Therapeutic options in biliary

disease
Dr Jun Kit Koong
Department of Surgery
 Outline
• Biliary anatomy
• Common biliary disorders
• Intervention in biliary disorders
 Introduction
Definition of therapeutic – relating to the
healing of a disease. May take the form of
intervention (surgical or non surgical) and
medicine (drugs)
Biliary anatomy
Biliary anatomy
 Biliary disorders

Benign Malignant

Biliary
disorders
 Biliary disorders

CAN BE INTRAHEPATIC
Benign AND EXTRAHEPATIC

1. Gallstone disease – Cholecystitis,

Empyema, Mucocoele
2. Inflammation - Benign stricture
Biliary 3. Infection – Cholangitis
4. Autoimmune - Primary Sclerosing
disorders Cholangitis (potentially malignant)
5. Congenital – Choledochal cyst (potentially
malignant); Biliary atresia
 Biliary disorders

CAN BE INTRAHEPATIC
Malignant AND EXTRAHEPATIC

1. Neoplastic – Cholangiocarcinoma,
Periampullary carcinoma, Gallbladder CA,
Metastatic lymph node
Biliary 2. Autoimmune - Primary Sclerosing
Cholangitis (potentially malignant)
disorders 3. Congenital – Choledochal cyst (potentially
malignant)
 Presentation
• Jaundice
• Abdominal pain
• Fever
• Weight loss
• Poor appetite
• Abdominal mass
Therapeutic options
Non
Surgical
surgical

Curative
Percutaneous
intent

Palliation Endoscopy
Therapeutic options

Non Percutaneuous
surgical
 Percutaneous
• Interventional radiology

• Image guided
1. Ultrasound
2. CT scan
3. Angiography

• Purpose: -
1. To decompress or drain
2. Drugs delivery
3. Ablative techniques
 Decompression
• Percutaneous transhepatic biliary drainage
(PTBD): -
1. Obstructive jaundice with/out cholangitis
2. Causes: stones, tumour, stricture

• Percutaneous transhepatic cholecystostomy

(PTC): -
1. Severe cholecystitis
2. Gallbladder empyema
 Others
• Loco-regional therapy
1. Transarterial chemo-embolization (TACE)
2. Selective internal radiation therapy (SIRT)

• Ablative technique
1. Radiofrequency ablation (RFA)
2. Microwave
3. Cryotherapy
Therapeutic options

Non Endoscopy
surgical
 Endoscopy
• Mainly ERCP – endoscopic retrograde
cholangiopancreatography

• Oral cholangioscopy

• Spyglass

• OGDS – stent placement e.g stomach stent for gastric

outlet obstruction in advanced malignancy
 ERCP
• Not diagnostic
• Allows imaging of the biliary tree and pancreatic
duct (contrast on image intensifier)

• Sphincterotomy

• Purpose: -
1. Stent placement – plastic or metal
2. Removal of stone – basket or lithotriptor
3. Cytobrushing of stricture
Image from Courtesy
of JAMA network
 ERCP
• Complications: -
1. Bleeding
2. Infection – ascending cholangitis
3. Pancreatitis
4. Perforation
Therapeutic options

Surgical Curative intent

 Surgery
• Types of surgery depending on pathology –
benign or malignant

• Malignant disease need staging and

determination of resectability before
proceeding

• Intra-operative choledochoscopy may be

required for gallstones disease
 Hepatolithiasis & Choledocholithiases
• Stones in the extrahepatic and intrahepatic system

• CBD exploration is performed and intra-op

choledochoscopy done and stones retrieve via basket or
balloon trawling

• Closure of CBD: either T-tube or Roux-en Y

hepaticojejunostomy (may have blind roux limb attached to
anterior abdominal wall)

• For hepatolithiasis, a hepatectomy or liver resection is

performed if unable to retrieve the stones
 Cholangiocarcinoma
• Takes 3 forms:
1. Intrahepatic
2. Hilar (Klatskin)
3. Extrahepatic

• Surgical treatment based on location

1. Hepatectomy with/out bile duct reconstruction – (1)
and (2)
2. CBD excision or Whipple’s op – (3)

• Porta hepatis lymph node clearance

Picture courtesy of John
Hopkins Medicine
 Gallbladder cancer
• Considered part of biliary system

• Requires good pre-operative evaluation before

surgery

• May or may not need liver resection (e.g.

segment 4/5 or wide liver resection)

• Porta hepatis lymph node clearance

Therapeutic options

Surgical
Palliative
 Palliative
• Usually methods in the non-surgical modality
such as PTBD or ERCP is sufficient for the
treatment of advanced malignancy

• Long term PTBD if cannot internalised the

stent or replaced with internal stent via ERCP
rendezvous procedure
 Palliative
• Advanced malignancy and lesion not resectable

• Surgical bypass:
1. Hepaticojejunostomy
2. Gastrojejunostomy
3. Cholecystojejunostomy

• Either omega loop or Roux-en Y reconstruction.

Therapeutic options in biliary
disease

THANK YOU
jkkoong@um.edu.my