MANEJO COMPLEJO DE LA ENFERMEDAD BILIAR POR CALCULOS

Indications Open Common Bile Duct Exploration Clearance of biliary obstruction due to calculus disease if endoscopic techniques (eg, endoscopic retrograde cholangiopancreatography) are unavailable, have failed, or are not feasible due to patient anatomy or status. Transduodenal Sphincteroplasty Impacted stone at the ampulla of Vater. Previous attempt at common bile duct exploration. Most often performed at the time of cholecystectomy when common bile duct exploration has failed to clear a stone impacted in the distal common bile duct. Choledochoduodenostomy Unresectable malignant distal common bile duct obstruction, as a palliative procedure. Benign strictures of the distal common bile duct. Salvage drainage procedure in the presence of large primary stones or numerous stones in the distal common bile duct.

Contraindications Open Common Bile Duct Exploration Absolute None. Relative Previous biliary bypass. Transduodenal Sphincteroplasty Absolute None. Relative Fibrotic ampulla. Inability to pass a 3-mm probe through the ampulla. Abnormal-appearing ampulloduodenal junction on cholangiography. Common bile duct diameter > 2 cm. Long common bile duct stricture. Choledochoduodenostomy Absolute Duodenal obstruction. Relative Primary resection of the obstructing lesion or clearance of the obstructing calculi. Nondilated bile duct. Proximal duodenal inflammation. Potential duodenal obstruction. Sclerosing cholangitis.

Informed Consent Open Common Bile Duct Exploration Expected Benefits Removal of the stone (or stones) from the common bile duct. Prevention of cholangitis and cholestatic liver injury. Potential Risks Bleeding requiring transfusion or reoperation. Retained bile duct stones requiring prolonged T-tube drainage, additional procedures by interventional radiology, or possible additional surgical intervention. Bile leak requiring prolonged T-tube drainage. Iatrogenic injury to the biliary tree or duodenum. Surgical site infection requiring drainage or antibiotics. Transduodenal Sphincteroplasty Expected Benefits Removal of the stone (or stones) from the distal common bile duct. Prevention of cholangitis and cholestatic liver injury. Potential Risks Bleeding requiring transfusion or reoperation. Bile leak requiring prolonged drainage, drain placement, or reoperation. Duodenal leak. Iatrogenic injury to the bile duct or duodenum. Pancreatitis. Biliary stricture. Surgical site infection requiring incision and drainage or antibiotics. Choledochoduodenostomy Expected Benefits Restoration of enteric biliary drainage. Prevention of cholangitis and cholestatic liver disease. Potential Risks Bleeding requiring transfusion or reoperation. Bile leak requiring prolonged drainage, drain placement, or reoperation. Surgical site infection requiring drainage or antibiotics. Conversion to choledochojejunostomy if choledochoduodenostomy cannot be performed.

Equipment Open Common Bile Duct Exploration Cholangiography catheter with occluding balloon. Contrast material, diluted to half strength if necessary. Imaging capability for intraoperative cholangiography, either fluoroscopy or plain film. Flexible choledochoscope with a working port and Dormia basket for stone extraction. Glassman stone extractors. Fogarty biliary catheter. No. 14 or 16 French T-tube. Bakes biliary dilators. Transduodenal Sphincteroplasty Surgical magnification loupes may be beneficial. No. 14 French T-tube. Choledochoduodenostomy No special equipment required.

Patient Preparation Nothing by mouth the evening before surgery. Magnetic resonance cholangiopancreatography may be useful to define biliary anatomy. Serum transaminases, total bilirubin, alkaline phosphatase, coagulation studies (PT, PTT). Coagulopathies should be treated with vitamin K, fresh frozen plasma, or both, accordingly. Anesthesiology consultation as needed. Preoperative broad-spectrum antibiotics.

Patient Positioning For all procedures, the patient should be supine.

Procedure Open Common Bile Duct Exploration General anesthesia with endotracheal intubation is required. Open common bile duct exploration is most often performed at the time of cholecystectomy. Incision and exposure: A right upper quadrant incision is made parallel to the right costal margin. This is approximately 3 fingerbreadths below the costal margin and should extend from the right of midline to the right anterior axillary line. If not previously completed, a cholecystectomy is performed. Using an abdominal retractor, the liver is elevated superiorly and the small bowel is packed inferiorly. A Kocher maneuver is performed to mobilize the first and second portions of the duodenum. Intraoperative cholangiography through the cystic duct stump should be performed before beginning common bile duct exploration in order to define the location and extent of calculi. Figure 12–1: The common bile duct is identified and its anterior aspect is dissected in preparation for longitudinal choledochotomy. If the location of the common bile duct is in question, cholangiography or aspiration of bile will confirm its identity. Stay sutures of 4-0 silk are placed on either side of the planned incision on the anterior wall of the common bile duct. A 1.0–1.5-cm incision is made longitudinally immediately distal to the cystic duct along the anterior aspect of the common bile duct between the previously placed 4-0 silk sutures. If not previously done, cholangiography should be performed. The common bile duct should be palpated from the choledochotomy distally through the head of the pancreas. Any palpable calculi may be "milked" proximally for extraction through the choledochotomy. Figure 12–2: Several maneuvers can be used to clear calculi from the bile duct. Bakes biliary dilators can be used to gently dilate the bile duct and aid in stone retrieval. A Fogarty balloon catheter can be passed through the choledochotomy distally and through the ampulla. The catheter can then be withdrawn back into the distal common bile duct and the balloon inflated to drag stones proximally and through the choledochotomy. Care must be taken to avoid either duodenal or biliary injury by excessive force on the catheter or overinflation of the balloon. Choledochoscopy can be performed using a flexible choledochoscope with a working port through which a Dormia wire basket can be placed for stone retrieval and extraction. A Glassman stone extractor may be passed distally into the bile duct, while maintaining tactile feedback of the instrument by direct palpation. The surgeon may be able to palpate the stone through the anterior duodenal wall and place it into the stone extractor to be removed. Figure 12–3: After the stone is extracted and a completion cholangiogram is performed confirming complete clearance of the bile duct, a 14 or 16 French T-tube is inserted through the choledochotomy. The choledochotomy is then closed over the T-tube limbs with interrupted 4-0 absorbable monofilament sutures. The tube is brought out through a separate stab incision in the anterior abdominal wall and connected to gravity drainage. A closed suction drain is placed posterior to the bile duct. Figure 12–1 Figure 12–2 Figure 12–3 Transduodenal Sphincteroplasty General anesthesia with endotracheal intubation is required. Sphincteroplasty is most often performed at the time of cholecystectomy when common bile duct exploration has failed to clear a stone impacted in the distal common bile duct. Incision and exposure: A right upper quadrant incision is made parallel to the right costal margin. This is approximately 3 fingerbreadths below the costal margin and should extend from the right of midline to the right anterior axillary line. If not previously completed, a cholecystectomy is performed. Using an abdominal retractor, the liver is elevated superiorly and the small bowel is packed inferiorly. A Kocher maneuver is performed to mobilize the first and second portions of the duodenum. Intraoperative cholangiography through the cystic duct stump should be performed in order to define the location and extent of calculi. Figure 12–4: Stay sutures of 4-0 silk are placed and a 1.0–1.5-cm anterior choledochotomy is performed in preparation for common bile duct exploration. If not previously done, cholangiography and common bile duct exploration should be performed. A Fogarty balloon catheter or a fine probe is placed through the choledochotomy and distally through the ampulla in order to identify the ampulla for duodenotomy. Stay sutures of 2-0 silk are placed on either side of the planned longitudinal duodenal incision. Using needle tip electrocautery, a 5-cm longitudinal duodenotomy is performed, centered directly over the ampulla. Figure 12–5A: Adequate exposure of the ampulla is required. If anterograde placement of either a fine probe or Fogarty biliary catheter was not possible, retrograde placement should be attempted to reliably identify the course of the common bile duct for sphincterotomy. Surgical magnification loupes may prove beneficial, particularly in identification of the pancreatic duct. Using needle tip electrocautery, the ampulla is opened for a distance of 4–5 mm in the 11 o'clock position. The cut edge of the ampulla is approximated to the duodenum using 4-0 or 5-0 interrupted absorbable monofilament sutures. The pancreatic duct should be identified and any injury to it avoided. Figure 12–5B: The ampulla can be incised with cautery another 4–5 mm with placement of sutures to approximate the ampulla to the duodenum as previously performed. The stone is either extracted through the opened sphincter or pushed proximally to be removed through the choledochotomy. Figure 12–5C: The sphincteroplasty is completed and the pancreatic duct identified. The duodenotomy is closed longitudinally in two layers. A running 3-0 braided absorbable suture is used for the inner layer followed by interrupted 3-0 silk sutures placed in a Lembert fashion. Care is taken not to narrow the duodenum. As with a common bile duct exploration, a T-tube should be placed and the choledochotomy closed as previously described. A closed suction drain should be placed lateral to the duodenotomy. The abdominal wall is closed in a routine manner. Figure 12–4 Figure 12–5A–C Choledochoduodenostomy General anesthesia is required. Incision and exposure: A right subcostal or an upper midline incision is made. General abdominal exploration is performed. Figure 12–6: Cholecystectomy. A generous Kocher maneuver is performed and the first and second portions of the duodenum are mobilized from the foramen of Winslow distally. The anterior aspect of the common bile duct is dissected and exposed from the cystic duct stump to the proximal extent of the obstruction. The surgeon should ensure that the duodenum can be easily elevated to the common bile duct, allowing a tension-free anastomosis. Stay sutures of 4-0 silk are placed on either side of the planned anterior longitudinal choledochotomy. A 2–2.5-cm longitudinal incision is made, centered on the anterior common bile duct below the cystic duct entrance. If the procedure is performed for biliary calculi, the common bile duct is palpated for stones and "milked" proximally for removal. A common bile duct exploration can also be performed through the choledochotomy. A 1.5–2.0-cm longitudinal incision is made on the adjacent anterior aspect of the proximal duodenum. Figure 12–7: The anastomosis is begun using 4-0 absorbable monofilament sutures by placing corner anchoring sutures between the midportion of the choledochotomy and the edges of the duodenotomy in order to "tent" the anastomosis open. These should be tied on the outside. The anastomosis should employ full-thickness bites of both the bile duct and the duodenum in order to effect a duct-to-mucosa approximation. The posterior anastomosis is continued by approximating the distal portion of the choledochotomy to the superior edge of the duodenotomy, using interrupted 4-0 absorbable monofilament sutures. Waiting until the entire back row of sutures is placed before they are tied may aid in forming the anastomosis. Figure 12–8: Complete the anastomosis between the bile duct and duodenum by placing the anterior row of sutures. These are then tied and cut. Figure 12–9: The completed anastomosis is shown utilizing the longitudinal choledochotomy made at a right angle to the longitudinal duodenotomy in order to tent open the anastomosis. A closed suction drain may be placed adjacent to the anastomosis. It can be removed several days postoperatively if there is no bile in the drain. Figure 12–6 Figure 12–7 Figure 12–8 Figure 12–9

Postoperative Care Open Common Bile Duct Exploration A T-tube cholangiogram is performed on postoperative day 3. If there is no residual obstruction, it can be clamped to allow for internal biliary drainage. The T-tube can be removed in the office 3–4 weeks postoperatively. If there are retained calculi, the T-tube tract can be used for stone extraction by interventional radiology. Transduodenal Sphincteroplasty Nasogastric decompression via low continuous wall suction should be continued for 3–5 days to allow for resolution of transient duodenal obstruction from duodenal edema. After the nasogastric tube is removed, with the return of bowel function, clear liquids can be started and the diet advanced as tolerated. If no bilious output occurs after resumption of diet, the drain can be removed. Choledochoduodenostomy If no bilious output is noted, the drain can be removed a few days after the procedure. A nasogastric tube attached to low continuous wall suction should be continued for 3–4 days postoperatively. With the resolution of ileus, it can be discontinued and the diet advanced as tolerated.

Potential Complications Open Common Bile Duct Exploration Iatrogenic injury to the common bile duct or duodenum. Retained stone despite exploration. Bile leak from the T-tube. Cholangitis. Excessive bile loss requiring fluid replacement. Transduodenal Sphincteroplasty Iatrogenic injury to the pancreatic duct, bile duct, or duodenum. Bile leak, duodenal leak, or pancreatic leak. Wound infection or intra-abdominal abscess. Choledochoduodenostomy Bile leak. Stenosis of the anastomosis. "Sump" syndrome, which affects 1% of patients, occurs when debris collects in the distal segment of the bile duct below the anastomosis. This can cause obstruction of the anastomosis or even pancreatitis.

Pearls and Tips Open Common Bile Duct Exploration If there is evidence of bile leak (bile in the closed suction drain) or obstruction (elevated transaminases, bilirubin, jaundice) after the T-tube is clamped, immediately reinstitute gravity drainage and obtain a cholangiogram. If there is any sign of cholangitis, reconnect the T-tube to gravity drainage and start broad-spectrum antibiotics. Transduodenal Sphincteroplasty A combination of manipulation through the sphincteroplasty and choledochotomy may be required for severely impacted stones. To avoid injury, identify the pancreatic duct early. Choledochoduodenostomy A double-layer anastomosis is unnecessary and may narrow the anastomotic orifice. If the duodenum does not mobilize despite extensive Kocherization, a choledochojejunostomy may be a better choice.

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