Indications and surgical technique Victor 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 procedures

There 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 bypass

Surgical 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)

Cholecystojenostomy
The 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).

Cholecystojenostomy
Operative Technique The 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/Hepaticojejunosto my
Indications
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/Hepaticojejunosto my
Preoperative 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/Hepaticojejunosto my
These 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/Hepaticojejunosto my
Surgical technique Right subcostal, right

paramedian or chevron incision. Kocher maneuver Meticulous dissection between duodenum and R lobe of liver. Localization of the dilated bile duct.

Choledoco/Hepaticojejunosto my
Two 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/Hepaticojejunosto my
Creation 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/Hepaticojejunosto my
When dealing with greatly dilated ducts and

end to end anastomosis can be performed.

Choledoco/Hepaticojejunos tomy
End 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

Electrocautery

4-0 seromuscular

Choledoco/Hepaticojejunosto my

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/Hepaticojejunosto my

Choledoco/Hepaticojejunosto my
If the bile duct is too

narrow a side to side Hepatocholedocojejunostomy 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.

Choledoco/Hepaticojejunosto my
When dealing with

malignant obstruction, a simple biliary enteric bypass is advisable.

Choledoco/Hepaticojejunosto my
Also an end-to-side

choledocojejunostom y can be done

Choledoco/Hepaticojejunosto my
Postoperative 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 patients condition and the return of bowel sounds and function.