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Surgery_Schwartz. as a complication of surgery of the gallbladder or the biliary tree can be confirmed and frequently localized by biliary scintigraphy.12 HIDA scanning with evalu-ation of the gallbladder ejection fraction with or without CCK provocation may also be helpful in diagnosing chronic bili-ary dyskinesia in patients with atypical symptoms. While an ejection fraction of <35% is considered abnormal, the exact interpretations and clinical implications of this finding remain a matter of some debate.13Magnetic Resonance ImagingAvailable since the mid-1990s, MRI provides anatomic details of the liver, gallbladder, and pancreas similar to those obtained from CT. Many MRI techniques (i.e., heavily T2-weighted sequences, pulse sequences with or without contrast materials) can generate high-resolution anatomic images of the biliary tree and the pancreatic duct. MRI with magnetic resonance chol-angiopancreatography (MRCP) offers a focused, noninvasive test for the diagnosis of biliary tract and


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Surgery_Schwartz. anatomic images of the biliary tree and the pancreatic duct. MRI with magnetic resonance chol-angiopancreatography (MRCP) offers a focused, noninvasive test for the diagnosis of biliary tract and pancreatic disease (Fig. 32-9).14 It has a sensitivity and specificity of 95% and 89%, respectively, for detecting choledocholithiasis.15 In many centers, MRCP is the preferred imaging modality for precise evaluation of biliary and pancreatic duct pathology, reserving endoscopic retrograde cholangiopancreatography (ERCP) for therapeutic purposes only.Figure 32-7. Computed tomography scan of the upper abdomen from a patient with cancer of the distal common bile duct. The cancer obstructs the common bile duct as well as the pancreatic duct. 1 = the portal vein; 2 = a dilated intrahepatic bile duct; 3 = dilated cystic duct and the neck of the gallbladder; 4 = dilated common hepatic duct; 5 = the bifurcation of the common hepatic artery into the gastroduodenal artery and the proper hepatic


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Surgery_Schwartz. duct; 3 = dilated cystic duct and the neck of the gallbladder; 4 = dilated common hepatic duct; 5 = the bifurcation of the common hepatic artery into the gastroduodenal artery and the proper hepatic artery; 6 = dilated pancreatic duct; 7 = the splenic vein.ABFigure 32-8. HIDA scanning. A. Normal HIDA scan showing filling of the extrahepatic biliary tree and gallbladder (white arrow). B. HIDA san in a patient with acute cholecystitis showing no filling of the gallbladder.Brunicardi_Ch32_p1393-p1428.indd 139911/02/19 2:43 PM 1400SPECIFIC CONSIDERATIONSPART IIEndoscopic Retrograde CholangiopancreatographyWhile the use of endoscopic retrograde cholangiopancrea-tography (ERCP) in biliary disease is particularly valuable for its therapeutic capabilities, its diagnostic role should not be overlooked. Using a side-viewing endoscope, the common bile duct can be cannulated through the ampulla of Vater and a cholangiogram performed using fluoroscopy (Fig. 32-10). The procedure requires at


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Surgery_Schwartz. overlooked. Using a side-viewing endoscope, the common bile duct can be cannulated through the ampulla of Vater and a cholangiogram performed using fluoroscopy (Fig. 32-10). The procedure requires at least intravenous (IV) sedation and in some cases general anesthesia. The advantages of ERCP include direct visualization of the ampullary region and direct access to the distal common bile duct for cholangiography or choledochoscopy. The test is rarely needed for uncomplicated gallstone disease. However, for cases of choledocholithiasis, obstructive jaundice, biliary strictures, or cholangitis, ERCP has the advantage of being both diagnostic and therapeutic. If ductal stones are identified on the endoscopic cholangiogram, biliary sphincterotomy and stone extraction can be performed, clearing the common bile duct of stones. If another etiology such as a biliary stricture is found, diagnostic brushings can be obtained at the time of the procedure. In the hands of experts, the success rate


Surgery_Schwartz

Surgery_Schwartz. the common bile duct of stones. If another etiology such as a biliary stricture is found, diagnostic brushings can be obtained at the time of the procedure. In the hands of experts, the success rate of common bile duct cannulation and cholan-giography is >90%. Notable complications of diagnostic ERCP include pancreatitis, which occurs in approximately 3.5% of patients, as well as rare occurrences of bleeding, perforation, or infection (cholangitis).16,17Endoscopic CholedochoscopyThe development of small fiber-optic cameras that can be threaded through endoscopes used for endoscopic retrograde cholangiopancreatography (ERCP) has facilitated the develop-ment of intraductal endoscopy. By providing direct visualiza-tion of the biliary and pancreatic ducts, this technology has been shown to increase the effectiveness of ERCP in the diag-nosis of certain biliary diseases.18 Intraductal endoscopy has been shown to have therapeutic applications that include bili-ary stone lithotripsy and


Surgery_Schwartz

Surgery_Schwartz. increase the effectiveness of ERCP in the diag-nosis of certain biliary diseases.18 Intraductal endoscopy has been shown to have therapeutic applications that include bili-ary stone lithotripsy and directed stone extraction in high-risk surgical patients.19 It can also allow for direct visualization and sampling of concerning lesions in order to evaluate for malig-nancy (Fig. 32-11). Studies have thus far shown intraductal endoscopy to be safe and effective, though complications such as bile duct perforation, minor bleeding, and cholangitis have Figure 32-9. Magnetic resonance cholangiopancreatography. This view shows the course of the extrahepatic bile ducts (arrow) and the pancreatic duct (arrowheads).BAFigure 32-10. Endoscopic retrograde cholangiography. A. A schematic picture showing the side-viewing endoscope in the duodenum and a catheter in the common bile duct. B. An endoscopic cholangiogram showing stones in the common bile duct. The catheter has been placed through the


Surgery_Schwartz

Surgery_Schwartz. the side-viewing endoscope in the duodenum and a catheter in the common bile duct. B. An endoscopic cholangiogram showing stones in the common bile duct. The catheter has been placed through the ampulla of Vater into the distal common bile duct (arrow). Note the duodenal shadow indicated with arrowheads.Brunicardi_Ch32_p1393-p1428.indd 140011/02/19 2:43 PM 1401GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32been described.20 Further refinement of this technology will likely enhance ERCP as a diagnostic and therapeutic tool.Endoscopic UltrasoundEndoscopic ultrasound (EUS) has improved significantly in recent years and offers additional diagnostic utility to the workup of biliary disease. It requires a specialized 30° endo-scope with either a radial or linear ultrasound transducer at its tip. The results are operator dependent and require a skilled endoscopist but offer noninvasive imaging of the bile ducts and adjacent structures. Endoscopic ultrasound can also be used to


Surgery_Schwartz

Surgery_Schwartz. at its tip. The results are operator dependent and require a skilled endoscopist but offer noninvasive imaging of the bile ducts and adjacent structures. Endoscopic ultrasound can also be used to identify choledocholithiasis. It is useful for evaluation of the retroduodenal potion of the bile duct, which is difficult to visu-alize with transabdominal ultrasonography. Although EUS is less sensitive than ERCP for biliary stones, the technique is less invasive as it does not require cannulation of the sphincter of Oddi. EUS is also of particular value in the evaluation of tumors near or behind the duodenum and their resectability. Using a linear EUS scope that has a biopsy channel, fine-needle aspira-tion (FNA) of tumors or lymph nodes, therapeutic injections, or drainage procedures under direct ultrasonic guidance can be performed.21Percutaneous Transhepatic CholangiographyIn settings in which the biliary tree cannot be accessed endo-scopically, antegrade cholangiography can be


Surgery_Schwartz

Surgery_Schwartz. under direct ultrasonic guidance can be performed.21Percutaneous Transhepatic CholangiographyIn settings in which the biliary tree cannot be accessed endo-scopically, antegrade cholangiography can be performed by accessing the intrahepatic bile ducts percutaneously with a small needle under fluoroscopic guidance. Once the position in a bile duct has been confirmed, a guidewire is inserted and a catheter is passed over the wire (Fig. 32-12). Through the catheter, an antegrade cholangiogram can be obtained and therapeutic inter-ventions such as tissue sampling, biliary drain insertions, or stent placements performed. Percutaneous transhepatic cholangiog-raphy (PTC) can also be performed through previously placed percutaneous biliary drainage tubes, if present. PTC has little role in the management of patients with uncomplicated gallstone disease but can be useful in patients with bile duct strictures or tumors, as it can define the anatomy of the biliary tree proximal to the affected


Surgery_Schwartz

Surgery_Schwartz. of patients with uncomplicated gallstone disease but can be useful in patients with bile duct strictures or tumors, as it can define the anatomy of the biliary tree proximal to the affected segment. As with any invasive procedure, there are potential risks. For PTC, these are mainly bleeding, cholan-gitis, bile leak, and other catheter-related problems.12GALLSTONE DISEASEPrevalence and IncidenceGallstone disease (cholelithiasis) is one of the most common afflictions of the digestive tract. Autopsy reports show that gallstones are present in between 10% and 15% of adults.22 The prevalence of gallstones is related to many factors, including diet, age, gender, BMI, and ethnic background with increased prevalence in patients of Native American and Latin American descent. Certain conditions also predispose to the development of gallstones including pregnancy, non-HDL hyperlipidemia, Crohn’s disease, and certain blood disorders such as heredi-tary spherocytosis, sickle cell disease, and


Surgery_Schwartz

Surgery_Schwartz. also predispose to the development of gallstones including pregnancy, non-HDL hyperlipidemia, Crohn’s disease, and certain blood disorders such as heredi-tary spherocytosis, sickle cell disease, and thalassemia. Sur-geries that alter the normal neural or hormonal regulation of the biliary tree including terminal ileal resection and gastric or duodenal surgery increase the risk of cholelithiasis. Rapid weight loss following bariatric surgery or lifestyle changes can also precipitate gallstone formation by creating an imbal-ance in bile composition. Medications such as somatostatin analogues and estrogen-containing oral contraceptives are also associated with an increased risk of developing gallstones.22 Women are three times more likely to develop gallstones than men, and first-degree relatives of patients with gallstones have a twofold greater prevalence, possibly indicating a genetic predisposition.23Natural HistoryDespite the high prevalence of cholelithiasis, most patients will


Surgery_Schwartz

Surgery_Schwartz. of patients with gallstones have a twofold greater prevalence, possibly indicating a genetic predisposition.23Natural HistoryDespite the high prevalence of cholelithiasis, most patients will remain asymptomatic from their gallstones throughout life. For unknown reasons, some patients progress to a symptom-atic stage, with typical symptoms of postprandial right upper quadrant pain (biliary colic) caused by a stone obstructing the cystic duct. In addition to pain, gallstones may progress to cause complications such as acute cholecystitis, choledocholithiasis, cholangitis, gallstone pancreatitis, gallstone ileus, and gallblad-der cancer. Rarely, one of these complications of gallstones may be the initial presenting picture.Gallstones in patients without biliary symptoms are com-monly diagnosed incidentally during unrelated abdominal imag-ing or at the time of surgery for an unrelated diagnosis. Several studies have examined the likelihood of developing biliary colic or developing


Surgery_Schwartz

Surgery_Schwartz. diagnosed incidentally during unrelated abdominal imag-ing or at the time of surgery for an unrelated diagnosis. Several studies have examined the likelihood of developing biliary colic or developing significant complications of gallstone disease after incidental diagnosis in the asymptomatic patient. About 80% of these patients will remain symptom free.24 However, 2% to 3% will become symptomatic per year (i.e., develop biliary colic). Once symptomatic, patients tend to have recurring bouts of biliary colic. Complicated gallstone disease (cholecystitis, choledocholithiasis, gallstone pancreatitis, etc.) develops in 3% to 5% of symptomatic patients per year.25Because few patients develop complications without previ-ous biliary symptoms, prophylactic cholecystectomy in asymp-tomatic persons with gallstones is rarely indicated.24 Exceptions exist for individuals who will be isolated from medical care for extended periods of time, or in populations with increased risk of gallbladder


Surgery_Schwartz

Surgery_Schwartz. with gallstones is rarely indicated.24 Exceptions exist for individuals who will be isolated from medical care for extended periods of time, or in populations with increased risk of gallbladder cancer, in which case a prophylactic cholecys-tectomy may be advisable. The presence of porcelain gallblad-der, marked by significant calcifications thought to be related to Figure 32-11. A view from the choledochoscope showing cholangiocarcinoma.Brunicardi_Ch32_p1393-p1428.indd 140111/02/19 2:43 PM 1402SPECIFIC CONSIDERATIONSPART IIgallstones, is a rare premalignant condition and is an absolute indication for cholecystectomy, even when asymptomatic.Gallstone FormationGallstones form as a result of solids settling out of solution. The major organic solutes in bile are bilirubin, bile salts, phospho-lipids, and cholesterol. Gallstones are classified by their choles-terol content as either cholesterol stones or pigment stones. Pigment stones can be further classified as either black or brown.


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Surgery_Schwartz. and cholesterol. Gallstones are classified by their choles-terol content as either cholesterol stones or pigment stones. Pigment stones can be further classified as either black or brown. In Western countries, about 80% of gallstones are cholesterol stones and about 15% to 20% are black pigment stones.22 Brown pigment stones account for only a small percentage. Both types of pigment stones are more common in Asia.Cholesterol Stones. Pure cholesterol stones are uncommon and account for <10% of all stones. They usually occur as a sin-gle large stone with a smooth surface. The majority of choles-terol stones are mixed but are at least 70% cholesterol by weight in addition to variable amounts of bile pigments and calcium. These stones are usually multiple, of variable size, and may be 2SafetywireinsertedExternaldrainagecatheter21-guageneedleBileducttumorGuidewire insertedthrough introducerDrainagecatheterABCDEFFigure 32-12. Schematic diagram of percutaneous transhepatic cholangiogram and


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Surgery_Schwartz. insertedthrough introducerDrainagecatheterABCDEFFigure 32-12. Schematic diagram of percutaneous transhepatic cholangiogram and drainage for obstructing proximal cholangiocarcinoma. A. Dilated intrahepatic bile duct is entered percutaneously with a fine needle. B. Small guidewire is passed through the needle into the duct. C. A plastic catheter has been passed over the wire, and the wire is subsequently removed. A cholangiogram can be performed through the catheter. D. An external drainage catheter in place. E. Long wire placed via the catheter and advanced past the tumor and into the duodenum. F. Internal stent has been placed through the tumor.Brunicardi_Ch32_p1393-p1428.indd 140211/02/19 2:43 PM 1403GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32Figure 32-13. Gallbladder with cholesterol stones. A. Stones of multiple shapes and sizes. B. Solitary large stone. C. Multiple stones of varying composition. (Reproduced with permission from Slesinger MH, Fordtran JS:


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Surgery_Schwartz. with cholesterol stones. A. Stones of multiple shapes and sizes. B. Solitary large stone. C. Multiple stones of varying composition. (Reproduced with permission from Slesinger MH, Fordtran JS: Gastrointestinal Diseases. Philadelphia, PA: Elsevier/Saunders; 1989.)100100Moles % Bile salts100808080606060Moles % CholesterolMoles % LecithinMicellarliquidMetastablesupersaturatedzone4040402020200002 or morephasesFigure 32-14. The three major components of bile plotted on triangular coordinates, cholesterol, bile salts and phospholipids (lecithin). A given point represents the relative molar ratios of each. The area labeled “micellar liquid” shows the range of concentrations in which cholesterol is fully solubilized. The shaded area directly above this region corresponds to a metastable zone, supersaturated with cholesterol. Above the shaded area, bile has exceeded the solubilization capacity of cholesterol and precipitation of cholesterol crystals and stones occurs.hard and faceted or


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Surgery_Schwartz. supersaturated with cholesterol. Above the shaded area, bile has exceeded the solubilization capacity of cholesterol and precipitation of cholesterol crystals and stones occurs.hard and faceted or irregular, multilobed, and soft (Fig. 32-13). Colors range from whitish yellow to green or black. Most cho-lesterol stones (>90%) are radiolucent, though some have a high calcium carbonate component and become radioopaque.The primary event in the formation of cholesterol stones is supersaturation of bile with cholesterol. Cholesterol is highly nonpolar and its solubility in water and bile depends on the relative concentration of cholesterol, bile salts, and lecithin (the main phospholipid in bile). Cholesterol is secreted into bile and is surrounded by bile salts and phospholipids to form a soluble vesicle complex. When cholesterol hypersecretion is present, either through increased intake or dysfunctional processing, supersaturation occurs. When cholesterol concentrations exceed the ability


Surgery_Schwartz

Surgery_Schwartz. vesicle complex. When cholesterol hypersecretion is present, either through increased intake or dysfunctional processing, supersaturation occurs. When cholesterol concentrations exceed the ability of the bile salts and phospholipid to maintain solu-bility, the cholesterol precipitates out of solution into a solid, forming a cholesterol stone (Fig. 32-14).26 Cholesterol hyperse-cretion is almost always the cause of supersaturation rather than reduced secretion of phospholipid or bile salts.2Pigmented Stones. Pigmented stones contain <20% choles-terol and are dark because of the presence of calcium bilirubi-nate. Black and brown pigment stones have little in common and should be considered as separate entities.Black pigment stones are usually small, brittle, dark, and sometimes spiculated. They are formed by supersaturation of unconjugated bilirubin within the bile. Deconjugation of bili-rubin occurs normally in bile at a slow rate. Thus, excessive levels of conjugated bilirubin


Surgery_Schwartz

Surgery_Schwartz. They are formed by supersaturation of unconjugated bilirubin within the bile. Deconjugation of bili-rubin occurs normally in bile at a slow rate. Thus, excessive levels of conjugated bilirubin excretion, as occurs in hemolytic disorders like hereditary spherocytosis and sickle cell disease will lead to an increased rate of production of unconjugated bilirubin. Cirrhosis and hepatic dysfunction may also lead to increased secretion of unconjugated bilirubin directly from the liver. The insoluble unconjugated bilirubin will then precipitate with calcium as insoluble calcium bilirubinate, forming a pig-ment stone. Due to their high calcium content, pigment stones are often radiopaque. Like cholesterol stones, they almost always form in the gallbladder. In Asian countries such as Japan, black stones account for a much higher percentage of gallstones than in the Western hemisphere.Brown stones are usually <1 cm in diameter, brownish-yel-low, soft, and often mushy. They may form either in


Surgery_Schwartz

Surgery_Schwartz. stones account for a much higher percentage of gallstones than in the Western hemisphere.Brown stones are usually <1 cm in diameter, brownish-yel-low, soft, and often mushy. They may form either in the gallblad-der or in the bile ducts secondary to bacterial infection and bile stasis. Bacteria such as Escherichia coli secrete β-glucuronidase that enzymatically cleaves conjugated bilirubin to produce the insoluble unconjugated bilirubin. This unconjugated bilirubin then precipitates with calcium, and along with dead bacterial cell bodies, forms soft brown stones in the biliary tree. Brown stones are typically found in Asian populations and are associated with stasis secondary to parasite infection with Ascaris lumbricoides BCABrunicardi_Ch32_p1393-p1428.indd 140311/02/19 2:43 PM 1404SPECIFIC CONSIDERATIONSPART II(roundworm) or Clonorchis sinensis (liver fluke). In Western populations, brown stones most often occur as primary bile duct stones in patients with biliary strictures or


Surgery_Schwartz

Surgery_Schwartz. CONSIDERATIONSPART II(roundworm) or Clonorchis sinensis (liver fluke). In Western populations, brown stones most often occur as primary bile duct stones in patients with biliary strictures or other common bile duct stones that cause stasis and bacterial contamination.2,27Symptomatic GallstonesSymptomatic Cholelithiasis. Patients with symptomatic gall-stone disease typically present with recurrent attacks of pain. The pain develops when a stone obstructs the cystic duct, resulting in a progressive increase of tension in the gallbladder wall as it contracts in response to a meal. This postprandial right upper quadrant or epigastric pain is often referred to as biliary colic. If untreated, about two-thirds of these patients will develop chronic noninfectious inflammation of the gallbladder wall, termed chronic cholecystitis. The pathologic changes, which often do not correlate well with symptoms, vary from an apparently nor-mal gallbladder with minor chronic inflammation in the mucosa,


Surgery_Schwartz

Surgery_Schwartz. wall, termed chronic cholecystitis. The pathologic changes, which often do not correlate well with symptoms, vary from an apparently nor-mal gallbladder with minor chronic inflammation in the mucosa, to a shrunken, nonfunctioning gallbladder with transmural fibro-sis and adhesions to nearby structures. The mucosa is initially normal or hypertrophied but later becomes atrophied, with the epithelium protruding into the muscle coat, leading to the forma-tion of the so-called Aschoff-Rokitansky sinuses.Clinical Manifestations The chief symptom associated with symptomatic cholelithiasis is pain (biliary colic). The pain is con-stant and increases in severity over the first half hour or so after a meal and can last 1 to 5 hours. It is located in the epigastrium or right upper quadrant and frequently radiates to the right upper back or between the scapulae (Fig. 32-15). The pain is severe and comes on abruptly, typically during the night or after a fatty meal. It often is associated with


Surgery_Schwartz

Surgery_Schwartz. radiates to the right upper back or between the scapulae (Fig. 32-15). The pain is severe and comes on abruptly, typically during the night or after a fatty meal. It often is associated with nausea and sometimes vomiting. Patients generally suffer discrete, recurrent attacks of pain, between which they feel well. Physical examination may reveal mild right upper quadrant tenderness during an episode of pain. If the patient is pain free, the physical examination is usually unremarkable. Labora-tory values, such as WBC count and liver function tests, are usu-ally normal in patients with uncomplicated gallstones.Atypical presentations of gallstone disease are common and a high index of suspicion for biliary disease must be main-tained when evaluating patients with abdominal complaints. Association with meals is present in only about 50% of patients. Some patients report milder attacks of pain but relate it to meals. The pain may be located primarily in the back or the left upper or right


Surgery_Schwartz

Surgery_Schwartz. with meals is present in only about 50% of patients. Some patients report milder attacks of pain but relate it to meals. The pain may be located primarily in the back or the left upper or right lower quadrant. Bloating and belching may be present and associated with the attacks of pain. In patients with atypi-cal presentations, other conditions that may be causing upper abdominal pain should be ruled out, even in the presence of gallstones. These include but are not limited to peptic ulcer dis-ease, gastroesophageal reflux disease, herpes zoster, abdominal wall hernias, inflammatory bowel disease, diverticular disease, pancreatitis, liver disease, renal calculi, pleuritic pain, and car-diac pain.When the pain lasts >24 hours without resolving, an impacted stone in the cystic duct or acute cholecystitis (see later “Acute Cholecystitis” section) should be suspected. An impacted stone without cholecystitis will result in what is called hydrops of the gallbladder. Bile will be unable to


Surgery_Schwartz

Surgery_Schwartz. cholecystitis (see later “Acute Cholecystitis” section) should be suspected. An impacted stone without cholecystitis will result in what is called hydrops of the gallbladder. Bile will be unable to enter the gall-bladder due to the obstructed cystic duct, but the gallbladder epithelium will continue to secrete mucus, and the gallbladder will become distended with clear-white mucinous material. The gallbladder may be palpable but usually is not tender. Hydrops of the gallbladder may result in edema of the gallbladder wall, inflammation, infection, and perforation. Although hydrops may persist with few consequences, early cholecystectomy is generally indicated to avoid complications.Diagnosis The diagnosis of symptomatic cholelithiasis or chronic cholecystitis depends on the presence of typical symp-toms and the demonstration of stones on diagnostic imaging. An abdominal ultrasound is the standard diagnostic test for gallstones as it is noninvasive and highly sensitive (see earlier


Surgery_Schwartz

Surgery_Schwartz. typical symp-toms and the demonstration of stones on diagnostic imaging. An abdominal ultrasound is the standard diagnostic test for gallstones as it is noninvasive and highly sensitive (see earlier “Ultrasonography” section).28 Gallstones are occasionally iden-tified on abdominal CT scans that were obtained as part of a broader workup of abdominal pain. In these cases, if the patient has typical symptoms, it is reasonable to proceed with interven-tion. Stones diagnosed incidentally on CT or plain radiographs in patients without symptoms should be left in place. Occasion-ally, patients with typical attacks of biliary pain have no evi-dence of stones on ultrasound but have evidence of sludge in the gallbladder. If a patient has attacks of typical biliary pain and sludge is detected, cholecystectomy is warranted.In addition to sludge and stones, cholesterolosis and adeno-myomatosis of the gallbladder may cause typical biliary symp-toms and may be detected on ultrasound or CT.


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Surgery_Schwartz. cholecystectomy is warranted.In addition to sludge and stones, cholesterolosis and adeno-myomatosis of the gallbladder may cause typical biliary symp-toms and may be detected on ultrasound or CT. Cholesterolosis is caused by the accumulation of cholesterol in macrophages in the 221514764501352441429614396322151911252311353323ABFigure 32-15. A. Sites of the most severe pain during an episode of biliary colic in 107 patients with gallstones (% values add up to >100% because of multiple responses). The subxiphoid and right subcostal areas were the most common sites; note that the left sub-costal area was not an unusual site of pain. B. Sites of pain radiation (%) during an episode of biliary colic in the same group of patients.Brunicardi_Ch32_p1393-p1428.indd 140411/02/19 2:43 PM 1405GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32gallbladder lamina propria, either locally or as polyps. It produces the classic studded macroscopic appearance of a “strawberry gallbladder.”


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Surgery_Schwartz. AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32gallbladder lamina propria, either locally or as polyps. It produces the classic studded macroscopic appearance of a “strawberry gallbladder.” Adenomyomatosis (cholecystitis glandularis prolif-erans) is characterized on microscopy by hypertrophic smooth muscle bundles and by the ingrowths of mucosal glands into the muscle layer (epithelial sinus formation). Granulomatous polyps develop in the lumen at the fundus, and the gallbladder wall is thickened. Septae or strictures may be seen within the gallblad-der. In symptomatic patients, cholecystectomy is the treatment of choice for patients with these conditions.29Treatment Nonsurgical management of gallstone disease using medications or lithotripsy has had disappointing long-term results. These modalities are not considered to be part of the primary treatment algorithm for gallstone disease.30 Surgi-cal cholecystectomy offers the best long-term results for patients with symptomatic


Surgery_Schwartz

Surgery_Schwartz. These modalities are not considered to be part of the primary treatment algorithm for gallstone disease.30 Surgi-cal cholecystectomy offers the best long-term results for patients with symptomatic gallstones. About 90% of patients with typical biliary symptoms and stones are rendered symp-tom free after cholecystectomy. For patients with atypical symptoms such as dyspepsia, flatulence, belching, bloating, and dietary fat intolerance, the results are not as favorable. The laparoscopic approach has been proven to be safe and effective and has become the standard of care for symptomatic gallstone disease, replacing open cholecystectomy in routine cases.29,31 3Due to the possibility of developing complications related to gallstone disease, patients with symptomatic choleli-thiasis should be offered elective cholecystectomy. While wait-ing for surgery, or if surgery has to be postponed, the patient should be advised to avoid dietary fats and large meals. Dia-betic patients with symptomatic


Surgery_Schwartz

Surgery_Schwartz. elective cholecystectomy. While wait-ing for surgery, or if surgery has to be postponed, the patient should be advised to avoid dietary fats and large meals. Dia-betic patients with symptomatic gallstones should be encour-aged to have a cholecystectomy promptly, as they are more prone to developing severe acute cholecystitis. Pregnant women with symptomatic gallstones who cannot be managed expectantly with diet modifications can safely undergo laparo-scopic cholecystectomy. The operation should be performed during the second trimester if possible.Acute Cholecystitis. Acute cholecystitis, or infection of the gallbladder, is associated with gallstones in 90% to 95% of cases. Rarely, acalculous cholecystitis can occur, usually in patients with other acute systemic diseases (see later “Acalculous Chole-cystitis” section). Obstruction of the cystic duct by a gall-stone is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall. In <1% of


Surgery_Schwartz

Surgery_Schwartz. Chole-cystitis” section). Obstruction of the cystic duct by a gall-stone is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall. In <1% of acute cholecystitis, the cause is a tumor obstructing the cystic duct. Why inflammation develops only occasionally with cystic duct obstruction is unknown, but it is probably related to the duration of obstruction. Initially, acute cholecystitis is an inflammatory process, probably mediated by the mucosal toxin lysolecithin, a product of lecithin, as well as bile salts and platelet-activat-ing factor. An increase in prostaglandin synthesis amplifies the inflammatory response. In acute cholecystitis, the gallbladder wall becomes grossly thickened and reddish with subserosal hemorrhages. Pericholecystic fluid often is present. The mucosa may show hyperemia and patchy necrosis. In severe cases, about 5% to 10%, the inflammatory process progresses and leads to ischemia and necrosis of the


Surgery_Schwartz

Surgery_Schwartz. fluid often is present. The mucosa may show hyperemia and patchy necrosis. In severe cases, about 5% to 10%, the inflammatory process progresses and leads to ischemia and necrosis of the gallbladder wall. More frequently, the gallstone is dislodged and the inflammation resolves.Not all episodes of uncomplicated acute cholecystitis involve infection. Secondary bacterial contamination is thought to occur in only 15% to 30% of patients. With some severe infections, gangrenous cholecystitis can develop, and an abscess or perforation may occur. When they happen, perforations are usually contained in the subhepatic space by the omentum and adjacent organs. However, free perforation with peritonitis, intrahepatic perforation with intrahepatic abscesses, and per-foration into adjacent organs (duodenum or colon) with cho-lecystoenteric fistula have been described. When gas-forming organisms are part of the secondary bacterial infection, gas may be seen in the gallbladder lumen and in the wall


Surgery_Schwartz

Surgery_Schwartz. or colon) with cho-lecystoenteric fistula have been described. When gas-forming organisms are part of the secondary bacterial infection, gas may be seen in the gallbladder lumen and in the wall of the gallblad-der on abdominal radiographs and CT scans, an entity called emphysematous cholecystitis.Clinical Manifestations About 80% of patients with acute cholecystitis give a history compatible with chronic cholecysti-tis. Acute cholecystitis often begins as an attack of biliary colic with relapsing and remitting pain in the right upper quadrant or epigastrium that may radiate to the right back or interscapular area. In contrast to biliary colic, the pain of acute cholecystitis does not subside. It is unremitting, may persist for several days, and is usually more severe than the pain associated with uncom-plicated gallstone disease. The patient is often febrile, complains of anorexia, nausea, and vomiting, and may be reluctant to move as the inflammatory process creates focal


Surgery_Schwartz

Surgery_Schwartz. associated with uncom-plicated gallstone disease. The patient is often febrile, complains of anorexia, nausea, and vomiting, and may be reluctant to move as the inflammatory process creates focal peritonitis. On physi-cal examination, tenderness and guarding are usually present in the right upper quadrant. A mass, the gallbladder and adherent omentum, is occasionally palpable; however, guarding may pre-vent identification of this. Murphy’s sign, an inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute cholecystitis.Laboratory evaluation commonly reveals a mild to mod-erate leukocytosis (12,000–15,000 cells/mm3). However, a normal WBC does not rule out the diagnosis. An unusually high WBC count (>20,000 cells/mm3) suggests a complicated form of cholecystitis such as gangrenous cholecystitis, perfo-ration, or associated cholangitis. In uncomplicated acute cho-lecystitis, serum liver chemistries are usually normal, but a mild elevation of serum


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Surgery_Schwartz. such as gangrenous cholecystitis, perfo-ration, or associated cholangitis. In uncomplicated acute cho-lecystitis, serum liver chemistries are usually normal, but a mild elevation of serum bilirubin (<4 mg/mL) may be present along with mild elevation of alkaline phosphatase, transami-nases, and amylase.28 Severe jaundice is suggestive of obstruc-tion of the bile ducts. This can be a result of common bile duct stones or severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallblad-der that mechanically obstructs the bile duct, known as Mir-izzi’s syndrome (Fig. 32-16). In elderly patients and in those with diabetes mellitus, acute cholecystitis may have a subtle Figure 32-16. Mirizzi’s syndrome. Impaction of a large stone in the neck of the gallbladder causing obstruction at the level of the confluence of the cystic duct and common hepatic duct.Brunicardi_Ch32_p1393-p1428.indd 140511/02/19 2:43 PM 1406SPECIFIC


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Surgery_Schwartz. in the neck of the gallbladder causing obstruction at the level of the confluence of the cystic duct and common hepatic duct.Brunicardi_Ch32_p1393-p1428.indd 140511/02/19 2:43 PM 1406SPECIFIC CONSIDERATIONSPART IIpresentation resulting in a delay in diagnosis. These patients may also have higher rates of treatment related morbidity com-pared to younger and healthier patients.The differential diagnosis for acute cholecystitis includes but is not limited to peptic ulcer disease, pancreatitis, appen-dicitis, hepatitis, perihepatitis (Fitz-Hugh–Curtis syndrome), myocardial ischemia, pneumonia, pleuritis, and herpes zoster involving the intercostal nerve.Diagnosis Ultrasonography is considered the most useful ini-tial radiologic test for diagnosing acute cholecystitis, with a sen-sitivity and specificity of 70% to 90%. Ultrasound is effective at documenting the presence or absence of stones, and it can show gallbladder wall thickening and pericholecystic fluid, both of which are highly


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Surgery_Schwartz. specificity of 70% to 90%. Ultrasound is effective at documenting the presence or absence of stones, and it can show gallbladder wall thickening and pericholecystic fluid, both of which are highly suggestive of acute cholecystitis (Fig. 32-17). Focal tenderness over the gallbladder when compressed by the sonographic probe (sonographic Murphy’s sign) also supports the diagnosis of acute cholecystitis. Biliary scintigraphy (HIDA scanning) may be of help in atypical cases if the diagnosis remains in question after initial workup. Lack of filling of the gallbladder after 4 hours indicates an obstructed cystic duct and, in the clinical setting of suspected acute cholecystitis, confirms the diagnosis with a reported sensitivity above 90%.32 Con-versely, a normal HIDA scan with clear filling of the gallblad-der rules out the diagnosis of acute cholecystitis. CT scans are frequently performed on patients with acute abdominal pain of unknown etiology, as they can evaluate for a number of


Surgery_Schwartz

Surgery_Schwartz. of the gallblad-der rules out the diagnosis of acute cholecystitis. CT scans are frequently performed on patients with acute abdominal pain of unknown etiology, as they can evaluate for a number of poten-tial pathologic processes at once. In patients with acute chole-cystitis, a CT scan can demonstrate thickening of the gallbladder wall, pericholecystic fluid, and the presence of gallstones, but it is somewhat less sensitive than ultrasonography.Treatment Patients who present with acute cholecystitis should receive IV fluids, broad-spectrum antibiotics, and anal-gesia. The antibiotics should cover gram-negative enteric organ-isms as well as anaerobes. Although the inflammation in acute cholecystitis may be sterile in some patients, it is difficult to know who is secondarily infected. Therefore, antibiotics have become a standard part of the initial management of acute cho-lecystitis in most centers.Cholecystectomy is the definitive treatment for acute cho-lecystitis. In the past, the


Surgery_Schwartz

Surgery_Schwartz. antibiotics have become a standard part of the initial management of acute cho-lecystitis in most centers.Cholecystectomy is the definitive treatment for acute cho-lecystitis. In the past, the timing of cholecystectomy has been a matter of debate. Early cholecystectomy performed within 72 hours of the onset of the illness is preferred over delayed cholecystectomy that is performed 6 to 10 weeks after initial medical treatment and recuperation. Several studies have shown that unless the patient is unfit for surgery, early cholecystectomy should be recommended as soon as possible, as it offers the patient a definitive solution in one hospital admission, quicker recovery times, similar complication rates, and an earlier return to work.33,34Laparoscopic cholecystectomy is the procedure of choice for acute cholecystitis. The conversion rate to an open cholecys-tectomy has fallen in recent years to less than 5% as laparoscopic equipment and experience has improved.35 While laparoscopic


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Surgery_Schwartz. choice for acute cholecystitis. The conversion rate to an open cholecys-tectomy has fallen in recent years to less than 5% as laparoscopic equipment and experience has improved.35 While laparoscopic cholecystectomy for acute cholecystitis may be more tedious and take longer than an elective cholecystectomy for symp-tomatic cholelithiasis, the laparoscopic approach remains safe and effective, even in the setting of acute and sometimes severe inflammation. Open cholecystectomy must remain an option in particularly difficult cases, or in patients suspected of having prohibitive intraabdominal adhesions, but it is rarely the primary treatment choice.When patients are medically unfit for surgery due to the severity of their illness or medical comorbidities, they can be treated with antibiotics and biliary decompression with cho-lecystostomy tube placement, which is usually effective in stabilizing the patient.36 For those who do recover after chole-cystostomy, the tube can be removed once


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Surgery_Schwartz. and biliary decompression with cho-lecystostomy tube placement, which is usually effective in stabilizing the patient.36 For those who do recover after chole-cystostomy, the tube can be removed once the track is mature (approximately 4 weeks) and cholangiography through it shows a patent cystic duct. Elective laparoscopic cholecystectomy can be scheduled within approximately 6 to 8 weeks, assum-ing their medical fitness recovers.37 Failure to improve after cholecystostomy may be due to gangrene of the gallbladder or perforation, in which case, damage control surgery may be unavoidable.Choledocholithiasis. Common bile duct (CBD) stones may be small or large, single or multiple, and are found in 6% to 12% of patients with stones in the gallbladder. The incidence increases with age. About 20% to 25% of patients above the age of 60 with symptomatic gallstones have stones in the common bile duct as well as in the gallbladder.38 The vast majority of ductal stones in Figure


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Surgery_Schwartz. age. About 20% to 25% of patients above the age of 60 with symptomatic gallstones have stones in the common bile duct as well as in the gallbladder.38 The vast majority of ductal stones in Figure 32-17. Ultrasonography from a patient with acute cholecystitis. The white arrowheads indicate the thickened gallbladder wall. There are several stones in the gallbladder (white arrows) throwing acoustic shadows (black arrowheads). Trace pericholecystic fluid can be seen surrounding the gallbladder (black arrows).Brunicardi_Ch32_p1393-p1428.indd 140611/02/19 2:43 PM 1407GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32Western countries are formed within the gallbladder and migrate down the cystic duct into the common bile duct. These are clas-sified as secondary CBD stones, in contrast to the primary CBD stones that form in the bile duct itself. Secondary stones are usu-ally cholesterol stones, whereas primary stones are usually of the brown pigment type. The primary stones are


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Surgery_Schwartz. to the primary CBD stones that form in the bile duct itself. Secondary stones are usu-ally cholesterol stones, whereas primary stones are usually of the brown pigment type. The primary stones are associated with biliary stasis and infection, and they are more commonly seen in Asian populations. Biliary stasis leading to the development of primary CBD stones can be caused by biliary strictures, papillary stenosis, tumors, or other (secondary) stones.Clinical Manifestations Choledochal stones may be silent and often are discovered incidentally. They may cause complete or incomplete obstruction, or they may manifest with cholangitis or gallstone pancreatitis. The typical pain caused by a stone in the bile duct is very similar to that of biliary colic caused by impaction of a stone in the cystic duct. Nausea and vomiting are common. Physical examination may be normal, but mild epigas-tric or right upper quadrant tenderness as well as mild icterus are common. The symptoms may also be


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Surgery_Schwartz. cystic duct. Nausea and vomiting are common. Physical examination may be normal, but mild epigas-tric or right upper quadrant tenderness as well as mild icterus are common. The symptoms may also be intermittent, such as pain and transient jaundice caused by a stone that temporar-ily impacts the ampulla but subsequently moves away, acting as a ball valve. A small stone may pass through the ampulla spontaneously with resolution of symptoms. Finally, the stones may become completely impacted, causing severe progressive jaundice. Elevation of serum bilirubin, alkaline phosphatase, and transaminases are commonly seen in patients with bile duct stones. However, in about one-third of patients with common bile duct stones, the liver chemistries are normal, particularly if the obstruction is incomplete or intermittent.Diagnosis Ultrasonography is useful for documenting stones in the gallbladder (if still present), as well as determining the size of the common bile duct. As stones in the bile


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Surgery_Schwartz. or intermittent.Diagnosis Ultrasonography is useful for documenting stones in the gallbladder (if still present), as well as determining the size of the common bile duct. As stones in the bile ducts tend to move down to the distal part of the common duct behind the duodenum, bowel gas can preclude their detection on ultraso-nography. A dilated common bile duct (>8 mm in diameter) on ultrasonography in a patient with gallstones, jaundice, and bili-ary pain is highly suggestive of common bile duct stones. If the presence of bile duct stones is in question, magnetic resonance cholangiopancreatography (MRCP) provides excellent anatomic detail and has a sensitivity and specificity of 95% and 89%, respectively, for detecting choledocholithiasis.14 Endoscopic retrograde cholangiopancreatography (ERCP) is highly effec-tive at diagnosing choledocholithiasis and in experienced hands, cannulation of the ampulla of Vater and diagnostic cholangiog-raphy are achieved in >90% of cases. However, due


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Surgery_Schwartz. (ERCP) is highly effec-tive at diagnosing choledocholithiasis and in experienced hands, cannulation of the ampulla of Vater and diagnostic cholangiog-raphy are achieved in >90% of cases. However, due to the risks associated with the procedure, it is rarely used as a purely diag-nostic modality, rather being reserved for cases in which a thera-peutic intervention such as stone extraction or sphincterotomy is planned. Endoscopic ultrasound has been demonstrated to be as good as ERCP for detecting common bile duct stones (sensitivity of 95% and specificity of 97%). However, EUS has fewer thera-peutic capabilities and requires endoscopic expertise, making it less desirable except in specific clinical senarios.39 Percutaneous transhepatic cholangiography (PTC) is rarely needed in patients with common bile duct stones but can be performed for both diagnostic and therapeutic reasons in patients with contraindica-tions to endoscopic or surgical approaches.Treatment For patients with


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Surgery_Schwartz. with common bile duct stones but can be performed for both diagnostic and therapeutic reasons in patients with contraindica-tions to endoscopic or surgical approaches.Treatment For patients with symptomatic gallstones and sus-pected common bile duct stones, bile duct clearance and cho-lecystectomy are indicated. This may be safely achieved either with preoperative ERCP followed by surgery or by going directly to surgery with intraoperative cholangiogram and common bile duct exploration to address retained stones. Both approaches are considered safe and effective, and no formal recommendation exists to definitively support one over the other.40,41If upfront laparoscopic cholecystectomy is pursued, the surgery should include an intraoperative cholangiogram to doc-ument the presence or absence of bile duct stones. If stones are identified, laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting (see


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Surgery_Schwartz. of bile duct stones. If stones are identified, laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting (see “Choledochal Explora-tion” section). If the expertise and/or instrumentation for lapa-roscopic common bile duct exploration are not available, the patient can be awoken and scheduled for ERCP with sphincter-otomy the following day. An open common bile duct explora-tion is an option if the endoscopic and laparoscopic methods are not feasible. If a choledochotomy is performed, primary repair can be considered in large ducts, while smaller ducts should be repaired over a T-tube. To do this, a standard T-tube should be modified by cutting the ends short enough to allow placement within the duct and dividing the T longitudinally to facilitate easy removal from the duct later on (Fig. 32-18). If a common Figure 32-18. T-tube placement. A. A standard T-tube that has been cut and modified for use


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Surgery_Schwartz. dividing the T longitudinally to facilitate easy removal from the duct later on (Fig. 32-18). If a common Figure 32-18. T-tube placement. A. A standard T-tube that has been cut and modified for use in the biliary tract. B. The T-tube is placed through a ductotomy in the common bile duct with the defect closed over the tube. The opposite end is brought out through the abdominal wall for decompression of the bile ducts.ABBrunicardi_Ch32_p1393-p1428.indd 140711/02/19 2:43 PM 1408SPECIFIC CONSIDERATIONSPART IIbile duct exploration was performed and a T tube left in place, a T-tube cholangiogram should be obtained before its removal, at least several weeks after its placement.In very severe cases, stones impacted in the ampulla may be unable to be cleared by endoscopic approaches or common bile duct exploration (open or laparoscopic). In these cases, transduodenal sphincterotomy can be considered. If one is entirely unable to disimpact the duct, choledochoduodenostomy or Roux-en-Y


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Surgery_Schwartz. bile duct exploration (open or laparoscopic). In these cases, transduodenal sphincterotomy can be considered. If one is entirely unable to disimpact the duct, choledochoduodenostomy or Roux-en-Y choledochojejunostomy may be the only option to restore biliary continuity.42If the stones were left in place at the time of surgery or diagnosed shortly after the cholecystectomy, they are classified as retained. Those diagnosed months or years later are termed recurrent (Fig. 32-19). Retained or recurrent stones following cholecystectomy are best treated endoscopically. A generous sphincterotomy will allow for stone retrieval as well as spon-taneous passage of stones. Alternately, retained stones can be cleared via a mature T-tube tract (4 weeks) if one was placed at the time of surgery. To do this, the T-tube is removed and a catheter passed through the tract into the common bile duct. Under fluoroscopic guidance, the stones can be retrieved with baskets or balloons. A similar approach will


Surgery_Schwartz

Surgery_Schwartz. the T-tube is removed and a catheter passed through the tract into the common bile duct. Under fluoroscopic guidance, the stones can be retrieved with baskets or balloons. A similar approach will allow for stone clearance by percutaneous transhepatic cholecystostomy (PTC) if there is no other way to reach the duct. Repeat surgery should be a last resort if other interventions have failed.Cholangitis. Cholangitis is one of the main complications of choledochal stones. Acute cholangitis is an ascending bac-terial infection associated with partial or complete obstruc-tion of the bile ducts.43 Hepatic bile is sterile, and bile in the bile ducts is kept sterile by continuous antegrade bile flow and by the presence of antibacterial substances in bile, such as immunoglobulin. Mechanical hindrance to bile flow facilitates ascending bacterial contamination from the bowel. Positive bile cultures are common in the presence of bile duct stones as well as with other causes of obstruction. Biliary


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Surgery_Schwartz. to bile flow facilitates ascending bacterial contamination from the bowel. Positive bile cultures are common in the presence of bile duct stones as well as with other causes of obstruction. Biliary bacterial contamination alone does not lead to clinical cholangitis; the combination of both significant bacterial contamination and biliary obstruction is required for its development. Gallstones are the most common cause of obstruction in cholangitis. Other causes include primary sclerosing cholangitis, benign and malignant strictures, parasites, instrumentation of the ducts, and indwelling stents, as well as partially obstructed biliary-enteric anastomoses. The most common organisms cultured from bile in patients with cholangitis include E coli, Klebsiella pneumoniae, Streptococcus faecalis, Enterobacter, and Bacteroides fragilis.43Clinical Manifestations Cholangitis may present as anything from a mild, self-limited episode to a fulminant, potentially life-threatening septicemia.


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Surgery_Schwartz. Enterobacter, and Bacteroides fragilis.43Clinical Manifestations Cholangitis may present as anything from a mild, self-limited episode to a fulminant, potentially life-threatening septicemia. Patients with gallstone-induced cholangitis are most commonly older and female. The most common presentation is fever, epigastric or right upper quad-rant pain, and jaundice. These classic symptoms, known as Charcot’s triad, are present in about two-thirds of patients. The illness can progress rapidly with the development of shock and altered mental status, known as Reynolds’ pentad (e.g., fever, jaundice, right upper quadrant pain, septic shock, and mental status changes). However, the presentation may be atypical, with little if any fever, jaundice, or pain. This occurs most commonly in the elderly, who may have unremarkable symptoms until the process is already quite advanced. Patients with indwelling stents are at particularly high risk for cholan-gitis, though rarely become jaundiced as a


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Surgery_Schwartz. who may have unremarkable symptoms until the process is already quite advanced. Patients with indwelling stents are at particularly high risk for cholan-gitis, though rarely become jaundiced as a patent stent will prevent the obstruction of bile flow. On abdominal examina-tion, the findings are indistinguishable from those of acute cholecystitis.44Diagnosis Leukocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases are common and, when present, support the clinical diagnosis of cholangitis. Ultraso-nography is helpful, as it will document the presence of gall-bladder stones, demonstrate dilated ducts, and possibly pinpoint a site of obstruction. CT scanning and MRI can show pancreatic and periampullary masses, if present, in addition to the ductal dilatation. However, abdominal imaging will rarely elucidate the exact cause of cholangitis, and the initial diagnosis is gener-ally made clinically.Treatment The initial treatment of patients with cholangi-tis


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Surgery_Schwartz. However, abdominal imaging will rarely elucidate the exact cause of cholangitis, and the initial diagnosis is gener-ally made clinically.Treatment The initial treatment of patients with cholangi-tis includes broad-spectrum IV antibiotics to cover enteric organisms and anaerobes, fluid resuscitation, and rapid biliary ABFigure 32-19. Retained common bile duct stones. The patient pre-sented 3 weeks after laparoscopic cholecystectomy. A. An ultra-sound shows a normal or mildly dilated common bile duct with a stone. Note the location of the right hepatic artery anterior to the common hepatic duct (an anatomic variation). B. An endoscopic retrograde cholangiography from the same patient shows multiple stones in the common bile duct. Only the top one showed on ultra-sound as the other stones lie in the distal common bile duct behind the duodenum.Brunicardi_Ch32_p1393-p1428.indd 140811/02/19 2:43 PM 1409GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32decompression. This is most


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Surgery_Schwartz. in the distal common bile duct behind the duodenum.Brunicardi_Ch32_p1393-p1428.indd 140811/02/19 2:43 PM 1409GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32decompression. This is most often accomplished through ERCP and sphincterotomy. ERCP will show the level and the reason for the obstruction, allow for culture of the bile, permit the removal of stones if present, and accomplish drainage of the bile ducts. Placement of drainage catheters or stents can also be performed if needed. In cases in which ERCP is not available, PTC, EUS, or surgical drainage can be utilized. The selection of the appropriate approach will depend on the type and location of the suspected obstruction as well as the avail-ability of local resources and expertise. Cholecystostomy tubes are not indicated in the acute management of cholangitis as the primary source of the infection is extrinsic to the gallbladder.Patients with cholangitis can deteriorate rapidly and may require intensive care unit


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Surgery_Schwartz. in the acute management of cholangitis as the primary source of the infection is extrinsic to the gallbladder.Patients with cholangitis can deteriorate rapidly and may require intensive care unit monitoring and vasopressor support. However, most patients will respond to biliary decompression and supportive measures. In the current era, acute cholangitis is associated with an overall mortality rate of approximately 5%. When associated with renal failure, cardiac impairment, hepatic abscesses, and malignancies, the morbidity and mortal-ity rates are much higher. Patients who have suffered an episode of acute cholangitis related to gallstone disease should be rec-ommended to undergo elective cholecystectomy approximately 6 weeks after the resolution of their cholangitis.45 Those whose cholangitis was related to another cause of biliary obstruction should be followed and treated for the specific etiology of their obstruction but do not necessarily require cholecystectomy if gallstones


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Surgery_Schwartz. was related to another cause of biliary obstruction should be followed and treated for the specific etiology of their obstruction but do not necessarily require cholecystectomy if gallstones were not the causative etiology of their cholangitis. Patients with indwelling stents and cholangitis usually require repeated imaging and stent exchange to mitigate the risk of recurrent infections.Gallstone Pancreatitis. Gallstones in the common bile duct can provoke attacks of acute pancreatitis through transient or persistent obstruction of the pancreatic duct by a stone passing through or impacted in the ampulla. The exact mechanism by which obstruction of the pancreatic duct leads to pancreatitis is unclear, but it may be related to increased ductal pressures causing leakage of pancreatic enzymes into the glandular tissue. The initial management of gallstone pancreatitis is supportive, including admission for bowel rest, IV hydration, and pain control. Antibiotics are not indicated in the


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Surgery_Schwartz. into the glandular tissue. The initial management of gallstone pancreatitis is supportive, including admission for bowel rest, IV hydration, and pain control. Antibiotics are not indicated in the absence of signs of infected pancreatic necrosis. Imaging of the biliary tree with ultrasound, CT, or MRCP is essential to confirm the diagnosis. When gallstones are present and the pancreatitis is mild and self-limited, the stone has probably passed. For these patients, a cholecystectomy with intraoperative cholangiogram is indi-cated as soon as the pancreatitis has clinically resolved. It is strongly recommended that cholecystectomy be performed dur-ing the same admission whenever possible due to the high rate of recurrence and increased morbidity of subsequent attacks of pancreatitis.46 If gallstones are present obstructing the duct and the pancreatitis is severe, an ERCP with sphincterotomy and stone extraction may be necessary. This must be balanced with the risk of ERCP-induced


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Surgery_Schwartz. If gallstones are present obstructing the duct and the pancreatitis is severe, an ERCP with sphincterotomy and stone extraction may be necessary. This must be balanced with the risk of ERCP-induced pancreatitis and thus is usually only employed if supportive measures are failing.Gallstone Ileus. Gallstone ileus can occur when a large gall-stone erodes through the wall of the gallbladder directly into the intestine via a choledochoenteric fistula (Fig. 32-20A). These stones can then pass through the intestinal tract until they reach an area of fixed obstruction. Proximal stones can become impacted in the pylorus or proximal duodenum causing gastric outlet obstruction (Bouveret syndrome). Those that travel dis-tally may become lodged at surgical anastomoses or the ileoce-cal valve, where they can become impacted and cause small bowel obstruction. Gallstone ileus is responsible for less than 1% of all intestinal obstructions.47 These patients present with symptoms of obstipation, nausea,


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Surgery_Schwartz. can become impacted and cause small bowel obstruction. Gallstone ileus is responsible for less than 1% of all intestinal obstructions.47 These patients present with symptoms of obstipation, nausea, and abdominal pain. Plain films may show an obstructive bowel gas pattern but may fail to identify a radiolucent stone. Ultrasound evaluation may be lim-ited by extensive bowel gas. CT is highly sensitive and specific for gallstone ileus and will help to determine the location of the obstruction. Management of gallstone ileus focuses on relieving the intestinal obstruction and removing the stone. In cases of very proximal obstructions in the stomach or duodenum, endo-scopic retrieval can be effective. For more distal stones, surgical enterolithotomy can be accomplished either laparoscopically or open. This procedure entails the removal of the stone through ABFigure 32-20. Gallstone Ileus. A. A choledochoenteric fistula has formed between the gallbladder and the duodenum, allowing a


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Surgery_Schwartz. or open. This procedure entails the removal of the stone through ABFigure 32-20. Gallstone Ileus. A. A choledochoenteric fistula has formed between the gallbladder and the duodenum, allowing a gallstone to pass into the intestinal tract. B. Intraoperative photo showing a longitudinal enterotomy and extraction of an impacted stone from the distal small bowel.Brunicardi_Ch32_p1393-p1428.indd 140911/02/19 2:43 PM 1410SPECIFIC CONSIDERATIONSPART IIan enterotomy that is then either repaired or resected depend-ing on its size (Fig. 32-20B). Stones that have successfully traversed the ileocecal valve are likely to pass without further intervention. The role of pursuing cholecystectomy and/or cho-ledochoenteric fistula closure at the time of enterolithotomy or addressing it at a later time remains a topic of debate, but it should be considered to reduce the risk of recurrence.47CholangiohepatitisCholangiohepatitis, also known as recurrent pyogenic cholan-gitis, is endemic to the Orient.


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Surgery_Schwartz. a topic of debate, but it should be considered to reduce the risk of recurrence.47CholangiohepatitisCholangiohepatitis, also known as recurrent pyogenic cholan-gitis, is endemic to the Orient. It also has been encountered in Asian population in the United States, Europe, and Australia. It affects both sexes equally and occurs most frequently in the third and fourth decades of life. Cholangiohepatitis is caused by bacterial contamination (commonly E coli, Klebsiella spe-cies, Bacteroides species, or Enterococcus faecalis) of the bili-ary tree, and often it is associated with biliary parasites such as Clonorchis sinensis, Opisthorchis viverrini, and A lumbri-coides. Bacterial enzymes cause deconjugation of bilirubin, which precipitates as bile sludge. The sludge and dead bacterial cell bodies form brown pigment stones, the nucleus of which may contain an adult Clonorchis worm, an ovum, or an ascarid. These stones can form throughout the biliary tree and cause par-tial obstructions that


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Surgery_Schwartz. form brown pigment stones, the nucleus of which may contain an adult Clonorchis worm, an ovum, or an ascarid. These stones can form throughout the biliary tree and cause par-tial obstructions that contribute to repeated bouts of cholangi-tis, biliary strictures, further stone formation, infection, hepatic abscesses, or liver failure (secondary biliary cirrhosis).48Patients with cholangiohepatitis usually present with pain in the right upper quadrant or epigastrium, fever, and jaundice. Relapsing symptoms are one of the most characteristic features of the disease. The episodes may vary in severity but, without intervention, will gradually lead to malnutrition and hepatic insufficiency. An ultrasound may detect stones in the biliary tree, pneumobilia from infection by gas-forming organisms, liver abscesses, and, occasionally, strictures. The gallbladder may be thickened and inflamed in about 20% of patients but rarely contains gallstones. ERCP or MRCP can be utilized for biliary imaging


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Surgery_Schwartz. liver abscesses, and, occasionally, strictures. The gallbladder may be thickened and inflamed in about 20% of patients but rarely contains gallstones. ERCP or MRCP can be utilized for biliary imaging for cholangiohepatitis. They can detect obstruc-tions and define strictures and stones. ERCP (or PTC if nec-essary) has the additional benefit of allowing for emergent decompression of the biliary tree in the septic patient. Hepatic abscesses may be drained percutaneously. The long-term goal of therapy is to extract stones and debris and relieve strictures. It may take several procedures, and in severe, refractory cases in which stones and strictures cannot be relieved, it may require a hepaticojejunostomy to reestablish biliary–enteric continuity. Occasionally, resection of involved areas of the liver may offer the best form of treatment. Recurrences are common, and the prognosis is poor once hepatic insufficiency has developed.49PROCEDURAL INTERVENTIONS FOR GALLSTONE


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Surgery_Schwartz. involved areas of the liver may offer the best form of treatment. Recurrences are common, and the prognosis is poor once hepatic insufficiency has developed.49PROCEDURAL INTERVENTIONS FOR GALLSTONE DISEASEPercutaneous Transhepatic Cholecystostomy TubesIn cases in which a patient with cholecystitis is deemed to be too ill to safely undergo cholecystectomy, a cholecystostomy tube may be placed into the gallbladder to decompress and drain a distended, inflamed, hydropic, or purulent gallbladder.36 Surgi-cal cholecystostomy with a large catheter placed under local anesthesia is rarely required today. Rather, percutaneous tran-shepatic cholecystostomy (PTC) tubes are most often pigtail catheters inserted percutaneously under ultrasound guidance.50 The catheter is inserted over a guidewire that has been passed through the abdominal wall, the liver, and into the gallblad-der (Fig. 32-21). By passing the catheter through the liver, the risk of uncontrolled bile leak around the catheter and


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Surgery_Schwartz. has been passed through the abdominal wall, the liver, and into the gallblad-der (Fig. 32-21). By passing the catheter through the liver, the risk of uncontrolled bile leak around the catheter and into the peritoneal cavity is minimized. The catheter can be removed when the inflammation has resolved and the patient’s condition has improved. A patent cystic duct should be confirmed by a tube cholangiogram prior to its removal. Interval cholecystec-tomy should be considered if the patient’s fitness has improved, particularly in individuals whose etiology of cholecystitis was gallstones.Endoscopic InterventionsEndoscopic advances in the last few decades have made endos-copy and ERCP a valuable therapeutic tool in the management of gallstone disease, particularly in the setting of common bile duct stones or abnormalities. Using a 90-degree side-viewing endoscope, the duodenum can be entered and the ampulla of Vater on the medial wall of the second portion of the duode-num visualized. This


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Surgery_Schwartz. duct stones or abnormalities. Using a 90-degree side-viewing endoscope, the duodenum can be entered and the ampulla of Vater on the medial wall of the second portion of the duode-num visualized. This can then be cannulated to allow wire and catheter access to the biliary tree, facilitating retrograde chol-angiogram, diagnostic brushings, stenting, dilations, or fluoro-scopically guided basket or balloon retrieval of common bile duct stones. When CBD stones are present, endoscopic sphinc-terotomy should be performed, which will allow for passage of larger stones both at the time of bile duct clearance and in the case of any ongoing choledocholithiasis (Fig. 32-22). In the hands of experts, ERCP has high rates of successful cannulation and bile duct clearance, and it is a safe and tolerable procedure. Debate remains when comparing ERCP to surgical common bile duct exploration in terms of timing and outcomes for choledo-cholithiasis, but both are considered acceptable treatments.41 In


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Surgery_Schwartz. procedure. Debate remains when comparing ERCP to surgical common bile duct exploration in terms of timing and outcomes for choledo-cholithiasis, but both are considered acceptable treatments.41 In special cases, such as the presence of Roux-en-Y anatomy or a previous hepaticojejunostomy, ERCP can be difficult. How-ever, such anatomy does not preclude the option for endoscopic intervention. Laparoscopic-assisted ERCP (in which the rem-nant stomach is accessed surgically and the endoscope passed into the duodenum) or double-balloon ERCP can be utilized to reach the biliary tree.CholecystectomyCholecystectomy is one of the most common abdominal sur-geries performed in Western countries, with over 750,000 Figure 32-21. Percutaneous cholecystostomy. A pigtail catheter has been placed through the abdominal wall, the right lobe of the liver, and into the gallbladder.Brunicardi_Ch32_p1393-p1428.indd 141011/02/19 2:43 PM 1411GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32being


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Surgery_Schwartz. the abdominal wall, the right lobe of the liver, and into the gallbladder.Brunicardi_Ch32_p1393-p1428.indd 141011/02/19 2:43 PM 1411GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32being performed each year in the United States alone.51 Carl Langenbuch performed the first successful open cholecystectomy in 1882, and for >100 years, it was the standard treatment for symptomatic gallbladder stones. In 1987, laparoscopic chole-cystectomy was introduced by Philippe Mouret in France and quickly revolutionized the treatment of gallstone disease. It not only supplanted open cholecystectomy, but it also more or less ended attempts for noninvasive management of gallstones (such as extracorporeal shock wave or cholangioscopic lithotripsy) or medical therapies (such as bile salts). Laparoscopic cholecystec-tomy offers a cure for gallstones with a minimally invasive pro-cedure, minor pain and scarring, and early return to full activity. Today, laparoscopic cholecystectomy is the


Surgery_Schwartz

Surgery_Schwartz. Laparoscopic cholecystec-tomy offers a cure for gallstones with a minimally invasive pro-cedure, minor pain and scarring, and early return to full activity. Today, laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones and the complications of gallstone disease.Few absolute contraindications exist to laparoscopic cholecystectomy, but they include hemodynamic instability, uncontrolled coagulopathy, or frank peritonitis. In addition, patients with severe obstructive pulmonary disease (COPD) or congestive heart failure (e.g., cardiac ejection fraction <20%) might not tolerate the increased intraabdominal pressures of pneumoperitoneum with carbon dioxide and may require open cholecystectomy. Conditions formerly believed to be relative contraindications such as acute cholecystitis, gangrene and empyema of the gallbladder, biliary-enteric fistulae, obesity, pregnancy, ventriculoperitoneal shunts, cirrhosis, and previous upper abdominal procedures are now


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Surgery_Schwartz. as acute cholecystitis, gangrene and empyema of the gallbladder, biliary-enteric fistulae, obesity, pregnancy, ventriculoperitoneal shunts, cirrhosis, and previous upper abdominal procedures are now considered risk factors for a potentially difficult cholecystectomy, but they do not preclude an attempt at laparoscopy. While laparoscopic outcomes have steadily improved and laparoscopic cholecystectomy has been shown multiple times to be safe and feasible, conversion to an open operation should always remain an option, and it is not a failure. Conversion to open may be necessary if the patient is unable to tolerate pneumoperitoneum, a complication occurs that cannot be fixed laparoscopically, important anatomic struc-tures cannot be clearly identified, or when no progress is made over a set period of time. In the elective setting, conversion to an open procedure is needed in about 5% of patients.51 Emer-gent procedures or patients with complicated gallstone disease can be more


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Surgery_Schwartz. a set period of time. In the elective setting, conversion to an open procedure is needed in about 5% of patients.51 Emer-gent procedures or patients with complicated gallstone disease can be more challenging, and the incidence of conversion has been reported to be between 10% and 30%. The possibility of conversion to open should always be discussed with the patient preoperatively.Serious complications of cholecystectomy are rare. The mortality rate for laparoscopic cholecystectomy is about 0.1%. Wound infection and cardiopulmonary complication rates are considerably lower following laparoscopic cholecystectomy than are those for an open procedure.52 While laparoscopic cho-lecystectomy has historically been associated with a higher rate of injury to the bile ducts than the open approach, modern data appears to show this trend disappearing as familiarity with lapa-roscopic techniques and technologies have improved.53Patients undergoing cholecystectomy should have a complete blood count


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Surgery_Schwartz. data appears to show this trend disappearing as familiarity with lapa-roscopic techniques and technologies have improved.53Patients undergoing cholecystectomy should have a complete blood count and liver function tests preoperatively. Prophylaxis against deep venous thrombosis with either low molecular weight heparin or compression stockings is indicated. ABCFigure 32-22. An endoscopic sphincterotomy. A. The sphincterotome in place. B. Completed sphincterotomy. C. Endoscopic picture of ampulla before and after sphincterotomy.Brunicardi_Ch32_p1393-p1428.indd 141111/02/19 2:43 PM 1412SPECIFIC CONSIDERATIONSPART IIThe patient should be instructed to empty their bladder before coming to the operating room to avoid the need for urinary cath-eterization. An orogastric tube can be placed if the stomach is distended with gas, but it is generally removed at the end of the operation.Laparoscopic Cholecystectomy. The patient is typically positioned supine with the operating surgeon standing


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Surgery_Schwartz. the stomach is distended with gas, but it is generally removed at the end of the operation.Laparoscopic Cholecystectomy. The patient is typically positioned supine with the operating surgeon standing at the patient’s left side. Split-leg positioning with the surgeon stand-ing between the patient’s legs can also provide ergonomic access to the right upper quadrant. Tucking one arm can be helpful if a cholangiogram is planned to allow easier maneu-vering of the fluoroscopy machine around the patient. Pneu-moperitoneum is established with carbon dioxide gas, either with an open technique (Hasson), optical viewing trocar, or closed-needle technique (Veress). Typical access is at the supra-umbilical region, though in the case of previous surgery or scars, alternate access sites should be considered. Once an adequate pneumoperitoneum is established, a 5or 10-mm trocar is inserted through the supraumbilical incision, through which a 5or 10-mm 30° laparoscope is introduced. Traditionally,


Surgery_Schwartz

Surgery_Schwartz. Once an adequate pneumoperitoneum is established, a 5or 10-mm trocar is inserted through the supraumbilical incision, through which a 5or 10-mm 30° laparoscope is introduced. Traditionally, three additional ports are then placed with a 10or 12-mm port in the epigastrium, a 5-mm port in the right midclavicular line, and a 5-mm port in the right flank (Fig. 32-23). Additional ports may be placed as needed to aid with retraction in difficult cases.Through the lateral-most port, the assistant uses a locking instrument to grasp the gallbladder fundus and retract it over the liver edge and upward towards the patient’s right shoulder. This will help visualize the body of the gallbladder and the hilar area. Exposure may be facilitated by placing the patient ABFCEDFigure 32-23. Laparoscopic cholecystectomy. A. The trocar placement. B. The fundus has been grasped and retracted cephalad to expose the proximal gallbladder and the hepatoduodenal ligament. Another grasper retracts the gallbladder


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Surgery_Schwartz. A. The trocar placement. B. The fundus has been grasped and retracted cephalad to expose the proximal gallbladder and the hepatoduodenal ligament. Another grasper retracts the gallbladder infundibulum posterolaterally to better expose the triangle of Calot (hepatocystic triangle bound by the common hepatic duct, cystic duct, and liver margin). C. Intraoperative photo of the critical view of safety. The hepatocystic triangle has been cleared of fat and fibrous tissue, the lower one-third of the gallbladder is separated from the liver to expose the cystic plate, and two and only two structures are seen entering the gallbladder. D. A clip is being placed on the cystic duct–gallbladder junction. E. A small opening has been made in the cystic duct, and a cholangiogram catheter is being inserted. F. Additional clips have been placed, the cystic duct has been divided, and the cystic artery is being divided.Brunicardi_Ch32_p1393-p1428.indd 141211/02/19 2:43 PM 1413GALLBLADDER AND THE


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Surgery_Schwartz. F. Additional clips have been placed, the cystic duct has been divided, and the cystic artery is being divided.Brunicardi_Ch32_p1393-p1428.indd 141211/02/19 2:43 PM 1413GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32in reverse Trendelenburg position with slight tilting of the table to bring the right side up. Through the midclavicular port, the surgeon uses a grasper in the left hand to retract the gallbladder infundibulum laterally and expose the neck of the gallbladder and hepatoduodenal ligament. It may be necessary to take down any adhesions between the omentum, duodenum, or colon to the gallbladder in order to reach the infundibulum. The majority of the dissection can then be performed with the right hand through the epigastric port, utilizing a combination of electrocautery and sharp and blunt dissection.Dissection starts at the infundibulum of the gallbladder, just above the takeoff of the cystic duct. The peritoneum, fat, and loose areolar tissue around the


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Surgery_Schwartz. and sharp and blunt dissection.Dissection starts at the infundibulum of the gallbladder, just above the takeoff of the cystic duct. The peritoneum, fat, and loose areolar tissue around the gallbladder and the cystic duct–gallbladder junction is dissected off and reflected inferi-orly toward the bile duct. This is continued until the gallbladder neck and the proximal cystic duct are clearly identified. The next step is the identification of the cystic artery, which usually runs parallel to and somewhat behind the cystic duct, and often lies behind a prominent lymph node (Lund’s node, often called Calot’s node). At this point, a critical view of safety should be obtained. This requires that the hepatocystic triangle is cleared of fat and fibrous tissue, the lower third of the gallbladder is separated from the liver to expose the cystic plate, and two and only two structures (cystic duct and cystic artery) are going into the gallbladder (see Fig. 32-19).54 At this point, an


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Surgery_Schwartz. is separated from the liver to expose the cystic plate, and two and only two structures (cystic duct and cystic artery) are going into the gallbladder (see Fig. 32-19).54 At this point, an intraopera-tive cholangiogram can be performed if indicated (see “Intraop-erative Cholangiogram” section).With a critical view of safety obtained, the cystic duct and artery are clipped with two clips at the base and one clip on the gallbladder side. They can then be safely divided. Sometimes, a very dilated cystic duct may be too large for clips. Such ducts can be successfully managed by ligation with an endoloop, lapa-roscopic stapler, or suture closure. Finally, the gallbladder is dissected off the liver bed using electrocautery while watching for potential abnormal posterior branches of ducts or arteries. Before the gallbladder is completely removed from the liver edge, it can be used as a retractor for a final evaluation of the operative field. The surgeon should be sure to evaluate for


Surgery_Schwartz

Surgery_Schwartz. or arteries. Before the gallbladder is completely removed from the liver edge, it can be used as a retractor for a final evaluation of the operative field. The surgeon should be sure to evaluate for bleed-ing points or bile staining, and confirm placement of the clips on the cystic duct and artery. The gallbladder is then divided from its final attachments and removed either through the epigastric or umbilical incision, often with the aid of a retrieval bag. The fascial defect and skin incision may need to be enlarged in order to remove the specimen, particularly if the stones are large or the gallbladder is very inflamed. Any bile or blood that has accumulated during the procedure should be cleaned away, and if stones were spilled, they should be retrieved and removed. If the gallbladder was severely inflamed or gangrenous, or if any bile or blood is expected to accumulate, a closed-suction drain can be placed through one of the 5-mm ports and left underneath the right liver lobe


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Surgery_Schwartz. was severely inflamed or gangrenous, or if any bile or blood is expected to accumulate, a closed-suction drain can be placed through one of the 5-mm ports and left underneath the right liver lobe close to the gallbladder fossa, though this is not routinely required.Open Cholecystectomy. The same surgical principles apply for laparoscopic and open cholecystectomies. Open cholecystec-tomy has become an uncommon procedure, usually performed either as a conversion from laparoscopic cholecystectomy or as a second procedure in patients who require laparotomy for another reason. The approach can either be through a midline laparotomy, or more commonly through a right subcostal inci-sion. The gallbladder is dissected free from the liver bed, usu-ally starting at the fundus and working proximally toward the hepatocystic triangle. Once the cystic artery and cystic duct have been dissected and clearly identified, they are ligated and divided, and the gallbladder is removed. In particularly


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Surgery_Schwartz. toward the hepatocystic triangle. Once the cystic artery and cystic duct have been dissected and clearly identified, they are ligated and divided, and the gallbladder is removed. In particularly difficult cases, in which the gallbladder is partially obliterated or ductal or arterial anatomy cannot be identified, a partial cholecystec-tomy may be performed. This includes removal of as much gall-bladder mucosa as possible and attempted closure of the cystic duct stump with wide drainage of the area.Intraoperative Cholangiogram. Intraoperative cholangio-gram is an optional but valuable tool for evaluating the extra-hepatic bile ducts, identifying common bile duct stones, or clarifying aberrant ductal anatomy. The use of routine versus selective cholangiography remains a topic of debate with a lack of definitive evidence on either side.55-57 However, routine intra-operative cholangiography will detect stones in approximately 7% of patients, and it assists with outlining anatomy and


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Surgery_Schwartz. with a lack of definitive evidence on either side.55-57 However, routine intra-operative cholangiography will detect stones in approximately 7% of patients, and it assists with outlining anatomy and detect-ing injury.58 Selective intraoperative cholangiogram should be performed when the patient has a history of abnormal liver func-tion tests, pancreatitis, jaundice, a large duct and small stones, a dilated duct on preoperative ultrasonography, or if preoperative endoscopic cholangiography for the aforementioned reasons was unsuccessful. Although there is no consensus recommenda-tion on the use of routine versus selective cholangiography, all surgeons performing cholecystectomy should be familiar with the procedure. If a cholangiogram is to be performed, a clip is placed on the proximal cystic duct, and a small incision is made on its anterior surface, just inferior to the clip. A cholangiogram catheter is passed into the cystic duct and secured with a clamp or clip. The fluoroscopy


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Surgery_Schwartz. cystic duct, and a small incision is made on its anterior surface, just inferior to the clip. A cholangiogram catheter is passed into the cystic duct and secured with a clamp or clip. The fluoroscopy machine is then positioned over the patient and a cholangiogram performed by injection of contrast through the cholangiocatheter during live fluoroscopic dynamic imaging. An ideal cholangiogram includes filling of the right and left hepatic ducts, emptying into the duodenum, and no visualized filling defects (Fig. 32-24). Care must be taken not to introduce air bubbles into the system during contrast injec-tion as these will appear as filling defects on the cholangiogram images. If no contrast is visualized in the duodenum, a dose of glucagon can be utilized to relax the sphincter of Oddi and facilitate contrast flow. Once the cholangiogram is completed, the catheter is removed. Laparoscopic ultrasonography is as accurate as intraoperative cholangiography in detecting com-mon bile duct


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Surgery_Schwartz. facilitate contrast flow. Once the cholangiogram is completed, the catheter is removed. Laparoscopic ultrasonography is as accurate as intraoperative cholangiography in detecting com-mon bile duct stones, and it is less invasive. However, it requires more skill to perform and interpret and is not always readily available.59Common Bile Duct ExplorationCommon bile duct stones that are detected preor intraopera-tively may be managed with common bile duct exploration (CBDE) at the time of the cholecystectomy. While preopera-tive ERCP is also an appropriate option for known bile duct stones, laparoscopic CBDE can be used as a primary approach to choledocholithiasis safely and with good outcomes, even in higher risk populations such as the elderly.60 If stones in the duct are small, they may sometimes be simply flushed into the duo-denum with saline irrigation via the cholangiography catheter. This can be facilitated by the administration of IV glucagon to relax the sphincter of Oddi. If


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Surgery_Schwartz. sometimes be simply flushed into the duo-denum with saline irrigation via the cholangiography catheter. This can be facilitated by the administration of IV glucagon to relax the sphincter of Oddi. If irrigation is unsuccessful, several options exist to clear the duct, including fluoroscopic or endo-scopic approaches.With access to the cystic duct by a small ductotomy, a bal-loon catheter is used to dilate the cystic duct, and a wire basket can be passed down the common bile duct under fluoroscopic Brunicardi_Ch32_p1393-p1428.indd 141311/02/19 2:43 PM 1414SPECIFIC CONSIDERATIONSPART IIguidance to catch and remove the stones (Fig. 32-25). Alter-nately, endoscopic evaluation with a flexible choledocho-scope will allow for direct visualization and retrieval of the stones within the common duct. To do this, reliable catheter access must be obtained with an introducer sheath placed either through one of the laparoscopic ports or a new stab incision in the anterior abdominal wall. The


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Surgery_Schwartz. duct. To do this, reliable catheter access must be obtained with an introducer sheath placed either through one of the laparoscopic ports or a new stab incision in the anterior abdominal wall. The cystic duct should first be dilated with a small balloon catheter to allow for passage of the introducer and scope and for effective retrieval of larger stones. Once the scope is within the common bile duct, irrigation is used to distend the lumen. Stones may then be caught in a wire basket under direct visualization or simply pushed into the duo-denum. Once the common bile duct has been cleared of stones, the cystic duct is ligated below the level of the ductotomy and divided, and the cholecystectomy is completed.While the cystic duct is the preferred route of access for common bile duct exploration, occasionally an incision into the common bile duct itself (choledochotomy) is necessary. The flexible choledochoscope is then passed into the duct for visu-alization and clearance of stones.


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Surgery_Schwartz. occasionally an incision into the common bile duct itself (choledochotomy) is necessary. The flexible choledochoscope is then passed into the duct for visu-alization and clearance of stones. The choledochotomy can be closed primarily of the duct is very large, or over a T-tube. If available, common bile duct exploration can be highly advan-tageous as it provides the opportunity to treat the entirety of the disease in a single event, rather that subjecting patients to multiple procedures. However, the procedure can be techni-cally challenging to perform and requires the availability of the proper equipment and surgical expertise.61Common Bile Duct Drainage ProceduresIn very rare cases in which stones or obstructions cannot be cleared by either ERCP with sphincterotomy or CBDE, and the patient is suffering clinical effects from their common duct stones, an additional choledochal drainage procedure may become necessary. In the case of an open operation, transduodenal sphincterotomy can


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Surgery_Schwartz. is suffering clinical effects from their common duct stones, an additional choledochal drainage procedure may become necessary. In the case of an open operation, transduodenal sphincterotomy can be attempted by incising the duodenum transversely and cutting the sphincter of Oddi at the 11 o’clock position, taking care to avoid injury to the pancreatic duct. The impacted stones can then be manually removed or simply allowed to pass through the sphincterotomy.Bypass procedures can also be used to restore continu-ity of bile flow in the setting of irretrievable impacted stones. For short distance bypasses, a Choledochoduodenostomy is performed by mobilizing the second part of the duodenum (a Kocher maneuver) and anastomosing it side to side with the common bile duct (Fig. 32-26A-C). If the distance is too great to safely complete a choledochoduodenostomy without ten-sion, a choledochojejunostomy can be done by bringing up a roughly 45-cm limb of jejunum and anastomosing it end to side to


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Surgery_Schwartz. is too great to safely complete a choledochoduodenostomy without ten-sion, a choledochojejunostomy can be done by bringing up a roughly 45-cm limb of jejunum and anastomosing it end to side to the common bile duct (Fig. 32-26D-E). If the entirety of the extrahepatic biliary tree must be bypassed, hepaticojejunostomy allows for drainage of the hepatic ducts directly a loop of jeju-num (Fig. 32-26F-G). These choledochal drainage procedures can also be used to manage common bile duct strictures or as a palliative procedure for malignant obstruction in the periampul-lary region.OTHER BENIGN DISEASES AND LESIONSBiliary Dyskinesia and Sphincter of Oddi DysfunctionBiliary dyskinesia is an umbrella term that refers to disorders affecting the normal motility and function of the gallbladder and sphincter of Oddi. These disorders are becoming increas-ingly recognized as improvements in imaging allow for more detailed evaluations of biliary tract function. Patients with bili-ary dyskinesia may


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Surgery_Schwartz. of Oddi. These disorders are becoming increas-ingly recognized as improvements in imaging allow for more detailed evaluations of biliary tract function. Patients with bili-ary dyskinesia may present with typical biliary type symptoms, but without evidence of stones or sludge on abdominal imaging. ABFigure 32-24. A. An intraoperative cholangiogram. The bile ducts are of normal size, with no intraluminal filling defects. The left and the right hepatic ducts are visualized, the distal common bile duct tapers down, and the contrast empties into the duodenum. Cholangiography grasper that holds the catheter and the cystic duct stump partly projects over the common hepatic duct. B. An intraoperative cholangiogram showing a common bile duct stone (arrow) with very little contrast passing into the duodenum.Brunicardi_Ch32_p1393-p1428.indd 141411/02/19 2:43 PM 1415GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32A decreased gallbladder ejection fraction on HIDA scanning (EF <35%) is


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Surgery_Schwartz. duodenum.Brunicardi_Ch32_p1393-p1428.indd 141411/02/19 2:43 PM 1415GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32A decreased gallbladder ejection fraction on HIDA scanning (EF <35%) is considered diagnostic of biliary dyskinesia. In these patients, studies suggest that symptoms will be improved or resolved by cholecystectomy in up to 90% of cases.62Sphincter of Oddi dysfunction can occur as a primary pre-sentation of episodic biliary type pain with abnormal liver func-tion tests or as recurrent biliary type pain after cholecystectomy. More severe cases may present with recurrent jaundice or pan-creatitis. If other causes are ruled out, such as retained stones, strictures or periampullary tumors, a stenotic or dyskinetic sphincter of Oddi should be suspected. A benign stenosis of the outlet of the common bile duct is usually associated with inflam-mation, fibrosis, or muscular hypertrophy. The pathogenesis is unclear, but trauma from the passage of stones, sphincter


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Surgery_Schwartz. of the outlet of the common bile duct is usually associated with inflam-mation, fibrosis, or muscular hypertrophy. The pathogenesis is unclear, but trauma from the passage of stones, sphincter motil-ity disorders, and congenital anomalies have been suggested. A dilated common bile duct that is difficult to cannulate during ERCP or delayed emptying of contrast from the biliary tree after ERCP are useful diagnostic features. Ampullary manometry and specific provocation tests are available in specialized units to aid in the diagnosis. Once identified, sphincterotomy will typi-cally yield good results.63Acalculous CholecystitisAcalculous cholecystitis is an acute inflammation of the gall-bladder that occurs in the absence of gallstones. It is a rare entity that typically develops in critically ill patients in the intensive care unit.64 Patients on parenteral nutrition, with extensive burns, sepsis, major operations, multiple trauma, or prolonged illness with multiple organ system failure


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Surgery_Schwartz. ill patients in the intensive care unit.64 Patients on parenteral nutrition, with extensive burns, sepsis, major operations, multiple trauma, or prolonged illness with multiple organ system failure are at risk for developing acalculous cholecystitis. The cause is unknown, but gallblad-der distention, bile stasis, and ischemia have been implicated as causative factors. After resection, pathologic examination of the gallbladder wall after an episode of acalculous cholecystitis reveals edema of the serosa and muscular layers, with patchy thrombosis of arterioles and venules.65The ability to recognize the symptoms and signs of acalculous cholecystitis can depend on the condition and mental status of the patient, but acalculous cholecystitis can be similar to acute calculous cholecystitis, with right upper quadrant pain and tenderness, fever, and leukocytosis. In the sedated or unconscious patient, the clinical features are often masked, but fever and elevated WBC count, as well as