CHAMBERLAIN Surgical relief of obstructive jaundice is indicated in benign as well as malignant strictures of the bile ducts and less

frequently for stone disease. Benign strictures are most commonly seen after injury to the common hepatic duct during cholecystectomy. A biliodigestive anastomosis of a jejunal Roux-en-Y loop to normal extrahepatic bile duct and proximal to the stricture provides the best results in these cases. Malignant strictures pose a different problem. If the lesion is resectable, one has to perform a hepaticojejunostomy to one or several intrahepatic bile ducts which can present a technical challenge. A biliodigestive bypass to an intrahepatic bile duct will provide excellent biliary decompression and palliation in the case of an unresectable bile duct cancer. Lastly, a biliodigestive anastomosis can be of use in complex stone disease. Choledochoduodenostomy A choledochoduodenostomy is infrequently used for the relief of biliary tract obstruction in malignant disease, and much more frequently for the patient with biliary obstruction due to gallstones. In the latter case, side-to-side choledochoduodenostomy is preferable. A choledochoduodenostomy is usually performed at the conclusion of a common bile duct exploration in lieu of T-tube placement.

Indications The single most important condition allowing the performance of a choledochoduodenostomy is an enlarged common bile duct. A duct measuring less than 12 mm in diameter is an absolute contraindication. The following are situations which are amenable to a choledochoduodenostomy. Contraindications include duodenal ulcer and acute pancreatitis. 1.Retained or recurrent stones in the common bile duct 2.Cholangitis 3.Ampullary stenosis 4.Primary common duct stones calculi or stasis bile 5.Tubular stricture of the transpancreatic portion of the Choledochus usually due to chronic pancreatitis 6.A combination of these above 7.Low iatrogenic stricture 8.Malignant obstruction in the periampullary area Technique Two technical criteria are essential for a proper choledocho-duodenostomy: a common duct of 1.4 cm in diameter at the minimum and a stoma size of 2.5 cm. The degree of satisfaction with the procedure will depend upon the development of a standard technique for the rapid construction of a stoma that allows free entry and egress from the common bile duct. While attempts are made to remove stones and particulate matter from the common bile duct, impacted stones at the distal common bile duct that are not easily retrieved, and stones in the hepatic duct are not pursued vigorously prior to the anastomosis. The duodenum is fully mobilized by a

Kocher maneuver and thus approximated toward the common bile duct. A duodenotomy is performed perpendicular to the choledochotomy. The anastomosis is performed either in an interrupted fashion or as a continuous suture.

SCHWARTZ Major bile duct injuries such as transection of the common hepatic or common bile duct are best managed at the time of injury. In many of these major injuries, the bile duct has not only been transected, but a variable length of the duct removed. This injury usually requires a biliary enteric anastomosis with a jejunal loop. Either an end-to-side Roux-en-Y choledochojejunostomy, or more commonly a Roux-en-Y hepatico-jejunostomy, should be performed. Transhepatic biliary catheters are placed through the anastomosis to stent it and to provide access to the biliary tract for drainage and imaging. Although rare, when the injury is to the distal common bile duct, a choledochoduodenostomy can be performed. If there is no or minimal loss of ductal length, a duct-to-duct repair may be done over a T tube that is placed through a separate incision. It is critical to perform a tension-free anastomosis to minimize the high risk of postoperative stricture formation. Major injuries diagnosed postoperatively require transhepatic biliary catheter placement for biliary decompression as well as percutaneous drainage of intra-abdominal bile collections, if any. When the acute inflammation has resolved 6 to 8 weeks later, operative repair is performed. Patients with bile duct stricture from an injury or as a sequela of previous repair usually present with either progressive elevation of liver function tests or cholangitis. The initial management usually includes transhepatic biliary drainage catheter placement for decompression as well as for defining the anatomy and the location and the extent of the damage. These catheters will also serve as useful technical aids during subsequent biliary enteric anastomosis. An anastomosis is performed between the duct proximal to the injury and a Roux loop of jejunum. Balloon dilatation of a stricture usually requires multiple attempts and rarely provides adequate long-term relief. OUTCOME Good results can be expected in 70 to 90% of patients with bile duct injuries. The best results are obtained when the injury is recognized during the cholecystectomy and repaired by an experienced biliary tract surgeon. The operative mortality rate varies from 0 to almost 30% in various series, but commonly is about 5 to 8%. Common complications that are specific for bile duct repairs include cholangitis, external biliary fistula, bile leak, subhepatic and subphrenic abscesses, and hemobilia. Restenosis of a biliary enteric anastomosis occurs in about 10% of patients, and may manifest up to 20 years after the initial procedure. Approximately two thirds of recurrent strictures become symptomatic within 2 years after repair. The more proximal strictures are associated with a lower success rate than are distal ones. The worst results are in patients with many operative revisions and in those who have evidence of liver failure and portal hypertension. However, previous repair does not preclude successful outcome of repeated attempts, particularly in patients with good liver function. Patients with deteriorating liver function are candidates for liver transplants.

The gallbladder is a pear-shaped sac, about 7 to 10 cm long, with an average capacity of 30 to 50 mL. When obstructed, the gallbladder can distend markedly and contain up to 300 mL. The left hepatic duct is longer than the right and has a greater propensity for dilatation as a consequence of distal obstruction. The two ducts join to form a common hepatic duct, close to their emergence from the liver. The common hepatic duct is 1 to 4 cm in length and has a diameter of approximately 4 mm. It lies in front of the portal vein and to the right of the hepatic artery. The common hepatic duct is joined at an acute angle by the cystic duct to form the common bile duct. The length of the cystic duct is quite variable. It may be short or absent and have a high union with the hepatic duct, or long and run parallel, behind, or spiral to the main hepatic duct before joining it, sometimes as far as at the duodenum. Variations of the cystic duct and its point of union with the common hepatic duct are surgically important. The common bile duct is about 7 to 11 cm in length and 5 to 10 mm in diameter. The upper third (supraduodenal portion) passes downward in the free edge of the hepatoduodenal ligament, to the right of the hepatic artery and anterior to the portal vein. The middle third (retroduodenal portion) of the common bile duct curves behind the first portion of the duodenum and diverges laterally from the portal vein and the hepatic arteries. The lower third (pancreatic portion) curves behind the head of the pancreas in a groove, or traverses through it and enters the second part of the duodenum.

The arterial supply to the bile ducts is derived from the gastroduodenal and the right hepatic arteries, with major trunks running along the medial and lateral walls of the common duct (sometimes referred to as 3 o'clock and 9 o'clock). These arteries anastomose freely within the duct walls. The normal adult consuming an average diet produces within the liver 500 to 1000 mL of bile a day. Eventually, about 95% of the bile acid pool is reabsorbed and returned via the portal venous system to the liver, the so-called enterohepatic circulation. Five percent is excreted in the stool, leaving the relatively small amount of bile acids to have maximum effect. The color of the bile is due to the presence of the pigment bilirubin diglucuronide, which is the metabolic product from the breakdown of hemoglobin, and is present in bile in concentrations 100 times greater than in plasma. The gallbladder, the bile ducts, and the sphincter of Oddi act together to store and regulate the flow of bile. The main function of the gallbladder is to concentrate and store hepatic bile and to deliver bile into the duodenum in response to a meal.

In the fasting state, approximately 80% of the bile secreted by the liver is stored in the gallbladder. This storage is made possible because of the remarkable absorptive capacity of the

gallbladder, as the gallbladder mucosa has the greatest absorptive power per unit area of any structure in the body. It rapidly absorbs sodium, chloride, and water against significant concentration gradients, concentrating the bile as much as 10-fold and leading to a marked change in bile composition. This rapid absorption is one of the mechanisms that prevent a rise in pressure within the biliary system under normal circumstances. Gradual relaxation as well as emptying of the gallbladder during the fasting period also plays a role in maintaining a relatively low intraluminal pressure in the biliary tree. The epithelial cells of the gallbladder secrete at least two important products into the gallbladder lumen: glycoprotein and andhydrogen ions. The mucosal glands in the infundibulum and the neck of the gallbladder secrete mucus glycoproteins that are believed to protect the mucosa from the lytic action of bile and to facilitate the passage of bile through the cystic duct. This mucus makes up the colorless "white bile" seen in hydrops of the gallbladder resulting from cystic duct obstruction. The transport of hydrogen ions by the gallbladder epithelium leads to a decrease in the gallbladder bile pH. The acidification promotes calcium solubility, thereby preventing its precipitation as calcium salts. The sphincter of Oddi regulates flow of bile (and pancreatic juice) into the duodenum, prevents the regurgitation of duodenal contents into the biliary tree, and diverts bile into the gallbladder. It is a complex structure that is functionally independent from the duodenal musculature and creates a high-pressure zone between the bile duct and the duodenum. The sphincter of Oddi is about 4 to 6 mm in length and has a basal resting pressure of about 13 mmHg above the duodenal pressure.

A complete blood count and liver function tests are routinely requested. An elevated white blood cell (WBC) count may indicate or raise suspicion of cholecystitis. If associated with an elevation of bilirubin, alkaline phosphatase, and aminotransferase, cholangitis should be suspected. Cholestasis, an obstruction to bile flow, is characterized by an elevation of bilirubin (i.e., the conjugated form), and a rise in alkaline phosphatase. Serum aminotransferases may be normal or mildly elevated. In patients with biliary colic or chronic cholecystitis, blood tests will typically be normal. Ultrasonography An ultrasound is the initial investigation of any patient suspected of disease of the biliary tree.13 It is noninvasive, painless, does not submit the patient to radiation, and can be performed on critically ill patients. It is dependent upon the skills and the experience of the operator, and it is dynamic. Ultrasound will show stones in the gallbladder with sensitivity and specificity of >90%. A thickened gallbladder wall and local tenderness indicate cholecystitis. The patient has acute cholecystitis if a layer of edema is seen within the wall of the gallbladder or between the gallbladder and the liver in association with localized tenderness. When a stone obstructs the neck of the gallbladder, the gallbladder may become very large, but thin walled. A contracted, thick-walled gallbladder is indicative of chronic cholecystitis.