Gastro 54 Biliary System Gall stones CBD stones

• In normal bile the cholesterol, phospholipids and bile salts remain in optimum concentration.This keeps the cholesterol in solution.
• Bile supersaturated with cholesterol is known as lithogenic bile as this predisposes to gallstone formation.

• Lithogenic bile -
• • Increase cholesterol- obesity,diet
• • Decrease bile acids- OCPs, genetic factors,PBC,ileal disease, ileal resection
• • Increase bilirubin- Hemolytic Anemia

• Nucleation 
• • Excess pronucleating factors-e.g. mucin
• • Decreased anti- nucleating factors- e.g. Apolipoproteins

• Stasis or hypomotility of gall bladder
• • OCPs
• • Vagotomy
• • Fasting
• • Pregnancy
• • Prolonged parenteral nutrition

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

• Acute onset of pain in right upper quadrant of abdomen
• May radiate to back of chest or shoulder.
• Pain may last for few minutes to several hours.
• Precipitated by a fatty meal.
• Attacks of pain are usually self-limiting, but recur in an unpredictable manner.
• Fever and leukocytosis are uncommon.

Prophylactic cholecystectomy is not indicated in all patients with silent gallstones. In long follow-up it is established that the chance of developing symptomsis approximately 1% per year. So, only 20% patient have the chance of developing symptomsover 20 years. 

• Hemolytic anemias, such as sickle cell anemia
• Por­celain gallbladder,
• Large (>2.5-cm) gallstones,
• Long common channel of bile and pancreatic ducts all have a higher risk of gallbladder cancer
• Asymptomatic gall­stones undergoing bariatric surgery
• Prior to receipt of an organ transplant

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

• The Rouviere’s sulcus is a fissure on the inferior surface of the liver between the right lobe and caudate process and is clearly seen during posterior dissection during laparoscopic cholecystectomy. 
• Dissection should be above the sulcus to prevent bile duct injury.

• present with classic symptoms of calculous biliary disease but have no ultrasonographic evidence of stones or sludge.
•  These patients will have other diagnoses excluded by CT and upper endoscopy,
• should undergo a CCK-stimulated HIDA scan.
• An ejection fraction less than one third at 20 minutes following CCK administration in patients without stones is considered diagnostic of dyskinesia,
• managed with cholecystectomy or  ERCP with sphincterotomy

• Exploration and enterotomy are required to relievethe obstruction.
• A longitudinal incision is made on the antimesenteric border of the ileum, a few centimeters proximal to the impacted stone. The stone can then be milked back through the enterotomy.
• The site of impaction is at risk for ischemia and pressure necrosis, with eventual perforation.
• any suggestion of non viability of this region should mandate resection.
• The remainder of the small intestine should be inspected.

• Chronic abscess,
• Fistula,
• Wound infection
• Bowel obstruction.

• cholecystitis
• presence of pigmented stones,
• number of stones (>15), and
• performance of the operation by surgical resident.

• dissolution with oral bile salt therapy, 
• contact dissolution, which requires cannulation of the gallbladder and infusion of organic solvent,
• extracorporeal shock wave lithotripsy. Extracorporeal shock wave lithotripsy has a lower recurrence rate, approximately 20%, and can be used in patients with single stones 0.5 to 2 cm in size

Calots triangle in Open surgery and Laparoscopic surgery is different 

• In Open surgery - 
• Laterally - cystic duct 
• Medially - CHD
• Superiorly - cystic artery 

Laparoscopic 

• Below by the cystic duct
• Medially by the common hepatic duct
• Above by the inferior surface of the liver.

The triangle is crossed by the cystic artery.

Calots triangle of laparoscopic surgery is two times the calots triangle of open surgery

• Inability to tolerate GA
• End stage liver disease with portal Hypertension
• Coagulopathy
• Severe COPD and Congestive Heart Failure are relative contraindications

• Abnormal hepatic function panel
• Anomalous or confusing biliary anatomy
• Inability to perform postoperative ERCP
• Dilated biliary tree
• Any suspicion of choledocholithiasis

• 1st - hepatorenal pouch of Morrison to retract the hepatic flexure
• 2nd - to retract transverse colon and the duodenum
• 3rd - medially to retract the stomach.

Mini-cholecystectomy - incision less than 5 cm

• „ Cholesterol stone
• „ Pigment stone - brown or black 
• „ Mixed stone.

• Brown stones - associated with infection
• Black stones - associated with chronic hemolytic diseases.

Primary  stones arise de novo in the bile duct. Primary choledocholithiasis is generally from brown pigment stones, which are a combination of precipitated bile pigments and cholesterol. Stones which form within the bile duct 2 years after initial operation are grouped as recurrent stones. This has the characteristics of primary bile duct stones. About 99% of primary bile duct stones are pigment type.

Secondary  stones pass from the gallbladder into the bile duct. Retained (residual) stones are the secondary stones found within 2 years following cholecystectomy.

• In patients with biliary pain, gallstones, and jaundice, a dilated bile duct (>8 mm) is highly suggestive of choledocholithiasis, even if common duct stones are not documented ultrasonographically.
• Even without symptoms of biliary colic, a dilated bile duct in the presence of gallstones suggests choledocholithiasis.
• ERCP is highly sensitive and specific for choledocholithiasis
• Alternatively, MRCP is highly sensitive (>90%) with an almost 100% specificity for the diagnosis of common duct stones

• Cholangitis
• Biliary pancreatitis
• Limited experience of the surgeon with common duct exploration
• Patients with multiple comorbidities

• ERCP with sphincterotomy followed by cholecystectomy.
• Lap CBD Exploration - CBD is accessed by transcystic approach or Choledochotomy
• Open common bile duct exploration.

• Large stones - Stones >1. 5 cm is not suitable for extraction endoscopically unless there is facility for contact lithotripsy. 
• Intrahepatic stones
• Multiple stones,
• Altered gastric or duodenal anatomy
• Impacted stones on ampulla
• Duodenal diverticula

Through a Seldinger technique or use of a balloon catheter, the cystic duct is gently dilated to allow passage of a flexible choledochoscope to CBD. 

Contraindications includes - 

• Stones in the common hepatic duct above the cystic duct insertion
• Small, Friable cystic duct
• Numerous stones (>8)
• Large stones (>1cm)

Longitudinal incision is made in the common bile duct (i.e., below the cystic duct), stone extraction performed  and a T tube should be placed through the choledochotomy and the bile duct closed with 4-0 absorbable sutures. Completion cholangiography through the T tube documents stone removal.


Contraindication of Choledochotomy includes small caliber of bile duct (<6mm) – which can be strictured on closure

In the condition of inability to clear all the stones from the distal duct, the following procedures are done: 

• A.Nondilated biliary tree
• - Transduodenal sphincteroplasty - 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

B. Dilated biliary tree

• 1. Choledochoduodenostomy - continues to allow endoscopic access to the entire biliary tree, may lead to Sump syndrome.
• 2. Roux-en-Y choledochojejunostomy - provides excellent drainage of the biliary tree without a risk of sump syndrome, does not allow future endoscopic evaluation of the biliary tree

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. 

When choledochoduodenostomy is done, bile duct distal to the anastomosis does not drain well and may collect debris that obstructs the anastomosis or the pancreatic duct, a process known as sump syndrome.

Extraction of Stone from T-tube

Benign condition by impaction of stone in neck of gall bladder, which in time induces sufficient pericholecystic inflammation to narrow and obstruct CHD.

Type 1: external compression of the common bile duct – 11%.

Type 2: cholecystobiliary fistula is present involving less than one-third the circumference of the bile duct – 41%.

Type 3: a fistula is present involving upto two-third the  circumference of the bile duct – 44%.

Type 4: a fistula is present with complete destruction of the wall of the bile duct – 4%

●Type I – Partial or total cholecystectomy, either laparoscopic or open. Common bile duct exploration is typically not required.

●Type II – Cholecystectomy plus closure of the fistula, either by suture repair with absorbable material, T tube placement, or choledochoplasty with the remnant gallbladder.

●Type III – Choledochoplasty or bilioenteric anastomosis (choledochoduodenostomy, cholecystoduodenostomy, or choledochojejunostomy) depending on the size of the fistula. Suture of the fistula is not indicated.

●Type IV – Bilioenteric anastomosis, typically choledochojejunostomy, is preferred because the entire wall of the common bile duct has been destroyed.

Single Incision Laparoscopic Surgery Laparoscopic surgery is done through one 20mm incision (cut) at the umbilicus. 

• SILS v/s Conventional Laparoscopy
• • Cosmetically superior
• • Lesser pain and decreased need for analgesics
• • Earlier recovery
• • Earlier return to activity
• • Applicable to many common surgical conditions – GB stones, Appendicitis, Hernia, to name a few

• Disadvantages of SILS
• - Restricted degrees of freedom of movement
• - Number of ports that can be used
• - Proximity of the instruments to each other during the operation all of which increase the complexity and technical challenges of the operation.

• NOTES - Natural orifice translumenal endoscopic surgery. 
• LESS - Laparo-endoscopic single-site surgery

3. Enumerate the diagnostic method and treatment modalities in acute pancreatitis. 2056

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