag. The fascial defect and skin incision may need to be enlarged in order to remove the specimen, particularly if the stones are large or the gallbladder is very inflamed. Any bile or blood that has accumulated during the procedure should be cleaned away, and if stones were spilled, they should be retrieved and removed. If the gallbladder was severely inflamed or gangrenous, or if any bile or blood is expected to accumulate, a closed-suction drain can be placed through one of the 5-mm ports and left underneath the right liver lobe | Surgery_Schwartz. or arteries. Before the gallbladder is completely removed from the liver edge, it can be used as a retractor for a final evaluation of the operative field. The surgeon should be sure to evaluate for bleed-ing points or bile staining, and confirm placement of the clips on the cystic duct and artery. The gallbladder is then divided from its final attachments and removed either through the epigastric or umbilical incision, often with the aid of a retrieval bag. The fascial defect and skin incision may need to be enlarged in order to remove the specimen, particularly if the stones are large or the gallbladder is very inflamed. Any bile or blood that has accumulated during the procedure should be cleaned away, and if stones were spilled, they should be retrieved and removed. If the gallbladder was severely inflamed or gangrenous, or if any bile or blood is expected to accumulate, a closed-suction drain can be placed through one of the 5-mm ports and left underneath the right liver lobe |
Surgery_Schwartz_9361 | Surgery_Schwartz | was severely inflamed or gangrenous, or if any bile or blood is expected to accumulate, a closed-suction drain can be placed through one of the 5-mm ports and left underneath the right liver lobe close to the gallbladder fossa, though this is not routinely required.Open Cholecystectomy. The same surgical principles apply for laparoscopic and open cholecystectomies. Open cholecystec-tomy has become an uncommon procedure, usually performed either as a conversion from laparoscopic cholecystectomy or as a second procedure in patients who require laparotomy for another reason. The approach can either be through a midline laparotomy, or more commonly through a right subcostal inci-sion. The gallbladder is dissected free from the liver bed, usu-ally starting at the fundus and working proximally toward the hepatocystic triangle. Once the cystic artery and cystic duct have been dissected and clearly identified, they are ligated and divided, and the gallbladder is removed. In particularly | Surgery_Schwartz. was severely inflamed or gangrenous, or if any bile or blood is expected to accumulate, a closed-suction drain can be placed through one of the 5-mm ports and left underneath the right liver lobe close to the gallbladder fossa, though this is not routinely required.Open Cholecystectomy. The same surgical principles apply for laparoscopic and open cholecystectomies. Open cholecystec-tomy has become an uncommon procedure, usually performed either as a conversion from laparoscopic cholecystectomy or as a second procedure in patients who require laparotomy for another reason. The approach can either be through a midline laparotomy, or more commonly through a right subcostal inci-sion. The gallbladder is dissected free from the liver bed, usu-ally starting at the fundus and working proximally toward the hepatocystic triangle. Once the cystic artery and cystic duct have been dissected and clearly identified, they are ligated and divided, and the gallbladder is removed. In particularly |
Surgery_Schwartz_9362 | Surgery_Schwartz | toward the hepatocystic triangle. Once the cystic artery and cystic duct have been dissected and clearly identified, they are ligated and divided, and the gallbladder is removed. In particularly difficult cases, in which the gallbladder is partially obliterated or ductal or arterial anatomy cannot be identified, a partial cholecystec-tomy may be performed. This includes removal of as much gall-bladder mucosa as possible and attempted closure of the cystic duct stump with wide drainage of the area.Intraoperative Cholangiogram. Intraoperative cholangio-gram is an optional but valuable tool for evaluating the extra-hepatic bile ducts, identifying common bile duct stones, or clarifying aberrant ductal anatomy. The use of routine versus selective cholangiography remains a topic of debate with a lack of definitive evidence on either side.55-57 However, routine intra-operative cholangiography will detect stones in approximately 7% of patients, and it assists with outlining anatomy and | Surgery_Schwartz. toward the hepatocystic triangle. Once the cystic artery and cystic duct have been dissected and clearly identified, they are ligated and divided, and the gallbladder is removed. In particularly difficult cases, in which the gallbladder is partially obliterated or ductal or arterial anatomy cannot be identified, a partial cholecystec-tomy may be performed. This includes removal of as much gall-bladder mucosa as possible and attempted closure of the cystic duct stump with wide drainage of the area.Intraoperative Cholangiogram. Intraoperative cholangio-gram is an optional but valuable tool for evaluating the extra-hepatic bile ducts, identifying common bile duct stones, or clarifying aberrant ductal anatomy. The use of routine versus selective cholangiography remains a topic of debate with a lack of definitive evidence on either side.55-57 However, routine intra-operative cholangiography will detect stones in approximately 7% of patients, and it assists with outlining anatomy and |
Surgery_Schwartz_9363 | Surgery_Schwartz | with a lack of definitive evidence on either side.55-57 However, routine intra-operative cholangiography will detect stones in approximately 7% of patients, and it assists with outlining anatomy and detect-ing injury.58 Selective intraoperative cholangiogram should be performed when the patient has a history of abnormal liver func-tion tests, pancreatitis, jaundice, a large duct and small stones, a dilated duct on preoperative ultrasonography, or if preoperative endoscopic cholangiography for the aforementioned reasons was unsuccessful. Although there is no consensus recommenda-tion on the use of routine versus selective cholangiography, all surgeons performing cholecystectomy should be familiar with the procedure. If a cholangiogram is to be performed, a clip is placed on the proximal cystic duct, and a small incision is made on its anterior surface, just inferior to the clip. A cholangiogram catheter is passed into the cystic duct and secured with a clamp or clip. The fluoroscopy | Surgery_Schwartz. with a lack of definitive evidence on either side.55-57 However, routine intra-operative cholangiography will detect stones in approximately 7% of patients, and it assists with outlining anatomy and detect-ing injury.58 Selective intraoperative cholangiogram should be performed when the patient has a history of abnormal liver func-tion tests, pancreatitis, jaundice, a large duct and small stones, a dilated duct on preoperative ultrasonography, or if preoperative endoscopic cholangiography for the aforementioned reasons was unsuccessful. Although there is no consensus recommenda-tion on the use of routine versus selective cholangiography, all surgeons performing cholecystectomy should be familiar with the procedure. If a cholangiogram is to be performed, a clip is placed on the proximal cystic duct, and a small incision is made on its anterior surface, just inferior to the clip. A cholangiogram catheter is passed into the cystic duct and secured with a clamp or clip. The fluoroscopy |
Surgery_Schwartz_9364 | Surgery_Schwartz | cystic duct, and a small incision is made on its anterior surface, just inferior to the clip. A cholangiogram catheter is passed into the cystic duct and secured with a clamp or clip. The fluoroscopy machine is then positioned over the patient and a cholangiogram performed by injection of contrast through the cholangiocatheter during live fluoroscopic dynamic imaging. An ideal cholangiogram includes filling of the right and left hepatic ducts, emptying into the duodenum, and no visualized filling defects (Fig. 32-24). Care must be taken not to introduce air bubbles into the system during contrast injec-tion as these will appear as filling defects on the cholangiogram images. If no contrast is visualized in the duodenum, a dose of glucagon can be utilized to relax the sphincter of Oddi and facilitate contrast flow. Once the cholangiogram is completed, the catheter is removed. Laparoscopic ultrasonography is as accurate as intraoperative cholangiography in detecting com-mon bile duct | Surgery_Schwartz. cystic duct, and a small incision is made on its anterior surface, just inferior to the clip. A cholangiogram catheter is passed into the cystic duct and secured with a clamp or clip. The fluoroscopy machine is then positioned over the patient and a cholangiogram performed by injection of contrast through the cholangiocatheter during live fluoroscopic dynamic imaging. An ideal cholangiogram includes filling of the right and left hepatic ducts, emptying into the duodenum, and no visualized filling defects (Fig. 32-24). Care must be taken not to introduce air bubbles into the system during contrast injec-tion as these will appear as filling defects on the cholangiogram images. If no contrast is visualized in the duodenum, a dose of glucagon can be utilized to relax the sphincter of Oddi and facilitate contrast flow. Once the cholangiogram is completed, the catheter is removed. Laparoscopic ultrasonography is as accurate as intraoperative cholangiography in detecting com-mon bile duct |
Surgery_Schwartz_9365 | Surgery_Schwartz | facilitate contrast flow. Once the cholangiogram is completed, the catheter is removed. Laparoscopic ultrasonography is as accurate as intraoperative cholangiography in detecting com-mon bile duct stones, and it is less invasive. However, it requires more skill to perform and interpret and is not always readily available.59Common Bile Duct ExplorationCommon bile duct stones that are detected preor intraopera-tively may be managed with common bile duct exploration (CBDE) at the time of the cholecystectomy. While preopera-tive ERCP is also an appropriate option for known bile duct stones, laparoscopic CBDE can be used as a primary approach to choledocholithiasis safely and with good outcomes, even in higher risk populations such as the elderly.60 If stones in the duct are small, they may sometimes be simply flushed into the duo-denum with saline irrigation via the cholangiography catheter. This can be facilitated by the administration of IV glucagon to relax the sphincter of Oddi. If | Surgery_Schwartz. facilitate contrast flow. Once the cholangiogram is completed, the catheter is removed. Laparoscopic ultrasonography is as accurate as intraoperative cholangiography in detecting com-mon bile duct stones, and it is less invasive. However, it requires more skill to perform and interpret and is not always readily available.59Common Bile Duct ExplorationCommon bile duct stones that are detected preor intraopera-tively may be managed with common bile duct exploration (CBDE) at the time of the cholecystectomy. While preopera-tive ERCP is also an appropriate option for known bile duct stones, laparoscopic CBDE can be used as a primary approach to choledocholithiasis safely and with good outcomes, even in higher risk populations such as the elderly.60 If stones in the duct are small, they may sometimes be simply flushed into the duo-denum with saline irrigation via the cholangiography catheter. This can be facilitated by the administration of IV glucagon to relax the sphincter of Oddi. If |
Surgery_Schwartz_9366 | Surgery_Schwartz | sometimes be simply flushed into the duo-denum with saline irrigation via the cholangiography catheter. This can be facilitated by the administration of IV glucagon to relax the sphincter of Oddi. If irrigation is unsuccessful, several options exist to clear the duct, including fluoroscopic or endo-scopic approaches.With access to the cystic duct by a small ductotomy, a bal-loon catheter is used to dilate the cystic duct, and a wire basket can be passed down the common bile duct under fluoroscopic Brunicardi_Ch32_p1393-p1428.indd 141311/02/19 2:43 PM 1414SPECIFIC CONSIDERATIONSPART IIguidance to catch and remove the stones (Fig. 32-25). Alter-nately, endoscopic evaluation with a flexible choledocho-scope will allow for direct visualization and retrieval of the stones within the common duct. To do this, reliable catheter access must be obtained with an introducer sheath placed either through one of the laparoscopic ports or a new stab incision in the anterior abdominal wall. The | Surgery_Schwartz. sometimes be simply flushed into the duo-denum with saline irrigation via the cholangiography catheter. This can be facilitated by the administration of IV glucagon to relax the sphincter of Oddi. If irrigation is unsuccessful, several options exist to clear the duct, including fluoroscopic or endo-scopic approaches.With access to the cystic duct by a small ductotomy, a bal-loon catheter is used to dilate the cystic duct, and a wire basket can be passed down the common bile duct under fluoroscopic Brunicardi_Ch32_p1393-p1428.indd 141311/02/19 2:43 PM 1414SPECIFIC CONSIDERATIONSPART IIguidance to catch and remove the stones (Fig. 32-25). Alter-nately, endoscopic evaluation with a flexible choledocho-scope will allow for direct visualization and retrieval of the stones within the common duct. To do this, reliable catheter access must be obtained with an introducer sheath placed either through one of the laparoscopic ports or a new stab incision in the anterior abdominal wall. The |
Surgery_Schwartz_9367 | Surgery_Schwartz | duct. To do this, reliable catheter access must be obtained with an introducer sheath placed either through one of the laparoscopic ports or a new stab incision in the anterior abdominal wall. The cystic duct should first be dilated with a small balloon catheter to allow for passage of the introducer and scope and for effective retrieval of larger stones. Once the scope is within the common bile duct, irrigation is used to distend the lumen. Stones may then be caught in a wire basket under direct visualization or simply pushed into the duo-denum. Once the common bile duct has been cleared of stones, the cystic duct is ligated below the level of the ductotomy and divided, and the cholecystectomy is completed.While the cystic duct is the preferred route of access for common bile duct exploration, occasionally an incision into the common bile duct itself (choledochotomy) is necessary. The flexible choledochoscope is then passed into the duct for visu-alization and clearance of stones. | Surgery_Schwartz. duct. To do this, reliable catheter access must be obtained with an introducer sheath placed either through one of the laparoscopic ports or a new stab incision in the anterior abdominal wall. The cystic duct should first be dilated with a small balloon catheter to allow for passage of the introducer and scope and for effective retrieval of larger stones. Once the scope is within the common bile duct, irrigation is used to distend the lumen. Stones may then be caught in a wire basket under direct visualization or simply pushed into the duo-denum. Once the common bile duct has been cleared of stones, the cystic duct is ligated below the level of the ductotomy and divided, and the cholecystectomy is completed.While the cystic duct is the preferred route of access for common bile duct exploration, occasionally an incision into the common bile duct itself (choledochotomy) is necessary. The flexible choledochoscope is then passed into the duct for visu-alization and clearance of stones. |
Surgery_Schwartz_9368 | Surgery_Schwartz | occasionally an incision into the common bile duct itself (choledochotomy) is necessary. The flexible choledochoscope is then passed into the duct for visu-alization and clearance of stones. The choledochotomy can be closed primarily of the duct is very large, or over a T-tube. If available, common bile duct exploration can be highly advan-tageous as it provides the opportunity to treat the entirety of the disease in a single event, rather that subjecting patients to multiple procedures. However, the procedure can be techni-cally challenging to perform and requires the availability of the proper equipment and surgical expertise.61Common Bile Duct Drainage ProceduresIn very rare cases in which stones or obstructions cannot be cleared by either ERCP with sphincterotomy or CBDE, and the patient is suffering clinical effects from their common duct stones, an additional choledochal drainage procedure may become necessary. In the case of an open operation, transduodenal sphincterotomy can | Surgery_Schwartz. occasionally an incision into the common bile duct itself (choledochotomy) is necessary. The flexible choledochoscope is then passed into the duct for visu-alization and clearance of stones. The choledochotomy can be closed primarily of the duct is very large, or over a T-tube. If available, common bile duct exploration can be highly advan-tageous as it provides the opportunity to treat the entirety of the disease in a single event, rather that subjecting patients to multiple procedures. However, the procedure can be techni-cally challenging to perform and requires the availability of the proper equipment and surgical expertise.61Common Bile Duct Drainage ProceduresIn very rare cases in which stones or obstructions cannot be cleared by either ERCP with sphincterotomy or CBDE, and the patient is suffering clinical effects from their common duct stones, an additional choledochal drainage procedure may become necessary. In the case of an open operation, transduodenal sphincterotomy can |
Surgery_Schwartz_9369 | Surgery_Schwartz | is suffering clinical effects from their common duct stones, an additional choledochal drainage procedure may become necessary. In the case of an open operation, transduodenal sphincterotomy can be attempted by incising the duodenum transversely and cutting the sphincter of Oddi at the 11 o’clock position, taking care to avoid injury to the pancreatic duct. The impacted stones can then be manually removed or simply allowed to pass through the sphincterotomy.Bypass procedures can also be used to restore continu-ity of bile flow in the setting of irretrievable impacted stones. For short distance bypasses, a Choledochoduodenostomy is performed by mobilizing the second part of the duodenum (a Kocher maneuver) and anastomosing it side to side with the common bile duct (Fig. 32-26A-C). If the distance is too great to safely complete a choledochoduodenostomy without ten-sion, a choledochojejunostomy can be done by bringing up a roughly 45-cm limb of jejunum and anastomosing it end to side to | Surgery_Schwartz. is suffering clinical effects from their common duct stones, an additional choledochal drainage procedure may become necessary. In the case of an open operation, transduodenal sphincterotomy can be attempted by incising the duodenum transversely and cutting the sphincter of Oddi at the 11 o’clock position, taking care to avoid injury to the pancreatic duct. The impacted stones can then be manually removed or simply allowed to pass through the sphincterotomy.Bypass procedures can also be used to restore continu-ity of bile flow in the setting of irretrievable impacted stones. For short distance bypasses, a Choledochoduodenostomy is performed by mobilizing the second part of the duodenum (a Kocher maneuver) and anastomosing it side to side with the common bile duct (Fig. 32-26A-C). If the distance is too great to safely complete a choledochoduodenostomy without ten-sion, a choledochojejunostomy can be done by bringing up a roughly 45-cm limb of jejunum and anastomosing it end to side to |
Surgery_Schwartz_9370 | Surgery_Schwartz | is too great to safely complete a choledochoduodenostomy without ten-sion, a choledochojejunostomy can be done by bringing up a roughly 45-cm limb of jejunum and anastomosing it end to side to the common bile duct (Fig. 32-26D-E). If the entirety of the extrahepatic biliary tree must be bypassed, hepaticojejunostomy allows for drainage of the hepatic ducts directly a loop of jeju-num (Fig. 32-26F-G). These choledochal drainage procedures can also be used to manage common bile duct strictures or as a palliative procedure for malignant obstruction in the periampul-lary region.OTHER BENIGN DISEASES AND LESIONSBiliary Dyskinesia and Sphincter of Oddi DysfunctionBiliary dyskinesia is an umbrella term that refers to disorders affecting the normal motility and function of the gallbladder and sphincter of Oddi. These disorders are becoming increas-ingly recognized as improvements in imaging allow for more detailed evaluations of biliary tract function. Patients with bili-ary dyskinesia may | Surgery_Schwartz. is too great to safely complete a choledochoduodenostomy without ten-sion, a choledochojejunostomy can be done by bringing up a roughly 45-cm limb of jejunum and anastomosing it end to side to the common bile duct (Fig. 32-26D-E). If the entirety of the extrahepatic biliary tree must be bypassed, hepaticojejunostomy allows for drainage of the hepatic ducts directly a loop of jeju-num (Fig. 32-26F-G). These choledochal drainage procedures can also be used to manage common bile duct strictures or as a palliative procedure for malignant obstruction in the periampul-lary region.OTHER BENIGN DISEASES AND LESIONSBiliary Dyskinesia and Sphincter of Oddi DysfunctionBiliary dyskinesia is an umbrella term that refers to disorders affecting the normal motility and function of the gallbladder and sphincter of Oddi. These disorders are becoming increas-ingly recognized as improvements in imaging allow for more detailed evaluations of biliary tract function. Patients with bili-ary dyskinesia may |
Surgery_Schwartz_9371 | Surgery_Schwartz | of Oddi. These disorders are becoming increas-ingly recognized as improvements in imaging allow for more detailed evaluations of biliary tract function. Patients with bili-ary dyskinesia may present with typical biliary type symptoms, but without evidence of stones or sludge on abdominal imaging. ABFigure 32-24. A. An intraoperative cholangiogram. The bile ducts are of normal size, with no intraluminal filling defects. The left and the right hepatic ducts are visualized, the distal common bile duct tapers down, and the contrast empties into the duodenum. Cholangiography grasper that holds the catheter and the cystic duct stump partly projects over the common hepatic duct. B. An intraoperative cholangiogram showing a common bile duct stone (arrow) with very little contrast passing into the duodenum.Brunicardi_Ch32_p1393-p1428.indd 141411/02/19 2:43 PM 1415GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32A decreased gallbladder ejection fraction on HIDA scanning (EF <35%) is | Surgery_Schwartz. of Oddi. These disorders are becoming increas-ingly recognized as improvements in imaging allow for more detailed evaluations of biliary tract function. Patients with bili-ary dyskinesia may present with typical biliary type symptoms, but without evidence of stones or sludge on abdominal imaging. ABFigure 32-24. A. An intraoperative cholangiogram. The bile ducts are of normal size, with no intraluminal filling defects. The left and the right hepatic ducts are visualized, the distal common bile duct tapers down, and the contrast empties into the duodenum. Cholangiography grasper that holds the catheter and the cystic duct stump partly projects over the common hepatic duct. B. An intraoperative cholangiogram showing a common bile duct stone (arrow) with very little contrast passing into the duodenum.Brunicardi_Ch32_p1393-p1428.indd 141411/02/19 2:43 PM 1415GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32A decreased gallbladder ejection fraction on HIDA scanning (EF <35%) is |
Surgery_Schwartz_9372 | Surgery_Schwartz | duodenum.Brunicardi_Ch32_p1393-p1428.indd 141411/02/19 2:43 PM 1415GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32A decreased gallbladder ejection fraction on HIDA scanning (EF <35%) is considered diagnostic of biliary dyskinesia. In these patients, studies suggest that symptoms will be improved or resolved by cholecystectomy in up to 90% of cases.62Sphincter of Oddi dysfunction can occur as a primary pre-sentation of episodic biliary type pain with abnormal liver func-tion tests or as recurrent biliary type pain after cholecystectomy. More severe cases may present with recurrent jaundice or pan-creatitis. If other causes are ruled out, such as retained stones, strictures or periampullary tumors, a stenotic or dyskinetic sphincter of Oddi should be suspected. A benign stenosis of the outlet of the common bile duct is usually associated with inflam-mation, fibrosis, or muscular hypertrophy. The pathogenesis is unclear, but trauma from the passage of stones, sphincter | Surgery_Schwartz. duodenum.Brunicardi_Ch32_p1393-p1428.indd 141411/02/19 2:43 PM 1415GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32A decreased gallbladder ejection fraction on HIDA scanning (EF <35%) is considered diagnostic of biliary dyskinesia. In these patients, studies suggest that symptoms will be improved or resolved by cholecystectomy in up to 90% of cases.62Sphincter of Oddi dysfunction can occur as a primary pre-sentation of episodic biliary type pain with abnormal liver func-tion tests or as recurrent biliary type pain after cholecystectomy. More severe cases may present with recurrent jaundice or pan-creatitis. If other causes are ruled out, such as retained stones, strictures or periampullary tumors, a stenotic or dyskinetic sphincter of Oddi should be suspected. A benign stenosis of the outlet of the common bile duct is usually associated with inflam-mation, fibrosis, or muscular hypertrophy. The pathogenesis is unclear, but trauma from the passage of stones, sphincter |
Surgery_Schwartz_9373 | Surgery_Schwartz | of the outlet of the common bile duct is usually associated with inflam-mation, fibrosis, or muscular hypertrophy. The pathogenesis is unclear, but trauma from the passage of stones, sphincter motil-ity disorders, and congenital anomalies have been suggested. A dilated common bile duct that is difficult to cannulate during ERCP or delayed emptying of contrast from the biliary tree after ERCP are useful diagnostic features. Ampullary manometry and specific provocation tests are available in specialized units to aid in the diagnosis. Once identified, sphincterotomy will typi-cally yield good results.63Acalculous CholecystitisAcalculous cholecystitis is an acute inflammation of the gall-bladder that occurs in the absence of gallstones. It is a rare entity that typically develops in critically ill patients in the intensive care unit.64 Patients on parenteral nutrition, with extensive burns, sepsis, major operations, multiple trauma, or prolonged illness with multiple organ system failure | Surgery_Schwartz. of the outlet of the common bile duct is usually associated with inflam-mation, fibrosis, or muscular hypertrophy. The pathogenesis is unclear, but trauma from the passage of stones, sphincter motil-ity disorders, and congenital anomalies have been suggested. A dilated common bile duct that is difficult to cannulate during ERCP or delayed emptying of contrast from the biliary tree after ERCP are useful diagnostic features. Ampullary manometry and specific provocation tests are available in specialized units to aid in the diagnosis. Once identified, sphincterotomy will typi-cally yield good results.63Acalculous CholecystitisAcalculous cholecystitis is an acute inflammation of the gall-bladder that occurs in the absence of gallstones. It is a rare entity that typically develops in critically ill patients in the intensive care unit.64 Patients on parenteral nutrition, with extensive burns, sepsis, major operations, multiple trauma, or prolonged illness with multiple organ system failure |
Surgery_Schwartz_9374 | Surgery_Schwartz | ill patients in the intensive care unit.64 Patients on parenteral nutrition, with extensive burns, sepsis, major operations, multiple trauma, or prolonged illness with multiple organ system failure are at risk for developing acalculous cholecystitis. The cause is unknown, but gallblad-der distention, bile stasis, and ischemia have been implicated as causative factors. After resection, pathologic examination of the gallbladder wall after an episode of acalculous cholecystitis reveals edema of the serosa and muscular layers, with patchy thrombosis of arterioles and venules.65The ability to recognize the symptoms and signs of acalculous cholecystitis can depend on the condition and mental status of the patient, but acalculous cholecystitis can be similar to acute calculous cholecystitis, with right upper quadrant pain and tenderness, fever, and leukocytosis. In the sedated or unconscious patient, the clinical features are often masked, but fever and elevated WBC count, as well as | Surgery_Schwartz. ill patients in the intensive care unit.64 Patients on parenteral nutrition, with extensive burns, sepsis, major operations, multiple trauma, or prolonged illness with multiple organ system failure are at risk for developing acalculous cholecystitis. The cause is unknown, but gallblad-der distention, bile stasis, and ischemia have been implicated as causative factors. After resection, pathologic examination of the gallbladder wall after an episode of acalculous cholecystitis reveals edema of the serosa and muscular layers, with patchy thrombosis of arterioles and venules.65The ability to recognize the symptoms and signs of acalculous cholecystitis can depend on the condition and mental status of the patient, but acalculous cholecystitis can be similar to acute calculous cholecystitis, with right upper quadrant pain and tenderness, fever, and leukocytosis. In the sedated or unconscious patient, the clinical features are often masked, but fever and elevated WBC count, as well as |
Surgery_Schwartz_9375 | Surgery_Schwartz | with right upper quadrant pain and tenderness, fever, and leukocytosis. In the sedated or unconscious patient, the clinical features are often masked, but fever and elevated WBC count, as well as eleva-tion of alkaline phosphatase and bilirubin, are indications for AIIIIIIEBFGCDFigure 32-25. Laparoscopic common bile duct exploration. I. Transcystic basket retrieval using fluoroscopy. A. The basket has been advanced past the stone and opened. B. The stone has been entrapped in the basket, and together, they are removed from the cystic duct. II. Transcystic choledochoscopy and stone removal. C. The basket has been passed through the working channel of the scope, and the stone is entrapped under direct vision. D. Entrapped stone. E. A view from the choledochoscope with stone captured in basket. III. Choledochotomy and stone removal. F. A small incision is made in the common bile duct. G. The common bile duct is cleared of stones.Brunicardi_Ch32_p1393-p1428.indd 141511/02/19 2:43 PM | Surgery_Schwartz. with right upper quadrant pain and tenderness, fever, and leukocytosis. In the sedated or unconscious patient, the clinical features are often masked, but fever and elevated WBC count, as well as eleva-tion of alkaline phosphatase and bilirubin, are indications for AIIIIIIEBFGCDFigure 32-25. Laparoscopic common bile duct exploration. I. Transcystic basket retrieval using fluoroscopy. A. The basket has been advanced past the stone and opened. B. The stone has been entrapped in the basket, and together, they are removed from the cystic duct. II. Transcystic choledochoscopy and stone removal. C. The basket has been passed through the working channel of the scope, and the stone is entrapped under direct vision. D. Entrapped stone. E. A view from the choledochoscope with stone captured in basket. III. Choledochotomy and stone removal. F. A small incision is made in the common bile duct. G. The common bile duct is cleared of stones.Brunicardi_Ch32_p1393-p1428.indd 141511/02/19 2:43 PM |
Surgery_Schwartz_9376 | Surgery_Schwartz | III. Choledochotomy and stone removal. F. A small incision is made in the common bile duct. G. The common bile duct is cleared of stones.Brunicardi_Ch32_p1393-p1428.indd 141511/02/19 2:43 PM 1416SPECIFIC CONSIDERATIONSPART IIAIIIIIIBCDEFGFigure 32-26. Biliary enteric anastomoses. There are three types. I. Choledochoduodenostomy. A. The distal common bile duct is opened longitudinally, as is the duodenum. B. Interrupted sutures are placed between the common bile duct and the duodenum. C. Completed cho-ledochoduodenostomy. II. Choledochojejunostomy. D. The common bile duct and small bowel are divided. E. A limb of jejunum is brought up in a Roux-en-Y configuration and anastomosed to the bile duct. III. Hepaticojejunostomy. F. The entire extrahepatic biliary tree has been resected and the reconstruction completed with a Roux-en-Y limb of jejunum. G. Percutaneous transhepatic stents are placed across hepati-cojejunostomy (optional).Brunicardi_Ch32_p1393-p1428.indd 141611/02/19 | Surgery_Schwartz. III. Choledochotomy and stone removal. F. A small incision is made in the common bile duct. G. The common bile duct is cleared of stones.Brunicardi_Ch32_p1393-p1428.indd 141511/02/19 2:43 PM 1416SPECIFIC CONSIDERATIONSPART IIAIIIIIIBCDEFGFigure 32-26. Biliary enteric anastomoses. There are three types. I. Choledochoduodenostomy. A. The distal common bile duct is opened longitudinally, as is the duodenum. B. Interrupted sutures are placed between the common bile duct and the duodenum. C. Completed cho-ledochoduodenostomy. II. Choledochojejunostomy. D. The common bile duct and small bowel are divided. E. A limb of jejunum is brought up in a Roux-en-Y configuration and anastomosed to the bile duct. III. Hepaticojejunostomy. F. The entire extrahepatic biliary tree has been resected and the reconstruction completed with a Roux-en-Y limb of jejunum. G. Percutaneous transhepatic stents are placed across hepati-cojejunostomy (optional).Brunicardi_Ch32_p1393-p1428.indd 141611/02/19 |
Surgery_Schwartz_9377 | Surgery_Schwartz | the reconstruction completed with a Roux-en-Y limb of jejunum. G. Percutaneous transhepatic stents are placed across hepati-cojejunostomy (optional).Brunicardi_Ch32_p1393-p1428.indd 141611/02/19 2:43 PM 1417GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32further investigation. Ultrasonography is usually the diagnos-tic test of choice, as it can be done bedside in the intensive care unit. It can demonstrate the distended gallbladder with thickened wall, biliary sludge, pericholecystic fluid, and the presence or absence of abscess formation. CT scanning can aid in the diagnosis of acalculous cholecystitis and addition-ally allows a more general evaluation of the abdomen and chest to rule out other sources of infection. A HIDA scan can also be useful if it shows nonvisualization of the gallblad-der, but it is less sensitive and can have higher false-positive rates in patients who are in a prolonged fasting state, on total parenteral nutrition, or have liver disease. Once the | Surgery_Schwartz. the reconstruction completed with a Roux-en-Y limb of jejunum. G. Percutaneous transhepatic stents are placed across hepati-cojejunostomy (optional).Brunicardi_Ch32_p1393-p1428.indd 141611/02/19 2:43 PM 1417GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32further investigation. Ultrasonography is usually the diagnos-tic test of choice, as it can be done bedside in the intensive care unit. It can demonstrate the distended gallbladder with thickened wall, biliary sludge, pericholecystic fluid, and the presence or absence of abscess formation. CT scanning can aid in the diagnosis of acalculous cholecystitis and addition-ally allows a more general evaluation of the abdomen and chest to rule out other sources of infection. A HIDA scan can also be useful if it shows nonvisualization of the gallblad-der, but it is less sensitive and can have higher false-positive rates in patients who are in a prolonged fasting state, on total parenteral nutrition, or have liver disease. Once the |
Surgery_Schwartz_9378 | Surgery_Schwartz | of the gallblad-der, but it is less sensitive and can have higher false-positive rates in patients who are in a prolonged fasting state, on total parenteral nutrition, or have liver disease. Once the diagnosis is confirmed, acalculous cholecystitis requires urgent inter-vention as rapid deterioration can occur. This should include early broad-spectrum antibiotics and fluid resuscitation. If the patient is stable to undergo an abdominal operation, lapa-roscopic cholecystectomy is the most definitive treatment, and it can be safely performed even in the setting of severe acute inflammation.64 However, if patients are critically ill and unfit for surgery, percutaneous cholecystostomy is the best treatment choice (see Fig. 32-18). About 90% of patients will improve with a percutaneous cholecystostomy tube. Interval cholecystectomy can be discussed with the patient after they have recovered from their acute illness, but it is not strictly required in the absence of gallstone or other | Surgery_Schwartz. of the gallblad-der, but it is less sensitive and can have higher false-positive rates in patients who are in a prolonged fasting state, on total parenteral nutrition, or have liver disease. Once the diagnosis is confirmed, acalculous cholecystitis requires urgent inter-vention as rapid deterioration can occur. This should include early broad-spectrum antibiotics and fluid resuscitation. If the patient is stable to undergo an abdominal operation, lapa-roscopic cholecystectomy is the most definitive treatment, and it can be safely performed even in the setting of severe acute inflammation.64 However, if patients are critically ill and unfit for surgery, percutaneous cholecystostomy is the best treatment choice (see Fig. 32-18). About 90% of patients will improve with a percutaneous cholecystostomy tube. Interval cholecystectomy can be discussed with the patient after they have recovered from their acute illness, but it is not strictly required in the absence of gallstone or other |
Surgery_Schwartz_9379 | Surgery_Schwartz | tube. Interval cholecystectomy can be discussed with the patient after they have recovered from their acute illness, but it is not strictly required in the absence of gallstone or other identi-fied gallbladder pathology.Choledochal (Biliary) CystsCholedochal cysts are congenital cystic dilatations of the extra-hepatic and/or intrahepatic biliary tree. They are rare, with an incidence of between 1:100,000 and 1:150,000 in populations of Western countries, but are more common in populations of Eastern countries occurring in as many as 1:1000 individuals. Choledochal cysts affect females three to eight times more often than males. Although frequently found in infancy or childhood, nearly one-half are diagnosed in adults. The cause is unknown, but it is believed that weakness of the bile duct wall and increased pressure secondary to partial biliary obstruction can contribute to biliary cyst formation. More than 90% of patients have an anomalous pancreaticobiliary duct junction, with the | Surgery_Schwartz. tube. Interval cholecystectomy can be discussed with the patient after they have recovered from their acute illness, but it is not strictly required in the absence of gallstone or other identi-fied gallbladder pathology.Choledochal (Biliary) CystsCholedochal cysts are congenital cystic dilatations of the extra-hepatic and/or intrahepatic biliary tree. They are rare, with an incidence of between 1:100,000 and 1:150,000 in populations of Western countries, but are more common in populations of Eastern countries occurring in as many as 1:1000 individuals. Choledochal cysts affect females three to eight times more often than males. Although frequently found in infancy or childhood, nearly one-half are diagnosed in adults. The cause is unknown, but it is believed that weakness of the bile duct wall and increased pressure secondary to partial biliary obstruction can contribute to biliary cyst formation. More than 90% of patients have an anomalous pancreaticobiliary duct junction, with the |
Surgery_Schwartz_9380 | Surgery_Schwartz | wall and increased pressure secondary to partial biliary obstruction can contribute to biliary cyst formation. More than 90% of patients have an anomalous pancreaticobiliary duct junction, with the pancreatic duct joining the common bile duct outside the duode-nal wall, creating a long common channel (>1.5 cm). This may allow free reflux of pancreatic secretions into the biliary tract, leading to inflammatory changes, increased biliary pressure, and cyst formation. The cysts are lined with cuboidal epithelium and can vary in size from small dilations to giant cystic masses. The typical clinical triad of biliary cysts includes abdominal pain, jaundice, and a palpable mass, though this constellation is seen in less than one-half of patients. Adults may present with chol-angitis. Blood tests will often be normal though elevations of transaminases can be seen in cases of infection or obstruction. Ultrasonography or CT scanning will confirm the diagnosis, but ERCP or MRCP are essential to | Surgery_Schwartz. wall and increased pressure secondary to partial biliary obstruction can contribute to biliary cyst formation. More than 90% of patients have an anomalous pancreaticobiliary duct junction, with the pancreatic duct joining the common bile duct outside the duode-nal wall, creating a long common channel (>1.5 cm). This may allow free reflux of pancreatic secretions into the biliary tract, leading to inflammatory changes, increased biliary pressure, and cyst formation. The cysts are lined with cuboidal epithelium and can vary in size from small dilations to giant cystic masses. The typical clinical triad of biliary cysts includes abdominal pain, jaundice, and a palpable mass, though this constellation is seen in less than one-half of patients. Adults may present with chol-angitis. Blood tests will often be normal though elevations of transaminases can be seen in cases of infection or obstruction. Ultrasonography or CT scanning will confirm the diagnosis, but ERCP or MRCP are essential to |
Surgery_Schwartz_9381 | Surgery_Schwartz | will often be normal though elevations of transaminases can be seen in cases of infection or obstruction. Ultrasonography or CT scanning will confirm the diagnosis, but ERCP or MRCP are essential to formally assess the biliary anatomy and to plan the appropriate surgical treatment. The risk of cholangiocarcinoma in patients with choledochal cysts is 20to 30-fold higher than in the general population and varies with the patient’s age and type of cyst. For this reason, excision is recommended whenever possible when high-risk choledochal cysts are diagnosed.Choledochal cysts are classified into five types depend-ing on the location and structure of the cysts. The subcatego-ries of choledochal cysts are defined in Fig. 32-27. Type I cysts (fusiform CBD dilations) are the most common form, account-ing for approximately 50% of cases, and have the highest risk of malignancy (>60%). For types I and II (saccular diverticula of the common bile duct), excision of the cystic dilations in the | Surgery_Schwartz. will often be normal though elevations of transaminases can be seen in cases of infection or obstruction. Ultrasonography or CT scanning will confirm the diagnosis, but ERCP or MRCP are essential to formally assess the biliary anatomy and to plan the appropriate surgical treatment. The risk of cholangiocarcinoma in patients with choledochal cysts is 20to 30-fold higher than in the general population and varies with the patient’s age and type of cyst. For this reason, excision is recommended whenever possible when high-risk choledochal cysts are diagnosed.Choledochal cysts are classified into five types depend-ing on the location and structure of the cysts. The subcatego-ries of choledochal cysts are defined in Fig. 32-27. Type I cysts (fusiform CBD dilations) are the most common form, account-ing for approximately 50% of cases, and have the highest risk of malignancy (>60%). For types I and II (saccular diverticula of the common bile duct), excision of the cystic dilations in the |
Surgery_Schwartz_9382 | Surgery_Schwartz | account-ing for approximately 50% of cases, and have the highest risk of malignancy (>60%). For types I and II (saccular diverticula of the common bile duct), excision of the cystic dilations in the extrahepatic biliary tree, including cholecystectomy, with either simple cyst excision or duct resection with Roux-en-Y hepaticojejunostomy is ideal. Type III cysts (intraduodenal) cre-ate a treatment challenge as full resection would require pan-creaticoduodenectomy. Given that type III cyst are associated with the lowest malignancy risk of any choledochal cyst (~2%), sphincterotomy and surveillance is generally recommended over formal excision.66 In Type IV (multiple cysts), excision of all cystic tissue and reconstruction is again recommended. For type IVa, which is characterized by multiple cysts with intrahe-patic involvement, additional segmental resection of the liver may be required if intrahepatic stones, strictures, or abscesses are present. Type V choledochal cysts (Caroli | Surgery_Schwartz. account-ing for approximately 50% of cases, and have the highest risk of malignancy (>60%). For types I and II (saccular diverticula of the common bile duct), excision of the cystic dilations in the extrahepatic biliary tree, including cholecystectomy, with either simple cyst excision or duct resection with Roux-en-Y hepaticojejunostomy is ideal. Type III cysts (intraduodenal) cre-ate a treatment challenge as full resection would require pan-creaticoduodenectomy. Given that type III cyst are associated with the lowest malignancy risk of any choledochal cyst (~2%), sphincterotomy and surveillance is generally recommended over formal excision.66 In Type IV (multiple cysts), excision of all cystic tissue and reconstruction is again recommended. For type IVa, which is characterized by multiple cysts with intrahe-patic involvement, additional segmental resection of the liver may be required if intrahepatic stones, strictures, or abscesses are present. Type V choledochal cysts (Caroli |
Surgery_Schwartz_9383 | Surgery_Schwartz | cysts with intrahe-patic involvement, additional segmental resection of the liver may be required if intrahepatic stones, strictures, or abscesses are present. Type V choledochal cysts (Caroli disease) are very rare and account for less than 1% of patients with choledochal cysts. These cysts are multiple and can affect the entire liver. In advanced stages, this may result in cirrhosis and liver failure necessitating liver transplantation.Primary Sclerosing CholangitisPrimary sclerosing cholangitis (PSC) is an uncommon disease characterized by inflammatory strictures involving the intrahe-patic and extrahepatic biliary tree. It is a progressive disease that eventually results in secondary biliary cirrhosis. Sometimes, biliary strictures are clearly secondary to bile duct stones, acute cholangitis, previous biliary surgery, or toxic agents, and are termed secondary sclerosing cholangitis. However, primary sclerosing cholangitis is a disease entity of its own, with no clear attributing | Surgery_Schwartz. cysts with intrahe-patic involvement, additional segmental resection of the liver may be required if intrahepatic stones, strictures, or abscesses are present. Type V choledochal cysts (Caroli disease) are very rare and account for less than 1% of patients with choledochal cysts. These cysts are multiple and can affect the entire liver. In advanced stages, this may result in cirrhosis and liver failure necessitating liver transplantation.Primary Sclerosing CholangitisPrimary sclerosing cholangitis (PSC) is an uncommon disease characterized by inflammatory strictures involving the intrahe-patic and extrahepatic biliary tree. It is a progressive disease that eventually results in secondary biliary cirrhosis. Sometimes, biliary strictures are clearly secondary to bile duct stones, acute cholangitis, previous biliary surgery, or toxic agents, and are termed secondary sclerosing cholangitis. However, primary sclerosing cholangitis is a disease entity of its own, with no clear attributing |
Surgery_Schwartz_9384 | Surgery_Schwartz | previous biliary surgery, or toxic agents, and are termed secondary sclerosing cholangitis. However, primary sclerosing cholangitis is a disease entity of its own, with no clear attributing cause. Autoimmune reaction, chronic low-grade bac-terial or viral infection, toxic reaction, and genetic factors have all been suggested to play a role in its pathogenesis. PSC is commonly associated with other autoimmune diseases includ-ing ulcerative colitis in about two-thirds of patients, Riedel’s thyroiditis, and retroperitoneal fibrosis. The human leukocyte antigen haplotypes HLA-B8, DR3, DQ2, and DRw52A, com-monly found in patients with autoimmune diseases, also are more frequently seen in patients with primary sclerosing chol-angitis than in controls. The mean age of presentation for PSC is 30 to 45 years, and men are affected twice as often as women. Most patients are symptomatic when diagnosed, and may com-plain of intermittent jaundice, fatigue, weight loss, pruritus, or abdominal pain. | Surgery_Schwartz. previous biliary surgery, or toxic agents, and are termed secondary sclerosing cholangitis. However, primary sclerosing cholangitis is a disease entity of its own, with no clear attributing cause. Autoimmune reaction, chronic low-grade bac-terial or viral infection, toxic reaction, and genetic factors have all been suggested to play a role in its pathogenesis. PSC is commonly associated with other autoimmune diseases includ-ing ulcerative colitis in about two-thirds of patients, Riedel’s thyroiditis, and retroperitoneal fibrosis. The human leukocyte antigen haplotypes HLA-B8, DR3, DQ2, and DRw52A, com-monly found in patients with autoimmune diseases, also are more frequently seen in patients with primary sclerosing chol-angitis than in controls. The mean age of presentation for PSC is 30 to 45 years, and men are affected twice as often as women. Most patients are symptomatic when diagnosed, and may com-plain of intermittent jaundice, fatigue, weight loss, pruritus, or abdominal pain. |
Surgery_Schwartz_9385 | Surgery_Schwartz | to 45 years, and men are affected twice as often as women. Most patients are symptomatic when diagnosed, and may com-plain of intermittent jaundice, fatigue, weight loss, pruritus, or abdominal pain. Initial presentation with acute cholangitis is rare without preceding biliary tract intervention or surgery. A minority of patients are diagnosed incidentally by elevated liver function tests, particular when found in a patient with ulcerative colitis. While the clinical presentation and laboratory results may suggest the PSC, ERCP revealing multiple dilatations and strictures (beading) of the intraand extrahepatic biliary tree confirms the diagnosis. The hepatic duct bifurcation is often the most severely affected segment. A liver biopsy may not be diagnostic, but it is important to determine the degree of hepatic fibrosis and the presence of cirrhosis.The clinical course in sclerosing cholangitis is highly vari-able, but cyclic remissions and exacerbations are typical. Some patients | Surgery_Schwartz. to 45 years, and men are affected twice as often as women. Most patients are symptomatic when diagnosed, and may com-plain of intermittent jaundice, fatigue, weight loss, pruritus, or abdominal pain. Initial presentation with acute cholangitis is rare without preceding biliary tract intervention or surgery. A minority of patients are diagnosed incidentally by elevated liver function tests, particular when found in a patient with ulcerative colitis. While the clinical presentation and laboratory results may suggest the PSC, ERCP revealing multiple dilatations and strictures (beading) of the intraand extrahepatic biliary tree confirms the diagnosis. The hepatic duct bifurcation is often the most severely affected segment. A liver biopsy may not be diagnostic, but it is important to determine the degree of hepatic fibrosis and the presence of cirrhosis.The clinical course in sclerosing cholangitis is highly vari-able, but cyclic remissions and exacerbations are typical. Some patients |
Surgery_Schwartz_9386 | Surgery_Schwartz | the degree of hepatic fibrosis and the presence of cirrhosis.The clinical course in sclerosing cholangitis is highly vari-able, but cyclic remissions and exacerbations are typical. Some patients will remain asymptomatic for years, while others prog-ress rapidly with the obliterative inflammatory changes leading to secondary biliary cirrhosis and liver failure. In patients with associated ulcerative colitis, the course of each disease seems independent of the other and colectomy has no effect on the Brunicardi_Ch32_p1393-p1428.indd 141711/02/19 2:43 PM 1418SPECIFIC CONSIDERATIONSPART IIcourse of primary sclerosing cholangitis. Of the patients with sclerosing cholangitis, 10% to 15% will develop cholangio-carcinoma, which can present at any time during the disease process and does not necessarily correlate with the extent of the sclerosing cholangitis or the development of liver failure.67 Cholangiocarcinoma in the setting of PSC frequently follows an aggressive course. Patients | Surgery_Schwartz. the degree of hepatic fibrosis and the presence of cirrhosis.The clinical course in sclerosing cholangitis is highly vari-able, but cyclic remissions and exacerbations are typical. Some patients will remain asymptomatic for years, while others prog-ress rapidly with the obliterative inflammatory changes leading to secondary biliary cirrhosis and liver failure. In patients with associated ulcerative colitis, the course of each disease seems independent of the other and colectomy has no effect on the Brunicardi_Ch32_p1393-p1428.indd 141711/02/19 2:43 PM 1418SPECIFIC CONSIDERATIONSPART IIcourse of primary sclerosing cholangitis. Of the patients with sclerosing cholangitis, 10% to 15% will develop cholangio-carcinoma, which can present at any time during the disease process and does not necessarily correlate with the extent of the sclerosing cholangitis or the development of liver failure.67 Cholangiocarcinoma in the setting of PSC frequently follows an aggressive course. Patients |
Surgery_Schwartz_9387 | Surgery_Schwartz | necessarily correlate with the extent of the sclerosing cholangitis or the development of liver failure.67 Cholangiocarcinoma in the setting of PSC frequently follows an aggressive course. Patients need to be followed by serial ERCP and liver biopsies to evaluate for the development of complica-tions such as strictures, cancers, or cirrhosis.There is no known curative treatment for primary scleros-ing cholangitis and medical management is largely supportive. Corticosteroids, immunosuppressants, ursodeoxycholic acid, and antibiotics have been attempted with disappointing results. If biliary strictures occur, they can be dilated and stented either endoscopically or percutaneously. These measures have given short-term improvements in symptoms and serum bilirubin lev-els but provide long-term results in less than half of patients. Surgical management with resection of the extrahepatic biliary tree and hepaticojejunostomy has produced reasonable results in patients with extrahepatic and | Surgery_Schwartz. necessarily correlate with the extent of the sclerosing cholangitis or the development of liver failure.67 Cholangiocarcinoma in the setting of PSC frequently follows an aggressive course. Patients need to be followed by serial ERCP and liver biopsies to evaluate for the development of complica-tions such as strictures, cancers, or cirrhosis.There is no known curative treatment for primary scleros-ing cholangitis and medical management is largely supportive. Corticosteroids, immunosuppressants, ursodeoxycholic acid, and antibiotics have been attempted with disappointing results. If biliary strictures occur, they can be dilated and stented either endoscopically or percutaneously. These measures have given short-term improvements in symptoms and serum bilirubin lev-els but provide long-term results in less than half of patients. Surgical management with resection of the extrahepatic biliary tree and hepaticojejunostomy has produced reasonable results in patients with extrahepatic and |
Surgery_Schwartz_9388 | Surgery_Schwartz | results in less than half of patients. Surgical management with resection of the extrahepatic biliary tree and hepaticojejunostomy has produced reasonable results in patients with extrahepatic and bifurcation strictures, but without cirrhosis or significant hepatic fibrosis.68 In patients with pri-mary sclerosing cholangitis and advanced liver disease, liver transplantation is the only option. It offers excellent results, with overall 5-year survival as high as 85%. Unfortunately, recur-rence of PSC can occur in 10% to 20% of patients and may require retransplantation.68Bile Duct StricturesBenign bile duct strictures can have numerous causes. However, the vast majority are related to operative injury, most commonly during cholecystectomy. Other causes include fibrosis due to chronic pancreatitis, common bile duct stones, acute cholan-gitis, biliary obstruction due to cholecystolithiasis (Mirizzi’s syndrome), sclerosing cholangitis, cholangiohepatitis, and stric-tures of a | Surgery_Schwartz. results in less than half of patients. Surgical management with resection of the extrahepatic biliary tree and hepaticojejunostomy has produced reasonable results in patients with extrahepatic and bifurcation strictures, but without cirrhosis or significant hepatic fibrosis.68 In patients with pri-mary sclerosing cholangitis and advanced liver disease, liver transplantation is the only option. It offers excellent results, with overall 5-year survival as high as 85%. Unfortunately, recur-rence of PSC can occur in 10% to 20% of patients and may require retransplantation.68Bile Duct StricturesBenign bile duct strictures can have numerous causes. However, the vast majority are related to operative injury, most commonly during cholecystectomy. Other causes include fibrosis due to chronic pancreatitis, common bile duct stones, acute cholan-gitis, biliary obstruction due to cholecystolithiasis (Mirizzi’s syndrome), sclerosing cholangitis, cholangiohepatitis, and stric-tures of a |
Surgery_Schwartz_9389 | Surgery_Schwartz | pancreatitis, common bile duct stones, acute cholan-gitis, biliary obstruction due to cholecystolithiasis (Mirizzi’s syndrome), sclerosing cholangitis, cholangiohepatitis, and stric-tures of a biliary-enteric anastomosis. Bile duct strictures that go unrecognized or are improperly managed can lead to severe complications such as recurrent cholangitis, secondary biliary cirrhosis, and portal hypertension.69Bile duct strictures most commonly result in recurrent episodes of cholangitis but may present with isolated jaundice without infection. Liver function tests usually show evidence of cholestasis with elevations of bilirubin and alkaline phosphatase. Imaging with ultrasound or CT can show dilated bile ducts proximal to the stricture, as well as provide informa-tion about the level of the stenosis. MRCP gives more detailed anatomic information about the location and the degree of dilatation. If the diagnosis remains in question, cholangiog-raphy (endoscopic or more rarely | Surgery_Schwartz. pancreatitis, common bile duct stones, acute cholan-gitis, biliary obstruction due to cholecystolithiasis (Mirizzi’s syndrome), sclerosing cholangitis, cholangiohepatitis, and stric-tures of a biliary-enteric anastomosis. Bile duct strictures that go unrecognized or are improperly managed can lead to severe complications such as recurrent cholangitis, secondary biliary cirrhosis, and portal hypertension.69Bile duct strictures most commonly result in recurrent episodes of cholangitis but may present with isolated jaundice without infection. Liver function tests usually show evidence of cholestasis with elevations of bilirubin and alkaline phosphatase. Imaging with ultrasound or CT can show dilated bile ducts proximal to the stricture, as well as provide informa-tion about the level of the stenosis. MRCP gives more detailed anatomic information about the location and the degree of dilatation. If the diagnosis remains in question, cholangiog-raphy (endoscopic or more rarely |
Surgery_Schwartz_9390 | Surgery_Schwartz | level of the stenosis. MRCP gives more detailed anatomic information about the location and the degree of dilatation. If the diagnosis remains in question, cholangiog-raphy (endoscopic or more rarely percutaneous) will outline the biliary tree, define the stricture and its location, and allow for therapeutic interventions (Fig. 32-28). The treatment of biliary strictures depends on the location and the cause of the stricture. Percutaneous or endoscopic dilatation and/or stent placement will provide good results in more than one half of Type IIIType IIType IType VType IVbType IVaFigure 32-27. Classification of choledochal cysts. Type I, fusiform or cystic dilations of the extrahepatic biliary tree, is the most common type, making up >50% of the choledochal cysts. Type II, saccular diverticulum of an extrahepatic bile duct. Rare, <5% of choledochal cysts. Type III, bile duct dilatation within the duodenal wall (choledochoceles), makes up about 5% of choledochal cysts. Types IVa and IVb, | Surgery_Schwartz. level of the stenosis. MRCP gives more detailed anatomic information about the location and the degree of dilatation. If the diagnosis remains in question, cholangiog-raphy (endoscopic or more rarely percutaneous) will outline the biliary tree, define the stricture and its location, and allow for therapeutic interventions (Fig. 32-28). The treatment of biliary strictures depends on the location and the cause of the stricture. Percutaneous or endoscopic dilatation and/or stent placement will provide good results in more than one half of Type IIIType IIType IType VType IVbType IVaFigure 32-27. Classification of choledochal cysts. Type I, fusiform or cystic dilations of the extrahepatic biliary tree, is the most common type, making up >50% of the choledochal cysts. Type II, saccular diverticulum of an extrahepatic bile duct. Rare, <5% of choledochal cysts. Type III, bile duct dilatation within the duodenal wall (choledochoceles), makes up about 5% of choledochal cysts. Types IVa and IVb, |
Surgery_Schwartz_9391 | Surgery_Schwartz | of an extrahepatic bile duct. Rare, <5% of choledochal cysts. Type III, bile duct dilatation within the duodenal wall (choledochoceles), makes up about 5% of choledochal cysts. Types IVa and IVb, mul-tiple cysts, make up 5% to 10% of choledochal cysts. Type IVa affects both extrahepatic and intrahepatic bile ducts, whereas type IVb cysts affect the extrahepatic bile ducts only. Type V (Caroli disease), intrahepatic biliary cysts, is very rare and makes up 1% of choledochal cysts.Brunicardi_Ch32_p1393-p1428.indd 141811/02/19 2:44 PM 1419GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32patients. For persistent or complex strictures, surgical resec-tion and reconstruction with Roux-en-Y choledochojejunos-tomy or hepaticojejunostomy may be necessary and will result in good or excellent outcomes in 80% to 90% of patients.70 Choledochoduodenostomy may be a choice for strictures in the distal-most part of the common bile duct if a tension free repair can be achieved.INJURY TO THE | Surgery_Schwartz. of an extrahepatic bile duct. Rare, <5% of choledochal cysts. Type III, bile duct dilatation within the duodenal wall (choledochoceles), makes up about 5% of choledochal cysts. Types IVa and IVb, mul-tiple cysts, make up 5% to 10% of choledochal cysts. Type IVa affects both extrahepatic and intrahepatic bile ducts, whereas type IVb cysts affect the extrahepatic bile ducts only. Type V (Caroli disease), intrahepatic biliary cysts, is very rare and makes up 1% of choledochal cysts.Brunicardi_Ch32_p1393-p1428.indd 141811/02/19 2:44 PM 1419GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32patients. For persistent or complex strictures, surgical resec-tion and reconstruction with Roux-en-Y choledochojejunos-tomy or hepaticojejunostomy may be necessary and will result in good or excellent outcomes in 80% to 90% of patients.70 Choledochoduodenostomy may be a choice for strictures in the distal-most part of the common bile duct if a tension free repair can be achieved.INJURY TO THE |
Surgery_Schwartz_9392 | Surgery_Schwartz | outcomes in 80% to 90% of patients.70 Choledochoduodenostomy may be a choice for strictures in the distal-most part of the common bile duct if a tension free repair can be achieved.INJURY TO THE BILIARY TRACTGallbladderInjuries to the gallbladder itself are uncommon but can occur in the setting of penetrating trauma (gunshot or stab wounds) or medical procedures (liver biopsy or surgery). Nonpenetrating trauma to the gallbladder is extremely rare but can cause con-tusion, avulsion, laceration, rupture, or traumatic cholecystitis. Regardless of the etiology of gallbladder injury, the treatment of choice is cholecystectomy. The prognosis is typically good but depends on the extent of related injury, as damage to nearby organs is not uncommon.Extrahepatic Bile DuctsRarely, penetrating trauma to the extrahepatic bile ducts does occur, and it is usually associated with trauma to other viscera. The vast majority of injuries to the extrahepatic bili-ary system, however, are iatrogenic, | Surgery_Schwartz. outcomes in 80% to 90% of patients.70 Choledochoduodenostomy may be a choice for strictures in the distal-most part of the common bile duct if a tension free repair can be achieved.INJURY TO THE BILIARY TRACTGallbladderInjuries to the gallbladder itself are uncommon but can occur in the setting of penetrating trauma (gunshot or stab wounds) or medical procedures (liver biopsy or surgery). Nonpenetrating trauma to the gallbladder is extremely rare but can cause con-tusion, avulsion, laceration, rupture, or traumatic cholecystitis. Regardless of the etiology of gallbladder injury, the treatment of choice is cholecystectomy. The prognosis is typically good but depends on the extent of related injury, as damage to nearby organs is not uncommon.Extrahepatic Bile DuctsRarely, penetrating trauma to the extrahepatic bile ducts does occur, and it is usually associated with trauma to other viscera. The vast majority of injuries to the extrahepatic bili-ary system, however, are iatrogenic, |
Surgery_Schwartz_9393 | Surgery_Schwartz | to the extrahepatic bile ducts does occur, and it is usually associated with trauma to other viscera. The vast majority of injuries to the extrahepatic bili-ary system, however, are iatrogenic, usually occurring during cholecystectomy. These injuries are among the most feared and litigated complications in surgery, and can result in sig-nificant morbidity.71,72 Biliary tract injury can also occur during common bile duct exploration, division or mobilization of the duodenum during gastrectomy, or dissection of the hepatic hilum during liver resections.The incidence of bile duct injury during cholecystectomy is estimated to be relatively low (about 0.2%).73 While ini-tial experience with laparoscopic cholecystectomy appeared to show a higher rate of injury to the bile ducts compared to the open approach, these trends appear to be disappearing as lapa-roscopic technology and familiarity with the techniques of the procedure have improved.53 A number of different factors are thought to be | Surgery_Schwartz. to the extrahepatic bile ducts does occur, and it is usually associated with trauma to other viscera. The vast majority of injuries to the extrahepatic bili-ary system, however, are iatrogenic, usually occurring during cholecystectomy. These injuries are among the most feared and litigated complications in surgery, and can result in sig-nificant morbidity.71,72 Biliary tract injury can also occur during common bile duct exploration, division or mobilization of the duodenum during gastrectomy, or dissection of the hepatic hilum during liver resections.The incidence of bile duct injury during cholecystectomy is estimated to be relatively low (about 0.2%).73 While ini-tial experience with laparoscopic cholecystectomy appeared to show a higher rate of injury to the bile ducts compared to the open approach, these trends appear to be disappearing as lapa-roscopic technology and familiarity with the techniques of the procedure have improved.53 A number of different factors are thought to be |
Surgery_Schwartz_9394 | Surgery_Schwartz | open approach, these trends appear to be disappearing as lapa-roscopic technology and familiarity with the techniques of the procedure have improved.53 A number of different factors are thought to be associated with bile duct injury during laparo-scopic cholecystectomy. These include acute or chronic inflam-mation, obesity, anatomic variations, and surgical technique. Inadequate exposure or failure to correctly identify structures before ligating or dividing them are the most common causes of significant biliary injury (see “Anatomic Variants” section). Excessive cephalad retraction of the gallbladder may align the cystic duct with the common bile duct, and the latter may then be mistakenly clipped and divided. Careless use of electrocau-tery can lead to thermal injury. Dissection deep into the liver parenchyma may cause injury to intrahepatic ducts, and poor clip placement close to the hilar area or to structures not well visualized can result in a clip across a bile | Surgery_Schwartz. open approach, these trends appear to be disappearing as lapa-roscopic technology and familiarity with the techniques of the procedure have improved.53 A number of different factors are thought to be associated with bile duct injury during laparo-scopic cholecystectomy. These include acute or chronic inflam-mation, obesity, anatomic variations, and surgical technique. Inadequate exposure or failure to correctly identify structures before ligating or dividing them are the most common causes of significant biliary injury (see “Anatomic Variants” section). Excessive cephalad retraction of the gallbladder may align the cystic duct with the common bile duct, and the latter may then be mistakenly clipped and divided. Careless use of electrocau-tery can lead to thermal injury. Dissection deep into the liver parenchyma may cause injury to intrahepatic ducts, and poor clip placement close to the hilar area or to structures not well visualized can result in a clip across a bile |
Surgery_Schwartz_9395 | Surgery_Schwartz | deep into the liver parenchyma may cause injury to intrahepatic ducts, and poor clip placement close to the hilar area or to structures not well visualized can result in a clip across a bile duct.74,75Techniques to avoid injury to the bile ducts during chole-cystectomy are important to understand. The use of an angled, 30° or 45° laparoscope instead of an end-viewing camera will help visualize the anatomic structures, in particular those around the triangle of Calot. An angled scope also will aid in the proper placement of clips. The routine use of intraoperative cholangi-ography during every cholecystectomy as a method to prevent bile duct injury remains controversial.55 Nonetheless, the fre-quency of bile duct injuries is cut by 50% when an intraop-erative cholangiogram is performed. Critical to the successful use of cholangiography is accurate interpretation of the imag-ing. It is important to check that the whole biliary system fills with contrast, including both major ducts on | Surgery_Schwartz. deep into the liver parenchyma may cause injury to intrahepatic ducts, and poor clip placement close to the hilar area or to structures not well visualized can result in a clip across a bile duct.74,75Techniques to avoid injury to the bile ducts during chole-cystectomy are important to understand. The use of an angled, 30° or 45° laparoscope instead of an end-viewing camera will help visualize the anatomic structures, in particular those around the triangle of Calot. An angled scope also will aid in the proper placement of clips. The routine use of intraoperative cholangi-ography during every cholecystectomy as a method to prevent bile duct injury remains controversial.55 Nonetheless, the fre-quency of bile duct injuries is cut by 50% when an intraop-erative cholangiogram is performed. Critical to the successful use of cholangiography is accurate interpretation of the imag-ing. It is important to check that the whole biliary system fills with contrast, including both major ducts on |
Surgery_Schwartz_9396 | Surgery_Schwartz | Critical to the successful use of cholangiography is accurate interpretation of the imag-ing. It is important to check that the whole biliary system fills with contrast, including both major ducts on the right and the left hepatic duct, and that there is no extravasation of contrast. While routine use may reduce or limit the extent of injury, or help identify it early, it does not seem to prevent it entirely.76 No consensus recommendation exists on the use of selective versus routine cholangiography.Perhaps the most universally agreed upon method for mitigating the risk of bile duct injury during laparoscopic cholecystectomy is obtaining the critical view of safety. This requires that the hepatocystic triangle is dissected free of fat and fibrous tissue, the lower third of the gallbladder is sepa-rated from the cystic plate, and there are two and only two structures running into the gallbladder, the cystic duct, and the cystic artery (see Fig. 32-23).54 Newer technologies such as | Surgery_Schwartz. Critical to the successful use of cholangiography is accurate interpretation of the imag-ing. It is important to check that the whole biliary system fills with contrast, including both major ducts on the right and the left hepatic duct, and that there is no extravasation of contrast. While routine use may reduce or limit the extent of injury, or help identify it early, it does not seem to prevent it entirely.76 No consensus recommendation exists on the use of selective versus routine cholangiography.Perhaps the most universally agreed upon method for mitigating the risk of bile duct injury during laparoscopic cholecystectomy is obtaining the critical view of safety. This requires that the hepatocystic triangle is dissected free of fat and fibrous tissue, the lower third of the gallbladder is sepa-rated from the cystic plate, and there are two and only two structures running into the gallbladder, the cystic duct, and the cystic artery (see Fig. 32-23).54 Newer technologies such as |
Surgery_Schwartz_9397 | Surgery_Schwartz | is sepa-rated from the cystic plate, and there are two and only two structures running into the gallbladder, the cystic duct, and the cystic artery (see Fig. 32-23).54 Newer technologies such as fluorescence cholangiography to help identify biliary anatomy intraoperatively have shown promising early results, though large-scale applications remain to be seen.77Diagnosis. Only about 25% of major bile duct injuries (com-mon bile duct or hepatic duct) are recognized at the time of surgery. In these cases, intraoperative bile leakage, recognition of the correct anatomy, or an abnormal cholangiogram led to the diagnosis of a bile duct injury. In those that go unrecognized at the time of surgery, more than half will re-present within the first month postoperatively, though some can present months or years later with strictures, cholangitis, or cirrhosis from a remote bile duct injury.4Figure 32-28. An endoscopic retrograde cholangiography show-ing stricture of the common hepatic duct | Surgery_Schwartz. is sepa-rated from the cystic plate, and there are two and only two structures running into the gallbladder, the cystic duct, and the cystic artery (see Fig. 32-23).54 Newer technologies such as fluorescence cholangiography to help identify biliary anatomy intraoperatively have shown promising early results, though large-scale applications remain to be seen.77Diagnosis. Only about 25% of major bile duct injuries (com-mon bile duct or hepatic duct) are recognized at the time of surgery. In these cases, intraoperative bile leakage, recognition of the correct anatomy, or an abnormal cholangiogram led to the diagnosis of a bile duct injury. In those that go unrecognized at the time of surgery, more than half will re-present within the first month postoperatively, though some can present months or years later with strictures, cholangitis, or cirrhosis from a remote bile duct injury.4Figure 32-28. An endoscopic retrograde cholangiography show-ing stricture of the common hepatic duct |
Surgery_Schwartz_9398 | Surgery_Schwartz | months or years later with strictures, cholangitis, or cirrhosis from a remote bile duct injury.4Figure 32-28. An endoscopic retrograde cholangiography show-ing stricture of the common hepatic duct (arrow). The patient had recently had a laparoscopic cholecystectomy; clips from the opera-tion can be seen projected over the common bile duct.Brunicardi_Ch32_p1393-p1428.indd 141911/02/19 2:44 PM 1420SPECIFIC CONSIDERATIONSPART IIBile duct injuries typically result in either leaks or obstruc-tions related to strictures. Bile leak, most commonly from the cystic duct stump, a transected aberrant right hepatic duct, or a lateral injury to the main bile duct, usually presents with abdom-inal pain, fever, and a mild elevation of liver function tests. If a drain was placed at the time of surgery, bilious fluid may be seen. A CT scan or ultrasound can show either a fluid collection in the gallbladder fossa (biloma), or free fluid (bile) in the peri-toneum (Fig. 32-29A). ERCP (Fig. 32-29B) or | Surgery_Schwartz. months or years later with strictures, cholangitis, or cirrhosis from a remote bile duct injury.4Figure 32-28. An endoscopic retrograde cholangiography show-ing stricture of the common hepatic duct (arrow). The patient had recently had a laparoscopic cholecystectomy; clips from the opera-tion can be seen projected over the common bile duct.Brunicardi_Ch32_p1393-p1428.indd 141911/02/19 2:44 PM 1420SPECIFIC CONSIDERATIONSPART IIBile duct injuries typically result in either leaks or obstruc-tions related to strictures. Bile leak, most commonly from the cystic duct stump, a transected aberrant right hepatic duct, or a lateral injury to the main bile duct, usually presents with abdom-inal pain, fever, and a mild elevation of liver function tests. If a drain was placed at the time of surgery, bilious fluid may be seen. A CT scan or ultrasound can show either a fluid collection in the gallbladder fossa (biloma), or free fluid (bile) in the peri-toneum (Fig. 32-29A). ERCP (Fig. 32-29B) or |
Surgery_Schwartz_9399 | Surgery_Schwartz | bilious fluid may be seen. A CT scan or ultrasound can show either a fluid collection in the gallbladder fossa (biloma), or free fluid (bile) in the peri-toneum (Fig. 32-29A). ERCP (Fig. 32-29B) or HIDA scan can be utilized to better localize the site of the bile leak.Obstruction or stricture should be suspected in patients with progressive elevations of liver function tests or jaundice after cholecystectomy. CT scan or ultrasound can demonstrate the dilated part of the biliary tree, and may identify the level of the bile duct obstruction. MRI cholangiography, if available, provides an excellent, noninvasive delineation of the biliary anatomy both proximal and distal to the injury. Endoscopic or percutaneous cholangiography may also be helpful to confirm the diagnosis, depending on the location and type of injury.Management. The management of bile duct injuries depends on the type, extent, and level of the injury, as well as the tim-ing of its diagnosis. Initial proper treatment of | Surgery_Schwartz. bilious fluid may be seen. A CT scan or ultrasound can show either a fluid collection in the gallbladder fossa (biloma), or free fluid (bile) in the peri-toneum (Fig. 32-29A). ERCP (Fig. 32-29B) or HIDA scan can be utilized to better localize the site of the bile leak.Obstruction or stricture should be suspected in patients with progressive elevations of liver function tests or jaundice after cholecystectomy. CT scan or ultrasound can demonstrate the dilated part of the biliary tree, and may identify the level of the bile duct obstruction. MRI cholangiography, if available, provides an excellent, noninvasive delineation of the biliary anatomy both proximal and distal to the injury. Endoscopic or percutaneous cholangiography may also be helpful to confirm the diagnosis, depending on the location and type of injury.Management. The management of bile duct injuries depends on the type, extent, and level of the injury, as well as the tim-ing of its diagnosis. Initial proper treatment of |
Surgery_Schwartz_9400 | Surgery_Schwartz | location and type of injury.Management. The management of bile duct injuries depends on the type, extent, and level of the injury, as well as the tim-ing of its diagnosis. Initial proper treatment of bile duct injury can avoid the development of further complications or bile duct strictures. If an injury is discovered that exceeds the capacity of the available surgical expertise, the patient should be transferred to a tertiary care center. In these situations, drains should be placed in the surgical bed and antibiotics initiated. If a complete obstructive transection has occurred, it may also be necessary to place a percutaneous transhepatic drainage catheter to decom-press the biliary tree prior to transfer.If identified at the time of surgery, bile leaks from small bile ducts (<3 mm) or those draining a single hepatic segment can safely be ligated. If the injured duct is ≥4 mm, however, it is likely to drain multiple segments or an entire lobe and thus needs to be repaired or | Surgery_Schwartz. location and type of injury.Management. The management of bile duct injuries depends on the type, extent, and level of the injury, as well as the tim-ing of its diagnosis. Initial proper treatment of bile duct injury can avoid the development of further complications or bile duct strictures. If an injury is discovered that exceeds the capacity of the available surgical expertise, the patient should be transferred to a tertiary care center. In these situations, drains should be placed in the surgical bed and antibiotics initiated. If a complete obstructive transection has occurred, it may also be necessary to place a percutaneous transhepatic drainage catheter to decom-press the biliary tree prior to transfer.If identified at the time of surgery, bile leaks from small bile ducts (<3 mm) or those draining a single hepatic segment can safely be ligated. If the injured duct is ≥4 mm, however, it is likely to drain multiple segments or an entire lobe and thus needs to be repaired or |
Surgery_Schwartz_9401 | Surgery_Schwartz | mm) or those draining a single hepatic segment can safely be ligated. If the injured duct is ≥4 mm, however, it is likely to drain multiple segments or an entire lobe and thus needs to be repaired or reimplanted. Minor injuries to the com-mon bile duct or the common hepatic duct are traditionally managed with placement of a T-tube that has been modified by cutting the ends to allow for its placement in and removal from the bile duct (see Fig. 32-18). If the injury is small, the T-tube may be placed through it as if it were a formal choledochotomy. In more extensive injuries, the T-tube should be placed through a separate choledochotomy and the injury closed over the T-tube end to minimize the risk of subsequent stricture formation.Major bile duct injuries identified intraoperatively such as complete transection of the common hepatic or common bile duct are best managed at the time of injury. In many of these major injuries, the bile duct has not only been transected, but a variable | Surgery_Schwartz. mm) or those draining a single hepatic segment can safely be ligated. If the injured duct is ≥4 mm, however, it is likely to drain multiple segments or an entire lobe and thus needs to be repaired or reimplanted. Minor injuries to the com-mon bile duct or the common hepatic duct are traditionally managed with placement of a T-tube that has been modified by cutting the ends to allow for its placement in and removal from the bile duct (see Fig. 32-18). If the injury is small, the T-tube may be placed through it as if it were a formal choledochotomy. In more extensive injuries, the T-tube should be placed through a separate choledochotomy and the injury closed over the T-tube end to minimize the risk of subsequent stricture formation.Major bile duct injuries identified intraoperatively such as complete transection of the common hepatic or common bile duct are best managed at the time of injury. In many of these major injuries, the bile duct has not only been transected, but a variable |
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