Biliary Enteric Bypass

transcript

Indications and surgical techniqueVictor H. Barnica

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 proceduresThere 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 bypassSurgical 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)

CholecystojenostomyThe 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).

CholecystojenostomyOperative TechniqueThe 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/HepaticojejunostomyIndications

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/HepaticojejunostomyPreoperative 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/HepaticojejunostomyThese 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/HepaticojejunostomySurgical technique Right subcostal, right

paramedian or chevron incision.

Kocher maneuverMeticulous dissection

between duodenum and R lobe of liver.

Localization of the dilated bile duct.

Choledoco/HepaticojejunostomyTwo 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/HepaticojejunostomyCreation 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/HepaticojejunostomyWhen dealing with greatly dilated ducts and

end to end anastomosis can be performed.

Choledoco/HepaticojejunostomyEnd 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 aspect.

Electrocautery

4-0 seromuscular

Choledoco/Hepaticojejunostomy

A first row of sutures placed in the anterior duct

Appropriate retraction to

allow posterior wall closure

Once the posterior wall closed should complete the anterior wall.

Choledoco/HepaticojejunostomyIf the bile duct is too

narrow a side to side 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.

D to A, D to B.

Hepatocholedocojejunostomy

When dealing with malignant obstruction, a simple biliary enteric bypass is advisable.

Also an end-to-side choledocojejunostomy can be done

Choledoco/HepaticojejunostomyPostoperative 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 patient’s condition and the return of bowel sounds and function.

Biliary Enteric Bypass

Documents