Section 5 Gastrointestinal Tract and Abdomen
3 JaundiceJeffrey S. Barkun, MD, FACS
McGill University Faculty of Medicine
Department of Surgery
McGill University Health Centre
McGill University Faculty of Medicine
Department of Surgery
McGill University Health Centre
McGill University Faculty of Medicine
Director, Division of Gastroenterology
McGill University Health Centre
Approach to the Jaundiced Patient
The term jaundice refers to the yellowish discoloration of skin, sclerae, and mucous membranes that results from excessive deposition of bilirubin in tissues. It usually is unmistakable but on occasion may manifest itself subtly. It is generally held that jaundice develops when serum bilirubin levels rise above 34.2 µmol/L (2 mg/dl)
1; however, the appearance of jaundice also depends on whether it is conjugated or unconjugated bilirubin that is elevated and on how long the episode of jaundice lasts.In what follows, we outline a problem-based approach to the jaundiced patient that involves assessing the incremental information provided by successive clinical and laboratory investigations, as well as the information obtained by means of modern imaging modalities. We also propose a classification of jaundice that stresses the therapeutic options most pertinent to surgeons. We have not attempted a detailed review of bilirubin metabolism and the various pediatric disorders that cause jaundice; such issues are beyond the scope of this chapter. Finally, we emphasize that modern decision making in the approach to the jaundiced patient includes not only careful evaluation of anatomic issues but also close attention to patient morbidity and quality-of-life concerns, as well as a focus on working up the patient in a cost-effective fashion. For optimal treatment, in our view, an integrated approach that involves the surgeon, the gastroenterologist, and the radiologist is essential.
Clinical Evaluation and Investigative StudiesHistory and Physical Examination
When a patient presents with a skin discoloration suggestive of jaundice, the first step is to confirm that icterus is indeed present. To this end, the mucous membranes of the mouth, the palms, the soles, and the sclerae should be examined in natural light. Because such areas are protected from the sun, photodegradation of bile is minimized; thus, the yellowish discoloration of elastic tissues may be more easily detected. Occasionally, deposition of a yellowish pigment on skin may mimic jaundice but may in fact be related to the consumption of large quantities of food containing lycopene or carotene or drugs such as rifampin or quinacrine. In these cases, the skin is usually the only site of coloration, and careful inspection of sclerae and mucous membranes generally reveals no icteric pigmentation. In certain cultures, long-term application of tea bags to the eyes may lead to a brownish discoloration of the sclerae that can mimic jaundice.2
Direct Versus Indirect Hyperbilirubinemia
Once the presence of jaundice has been confirmed, further clinical assessment determines whether the hyperbilirubinemia is predominantly direct or indirect. This distinction is based on the division of bilirubin into conjugated and unconjugated fractions, which are also known, respectively, as direct and indirect fractions on the basis of their behavior in the van den Bergh (diazo) reaction.
3 If the patient has normal-colored urine and stools, unconjugated bilirubin [see Sidebar Unconjugated (Indirect) Bilirubin] is predominant [see Table 1]. If the patient has dark urine, pale stools, or any other signs or symptoms of a cholestatic syndrome (see below), the serum bilirubin fractionation usually indicates that conjugated bilirubin is predominant. Rarely, the clinical picture may be secondary to a massive increase in both direct and indirect bilirubin production after the latter has overcome the ability of the hepatocytes to secrete conjugated bilirubin.It is nearly always possible to distinguish between direct and indirect hyperbilirubinemia on clinical grounds alone.4 Our emphasis here is on direct hyperbilirubinemia, which is the type that is more relevant to general surgeons.
Cholestatic Syndrome
The term cholestasis refers to decreased delivery of bilirubin into the intestine (and subsequent accumulation in the hepatocytes and in blood), irrespective of the underlying cause. When cholestasis is mild, it may not be associated with clinical jaundice. As it worsens, a conjugated hyperbilirubinemia develops that presents as jaundice. The conjugated hyperbilirubinemia may derive either from a defect in hepatocellular function (hepatic jaundice, also referred to as nonobstructive or medical jaundice) or from a blockage somewhere in the biliary tree (posthepatic jaundice, also referred to as obstructive or surgical jaundice). In this chapter, we refer to hepatic and posthepatic causes of jaundice, reserving the term cholestasis for the specific clinical syndrome that is attributable to a chronic lack of delivery of bile into the intestine. This syndrome is characterized by signs and symptoms that are related either to the conjugated hyperbilirubinemia or to chronic malabsorption of fat-soluble vitamins (i.e., vitamins A, D, E, and K): jaundice, dark urine, pale stools, pruritus, bruising, steatorrhea, night blindness, osteomalacia, and neuromuscular weakness.5
Hepatic Versus Posthepatic Jaundice
Once the presence of direct hyperbilirubinemia is confirmed, the next step is to determine whether the jaundice is hepatic or posthepatic. A number of authors have studied the reliability of clinical assessment for making this determination.
6–17 The sensitivities of history, physical examination, and blood tests alone range from 70% to 95%,6–11 whereas the specificities are approximately 75%.10,11 The overall accuracy of clinical assessment of hepatic and posthepatic causes of jaundice ranges from 87% to 97%.8,12 Clinically, hepatic jaundice is most often signaled by acute hepatitis, a history of alcohol abuse, or physical findings reflecting cirrhosis or portal hypertension13; posthepatic jaundice is most often signaled by abdominal pain, rigors, itching, or a palpable liver more than 2 cm below the costal margin.14By using discriminant analysis in a pediatric patient population, two investigators were able to isolate three biochemical tests that differentiated between biliary atresia and intrahepatic cholestasis with an accuracy of 95%: total serum bilirubin concentration, alkaline phosphatase level, and g-glutamyltranspeptidase level.15 Serum transaminase levels added no independent information of significance to the model. Another multivariate analysis model demonstrated that patients with posthepatic jaundice were younger, had a longer history of jaundice, were more likely to present with fever, and had greater elevations of serum protein concentrations and shorter coagulation times than patients with hepatic jaundice.16 This model, however, despite its 96% sensitivity (greater than that of any single radiologic diagnostic modality), could not accurately predict the level of a biliary obstruction. Other investigators have reported similar findings,8,12,13 and most agree that strategies that omit ultrasonography are clearly inferior.17
In summary, a clinical approach supported by simple biochemical evaluation displays good predictive ability to distinguish hepatic from posthepatic jaundice; however, a clinical approach alone does not accurately identify the level of biliary obstruction in a patient with posthepatic jaundice.
The remainder of this chapter focuses primarily on management of posthepatic jaundice; hepatic jaundice is less often seen and dealt with by general surgeons [see Table 2 and Sidebar Hepatic Jaundice].
Imaging
Of the many imaging methods available today, the gold standard for defining the level of a biliary obstruction before operation in a jaundiced patient remains direct cholangiography, which can be performed either via endoscopic retrograde cholangiopancreatography (ERCP) [see 5:18 Gastrointestinal Endoscopy] or via percutaneous transhepatic cholangiography (PTC). Unlike other imaging modalities, direct cholangiography poses significant risks to the patient: there is a 4% to 7% incidence of pancreatitis or cholangitis after ERCP,18,19 and there is a 4% incidence of bile leakage, cholangitis, or bleeding after PTC.20 There are also several risks that are particular to the manipulation of an obstructed biliary system (see below). For these reasons, the role of ERCP and PTC is increasingly a therapeutic one: therefore, it is important to gather as much imaging information as possible on the likely cause of the jaundice before performing either investigation.21 We have found the following approach to be an efficacious, cost-effective,22 and safe way of obtaining such information in a patient with presumed posthepatic jaundice.
The presence of ductal dilatation of the intrahepatic or extrahepatic biliary system confirms that a posthepatic cause is responsible for the jaundice. Ultrasonography detects ductal dilatation with an accuracy of 95%, though results are to some extent operator-dependent.23 If ultrasonography does not reveal bile duct dilatation, it is unlikely that an obstructing lesion is present. In some cases, even though ductal dilatation is absent, other ultrasonographic findings may still point to a specific hepatic cause of jaundice (e.g., cirrhosis or infiltration of the liver by tumor).
There are a few specific instances in which ultrasonography may fail to detect a posthepatic cause of jaundice. For instance, very early in the course of an obstructive process, not enough time may have elapsed for biliary dilatation to occur. In this setting, a hepato-iminodiacetic acid (HIDA) scan has often helped identify bile duct blockage.24 The yield from this test is highest when the serum bilirubin level is lower than 100 µmol/L.1 Occasionally, the intrahepatic biliary tree is unable to dilate; possible causes of such inability include extensive hepatic fibrosis, cirrhosis, sclerosing cholangitis, and liver transplantation. If one of these diagnoses is suspected, ERCP, magnetic resonance cholangiopancreatography (MRCP), or PTC will eventually be required to confirm the diagnosis of biliary obstruction. Occasionally, the biliary tree dilatation may be intermittent; possible causes of this condition include choledocholithiasis and some biliary tumors. In a patient with gallstones, transient liver test abnormalities by themselves may suggest an intermediate to high likelihood of common bile duct (CBD) stones, even if there is no biliary ductal dilatation.25,26 If one of these diagnoses is suspected, ultrasonography may be repeated after a short period of observation (when clinically applicable); biliary ductal dilatation then generally becomes apparent. If all of these unusual clinical situations have been ruled out, a hepatic cause for the jaundice should be sought [see Table 2] and a liver biopsy considered.27,28
Besides being able to identify the presence of extrahepatic ductal obstruction with a high degree of reliability, ultrasonography can accurately determine the level of the obstruction in 90% of cases.29 For example, a dilated gallbladder suggests that the obstruction is probably located in the middle third or the distal third of the CBD.
Some centers prefer CT to ultrasonography as the initial imaging modality,30 but we, like a number of other authors,31 find ultrasonography to be the most expedient, least invasive, and most economical imaging method for differentiating between hepatic and posthepatic causes of jaundice, as well as for suggesting the level of obstruction.32 Traditional imaging techniques, such as oral or intravenous cholangiography, have a negligible role to play in this setting because of their very poor accuracy and safety, especially in jaundiced patients.
 |
| Figure 1a. ERCP showing stone in distal CBD |
 |
| Figure 1b. MRCP showing stone in distal CBD |
MRCP [see Figures 1a and 1b] and endoscopic ultrasonography (EUS) have been used to visualize the biliary and pancreatic trees in various populations of patients with obstructive jaundice.33–37 Compared with direct cholangiography, both appear to be excellent at diagnosing biliary obstruction and establishing its location and nature.38,39 MRCP exhibits more modest detection rates when diagnosing small CBD stones.40,41 Spiral (helical) CT scanning is also useful in diagnosing biliary obstruction and determining its cause, though concomitant oral or I.V. cholangiography is required to detect choledocholithiasis.42–44
In addition to their ability to detect choledocholithiasis, spiral CT, EUS, and MRCP in combination with abdominal magnetic resonance imaging (e.g., of the pancreas) are very useful in diagnosing and staging biliopancreatic tumors.45–47 Cytology specimens are readily obtained via fine-needle aspiration (FNA) during CT or EUS.46
It is our current practice to employ these modalities as second-line tests after the initial abdominal ultrasonographic examination. To obtain a diagnosis, we favor EUS for periampullary pathologic conditions and MRI with MRCP for more proximal diseases of the biliary tree.
In making the choice among the various available second-line tests, local expertise and cost-effectiveness become important considerations. Unfortunately, the reports on cost-effectiveness published to date have suffered either from limited assumptions (when the methodology involved decision modeling) or from the lack of an effectiveness-type design (when the methodology involved allocation of patients).
Workup and Management of Posthepatic JaundiceOnce ultrasonography has confirmed that ductal obstruction is present, there are three possible clinical scenarios: suspected cholangitis, suspected choledocholithiasis without cholangitis, and a suspected lesion other than choledocholithiasis. The direction of the subsequent workup depends on which of the three appears most likely.
Suspected Cholangitis
If a jaundiced patient exhibits a clinical picture compatible with acute suppurative cholangitis (Charcot's triad or Raynaud's pentad), the most likely diagnosis is choledocholithiasis. After appropriate resuscitation, correction of any coagulopathies present, and administration of antibiotics, ERCP is indicated for diagnosis and treatment.
48 If ERCP is unavailable or is not feasible (e.g., because of previous Roux-en-Y reconstruction), transhepatic drainage or surgery may be necessary. It is important to emphasize here that the mainstay of treatment of severe cholangitis is not just the administration of appropriate antibiotics but rather the establishment of adequate biliary drainage.Suspected Choledocholithiasis without Cholangitis
Choledocholithiasis is the most common cause of biliary obstruction.
13,14 It should be strongly suspected if the jaundice is episodic or painful or if ultrasonography has demonstrated the presence of gallstones or bile duct stones. Patients with suspected choledocholithiasis should be referred for laparoscopic cholecystectomy with either preoperative ERCP, intraoperative cholangiography, or intraoperative ultrasonography [see 5:21 Cholecystectomy and Common Bile Duct Exploration].49 We favor preoperative ERCP in this setting of jaundice because its diagnostic yield is high,50 it allows confirmation of the diagnosis preoperatively (thus obviating intraoperative surprises), and it is capable of clearing the CBD of stones in 95% of cases. Decision analyses appear to confirm the utility of this strategy when laparoscopic CBD exploration is not an option.51–55 Many authors, however, favor a fully laparoscopic approach, in which choledocholithiasis is detected in the OR by means of intraoperative cholangiography56,57 or ultrasonography58–60 and laparoscopic biliary clearance is performed when choledocholithiasis is confirmed. Given that both the ERCP approach and the fully laparoscopic approach have advantages and limitations, the optimal approach in a particular setting should be dictated by local expertise.Suspected Lesion Other than Choledocholithiasis
If no gallstones are identified, if the clinical presentation is less acute (e.g., constant abdominal or back pain), or if there are associated constitutional symptoms (e.g., weight loss, fatigue, and long-standing anorexia), the presence of a lesion other than choledocholithiasis should be suspected. In such cases, another imaging modality besides the ultrasonography already performed must be considered before the decision is made to proceed to cholangiography or operation.
Possible causes of posthepatic obstruction (other than choledocholithiasis) may be classified into three categories, depending on the location of the obstructing lesion (as suggested by the pattern of gallbladder and biliary tree dilatation on the ultrasonogram): the upper third of the biliary tree, the middle third, or the lower (distal) third [
see Table 3]. Once it has been determined that choledocholithiasis is unlikely, the most common cause of such obstruction is pancreatic cancer [see 5:9 Tumors of the Pancreas, Biliary Tract, and Liver].Diagnosis and Assessment of Resectability
Assessment of the resectability of a tumor usually hinges on whether the superior mesenteric vein, the portal vein, the superior mesenteric artery, and the porta hepatis are free of tumor and on whether there is evidence of significant local adenopathy or extrapancreatic extension of tumor. Unfortunately, the majority of lesions will be clearly unresectable, either because of tumor extension or because of the presence of hepatic or peritoneal metastases.
Many imaging modalities are currently used to determine resectability, and several of these have been established as effective alternatives to direct cholangiography because they involve little if any morbidity. Their accuracy varies according to the underlying pathology and the expertise of the user. They have been studied mostly with respect to the staging and diagnosis of pancreatic, periampullary, and biliary hilar cancers.
For determining resectability and staging lesions before operation, we rely mainly on spiral CT. The advent and widespread availability of multidetector CT have made this modality the dominant second-line imaging method in cases of suspected pancreatic masses. For optimal evaluation of the pancreas, a fine-cut dual-phase (arterial phase and portal venous phase) scan should be obtained. Oral administration of water allows better evaluation of the duodenum and the ampulla.61,62 At present, spiral CT is considered to be superior for the diagnosis and staging of lesions such as pancreatic cancer.45,63,64 It exhibits a high negative predictive value and has a false positive rate of less than 10%; its sensitivity is optimal for pancreatic lesions larger than 1.5 cm in diameter. Ascites, liver metastases, lymph nodes larger than 2 cm in diameter, and invasion into adjacent organs are all signs of advanced disease.65 On the basis of these criteria, spiral CT can predict that a lesion will not be resectable with an accuracy approaching 95%; however, as many as 33% of tumors that appear to be resectable on CT are found to be unresectable at operation.64
MRI-based staging, along with MRCP, can further dictate the subsequent choice of therapy.65–68 MRI may be particularly useful for following up patients in whom clip artifacts interfere with a CT image.65 It also appears to be successful in detecting cholangiocarcinoma spreading along the proximal biliary tree.69 Given the renewed interest in biliary contrast media and the availability of software optimized for multidetector scanners, CT cholangiography may soon rival MRCP for evaluation of the biliary tree in cases of suspected malignancy.70
Only in a few very rare instances is traditional angiography used to assess resectability or stage a hepatobiliary or pancreatic neoplasm. Increasingly, it is being replaced by CT angiography or duplex Doppler ultrasonography, which can confirm the presence of flow in the hepatic arterial or portal venous systems and occasionally can demonstrate invasion of these vessels by tumor.71 Magnetic resonance angiography (MRA) has also been used with excellent results. As yet, none of these noninvasive modalities has been shown to be clearly superior to any of the others.72
EUS is a highly sensitive method of imaging the pancreas and the duodenum.46,73,74 In two large studies, it was found to be superior to CT and standard ultrasonography in staging pancreatic and ampullary cancers.75,76 Subsequent studies indicated that whereas EUS is superior to CT for detection and staging, it provides similar information regarding nodal status and overall assessment of resectability.61,77 From a cost-minimization point of view, the optimal strategy is to begin with a dual-phase CT scan and to follow up with EUS only in cases in which further information or a tissue diagnosis is required.78,79 In another large series, EUS was reported to be more accurate than CT in the comparative staging of pancreatic and ampullary cancers. It has also been found useful for identifying small (< 2 cm) pancreatic tumors, which may be suspected in a patient who has an obstruction of the distal third of the bile duct and whose CT scan is normal.74 Furthermore, EUS is currently the dominant technique for staging ampullary tumors.80
In patients with a suspected pancreatic tumor, direct FNA of the lesion at the time of EUS has become the gold-standard method for obtaining a tissue diagnosis. In the case of potentially resectable lesions, however, this measure adds very little to the decision-making process. The limited data currently available suggest that assays of tumor markers in serum and pancreatic fluid are useful, particularly for cystic lesions of the pancreas.81
At this point in the evaluation, patients can be referred either for cholangiography (ERCP or MRCP) to clarify a still-unclear diagnosis or for biliary decompression (see below). MRI of the pancreas with MRCP continues to improve rapidly. It is a noninvasive modality that evaluates the pancreas, vasculature, and the pancreatobiliary ductal system in a single examination, with the additional benefit of avoiding ionizing radiation and iodinated contrast agents.82 MRCP remains our test of choice for evaluation of middle- and upper-third lesions in cases in which decompression is not required.
In the event that none of these modalities point to a diagnosis, the use of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) may be considered to help differentiate benign pancreatic conditions from malignant ones.83,84 Besides facilitating diagnosis, FDG-PET provides information regarding occult metastases and can be useful in detecting recurrent disease. Experience with FDG-PET is growing rapidly as this imaging modality becomes more readily accessible.
When a biliary stricture is detected at cholangiography, brush cytology or biopsy is mandatory. Biliary cytology, however, has been disappointing, particularly at ERCP: diagnostic accuracy ranges from 40% to 85%,85,86 mostly because the negative predictive value is poor. Accuracy improves with multiple sampling and when a biliary rather than a pancreatic malignancy is detected. In addition, biopsy tends to be more accurate than brush cytology.85
Nonoperative Management: Drainage and Cholangiography
In the majority of patients with malignant obstructions, treatment is palliative rather than curative. It is therefore especially important to recognize and minimize the iatrogenic risks related to the manipulation of an obstructed biliary system; this is why staging and cholangiography are currently being performed with EUS and MRCP.
Cholangiography and decompression of obstructed biliary system As a rule, we favor ERCP, though PTC may be preferable for obstructions near the hepatic duct bifurcation. Whichever imaging modality is used, the following four principles apply.
-
In the absence of preexisting or concomitant hepatocellular dysfunction, drainage of one half of the liver is generally sufficient for resolution of jaundice.87
-
Because of its external diameter, a transhepatic drain, once inserted, does not necessarily permit equal drainage of all segments of the liver, particularly if there are a number of intrahepatic ductal stenoses. Accordingly, some patients with conditions such as sclerosing cholangitis or a growing tumor may experience persistent sepsis from an infected excluded liver segment even when the prosthesis is patent [see Figures 2a, 2b, and 2c]. An excluded segment may even be responsible for severe persistent pruritus.
-
Any attempt at opacifying an obstructed biliary tree introduces a significant risk of subsequent cholangitis, even when appropriate antibiotic prophylaxis is provided. Accordingly, when one elects to perform direct cholangiography, there should be a plan for biliary drainage either at the time of ERCP or PTC or soon thereafter.
-
Even though jaundice is believed to be associated with multiple adverse systemic effects (e.g., renal failure, sepsis, and impaired wound healing),88,89 routine preoperative drainage of an obstructed biliary system does not benefit patients who will soon undergo resection.90,91 There is a growing body of evidence suggesting that in patients with either pancreatic92,93 or hepatic94 malignancies, routine preoperative direct cholangiography with decompression is associated with a higher incidence of postoperative complications when tumor resection is ultimately carried out.
When direct cholangiography is ordered, it should be thought of as more than just a diagnostic test: it is the ideal setting for cytology, biopsy, or even drainage of the obstructed bile duct via a sphincterotomy, a nasobiliary tube, or a catheter or stent. Accordingly, it is essential that the surgeon, the gastroenterologist, and the radiologist discuss the possible need for drainage well before it is required. Early, open communication among all the members of the treating team is a hallmark of the modern management of biliary obstruction.
Palliation in patients with advanced malignant disease When a patient has advanced malignant disease, drainage of the biliary system for palliation is not routinely indicated, because the risk of complications related to the procedure may outweigh the potential benefit. Indeed, the best treatment for a patient with asymptomatic obstructive jaundice and liver metastases may be supportive care alone.95 Biliary decompression is indicated if cholangitis or severe pruritus interferes with quality of life.
We, like others,22 consider a stent placed with ERCP to be the palliative modality of choice for advanced disease, though upper-third lesions may be managed most easily through the initial placement of an internal/external catheter at the time of PTC. Metal expandable stents remain patent longer than large conventional plastic stents,96,97 but the high price of the metal stents has kept them from being widely used, and their overall cost-effectiveness has yet to be clearly demonstrated. Whether plastic biliary stents should be replaced prophylactically or only after obstruction has occurred remains controversial; however, results from a randomized, controlled trial (RCT) favor the former approach.98 In another RCT, the use of prophylactic ciprofloxacin did not prolong stent patency but did reduce the incidence of cholangitis and improve quality of life scores.99
RCTs suggest that surgical biliary bypass should be reserved for patients who are expected to survive for 6 months or longer because bypass is associated with more prolonged palliation at the cost of greater initial morbidity.100
The role of prophylactic gastric drainage at the time of operative biliary drainage remains controversial,101,102 though two RCTs demonstrated a reduced incidence of subsequent clinical gastric outlet obstruction when this measure was employed. Jaundiced patients with unresectable lesions who also present with duodenal or jejunal obstruction should be referred for gastrojejunostomy at the time of biliary bypass surgery. There is evidence to suggest that when a pancreatic malignancy is present, intraoperative celiac ganglion injection should be performed for either prophylactic or therapeutic pain control.103
Operative Management at Specific Sites: Bypass and Resection
Surgical treatment of tumors causing biliary obstruction is determined primarily by the level of the biliary obstruction. Current evidence indicates that modern surgical approaches are resulting in lower postoperative morbidity and, possibly, improved 5-year survival104; however, the prognosis is still uniformly poor, except for patients with ampullary tumors. In fact, the surgical procedure rarely proves curative, even after meticulous preoperative patient selection.
At one time, there was considerable enthusiasm for routine use of staging laparoscopy; at present, however, selective use is recommended.105 The benefits of staging laparoscopy include more accurate assessment of resectability and prevention of the prolonged hospital stay and convalescence associated with an unnecessary laparotomy. Laparoscopy is used mostly to detect peritoneal carcinomatosis, liver metastases, malignant ascites, and gross hilar adenopathy.106,107 The main limitation of laparoscopy in this setting appears to be that it does not accurately detect the spread of tumors to lymph nodes or the vascular system.108 In several studies, a combined approach that included both laparoscopy and laparoscopic ultrasonography was associated with shorter hospital stays and lower costs.105,107–109
In what follows, only the general principles of resection or bypass at each level of obstruction are discussed; operative technical details are addressed elsewhere [see 5:22 Procedures for Benign and Malignant Biliary Tract Disease]. Our preferred method of biliary anastomosis, for either reconstruction or bypass, involves the fashioning of a Roux-en-Y loop, followed by a mucosa-to-mucosa anastomosis. In all cases, a cholecystectomy is performed to facilitate access to the biliary tree.
Upper-third obstruction Palliation. Because the left hepatic duct has a long extrahepatic segment that makes it more accessible, the preferred bypass technique for an obstructing upper-third lesion is a left (or segment 3) hepaticojejunostomy. This operation has superseded the Longmire procedure because it does not involve formal resection of liver parenchyma. Laparoscopic bypass techniques that make use of segment 3 have been developed, but their performance has yet to be formally assessed, and they cannot yet be incorporated into a management algorithm.110,111
Resection for cure. The hilar plate is taken down to lengthen the hepatic duct segment available for subsequent anastomosis. Often, a formal hepatectomy or segmentectomy is required to ensure an adequate proximal margin of resection. If the resection must be carried out proximal to the hepatic duct bifurcation, several cholangiojejunostomies will have to be done to anastomose individual hepatic biliary branches. Frozen-section examination of the proximal and distal resection margins is important because of the propensity of tumors such as cholangiocarcinoma to spread in a submucosal or perineural plane.
The results of aggressive hilar tumor resections that included as much liver tissue as was necessary to obtain a negative margin appear to justify this approach.112 In cases of left hepatic involvement, resection of the caudate lobe (segments 1 and 9) is indicated as well.113,114
Middle-third obstruction Palliation. Surgical bypass of middle-third lesions is technically simpler because a hepaticojejunostomy can often be performed distal to the hepatic duct bifurcation, which means that exposure of the hilar plate or the intrahepatic ducts is unnecessary.
 |
| Figure 3. ERCP: Stone in Hartmann's pouch |
Lower-third obstruction Palliation. The preferred bypass technique for lower-third lesions is a Roux-en-Y choledochojejunostomy. Cholecystojejunostomy carries a higher risk of complications and subsequent development of jaundice117; this remains true even when it is performed laparoscopically. Occasionally, it may be done as a temporizing measure before a more definitive procedure in the context of an upcoming transfer to a specialized center.
Resection for cure. Occasionally, an impacted CBD stone at the duodenal ampulla mimics a tumor and is not clearly identified preoperatively. Because of the growing use of EUS and MRCP, such a situation is increasingly uncommon. Resection of a lower-third lesion usually involves a pancreaticoduodenectomy [see 5:24 Procedures for Benign and Malignant Pancreatic Disease]; local duodenal resection without removal of the head of the pancreas has also been described.118 For optimal results, pancreaticoduodenectomy is best performed in specialized centers.119
It has been suggested that postoperative adjuvant therapy may improve the prognosis after resection of a pancreatic adenocarcinoma,104 but this debate falls outside the scope of our discussion.
Postoperative JaundiceA clinical scenario of particular pertinence to surgeons that we have not yet addressed is the development of jaundice in the postoperative setting.
 |
| Figure 4. Stent insertion |
Jaundice develops in approximately 1% of all surgical patients after operation.120 When jaundice occurs after a hepatobiliary procedure, it may be attributable to specific biliary causes, such as retained CBD stones, postoperative biliary leakage (through reabsorption of bile leaking into the peritoneum) [see Figure 4], injury to the CBD, and the subsequent development of biliary strictures. In most instances, however, the jaundice derives from a combination of disease processes, and only rarely is invasive testing or active treatment required.121
A diagnostic approach similar to the one outlined earlier (see above) is applicable to postoperative jaundice; however, another useful approach is to consider the possible causes in the light of the time interval between the operation and the subsequent development of jaundice.
-
Jaundice may develop within 48 hours of the operation; this is most often the result of the breakdown of red blood cells, occurring in the context of multiple blood transfusions (particularly with stored blood), the resorption of a large hematoma, or a transfusion reaction. Hemolysis may also develop in a patient with a known underlying hemolytic anemia and may be precipitated by the administration of specific drugs (e.g., sulfa drugs in a patient who has glucose-6-phosphate dehydrogenase deficiency).122 Cardiopulmonary bypass or the insertion of a prosthetic valve may be associated with the development of early postoperative jaundice as well. Gilbert syndrome [see Sidebar Hepatic Jaundice] may first manifest itself early in the postoperative period. Occasionally, a mild conjugated hyperbilirubinemia may be related to Dubin-Johnson syndrome, which is an inherited disorder of bilirubin metabolism. This condition is usually self-limited and is characterized by the presence of a melaninlike pigment in the liver.
-
Intraoperative hypotension or hypoxemia or the early development of heart failure can lead to conjugated hyperbilirubinemia within 5 to 10 days after operation. The hyperbilirubinemia may be associated with other end-organ damage (e.g., acute tubular necrosis). In fact, any impairment of renal function causes a decrease in bilirubin excretion and can be responsible for a mild hyperbilirubinemia.
-
Jaundice may develop 7 to 10 days after operation in association with a medication-induced hepatitis attributable to an anesthetic agent. This syndrome has an estimated incidence of 1/10,000 after an initial exposure.122 More commonly, the jaundice is related to the administration of antibiotics or other medications used in the perioperative setting.122
-
After the first week, jaundice associated with intrahepatic cholestasis is often a manifestation of a septic response and usually presents in the setting of overt infection, particularly in patients with multiple organ dysfunction syndrome. Gram-negative sepsis from an intra-abdominal source is typical; if it persists, the outcome is likely to be poor. Jaundice may occur in as many as 30% of patients receiving total parenteral nutrition (TPN). It may be attributable to steatosis, particularly with formulas containing large amounts of carbohydrates. In addition, decreased export of bilirubin from the hepatocytes may lead to cholestasis, the severity of which appears to be related to the duration of TPN administration. Acalculous cholecystitis or even ductal obstruction may develop as a result of sludge in the gallbladder and the CBD. An elevated postoperative bilirubin level at any time may also result from unsuspected hepatic or post-hepatic causes (e.g., occult cirrhosis, choledocholithiasis, or cholecystitis). A rare cause of postoperative jaundice is the development of thyrotoxicosis. Another entity to consider (as a diagnosis of exclusion) is so-called benign postoperative cholestasis, a primarily cholestatic, self-limited process with no clearly demonstrable cause that typically arises within 2 to 10 days after operation. Benign postoperative cholestasis may be attributable to a combination of mechanisms, including an increased pigment load, impaired liver function resulting from hypoxemia and hypotension, and decreased renal bilirubin excretion caused by varying degrees of tubular necrosis.123 The predominantly conjugated hyperbilirubinemia may reach 40 mg/dl and remain elevated for as long as 3 weeks.122
-
In the late postoperative period, the development of non-A, non-B, non-C viral hepatitis after transfusion of blood products will usually occur within 5 to 12 weeks of operation.
Figure 2c From MRI of the Abdomen and Pelvis: A Text-Atlas, by R. C. Semelka, S. M. Asher, and C. Reinhold. John Wiley and Sons, New York, 1997. Used with permission.
References1. Schiff L: Jaundice: a clinical approach. Diseases of the Liver, 7th ed. Schiff L, Schiff ER, Eds. JB Lippincott Co, Philadelphia, 1993 , p 334
2. Jabbari M: Personal communication
3. Scharschmidt BF, Gollan JL: Current concepts of bilirubin metabolism and hereditary hyperbilirubinemia. Progress in Liver Diseases. Popper H, Schaffner F, Eds. Grune & Stratton, New York, 1979 , p 187
4. Frank BB: Clinical evaluation of jaundice: a guideline of the Patient Care Committee of the American Gastroenterological Association. JAMA 262:3031, 1989 [PMID 2681857]
5. Schiff's Diseases of the Liver 8th ed. Schiff ER, Sorrell MF, Maddrey WC, Eds. Lippincott-Raven, Philadelphia, 1999 , p 119
6. Lindberg G, Björkman A, Helmers C: A description of diagnostic strategies in jaundice. Scand J Gastroenterol 18:257, 1983
7. Lumeng L, Snodgrass PJ, Swonder JW: Final report of a blinded prospective study comparing current non-invasive approaches in the differential diagnosis of medical and surgical jaundice. Gastroenterology 78:1312, 1980
8. Martin W, Apostolakos PC, Roazen H: Clinical versus actuarial prediction in the differential diagnosis of jaundice. Am J Med Sci 240:571, 1960 [PMID 13767416]
9. Matzen P, Malchow-Möller A, Hilden J, et al: Differential diagnosis of jaundice: a pocket diagnostic chart. Liver 4:360, 1984
10. O'Connor K, Snodgrass PJ, Swonder JE, et al: A blinded prospective study comparing four current non-invasive approaches in the differential diagnosis of medical versus surgical jaundice. Gastroenterology 84:1498, 1983 [PMID 6840479]
11. Schenker S, Balint J, Schiff L: Differential diagnosis of jaundice: report of a prospective study of 61 proved cases. Am J Dig Dis 7:449, 1962
12. Theodossi A, Spiegelhalter D, Portmann B, et al: The value of clinical, biochemical, ultrasound and liver biopsy data in assessing patients with liver disease. Liver 3:315, 1983 [PMID 6645816]
13. Pasanen PA, Pikkarainen P, Alhava E, et al: The value of clinical assessment in the diagnosis of icterus and cholestasis. Ital J Gastroenterol Hepatol 24:313, 1992
14. Theodossi A: The value of symptoms and signs in the assessment of jaundiced patients. Clin Gastroenterol 14:545, 1985 [PMID 3905088]
15. Fung KP, Lau SP: Differentiation between extrahepatic and intrahepatic cholestasis by discriminant analysis. J Paediatr Child Health 26:132, 1990 [PMID 1976325]
16. Pasanen PA, Pikkarainen P, Alhava E, et al: Evaluation of a computer-based diagnostic score system in the diagnosis of jaundice and cholestasis. Scand J Gastroenterol 28:732, 1993 [PMID 8210991]
17. Malchow-Möller A, Gronvall S, Hilden J, et al: Ultrasound examination in jaundiced patients: is computer-assisted preclassification helpful? J Hepatol 12:321, 1991
18. Loperfido S, Angelini G, Benedetti G, et al: Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 48:1, 1998 [PMID 9684657]
19. Freeman ML, DiSario JA, Nelson DB, et al: Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 54:425, 2001 [PMID 11577302]
20. Lillemoe KD: Surgical treatment of biliary tract infections. Am Surg 66:138, 2000 [PMID 10695743]
21. NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. NIH Consens State Sci Statements 19:1, 2002
22. Rossi LR, Traverso W, Pimentel F: Malignant obstructive jaundice: evaluation and management. Surg Clin North Am 76:63, 1996 [PMID 8629203]
23. Taylor KJW, Rosenfield A: Grey-scale ultrasonography in the differential diagnosis of jaundice. Arch Surg 112:820, 1977 [PMID 880026]
24. Kaplun L, Weissman HS, Rosenblatt RR, et al: The early diagnosis of common bile duct obstruction using cholescintigraphy. JAMA 254:2431, 1985 [PMID 3900452]
25. Abboud PA, Malet PF, Berlin JA, et al: Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 44:450, 1996 [PMID 8905367]
26. Roston AD, Jacobson IM: Evaluation of the pattern of liver tests and yield of cholangiography in symptomatic choledocholithiasis: a prospective study. Gastrointest Endosc 45:394, 1997 [PMID 9165321]
27. Richter JM, Silverstein MD, Schapiro R: Suspected obstructive jaundice: a decision analysis of diagnostic strategies. Ann Intern Med 99:46, 1983 [PMID 6859725]
28. Bravo AA, Sheth SG, Chopra S: Liver biopsy. N Engl J Med 344:495, 2001 [PMID 11172192]
29. Blackbourne LH, Earnhardt RC, Sistrom CL, et al: The sensitivity and role of ultrasound in the evaluation of biliary obstruction. Am Surg 60:683, 1994 [PMID 8060040]
30. Sherlock S: Ultrasound (US), computerized axial tomography (CT) and magnetic resonance imaging (MRI). Diseases of the Liver and Biliary System 5:70, 1989
31. Cosgrove DO: Ultrasound in surgery of the liver and biliary tract. Surgery of the Liver and Biliary Tract, 2nd ed, Vol 1. Blumgart LH, Ed. New York, Churchill Livingstone, 1994 , p 189
32. Lindsell DRM: Ultrasound imaging of pancreas and biliary tract. Lancet 335:390, 1990 [PMID 1968124]
33. Gillams A, Gardener J, Richards R, et al: Three-dimensional computed tomography cholangiography: a new technique for biliary tract imaging. Br J Radiol 67:445, 1994 [PMID 8193889]
34. Low RN, Sigeti JS, Francis IR, et al: Evaluation of malignant biliary obstruction: efficacy of fast multiplanar spoiled gradient-recalled MR imaging vs spin-echo MR imaging, CT, and cholangiography. AJR Am J Roentgenol 162:315, 1994 [PMID 8310918]
35. Amouyal P, Amouyal G, Levy P, et al: Diagnosis of choledocholithiasis by endoscopic ultrasonography. Gastroenterology 106:1062, 1994 [PMID 8143973]
36. Guibaud L, Bret PM, Reinhold C, et al: Bile duct obstruction and choledocholithiasis: diagnosis with MR cholangiography. Radiology 197:109, 1995 [PMID 7568807]
37. Ishizaki Y, Wakayama T, Okada Y, et al: MR cholangiography for evaluation of obstructed jaundice. Am J Gastroenterol 88:2072, 1993 [PMID 8249976]
38. Bardou M, Romagnuolo J, Barkun AN, et al: Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. Ann Intern Med 139:547, 2002
39. Mallery S, Van Dam J: Current status of diagnostic and therapeutic endoscopic ultrasonography. Radiol Clin North Am 39:449, 2001 [PMID 11506087]
40. Sugiyama M, Atomi Y, Hachiya J: Magnetic resonance cholangiography using half-Fourier acquisition for diagnosing choledocholithiasis. Am J Gastroenterol 93:1886, 1998 [PMID 9772049]
41. Jendresen MB, Thorboll JE, Adamsen S, et al: Preoperative routine magnetic resonance cholangiopancreatography before laparoscopic cholecystectomy: a prospective study. Eur J Surg 168:690, 2002 [PMID 15362577]
42. Soto JA, Alvarez O, Munera F, et al: Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography. AJR Am J Roentgenol 175:1127, 2000 [PMID 11000177]
43. Soto JA, Velez SM, Guzman J: Choledocholithiasis: diagnosis with oral-contrast-enhanced CT cholangiography. AJR Am J Roentgenol 172:943, 1999 [PMID 10587126]
44. Stabile Ianora AA, Memeo M, Scardapane A, et al: Oral contrast enhanced three-dimensional helical-CT cholangiography: clinical applications. Eur Radiol 13(4):867, 2003
45. Freeny PC: Computed tomography in the diagnosis and staging of cholangiocarcinoma and pancreatic carcinoma. Ann Oncol 10(suppl 4):12, 1999 [PMID 10436776]
46. Hawes RH, Xiong Q, Waxman I, et al: A multispecialty approach to the diagnosis and management of pancreatic cancer. Am J Gastroenterol 95:17, 2000 [PMID 10638554]
47. Megibow AJ, Lavelle MT, Rofsky NM: MR imaging of the pancreas. Surg Clin North Am 81:307, 2001 [PMID 11392418]
48. Lai EC, Mok FP, Tan ES, et al: Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 326:1582, 1992 [PMID 1584258]
49. Siperstein AE, Pearl J, Macho J, et al: Comparison of laparoscopic ultrasonography and fluorocholangiography in 300 patients undergoing laparoscopic cholecystectomy. Surg Endosc 13:967, 1999 [PMID 10526028]
50. Barkun JS, Fried GM, Barkun AN, et al: Cholecystectomy without operative cholangiography: implications for bile duct injury and common bile duct stones. Ann Surg 218:371, 1993 [PMID 8373278]
51. Sahai AV, Mauldin PD, Marsi V, et al: Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc 49(3 pt 1):334, 1999
52. Abraham N, Barkun AN, Barkun JS, et al: What is the optimal management of patients with suspected choledocholithiasis in the era of laparoscopic cholecystectomy? a decision analysis. Gastroenterology 116:G0012, 1999
53. Tse F, Barkun JS, Barkun AN: The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystectomy. Gastrointest Endosc 60:437, 2004 [PMID 15332044]
54. Erickson RA, Carlson B: The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies. Gastroenterology 109:252, 1995 [PMID 7797023]
55. Urbach DR, Khajanchee YS, Jobe BA, et al: Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc 15:4, 2001 [PMID 11178753]
56. Memon MA, Hassaballa H, Memon MI: Laparoscopic common bile duct exploration: the past, the present, and the future. Am J Surg 179:309, 2000 [PMID 10875992]
57. Crawford DL, Phillips EH: Laparoscopic common bile duct exploration. World J Surg 23:343, 1999 [PMID 10030857]
58. Falcone RA Jr, Fegelman EJ, Nussbaum MS, et al: A prospective comparison of laparoscopic ultrasound vs intraoperative cholangiogram during laparoscopic cholecystectomy. Surg Endosc 13:784, 1999 [PMID 10430685]
59. Thompson DM, Arregui ME, Tetik C, et al: A comparison of laparoscopic ultrasound with digital fluorocholangiography for detecting choledocholithiasis during laparoscopic cholecystectomy. Surg Endosc 12:929, 1998 [PMID 9632863]
60. Wu JS, Dunnegan DL, Soper NJ: The utility of intracorporeal ultrasonography for screening of the bile duct during laparoscopic cholecystectomy. J Gastrointest Surg 2:50, 1998 [PMID 9841968]
61. Stroszczynski C, Hunerbein M: Malignant biliary obstruction: value of imaging findings. Abdom Imaging 30:314, 2005 [PMID 15965779]
62. Legmann P, Vignaux O, Dousset B, et al: Pancreatic tumors: comparison of dual-phase helical CT and endosocpic sonography. AJR Am J Roentgenol 170:1315, 1998 [PMID 9574609]
63. Freeny PC, Traverso LW, Ryan JA: Diagnosis and staging of pancreatic adenocarcinoma with dynamic computed tomography. Am J Surg 165:600, 1993 [PMID 8488945]
64. Moosa AR, Gamagami RA: Diagnosis and staging of pancreatic neoplasms. Surg Clin North Am 75:871, 1995 [PMID 7660251]
65. Megibow AJ, Zhou XH, Rotterdam H, et al: Pancreatic carcinoma: CT vs MR imaging in the evaluation of resectability. Radiology 195:327, 1995 [PMID 7724748]
66. Hann LE, Winston CB, Brown KT, et al: Diagnostic imaging approaches and relationship to hepatobiliary cancer staging and therapy. Semin Surg Oncol 19:94, 2000 [PMID 11126385]
67. Zidi SH, Prat F, Le Guen O, et al: Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures. Gut 46:103, 2000 [PMID 10601064]
68. Kim MJ, Mitchell DG, Ito K, et al: Biliary dilatation: differentiation of benign from malignant causes—value of adding conventional MR imaging to MR cholangiopancreatography. Radiology 214:173, 2000
69. Georgopoulos SK, Schwartz LH, Jarnagin WR, et al: Comparison of magnetic resonance and endoscopic retrograde cholangiopancreatography in malignant pancreaticobiliary obstruction. Arch Surg 134:1002, 1999 [PMID 10487597]
70. McNulty N, Francis I, Platt J, et al: Multi-detector row helical CT of the pancreas: effect of contrast-enhanced multiphasic imaging on enhancement of the pancreas, peripancreatic vasculature, and pancreatic adenocarcinoma. Radiology 220:97, 2001 [PMID 11425979]
71. Smits NJ, Reeders JW: Current applicability of duplex Doppler ultrasonography in pancreatic head and biliary malignancies. Baillieres Clin Gastroenterol 9:153, 1995 [PMID 7772812]
72. Arslan A, Buanes T, Geitung JT: Pancreatic carcinoma: MR, MR angiography and dynamic helical CT in the evaluation of vascular invasion. Eur J Radiol 38:151, 2001 [PMID 11335098]
73. Giovannini M, Seitz JF: Endoscopic ultrasonography with a linear-type echoendoscope in the evaluation of 94 patients with pancreatobiliary disease. Endoscopy 26:579, 1994 [PMID 8001484]
74. Snady H, Cooperman A, Siegel J: Endoscopic ultrasonography compared with computed tomography and E.R.C.P. in patients with obstructive jaundice or small peri-pancreatic mass. Gastrointest Endoscopy 38:27, 1992
75. Nakaizumi A, Uehara H, Iishi H, et al: Endoscopic ultrasonography in diagnosis and staging of pancreatic cancer. Dig Dis Sci 40:696, 1995 [PMID 7895567]
76. Bakkevold KE, Arnesjo B, Kambestad B: Carcinoma of the pancreas and papilla of Vater—assessment of resectability and factors influencing resectability in stage I carcinomas: a prospective multicentre trial in 472 patients. Eur J Surg Oncol 18:494, 1992
77. DeWitt J, Devereaux B, Chiswell M, et al: Comparison of endoscopic ultrasonagraphy and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med 141:753, 2004 [PMID 15545675]
78. Soriano A, Castells A, Ayuso C, et al: Preoperative staging and tumor resectability assessment of pancreatic cancer: prospective study comparing endoscopic ultrasonography, helical computed tomography, magnetic resonance imaging and angiography. Am J Gastroenterol 99:492, 2004 [PMID 15056091]
79. Agarwal B, Abu-Hamda E, Molke KL, et al: Endoscopic Ultrasound-guided fine needle aspiration and multidetector spiral CT in the diagnosis of pancreatic cancer. Am J Gastroenterol 99:844, 2004 [PMID 15128348]
80. Cannon ME, Carpenter SL, Elta GH, et al: EUS compared with CT, magnetic resonance imaging, and angiography and the influence of biliary stenting on staging accuracy of ampullary neoplasms. Gastrointest Endosc 50:27, 1999 [PMID 10385718]
81. Brugge WR, Lauwers GY, Sahani D, et al: Current concepts: cystic neoplasms of the pancreas. N Engl J Med 351:1218, 2004 [PMID 15371579]
82. Keppke AL, Miller FH: Magnetic resonance imaging of the pancreas: the future is now. Semin Ultrasound CT MR 26:132, 2005 [PMID 15987063]
83. Delbeke D, Pinson CW: Pancreatic tumors: role of imaging in the diagnosis, staging and treatment. J Hepatobiliary Pancreat Surg 11:4, 2004 [PMID 15747028]
84. Heinrich S, Goerres G, Schafer M, et al: Positron emission tomography/computed tomography influences in the management of resectable pancreatic cancer and its cost-effectiveness. Ann Surg 242:235, 2005 [PMID 16041214]
85. Davidson BR: Progress in determining the nature of biliary strictures. Gut 34:725, 1993 [PMID 8314501]
86. Hawes RH: Endoscopy and non-calculus biliary obstruction. Annuals of Gastrointestinal Endoscopy, 8th ed. Cotton PB, Tytgat GNJ, Williams CB, Eds. Current Science, England, 1995 , p 101
87. Baer HU, Rhyner M, Stain SC, et al: The effect of communication between the right and left liver on the outcome of surgical drainage from jaundice due to malignant obstruction at the hilus of the liver. HPB Surg 8:27, 1994 [PMID 7993861]
88. Rege RV: Adverse effects of biliary obstruction: implications for treatment of patients with obstructive jaundice. AJR Am J Roentgenol 164:287, 1995 [PMID 7839957]
89. Grande L, Garcia-Valdecasas JC, Fuster J, et al: Obstructive jaundice and wound healing. Br J Surg 77:440, 1990 [PMID 2160307]
90. Pitt HA, Gomes AS, Lois JF: Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost? Ann Surg 201:545, 1985 [PMID 2986562]
91. McPherson GA, Benjamin IS, Hodgson HJ, et al: Preoperative percutaneous transhepatic biliary drainage: results of a controlled trial. Br J Surg 71:371, 1984 [PMID 6372935]
92. Povoski SP, Karpeh MS Jr, Conlon KC, et al: Preoperative biliary drainage: impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy. J Gastrointest Surg 3:496, 1999 [PMID 10482706]
93. Sohn TA, Yeo CJ, Cameron JL, et al: Do preoperative biliary stents increase postpancreaticoduodenectomy complications? J Gastrointest Surg 4:258, 2000 [PMID 10769088]
94. Jarnagin WR, Bodniewicz J, Dougherty E, et al: A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies. J Gastrointest Surg 4:34, 2000 [PMID 10631360]
95. Abraham N, Barkun J, Barkun AN, et al: Clinical risk factors of plastic biliary stent obstruction: a prospective trial. Am J Gastroenterol 95:2471, 2000
96. Knyrim K, Wagner HJ, Pausch J, et al: A prospective, randomized controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 25:207, 1993 [PMID 8519239]
97. Davids P, Groen A, Rauws E, et al: Randomized trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 340:1488, 1992 [PMID 1281903]
98. Prat F, Chapat O, Ducot B, et al: A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct. Gastrointest Endosc 47:1, 1998 [PMID 9468416]
99. Chan G, Barkun J, Barkun AN, et al: The role of ciprofloxacin in prolonging polyethylene biliary stent patency: a multicenter, double-blinded effectiveness study. J Gastrointest Surg 9:481, 2005 [PMID 15797227]
100. Smith AC, Dowsett JF, Russell RC, et al: Randomized trial of endoscopic stenting vs surgical bypass in malignant low bile duct obstruction. Lancet 344:1655, 1994 [PMID 7996958]
101. Lillemoe KD, Sauter P, Pitt HA, et al: Current status of surgical palliation of periampullary carcinoma. Surg Gynecol Obstet 176:1, 1993 [PMID 7678945]
102. Van Heek NT, De Castro SM, Van Eijck CH, et al: Need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a propsective randomized multicenter trial with special focus on assessment of quality of life. Ann Surg 238:894, 2003 [PMID 14631226]
103. Lillemoe KD, Cameron JL, Kaufman HS, et al: Chemical splanchnicectomy in patients with unresectable pancreatic cancer: a prospective randomized trial. Ann Surg 217:447, 1993 [PMID 7683868]
104. Lillemoe KD, Cameron JL, Yeo CJ, et al: Pancreaticoduodenectomy: does it have a role in the palliation of pancreatic cancer? Ann Surg 223:718, 1996 [PMID 8645045]
105. D'Angelica M, Fong Y, Weber S, et al: The role of staging laparoscopy in hepatobiliary malignancy: prospective analysis of 401 cases. Ann Surg Oncol 10:183, 2003 [PMID 12620915]
106. Conlon KC, Dougherty E, Klimstra DS, et al: The value of minimal access surgery in the staging of patients with potentially resectable pancreatic malignancy. Ann Surg 223:134, 1996 [PMID 8597506]
107. John TG, Greig JD, Carter DC, et al: Carcinoma of the pancreatic head and periampullary region: tumor staging with laparoscopy and laparoscopic ultrasonography. Ann Surg 221:156, 1995 [PMID 7857143]
108. Jarnagin WR, Bodniewicz J, Dougherty E, et al: A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies. J Gastrointest Surg 4:34, 2000 [PMID 10631360]
109. Hunerbein M, Rau B, Schlag PM: Laparoscopic ultrasound for staging of upper gastrointestinal tumours. Eur J Surg Oncol 21:50, 1995 [PMID 7851554]
110. Scott-Conner CE: Laparoscopic biliary bypass for inoperable pancreatic cancer. Semin Laparosc Surg 5:185, 1998 [PMID 9787205]
111. Date RS, Siriwardena AK: Current status of laparoscopic biliary bypass in the management of non-resectable peri-ampullary cancer. Pancreatology 5:325, 2005 [PMID 15980662]
112. Chamberlain RS, Blumgart LH: Hilar cholangiocarcinoma: a review and commentary. Ann Surg Oncol 7:55, 2000 [PMID 10674450]
113. Ogura Y, Kawarada Y: Surgical strategies for carcinoma of the hepatic duct confluence. Br J Surg 85:20, 1998 [PMID 9462376]
114. Jarnagin W, Shoup M: Surgical management of cholangiocarcinoma. Seminars in liver disease 24, 189, 2004
115. Bartlett D: Gallbladder cancer. Semin Surg Oncol 19:145, 2000 [PMID 11126379]
116. Baer HU, Matthews JB, Schweizer WP, et al: Management of the Mirizzi syndrome and the surgical implications of cholecystocholedochal fistula. Br J Surg 77:743, 1990 [PMID 2383747]
117. Sarfeh MG, Rypins EB, Jakowatz JG, et al: A prospective, randomized clinical investigation of cholecystoenterostomy and choledochoenterostomy. Am J Surg 155:411, 1988 [PMID 3278638]
118. Kalady MF, Clary BM, Tyler DS, Pappas TN: Pancreas-preserving duodenectomy in the management of duodenal familial adenomatous polyposis. J Gastrointest Surg , 6822002
119. Lieberman MD, Kilburn H, Lindsey M, et al: Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 222:638, 1995 [PMID 7487211]
120. Lamont JT, Isselbacher KJ: Current concepts of postoperative hepatic dysfunction. Conn Med 39:461, 1975 [PMID 1183209]
121. Matlof DS, Kaplan MM: Postoperative jaundice. Orthop Clin North Am 9:799, 1978 [PMID 99709]
122. Moody FG, Potts JR III: Postoperative jaundice. Diseases of the Liver, 7th ed. Schiff L, Schiff ER, Eds. JB Lippincott Co, Philadelphia, 1993 , p 370
123. Isselbacher KJ: Bilirubin metabolism and hyperbilirubinemia. Harrison's Principles of Internal Medicine, 12th ed. Wilson JD, Braunwald E, Isselbacher KJ, et al, Eds. McGraw-Hill, New York, 1991 , p 1320
124. Watson CJ: Prognosis and treatment of hepatic insufficiency. Ann Intern Med 31:405, 1959
125. Sherlock S: Jaundice. Diseases of the Liver and Biliary System, 8th ed. Sherlock S, Ed. Blackwell Scientific Publications, Oxford, 1989 , p 230
126. Gollan JL, Keefe EB, Scharschmidt BF: Cholestasis and hyperbilirubinemia. Current Hepatology, Vol I. Gitnick G, Ed. Houghton Mifflin, Boston, 1980 , p 277
127. Bosma PJ, Chowdhury JR, Bakker C, et al: The genetic basis of the reduced expression of bilirubin UCP-glucuronosyltransferase 1 in Gilbert's syndrome. N Engl J Med 333:1171, 1995 [PMID 7565971]
128. O'grady JG, Portmann B, Williams R: Fulminant hepatic failure. Diseases of the Liver, 7th ed. Schiff L, Schiff ER, Eds. JB Lippincott Co, Philadelphia, 1993 , p 1077
129. Bismuth H, Samuel D, Castaing D, et al: Orthotopic liver transplantation in fulminant and subfulminant hepatitis. Ann Surg 222:109, 1995 [PMID 7639578]
130. Boyer JL, Reuben A: Chronic hepatitis. Diseases of the Liver, 7th ed. Schiff L, Schiff ER, Eds. JB Lippincott Co, Philadelphia, 1993 , p 586
131. Pugh RN, Murray-Lyon IM, Dawson JL, et al: Transection of the esophagus for bleeding esophageal varices. Br J Surg 60:646, 1973 [PMID 4541913]
132. Kamath PS, Wiesner RH, Malinchoc M, et al: A model to predict survival in patients with end-stage liver disease. Hepatology 33:464, 2001 [PMID 11172350]
133. Fallon MB, Anderson JM, Boyer JL: Intrahepatic cholestasis. Diseases of the Liver, 7th ed. Schiff L, Schiff ER, Eds. JB Lippincott Co, Philadelphia, 1993 , p 343
Section 5 Gastrointestinal Tract and Abdomen
3 JaundiceJeffrey S. Barkun, MD, FACS
Approach to the jaundiced patient, including clinical evaluation and investigative studies, workup and management of posthepatic jaundice, and postoperative jaundice, is described.
Role of Spiral CT in Assessing ResectabilityPossible causes of posthepatic obstruction (other than choledocholithiasis) may be classified into three categories, depending on the location of the obstructing lesion (as suggested by the pattern of gallbladder and biliary tree dilatation on the ultrasonogram): the upper third of the biliary tree, the middle third, or the lower (distal) third. Once it has been determined that choledocholithiasis is unlikely, the most common cause of such obstruction is pancreatic cancer.
Assessment of the resectability of a tumor usually hinges on whether the superior mesenteric vein, the portal vein, the superior mesenteric artery, and the porta hepatis are free of tumor and on whether there is evidence of significant local adenopathy or extrapancreatic extension of tumor. Unfortunately, the majority of lesions will be clearly unresectable, either because of tumor extension or because of the presence of hepatic or peritoneal metastases.
Many imaging modalities are currently used to determine resectability, and several of these have been established as effective alternatives to direct cholangiography because they involve little if any morbidity. Their accuracy varies according to the underlying pathology and the expertise of the user. They have been studied mostly with respect to the staging and diagnosis of pancreatic, periampullary, and biliary hilar cancers.
For determining resectability and for staging lesions before operation, we rely mainly on spiral computed tomography. The advent and widespread availability of multidetector CT have made this modality the dominant second-line imaging method in cases of suspected pancreatic masses. For optimal evaluation of the pancreas, a fine-cut dual-phase (arterial phase and portal venous phase) scan should be obtained. Oral administration of water allows better evaluation of the duodenum and the ampulla.1
1. Stroszczynski C, Hunerbein M: Malignant biliary obstruction: value of imaging findings. Abdom Imaging 30:314, 2005 [PMID 15965779]
In patients with a suspected pancreatic tumor, direct fine-needle aspiration of the lesion at the time of endoscopic ultrasonography has become the gold standard for obtaining a tissue diagnosis. In the case of potentially resectable lesions, however, this measure adds very little to the decision-making process. The limited data currently available suggest that assays of tumor markers in serum and pancreatic fluid are useful, particularly for cystic lesions of the pancreas.1
At this point in the evaluation, patients can be referred either for cholangiography (endoscopic retrograde cholangiopancreatography [ERCP] or magnetic resonance cholangiopancreatography [MRCP]) to clarify a still-unclear diagnosis or for biliary decompression. MRI of the pancreas with MRCP continues to improve rapidly. It is a noninvasive modality that evaluates the pancreas, vasculature and the pancreatobiliary ductal system in a single examination, with the additional benefit of avoiding ionizing radiation and iodinated contrast agents.2 MRCP remains our test of choice for evaluation of middle- and upper-third lesions in cases in which decompression is not required.
In the event that none of these modalities point to a diagnosis, the use of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) may be considered to help differentiate benign pancreatic conditions from malignant ones.3,4 Besides facilitating diagnosis, FDG-PET provides information regarding occult metastases and can be useful in detecting recurrent disease. Experience with FDG-PET is growing rapidly as this imaging modality becomes more readily accessible.
1. Brugge WR, Lauwers GY, Sahani D, et al: Current concepts: cystic neoplasms of the pancreas. N Engl J Med 351:1218, 2004 [PMID 15371579]
2. Keppke AL, Miller FH: Magnetic resonance imaging of the pancreas: the future is now. Semin Ultrasound CT MR 26:132, 2005 [PMID 15987063]
3. Delbeke D, Pinson CW: Pancreatic tumors: role of imaging in the diagnosis, staging and treatment. J Hepatobiliary Pancreat Surg 11:4, 2004 [PMID 15747028]
4. Heinrich S, Goerres G, Schafer M, et al: Positron emission tomography/computed tomography influences in the management of resectable pancreatic cancer and its cost-effectiveness. Ann Surg 242:235, 2005 [PMID 16041214]
When a patient has advanced malignant disease, drainage of the biliary system for palliation is not routinely indicated, because the risk of complications related to the procedure may outweigh the potential benefit. Indeed, the best treatment for a patient with asymptomatic obstructive jaundice and liver metastases may be supportive care alone. Biliary decompression is indicated if cholangitis or severe pruritus interferes with quality of life.
We consider a stent placed with ERCP to be the palliative modality of choice for advanced disease, though upper-third lesions may be managed most easily through the initial placement of an internal/external catheter at the time of percutaneous transhepatic cholangiography. Metal expandable stents remain patent longer than large conventional plastic stents, but the high price of the metal stents has kept them from being widely used, and their overall cost-effectiveness has yet to be clearly demonstrated. Whether plastic biliary stents should be replaced prophylactically or only after obstruction has occurred remains controversial; however, results from a randomized, controlled trial (RCT) favor the former approach. In another RCT, the use of prophylactic ciprofloxacin did not prolong stent patency but did reduce the incidence of cholangitis and improve quality of life scores.1
Because the left hepatic duct has a long extrahepatic segment that makes it more accessible, the preferred bypass technique for an obstructing upper-third lesion is a left (or segment 3) hepaticojejunostomy. This operation has superseded the Longmire procedure because it does not involve formal resection of liver parenchyma. Laparoscopic bypass techniques that make use of segment 3 have been developed, but their performance has yet to be formally assessed, and they cannot yet be incorporated into a management algorithm.2
1. Chan G, Barkun J, Barkun AN, et al: The role of ciprofloxacin in prolonging polyethylene biliary stent patency: a multicenter, double-blinded effectiveness study. J Gastrointest Surg 9:481, 2005 [PMID 15797227]
2. Date RS, Siriwardena AK: Current status of laparoscopic biliary bypass in the management of non-resectable peri-ampullary cancer. Pancreatology 5:325, 2005 [PMID 15980662]
The hilar plate is taken down to lengthen the hepatic duct segment available for subsequent anastomosis. Often, a formal hepatectomy or segmentectomy is required to ensure an adequate proximal margin of resection. If the resection must be carried out proximal to the hepatic duct bifurcation, several cholangiojejunostomies will have to be done to anastomose individual hepatic biliary branches. Frozen-section examination of the proximal and distal resection margins is important because of the propensity of tumors such as cholangiocarcinoma to spread in a submucosal or perineural plane.
The results of aggressive hilar tumor resections that included as much liver tissue as was necessary to obtain a negative margin appear to justify this approach. In cases of left hepatic involvement, resection of the caudate lobe (segments 1 and 9) is indicated as well.1
1. Jarnagin W, Shoup M: Surgical management of cholangiocarcinoma. Seminars in liver disease 24:189, 2004 [PMID 15192791]
An Expert Panel on Gastrointestinal Imaging evaluated various imaging strategies in the initial radiologic examination of patients with jaundice. They gauged the utility in differential diagnosis of the following modalities: ultrasound, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, computed tomography, nuclear medicine, cholescintigraphy, and magnetic resonance imaging with magnetic resonance cholangiopancreatography. To view the complete guidelines, click on the following link: http://www.guideline.gov/summary/summary.aspx?doc_id=8294&nbr=004626
For further information, see Section 5, Chapter 3, Jaundice.
Jaundice
Question 1 A 40-year-old woman presents to the office for evaluation of yellowish skin. She states that over the past few weeks, she has noticed that her eyes and skin have developed a yellow tint. She also reports that she has dark urine and pale-colored stools. Further history elicits periodic bouts of right upper quadrant pain after eating. She is otherwise healthy. She denies using any medications. On physical examination, a yellowish tint is observed on the patient's skin, sclera, and mucous membranes.
On the basis of this patient's history and clinical examination, which type of bilirubin would you expect to predominate?
Please choose the single most appropriate answer to the question - Conjugated
This is correct.
Objective: To understand the determination of hyperbilirubinemia as either direct or indirectOnce the presence of jaundice has been confirmed, further clinical assessment determines whether the hyperbilirubinemia is predominantly direct or indirect. This distinction is based on the division of bilirubin into conjugated and unconjugated fractions, which are also known, respectively, as direct and indirect fractions on the basis of their behavior in the van den Bergh (diazo) reaction. If the patient has normal colored urine and stools, unconjugated bilirubin is predominant. If the patient has dark urine, pale stools, or any other signs or symptoms of cholestatic syndrome, the serum bilirubin fractionation usually indicates that conjugated bilirubin is predominant. Rarely, the clinical picture may be secondary to a massive increase in both direct and indirect bilirubin production after the latter has overcome the ability of the hepatocytes to secrete conjugated bilirubin. - Unconjugated
Sorry, this is incorrect. Try again!
- Indirect
- Mixed
Question 2 A 48-year-old woman presents to the emergency department complaining of right upper quadrant pain, which began 4 hours ago. She reports the pain as being spasmodic and sharp and that it radiates to her right shoulder blade. She says that she has had similar episodes over the past few months, especially after eating large meals. Associated with the pain is nausea and vomiting. Her blood pressure is 120/85 mm Hg, and her pulse is 100 beats/min. On physical examination, the patient is found to have a nontender abdomen with no palpable masses. Her chest and cardiovascular examinations are normal. The nurse notices that her sclerae are slightly icteric. On subsequent laboratory studies, her serum bilirubin level is found to be 10 mg/dl.
What imaging study should be performed next for this patient with presumed posthepatic jaundice? Please choose the single most appropriate answer to the question - Endoscopic retrograde cholangiopancreatography (ERCP)
- Magnetic resonance imaging
- Percutaneous transhepatic cholangiography (PTC)
- Ultrasonography
Objective: To understand the various imaging methods used in the evaluation of jaundiceThe presence of ductal dilatation of the intrahepatic or extrahepatic biliary system confirms that a posthepatic cause is responsible for the jaundice. Ultrasonography detects ductal dilatation with an accuracy of 95%, though results are to some extent operator dependent. If ultrasonography does not reveal bile duct dilatation, it is unlikely that an obstructing lesion is present. In some cases, even though ductal dilatation is absent, other ultrasonographic findings may still point to a specific hepatic cause of jaundice (e.g., cirrhosis or infiltration of the liver by tumor). There are a few specific instances in which ultrasonography may fail to detect a posthepatic cause of jaundice. For instance, very early in the course of an obstructive process, not enough time may have elapsed for biliary dilatation to occur. In this setting, a hepato-iminodiacetic acid (HIDA) scan has often helped identify bile duct blockage. The yield from this test is highest when the serum bilirubin level is lower than 100 #x00B5mol/L. Occasionally, the intrahepatic biliary tree is unable to dilate; possible causes of such inability include extensive hepatic fibrosis, cirrhosis, sclerosing cholangitis, and liver transplantation. If one of these diagnoses is suspected, ERCP, magnetic resonance cholangiopancreatography (MRCP), or PTC will eventually be required to confirm the diagnosis of biliary obstruction. Occasionally, the biliary tree dilatation may be intermittent; possible causes of this condition include choledocholithiasis and some biliary tumors. In a patient with gallstones, transient liver test abnormalities by themselves may suggest an intermediate to high likelihood of common bile duct stones, even if there is no biliary ductal dilatation. If one of these diagnoses is suspected, ultrasonography may be repeated after a short period of observation (when clinically applicable); biliary ductal dilatation then generally becomes apparent. If all of these unusual clinical situations have been ruled out, a hepatic cause for the jaundice should be sought and a liver biopsy considered.
Question 3 A 50-year-old man presents to your office for evaluation of jaundice, weight loss, and fatigue. Over the past 6 months, the patient has been experiencing generalized, aching pain in his abdomen and back. The pain has worsened over the past few weeks. In addition, the patient has lost his desire to eat; over the past 3 months, he has lost 20 lb. Physical examination reveals a cachectic man with yellowish skin. Abdominal examination elicits diffuse tenderness along the upper right and left quadrants. Ultrasonography reveals no evidence of gallstones, and the hepatic ducts are normal.
Of the following, which is the most likely cause of this patient's posthepatic obstruction? Please choose the single most appropriate answer to the question - Pancreatic cancer
Objective: To understand possible causes of posthepatic obstruction other than choledocholithiasisPossible causes of posthepatic obstruction other than choledocholithiasis may be classified into three categories, depending on the location of the obstructing lesion (as suggested by the pattern of gallbladder and biliary tree dilatation on the ultrasonogram): those relating to the upper third of the biliary tree, those relating to the middle third, or those relating to the lower (distal) third. Once it has been determined that choledocholithiasis is unlikely, the most common cause of such obstruction is pancreatic cancer. In adults, many of the other possible causes also involve malignant processes. Consequently, the next step in the workup of a patient such as this one is typically the assessment of resectability and operability. - Choledocholithiasis
- Hepatitis C virus infection
- Diseased gallbladder
Không có nhận xét nào:
Đăng nhận xét