Biliary Tract

Glucagon

In patient with jaundice, if GB is palpable, it is not due to stones. In stone disease, GB is contracted and fibrosed, so not distended. 

• Exceptions of the law - 
• - Double impaction of stone, one in CBD and one is cystic duct 
• - Large stone in Hartman Pouch

Type I - Compression of CBD without lumen narrowing 

Type II - Compressing causing CBD lumen narrowing 

Type III - Comprssion causing CBD wall necrosis 

Type IV - Cholecysto-choledochal fistula

• Small, Friable cystic duct
• Numerous stones (>8)
• Large stones (>1cm)

Small caliber of bile duct (<6mm) – which can be strictured by closure

In choledochoduodenostomy, distal bile duct does not drain, debris collected that leads to occlusion of ampulla, pancreatitis, anastomotic stricture and cholangitis

Incision at 11 o’clock, avoid 5’clock (to avoid injury to pancreatic duct), duodenal mucosa sewn with bile duct mucosa with absorbable 4.0 suture

• Traction of fundus – Cystic duct overlies CHD, cystic duct is parallel with CHD
• Inferolateral traction of Infundibulum – dissociate these structures, opens calots triangle

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Bismuth form E1-5 for Enjury 

• RESUSCITATION 
• RESTITUTION (SNAP)
• - Sepsis, skin care
• - Nutrition
• - Anatomy - define intestinal anatomy
• - Plan
• RECONSTRUCTION
• REHABILITATION

At least 14F, 2.5cm of each limb, The back wall of vertical stem should be excised, V-shaped wedge fashioned at the junction of limbs, to facilitate subsequent removal

Biliary pathogens Clonarchis sinensis, Ascaris lumbroides populate biliary tree – secrete enzyme that hydrolyze water soluble bilirubin glucuronides to form bilirubin, that precipitates to brown pigment stone – obstruct biliary tree to cause recurrent cholangitis and eventually abscess or even cirrhosis

• Ulcerative Colitis
• Riedel Thyroiditis

Chain of lakes, Diverticular like outpouch, multiple short segment strictures

Long, Smooth, gradually tapered narrowing

Jaundice, Mass, Pain

Bailey 1098

• Type I – Atresia restricted to CBD
• Type II – Atresia of CHD
• Type III – Atresia of left and right Hepatic duct

For type II and III – Kasai Operation – Excision of biliary tract with Roux-en-Y loop of jejunum anastomosis with exposed area of liver capsule, above the bifurcation of portal vein

Extraction of Stone from T-tube

• Size >10mm 
• Age > 60 years 
• Symptomatic GB polyp disease

T1 - Tumor invades lamina propria (T1a) or Muscle layer (T1b) 

T2 - Perimuscular connective tissue 

T3 - Invade liver or any one of stomach, duodenum, colon or pancreas 

T4 - Invades two structures or Invasion to main portal vein or Hepatic artery

• T1a - Cholecystectomy 
• T1b, T2 - Extended Cholecystectomy 
• T3 - Radical Cholecystectomy 
• T4 - Paliative care 

Radical Cholecystectomy - GB + Segment IV, V and VIII (Trisegmentectomy)

T1 - Soliary Tumor without vascular invasion 

T2a - Solitary tumor with vascular invasion 

T2b - Multiple tumor with/without vascular invasion 

T3 - Tumor perforating the visceral peritoneum or involving extrahepatic structure by direct extension 

T4 - Tumor with periductal invasion

T1 - Tumor Confined to bile duct, with extension upto muscular layer or fibrous tissue 

T2a - Tumor invading beyond the wall of bile duct to surrounding adipose tissue 

T2b - Tumor invades adjacant Hepatic parenchyma 

T3 - Tumor invades unilateral branches of portal vein or hepatic artery 


T4 - Tumor invades main portal vein or its branches bilaterally or CHA or the secondaries, biliary radicals b/l or, Unilateral second order biliary radical with contralateral portal vein or hepatic artery involved

N1 - Node along cystic duct, CBD, Hepatic artery, or portal vein 

N2 - Periaortic, pericaval, SVC, Celiac artery nodes