biliary enteric bypass
TRANSCRIPT
Indications and surgical techniqueVictor H. Barnica
MCMC
FACTS
Only 20% of patients have resectable pancreatic tumors.
The remaining require some sort of palliation for relief of jaundice, actual or pending duodenal obstruction or pain.
Biliary drainage proceduresThere are three major options
Percutaneous transhepatic
Endoscopic papillotomy with internal biliary-duodenal stent.
Biliary enteric bypass
Biliary diversion procedures
Cholecysto jejunostomy
Choledocojejunostomy
Hepaticojejunostomy
Note: with or w/o gastroenteric bypass.
Biliary enteric bypassSurgical biliary enteric bypass has a viable role
in palliation in patients with unresectable periampullary tumors.
Particulary in younger, more fit patients, who are likely to survive a reasonable length of time.
Gastrojejunostomy can be coupled with a biliary enteric bypass in selected patients. (double bypass)
CholecystojenostomyThe use of the gallbladder for internal biliary
drainage is quick, effective and safe.
Conduit of choice when cystic duct is patent and enters the common duct well away (1cm) from the tumor mass.
The gallbladder should not be used if previously diseased or the cystic duct is narrow.
Cholecystojenostomy
A loop of jejunum is the preferred component of the bypass.
Roux-en-Y is the preferred technique for choledoco J and hepatico J.
Cholecystojenostomy
Who is a good candidate?
Patients who were operated on for cure and were found to have locally advanced disease. (peritoneal implants or liver mets).
CholecystojenostomyOperative TechniqueThe first loop of jejunum
is mobilized to the subhepatic space.
Approximated to the GB with a posterior row of seromuscular interrupted absorbable 4-0 or 3-0 sutures.
Using electrocautery and incision as long as possible in the GB body.
Shorter incision always on the Jejunum.
Cholecystojenostomy
Choledoco/HepaticojejunostomyIndications
Benign, mainly iatrogenic biliary strictures
Malignant obstruction of the biliary system, caused by pancreatic or duct wall tumors.
Rarely indicated for traumatic lesions or select instances of sclerosing cholangitis.
Choledoco/HepaticojejunostomyPreoperative assessment of the anatomy
should be attained by percutaneous or endoscopic cholagiography.
These catheters can be left in place to help the surgeon exploring a previously damaged or transected ductal system.
Removed once the anastomosis is healed and patent (1 to 2 weeks following repair)
Choledoco/HepaticojejunostomyThese patients may require the use of prophilactic
abx, parenteral vitamin K and possibly FFP.
Combination of ampicillin and gentamycin/amikacin or a third generation cephalosporin.
E coli, Klebsiella and streptococcus.
Bowel preparation is not always required.
Choledoco/HepaticojejunostomySurgical technique Right subcostal, right
paramedian or chevron incision.
Kocher maneuverMeticulous dissection
between duodenum and R lobe of liver.
Localization of the dilated bile duct.
Choledoco/HepaticojejunostomyTwo 4-0 traction
sutures above the stricture.
The common duct ligated with 00 suture below the stricture and divided below the traction sutures.
Bile for C+S should be sent.
Choledoco/HepaticojejunostomyCreation of a Roux-
en-Y conduit.The proximal
(afferent) limb is anastomosed to the distal defuntionalized jejunum.
The distal limb is brought to the bile duct in a retrocolic fashion.
45 to 75cm
Choledoco/HepaticojejunostomyWhen dealing with greatly dilated ducts and
end to end anastomosis can be performed.
Choledoco/HepaticojejunostomyEnd to side
anastomosis is more commonly performed.
Seromuscular stitches are placed to fix the two structures to each other.
5cm away from the jejunal closure, at the antimesenteric aspect.
Electrocautery
4-0 seromuscular
Choledoco/Hepaticojejunostomy
A first row of sutures placed in the anterior duct
wall
Appropriate retraction to
allow posterior wall closure
Once the posterior wall closed should complete the anterior wall.
Choledoco/Hepaticojejunostomy
Choledoco/HepaticojejunostomyIf the bile duct is too
narrow a side to side Y type anastomosis can be used.
The posterior wall is created by attaching first A to A, B to B and C to C.
The anterior wall created by attaching D to D.
D to A, D to B.
Hepatocholedocojejunostomy
Choledoco/Hepaticojejunostomy
When dealing with malignant obstruction, a simple biliary enteric bypass is advisable.
Choledoco/Hepaticojejunostomy
Also an end-to-side choledocojejunostomy can be done
Choledoco/HepaticojejunostomyPostoperative care
If the use of drain seems appropriate a closed system drain is left in the foramen of Winslow.
Removed 3-5 days postop if no bile leak.
Nasogastric tube and NPO 3 to 5 days depending on the patient’s condition and the return of bowel sounds and function.