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Indications and surgical technique Victor H.

Barnica MCMC

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 enteric bypass .Biliary drainage procedures There are three major options Percutaneous transhepatic Endoscopic papillotomy with internal biliary- duodenal stent.

Biliary diversion procedures Cholecysto jejunostomy Choledocojejunostomy Hepaticojejunostomy Note: with or w/o gastroenteric bypass. .

(double bypass) . who are likely to survive a reasonable length of time. more fit patients. Gastrojejunostomy can be coupled with a biliary enteric bypass in selected patients.Biliary enteric bypass Surgical biliary enteric bypass has a viable role in palliation in patients with unresectable periampullary tumors. Particulary in younger.

The gallbladder should not be used if previously diseased or the cystic duct is narrow. . effective and safe.Cholecystojenostomy The use of the gallbladder for internal biliary drainage is quick. Conduit of choice when cystic duct is patent and enters the common duct well away (1cm) from the tumor mass.

.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).

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.Cholecystojenostomy Operative Technique The first loop of jejunum is mobilized to the subhepatic space. Shorter incision always on the Jejunum.

Cholecystojenostomy .

Rarely indicated for traumatic lesions or select instances of sclerosing cholangitis. caused by pancreatic or duct wall tumors.Choledoco/Hepaticojejunosto my Indications Benign. mainly iatrogenic biliary strictures Malignant obstruction of the biliary system. .

Choledoco/Hepaticojejunosto my Preoperative assessment of the anatomy should be attained by percutaneous or endoscopic cholagiography. Removed once the anastomosis is healed and patent (1 to 2 weeks following repair) . These catheters can be left in place to help the surgeon exploring a previously damaged or transected ductal system.

. E coli.Choledoco/Hepaticojejunosto my These patients may require the use of prophilactic abx. Bowel preparation is not always required. parenteral vitamin K and possibly FFP. Combination of ampicillin and gentamycin/amikacin or a third generation cephalosporin. Klebsiella and streptococcus.

. right paramedian or chevron incision. Kocher maneuver Meticulous dissection between duodenum and R lobe of liver.Choledoco/Hepaticojejunosto my Surgical technique Right subcostal. 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.

The distal limb is brought to the bile duct in a retrocolic fashion.Choledoco/Hepaticojejunosto my Creation of a Roux- en-Y conduit. The proximal (afferent) limb is anastomosed to the distal defuntionalized jejunum. 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. at the antimesenteric Electrocautery 4-0 seromuscular . Seromuscular stitches are placed to fix the two structures to each other. 5cm away from the jejunal closure.

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. . The anterior wall created by attaching D to D. B to B and C to C.

.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 .

Removed 3-5 days postop if no bile leak.Choledoco/Hepaticojejunosto my Postoperative care If the use of drain seems appropriate a closed system drain is left in the foramen of Winslow. Nasogastric tube and NPO 3 to 5 days depending on the patient’s condition and the return of bowel sounds and function. .