SURGERY I

Surgical Management of Hepato-Biliary and

Pancreatic Diseases Part I
Miguel C. Mendoza, M.D., F.P.C.S.

CHOLECYSTITIS & CHOLELITHIASIS o increased amylase and lipase

 Inflammation of the gallbladder secondary to gallbladder o gallbladder pancreatitis
stones  penetrating in character
 Gallbladder stones (Cholelithiasis) is the most common cause  relieved by leaning forward
of cholecystitis  aggravated when supine due to celiac nerve
 Fever, bloatedness, RUQ pain radiating to the right shoulder compression
or scapula especially after having fatty food intake several o When stones are drained into the intestines, it is favourable.
hours before But if it is lodged into the ducts, bile flow is obstructed. Bile
 Most common disease in the hepatobiliary system is acute that is produced by the liver 800-1500ml per day backflows
and chronic cholecystitis. And the most common cause of to the lliver parenchyma and backflows to the systemic
cholecystitis is stones in the gallbladder. The reason for this is circulation.
an imbalance of metabolism or dissolution of cholesterol in o Patient will have fever because of bacteria; jaundice
the body. This is associated with hereditary, factors, and in because bile accumulates in the connective tissue. And
gallbladder diseases itself, that’s why stones are patient may have abdominal pain.
accumulated. Diagnostics
 Gallbladder is thin walled. But if in the case of chronic
Imaging techniques
cholecystitis, the gallbladder inflammation is recurrent,
 If the patient presented with RUQ pain and recurrent bouts of
causing the thickening of the gallbladder wall.
bloatedness precipitated by fatty food intake, the best
Complications procedure is the Ultrasound
Obstruction of the cystic duct  X-Ray Some physicians will just request for an abdominal x-
 Hydrops of gallbladder - the white bile (mucus that is ray.
secreted by the lining of the gallbladder) and when there are o An oral cholecystogram. The ingested dye is absorbed
stones obstructing the duct, there is failure of the mucus to by the biliary system, and it will now outline the gallbladder
drain into the bile duct and intestine →excessive lumen. You will see any filling defect as stone. Or you
accumulation of mucus. won’t see the gallbladder at all because of the obstruction
 Empyema – when there are stones, there is higher of stone in the cystic duct that prevented the dye from
occurrence of bacteria ◊ causing the empyema of the reaching the gallbladder. Used if (-) US, CT Scan. Not
gallbladder (empyema: pus in the gallbladder) used today.
 Gangrene – because of the distension of the gallbladder, it
will cause compromised circulation causing the gangrene.
 Perforation – there is perforation and spillage of bile to
peritoneal cavity ◊will cause bile peritonitis that will lead to
sepsis.
Obstruction of the common bile duct (CBD)
Cholangitis
o Charcots triad
 If the patient has FEVER, JAUNDICE AND
ABDOMINAL PAIN L: Calcified gallstones in the gallbladder. R: Air in gallstones in
 manifestation of cholangitis or the infection of biliary the gall bladder
tree.
o Reynold’s Pentad
 If Charcot’s triad worsens, patient will develop
hypotension and changes in the sensorium leading to
Reynold’s pentad.
 This means bacteria have gone into systemic circulation
and patient may have septicemia or overwhelming
infection.
1. Fever Bile with calcium in the gall bladder
2. jaundice
3. right upper quadrant pain
4. septic shock
5. mental status changes
Pancreatitis
o With CBD obstructing pancreatic duct
o If obstructed at the distal common bile duct and the
pancreatic duct, even pancreatic enzymes will not flow to the
intestine, in this case, there will be pancreatic enzymes back
flow into the pancreas, and autodigestion, May develop
inflammation, edema, bleeding, necrosis and infection of the Porcelain gallbladder. Calcifications in the gallbladder wall:
pancreas. GALLBLADDER CARCINOMA. (Surgery should not be delayed
o Severe epigastric pain radiating to the back, this condition is even if the patient is asymptomatic because the occurrence of
called gallstones pancreatits. carcinoma in porcelain gallbladder is high).

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 CT scan
o not a standard procedure
o very expensive
o inferior to ultrasonography in diagnosing gallstones.
o The major application of CT scan is to define the course
and status of the extrahepatic biliary tree and adjacent
structures.
o It is the test of choice in evaluating the patient with
suspected malignancy of the gallbladder, the extrahepatic (Left) normal. (Right) abnormal. In the diseased image, notice the
biliary system, or nearby organs, in particular, the head of acoustic shadowing of the gallbladder stone (with an arrow)
the pancreas.
Liver function tests
 Elevated SGPT (serum glutamic-pyruvic transaminase), but
not as high with viral hepatitis where you have SGPT in the
1000 range.
 Elevated alkaline phosphatase because of obstruction in
biliary system. Alkaline phosphatiae is produced by the lining
of the bile duct.
 Elevation of bilirubin levels
o B1 – indirect, uncojugated
Scan of abdominal region. Gallbladder on the liver bed. You o B2 – direct. Conjugated
will sometimes see stones in the gallbladder CT Scan (Vertebra o In an obstructed biliary tree, conjugation has already
at lower middle; Liver at left side). occurred, you’ll see high B2 levels.
 High prothrombin time – PTT measures extrinsic factors
 Ultrasound (primarily produced by liver)
o The 1st diagnostic test you will request for is the
ULTRASOUND of the gallbladder, liver, biliary tree!!! Treatment
o more than 90% accuracy  Not really medical but surgical (removal of gallbladder and
o It is the best test because it is available, inexpensive and stones) = Cholecystectomy
the results are there right away. In the ultrasound, you can  You already have a diseased gallbladder and stones may be
see if there is any dilation in the biliary tree. produced again in the future.
o the ultrasound waves have poor penetration of air filled  Gallbladder is an accessory organ, if it is removed, it won’t
structures like duodenum. And remember that the affect the feeding of the patient. just like appendectomy (no
common bile duct is behind the duodenum and you won’t bad effect on the patient).
see stones in the distal portion of biliary tree because of
the air-filled duodenum. But in this case, you’ll see dilation Laparoscopic cholecystectomy
of the proximal biliary tree w/c can be interpreted as  standard (procedure of choice)
probable stones in the biliary tree  the patient is asleep, in general anesthesia
o Stones are acoustically dense and reflect the ultrasound  Advantages of Laparoscopic Cholecystectomy (from an
waves back to the ultrasonic transducer. Because stones industry-driven procedure to a patient-driven procedure. But
block the passage of sound waves to the region behind more expensive)
them, they also produce an acoustic shadow o Shorter hospital stay
 Stones move with changes in position. o Faster recovery period
 Polyps may be calcified and reflect shadows, but do o Less postoperative pain
not move with change in posture. o Less suppression of the immune system
o A thickened gallbladder wall and local tenderness indicate o Less infection
cholecystitis. -The patient has acute cholecystitis if a layer o Earlier return to work
of edema is seen within the wall of the gallbladder or o Earlier return to normal activitiesCosmetically more
between the gallbladder and the liver in association with acceptable scar
localized tenderness. When a stone obstructs the neck of  Absolute Contraindications
the gallbladder, the gallbladder may become very large, o Severe cardiac disease
but thin walled. o Severe pulmonary disease
o A contracted, thick-walled gallbladder is indicative of o Uncorrectable bleeding disorders
chronic cholecystitis. o absolute contraindications are uncontrolled coagulopathy
o Frequently, the site and, sometimes, the cause of and end-stage liver disease (Schwartz)
obstruction can be determined by ultrasound. Small
stones in the common bile duct frequently get lodged at
the distal end of it, behind the duodenum, and are,
therefore, difficult to detect.
o A dilated common bile duct on ultrasound, small stones in
the gallbladder, and the clinical presentation allow one to
assume that a stone or stones are causing the obstruction.
o Periampullary tumors can be difficult to diagnose on
ultrasound, but beyond the retroduodenal portion, the level
of obstruction and the cause may be visualized quite well.
Ultrasound can be helpful in evaluating tumor invasion and
flow in the portal vein, an important guideline for
resectability of periampullary and pancreatic head tumors.

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STEP 1: 4 incisions (which are not visible after 6months)
o 1 cm at belly button (inserted here is the laparoscope)
o 1 cm epigastric area (inserted is the endoclip)
o ½ cm at RMCL at R subcostal area
o ½ cm at right anterior axillary line at the right subcostal area.
STEP 2: Insufflation
o Abdomen insufflated with CO2 because it is inert, easily
absorbed and easily excreted and not combustible. We
insufflate to have a working area.
STEP 3: Cutting of cytic artery and duct
o Gallbladder identified at the liver bed. It is lifted up
o Identify and cut the cystic artery (a branch of right hepatic
artery)
o Identify, clip and cut the cystic duct (sometimes,
cholangiogram is used to visualize if there are stones in the
common bile duct.
 cystic artery- main blood supply of the gallbladder
 cystic duct- connects the gallbladder to the common bile
duct
o Indications for Cholangiogram
 History of jaundice
 Recurrent attacks of pancreatitis
 Elevated alkaline phosphatase
 Elevated total bilirubin with a conjugated
hyperbilirubinemia
o Injection of contrast medium thru a catheter inserted into the
cystic duct. Injected with contrast medium, fills up the biliary
tree and then do X-ray. If there are stones (remove by a
common bile duct exploration – CBDE)
STEP 4: Gallbladder is removed, placed inside a specimen
bag (sometimes a condom) and removed thru the umbilicus.
o Sometimes, gallbladder can’t come out of the belly button
because of the stones. Open up the gallbladder, remove
stones then extract the organ.
CHOLEDOCHOLITHIASIS
 Stones in the Bile Duct
 Cholelithiasis- stones in the GALLBLADDER
 Choledocholithiasis- stones in the BILE DUCT
SCHWARTZ:
o Common bile duct stones are found in 6-12 % of patients
with stones in the gallbladder
o Primary common bile duct stones
 Formed within the gallbladder and migrate down the
cystic duct to the common bile duct
 More common in Western countries
 Usually cholesterol stones
o Secondary common bile duct stones
 Formed in the bile ducts
 More common in Asians
 Usually brown pigment stones
 Associated with biliary stasis and infection
o Clinical manifestations
 may be silent and often are discovered incidentally.
 may cause obstruction, complete or incomplete
 may manifest with cholangitis or gallstone pancreatitis.
 Pain - 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 epigastric
or right upper quadrant tenderness as well as mild
icterus are common.
 Intermittent symptoms, such as pain and transient
jaundice, occur when a stone temporarily impacts the
ampulla but subsequently moves away, acting as a ball
valve
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 Resolution of symptoms occur when the small stone
may pass through the ampulla spontaneously
 Progression of symptoms occur when the stones
become completely impacted causing sever jaundice.
o Laboratory findings
 Elevation of serum bilirubin, alkaline phosphatase, and
transaminases are commonly seen. However, 1/3 of
patents have normal liver chemistries
Complications
Bile duct obstruction
 Cholangitis- manifests as Charcot’s triad (fever, chills,
abdominal pain)
 Cirrhosis-because of backflow of bile in the liver parenchyma
 Pancreatitis-because the stone obstructs the pancreatic duct
and there will be inflammation and edema of the pancreas
Ascending cholangitis
 Fever, chills, Abdominal pain, and Jaundice (Charcot’s Triad)
 Plus Hypotension and Sensorial Changes (Reynold’s Pentad)
 manifestation of septicemia or overwhelming infections
Hyperbilirubinemia
 Mostly conjugated type
 elevated B2 (direct bilirubin)
 presents as icteric sclera and pruritus (because the bile
deposits in the collagen tissue)
DIagnostics
Intraoperative cholangiogram
 During cholecystectomy, a contrast media is injected into the
biliary tree to visualize through X-ray presence of stones.
 Indications: history of jaundice, recurrent pancreatitis and
increase alkaline phosphatase level.
 Cholangiogram (also see Laparoscopic Cholecystectomy) is
used if the presence of stones is not yet established
 looks for any filling defects
Ultrasound of hepatobiliary tree
 only good if the obstruction is in the proximal part of the CBD
 Distal CBD obstructions cannot be directly seen using this
procedure due to its location behind the duodenum (air-filled
structure that is poorly infiltrated by ultrasound wave).
 this is used to see if the condition is obstructive in nature,
surgical, or another condition
 the problem with US: stones are more common in the distal
parts; difficulty in air-filled structures
 Initial test
 Useful for documenting and determining the size of the stones
 A dilated common bile duct (>8 mm) on UZ in patients with
gallstones, jaundice, and biliary pain is highly suggestive of
common bile duct stones
Endoscopic retrograde cholangio-pancreatography ( ERCP)
 A side viewing endoscope passed through the mouth down
into the duodenum.
 The ampulla of Vater is cannulated using a thin plasti catheter
and contrast material is injected into the CBD to visualize
stones with the help of X-ray.
 Filling defect stone; tumor in the ampulla , no filling defect.
 Gold standard
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 Advantage of providing a therapeutic option at the time of
diagnosis
 Cannulation of the ampulla of Vater and diagnostic
cholangiography are achieved in >90% of cases.
Treatments
Non-surgical treatment
Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
with Stone Extraction and Endoscopic Sphincterotomy (ES)
o can be diagnostic and therapeutic
o Electrocauterization of the sphincter of Oddi to relax the
diameter of the distal CBD, facilitating stone passage
o Stones freely pass through the widened sphincter and goes
out of the body with feces
Stone Extraction
o Endoscopic balloon extraction
(Left) Balloon is deflated  pass the catheter beyond the stone
 inflate the balloon and pull out the catheter together with the
inflated balloon and stone  Stones then goes out the body
through the feces.
(Right) ERCP of the CBD. See the filling defect (arrow) where the
stone is.
o Endoscopic stone basket extraction
 just like the Balloon extraction this time using a basket.
Basket is not yet deployed, goes beyond the stone the
basket is open and stone is catch in the basket and
goes out into the mouth.
o Schedule the patient for an operation to remove the stone as
a definitive procedure
o Temporary measure only: to allow the passage of bile, but
the stone is still inside
o Used if despite all measures, the stone/s cannot be
extracted
 Retained or recurrent stones following cholecystectomy are
best treated endoscopically.
o Retained – if the stones were deliberately left in place at
the time of surgery or diagnosed shortly fter the
cholecystectomy
o Recurrent – diagnosed months or years later
 Patients >70 yrs old presenting with bile duct stones should
have their ductal stones cleared endoscopically. Studies
comparing surgery to endoscopic treatment have documented
less morbidity and mortality for endoscopic treatment in this
group of patients.
Surgical treatment
 if ERCP is not effective
 GOAL: to relieve the patient of the bile stone to prevent
cholangitis.
Open common bile duct exploration (Open CBDE)
o Manual
o Choledochoscope
o Open CBDE is an option if the endoscopic method has
already been tried and is, for some, reason, not feasible
Laparoscopic common bile duct exploration
o Transcystic choledochoscopy
 A choledochoscope is inserted in the cystic duct
 A basket is passed through the working channel of the
scope and stone is entrapped under direct vision.
o Trans CBD choledochoscopy
 If the stone is large and cannot pass thorough the cystic
duct.
 Small incision in the CBD.
 Insert a scope go the the distal CBD basket the stone
and pull it out.
Points to remember
 The first option of treatment is ERCP  if not possible then
laparoscopically  Open surgery (Less invasive to more
invasive treatment)
 Indication of common bile duct exploration (CBDE): presence
of stone in the bile duct
 Knowing the difference between primary and secondary stone
is important because they have different treatment.
PRIMARY STONE SECONDARY STONE
Originate from the gallbladder
Originates from the CBD then gets lodged down the bile
duct

Tubular (assume the shape of Round shaped (assumes shape

CBD of GB)

(Left) Endoscopic stone basket extraction Brown, earthy and easily Lighter color, hard
(Right) Nasobiliary stenting crushable

o Endoscopic lithotripsy Recurent stones >2 years after Retained stones < 2 years after
 Stones that are too big to be extracted are first the cholecystectomy procedure the cholecystectomy
subjected to high frequency sound waves or mechanical
means to shatter them into smaller manageable pieces Usually seen in Asian
for extraction without damaging the surrounding
structures Treatment of primary bile duct stones
Nasobiliary stenting  Caused by stasis of bile. Inadequate flow of bile from the liver
o Temporary measure to prevent sepsis (Cholangitis) to the bile duct forming a stone due to a narrow bile duct.
o To facilitate the release of bile in the intestinal tract  Treatment: remove the stone and facilitate the drainage of
o Uses an endoscope for guidance. Placing a stent in the bile bile in the intestinal tract.
duct to allow bile to flow from the liver to the intestinal tract.

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 Operative Treatment Options:
o Sphincteroplasty – increase the diameter of sphincter of
Oddi.
o Choledochoduodenostomy- performed by mobilizing the
2nd part of the duodenum and anastomosing it side to
side with the common bile duct (side to side technique)
o Choledochojejunostomy
 Loop -a loop of jejunum is anastomose to the CBD
 Roux-en-Y - done by bringing up a 45-cm Roux-en-Y
limb of jejunum and anastomosing it end to side to the
choledochus.
 This procedure may be the best option in cases wherein
the stones impacted in the ampulla may be difficult for
both endoscopic ductal clearance as well as common
bile duct exploration (open or laparoscopic). In these
cases, the common bile duct is usually quite dilated (2
cm)
NOTE: The next topic is from SCHWARTZ
OPERATIVE INTERVENTIONS
Cholecystostomy
 Decompresses and drains the distended, inflamed, hydropic,
or purulent gallbladder
 Applicable if the patient is not fit to tolerate an abdominal
operation
 Ultrasound-guided percutaneous drainage with a pigtail
catheter is the procedure of choice
o the catheter is passed through the abdominal wall, liver,
and into the gallbladder
o By passing the catheter through the liver, the risk of bile
leakage around the catheter is minimized
 Gallbladder can be removed later
Cholecystectomy
 most common major abdominal procedure performed in the
Weatern countries
 laparoscopic cholecystectomy is the treatement of choice for
symptomatic gallstones
 Absolute contraindications
o Uncontrolled coagulopathy
o End-stage liver disease
o Rarely, patients with sever obstructive pulmonary disease
or congestive heart failure may not tolerate
pneumoperitoneum with carbon dioxide and require open
cholecystectomy.
 When important anatomic structures cannot be clearly
identified or when no progress is made over a set period of
time, a conversion to an open procedure is usually indicated
 Patients undergoing cholecystectomy should have:
o CBC and liver functions tests preop
o Prophylaxis against DVT with either LMW Heparin or
compression stockings
o Emptied their bladder before coming to the operating room
Laparoscopic cholecystectomy
 procedure is discussed above
Open cholecystectomy
 Usually performed either as a conversion from laparoscopic
cholecystectomy or as a second procedure in patients who
require laparotomy fot another reason
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Intraoperative Cholangiogram or Ultrasound
 Intraoperative cholangiogram
o Injecting contrast through a catheter placed in the cytic
duct
o Routine intraoperative cholangiography will detect sones
in approximately 7% of patients
 Intraoperative ultrasound
o As accurate as cholangiogram in detecting common bile
duct stones and is less invasive
o Requires more skill to perform and interpret
Choledochal Exploration
 Common bile duct stones that are detected intraoperatively
on intraoperative cholangriography or ultrasound may be
managed with laparoscopic choledochal exploration
 If the stones in the duct are small, they may sometimes be
flushed into the duodenum with saline irrigation via the
cholangiography catheter after the sphincter of Oddi has been
relaxed with glucagon
 If irrigation is unsuccessful, a balloon catheter may be passed
via the cystic duct and down the common bile duct, where it is
inflated and withdrawn to retrieve the stones.
 When the duct has been cleared, the cytic duct is ligated and
cut and the cholecystectomy is completed. Occassionaly, a
choledochotomy, incision ino the common bile duct, is
necessary. The choledochotomy is sutured with a T tube ledt
in the common bile duct with one end taken out through the
abdominal wall for decompression of the bile ducts.
Choledochal Drainage Procedures
 Used when stones cannot be cleared and/or when the duct is
very dilated (larger than 1.5 cm)
 Choledochoduodenostomy
o Performed by mobilizing the second part of the duodenum
 Cheledochohehunostomy
o Done by brining up a 45.cm Roux-en-Y imb of te jejunum
and anastomosing it end to side to the choledochus
o Can be used to repair common bile duct strictures or as a
palliative procedure for malignant obstruction in the
periampullary region
Transduodenal Sphincterotomy
 If an open procedure for common bile duct stones is being
done in which the stones are impacted, recurrent, or multiple,
the transduodenal approach may be feasible
 The duodenum is incised traversely, then the sphincter is
incised at the 11 o’clock position to avoid injury to the
pancreatic duct.
REFERENCES
th
1. Schwartz Principles of Surgery 9 Edition
2. Dr. Mendoza’s Powerpoint presentation
3. 2013B Transcription
Llabres, Ramos, Relampagos
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