Gastroenterology and Hepatology Board Review: Pearls of Wisdom, Third Edition

Section VI GALLBLADDER, BILE DUCTS, AND PANCREAS

CHAPTER 40. Surgical Aspects of Cholelithiasis

Ibraheem Mizyed, MD and Eugene A. Trowers, MD, MPH, FACP

Image In the era of laparoscopic cholecystectomy, what are the indications for conventional open cholecystectomy?

Open cholecystectomy should be reserved for patients with suspected cancer of the gallbladder, cases of severe acute or chronic inflammation, liver cirrhosis with portal hypertension, severe upper abdominal adhesions following previous surgery, and in patients with biliary disease.

Image True/False: The presence of acute cholecystitis is an absolute contraindication to laparoscopic cholecystectomy.

False.

Image What are absolute contraindications to laparoscopic cholecystectomy?

Inability to tolerate general anesthesia, uncontrolled coagulopathy, suspected cancer of the gallbladder, liver cirrhosis with portal hypertension, and cholecystoenteric fistulas.

Image What are some relative contraindications to laparoscopic cholecystectomy?

Morbid obesity, cardiopulmonary diseases, Mirizzi’s syndrome, empyema of the gallbladder, a contracted gallbladder, pregnancy, and severe acute or chronic inflammation of the gallbladder.

Image True/False: Cholecystectomy is a reasonable consideration during weight loss operations, even without existing stones, because the subsequent development of stones can be anticipated.

True.

Image To which patients with asymptomatic gallstones would you recommend prophylactic cholecystectomy?

Patients awaiting lung transplantation, patients with porcelain gallbladder, and young women of American Indian ancestry. The latter two conditions are associated with a high prevalence of gallbladder carcinoma. The risk of malignancy in calcified gallbladders exceeds 25%.

Image True/False: Prophylactic cholecystectomy is justified in diabetics.

False. Diabetics seem to be prone to developing both gallstones and gallstone-related complications. It has been suggested that diabetics have a high morbidity and mortality when undergoing emergency operations for gallstones. However, these perceptions have not been borne out when confounding variables such as hyperlipidemia, obesity, cardiovascular disease, and renal insufficiency are taken into account.

Image True/False: Prophylactic cholecystectomy should be entertained for patients with asymptomatic stones prior to extended travel to remote areas.

True. Remote areas may not have the capacity to perform a cholecystectomy if needed.

Image True/False: Elective cholecystectomy should be considered in a patient with an 8-mm gallbladder polyp and concomitant gallstones.

True. Polyps < 10 mm in absence of symptoms generally do not require surgery; however, a gallbladder polyp with a stone should be considered for elective cholecystectomy.

Image True/False: Pregnancy is a contraindication to laparoscopic cholecystectomy.

False. Improvements in anesthesia and tocolytic agents have made cholecystectomy safer during pregnancy. Complications such as spontaneous abortion and preterm labor are more common in operated women in the first and third trimesters of gestation, respectively. Laparoscopic cholecystectomy can be performed safely in a carefully controlled clinical setting.

Image Hepatic cirrhosis is a major risk factor of morbidity and mortality in patients undergoing elective cholecystectomy. What are the major perioperative causes of death associated with this condition?

The two major causes of death associated with this condition are intra-operative bleeding and postoperative hepatic failure.

Image What conditions justify cholecystectomy in cirrhotics?

Symptoms are severe and/or the cirrhosis is well compensated.

Image What is the most common cause of death after cholecystectomy?

Most deaths occurring after cholecystectomy are related to cardiac disease, particularly myocardial infarction.

Image What are the complications of laparoscopic cholecystectomy performed for acute cholecystitis?

The main intra-operative complications are perforation of the gallbladder, bleeding from the liver bed or cystic artery, bile duct leaks, and iatrogenic injuries to the bowel or vessels due to unclear anatomy. The main postoperative complications are local wound hematoma or infection and systemic hematoma.

Image In a patient who has gallstone pancreatitis, when should cholecystectomy generally be performed?

Cholecystectomy should generally be performed during the same hospitalization once the clinical signs of pancreatitis have resolved.

Image What should be done if small, unsuspected stones are visualized in the common bile duct (CBD) during intra-operative cholangiography?

Nothing. It is believed that most small stones will pass spontaneously without symptoms or complications. It is estimated that only 10% of small, unsuspected stones will become symptomatic. If they become symptomatic, endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy with stone extraction can be performed.

Image True/False: An endoscopic approach is most useful to treat bile leaks following cholecystectomy.

True. A 90%–100% success rate is reported in treating biliary leaks with endoscopic management. Sphincterotomy alone, stent/nasobiliary catheter placement, or the combination of sphincterotomy and stent placement has been used successfully to reduce the intrabiliary pressure and allow fistula healing.

Image True/False: The finding of a localized fluid collection or ascites in a patient who has recently undergone a laparoscopic cholecystectomy requires immediate surgical intervention.

False. Postoperative ascites and edema of the gallbladder fossa on CT scan or ultrasonography is a normal postoperative change and has been reported in 19% and 22% of patients, respectively.

Image What noninvasive test is most useful in detecting postcholecystectomy bile leaks?

Hepatobiliary scintigraphy is highly sensitive and specific.

Image What confirmatory test(s) should be performed if a bile leak is found on scintigraphy?

Cholangiography, via an endoscopic or percutaneous approach, will usually confirm the presence of a leak, detect coexistent biliary strictures or retained stones, and allow for the appropriate therapeutic procedure.

Image True/False: A CT scan can differentiate between the various types of fluid collections after cholecystectomy.

False. CT scans have limited ability to differentiate bile from blood, ascites, pus, or lymph.

Image What should be the first-line of investigation in a patient who presents early after laparoscopic cholecystectomy with jaundice?

ERC.

Image What is the best approach to take in a patient who has a postcholecystectomy bile duct injury and presents with biliary peritonitis?

This is usually caused by infected bile. External percutaneous drainage is the best initial approach. Definitive repair of the lesion can be done after the infection has been treated.

Image If at laparoscopy, one unexpectedly encounters an acutely inflamed pus-filled gallbladder with multiple adhesions such that the anatomy around the porta hepatis is obscured and cholecystectomy is deemed unsafe, what therapeutic laparoscopic procedure could be done?

The fundus of the gallbladder is exposed, a trocar is inserted into the gallbladder, and the contents are aspirated. A drainage catheter can then be inserted into the gallbladder and the operation concluded.

Image What are sites of bile duct leaks after cholecystectomy?

Bile leaks can occur from the damaged main duct, the cystic duct remnant (most common), a gallbladder leak due to trauma to a duct during dissection of the gallbladder from the liver, clipping of the right hepatic duct proximally leaving the hepatic end free to drain, and damage to the duct of Luschka.

Image Name three patterns of presentation in bile duct injury.

Complete occlusion of the bile duct with rapid development of jaundice in the postoperative period; bile peritonitis; and partial duct obstruction with intermittent episodes of pain, jaundice, or cholangitis usually within 2 years of the cholecystectomy.

Image What is the classification of bile duct injuries?

Type A: Injuries to minor ducts without loss of continuity of biliary tree.

Type B: Injuries to aberrant right hepatic bile duct with duct occlusion.

Type C: Injuries to aberrant right hepatic bile duct with transection.

Type D: Lateral injuries that involve the main ducts and can progress to Type E injuries.

Type E: Injuries to the main duct with complete obstruction.

Image In a patient with a bile duct injury following cholecystectomy, what is the procedure of choice if the distal CBD is found to be occluded by endoscopic retrograde cholangiopancreatography (ERCP)?

If the distal duct is found to be occluded or transected and continuity to the proximal duct is lost, percutaneous transhepatic cholangiography (PTC) is necessary to outline the proximal ducts and to provide external biliary drainage. Surgery will eventually be necessary.

Image What are the typical presenting symptoms in a patient with a Type A bile duct injury?

Sixty-six percent of these patients present with a symptom complex of pain and fever. In about 33% of these cases, the presentation is that of an external bile fistula. Patients with Type A injuries are almost never jaundiced.

Image What is the optimal approach to take in patients who present in the early postcholecystectomy period with abdominal distension suspicious of a bile leak?

A CT scan or ultrasonography of the abdomen is used to search for intraperitoneal fluid. If a bile collection is present, it may be drained percutaneously. Biliary scintigraphy is then done to determine if a leak persists followed by therapeutic ERC if a leak is found.

Image What is the treatment of choice for Type E injuries?

Roux-en-Y hepaticojejunostomy.

Image In a patient with a recent bile duct injury, what is the role of abdominal ultrasound?

Abdominal ultrasonography may demonstrate dilated intra/extrahepatic ducts, fluid collections, or abscesses in the perihepatic region. It may also be helpful in suggesting changes of cirrhosis, splenomegaly, and portal hypertension, which are particularly important considerations in planning an intervention in any such patient.

Image What are the situations in which the bile duct size is normal in a patient with bile duct injury?

Presence of a biliary fistula, long-standing partial obstruction with biliary fibrosis, and cirrhosis.

Image What is the most important cause of bile duct injury during laparoscopic cholecystectomy?

The most important cause of bile duct injury during laparoscopic cholecystectomy is aberrant biliary anatomy found in about 3% of patients.

Image In some patients, bile duct injury with stricture formation may appear several months after laparoscopic cholecystectomy. What is the management at this time?

Prompt endoscopic dilatation and stenting of such strictures may lead to resolution without the need for surgical intervention.

Image What is the significance of cholecystohepatic ducts?

Cholecystohepatic ducts (ducts of Luschka), present in 3%–5% of cadavers, may be transected during laparoscopic cholecystectomy and are another source of biliary leakage.

Image What factors prevent spontaneous closure of postoperative bile leaks?

Most postoperative bile leaks heal spontaneously. The presence of distal biliary obstruction secondary to a stone or stricture contributes to the formation of leaks and bilomas and prevents spontaneous closure.

Image Patients may have a variety of postoperative symptoms following cholecystectomy. In what group is investigation most likely to reveal a cause?

Common postoperative symptoms include flatulence, bloating, and right upper quadrant and epigastric pain. A small percentage present with severe abdominal pain, jaundice, or emesis. Investigation in the latter group is more likely to reveal a distinct treatable cause.

Image What happens when the gallbladder perforates into the adjacent intestine during an acute attack of cholecystitis?

The acute attack often subsides as the inflamed organ is decompressed. If the gallstones are completely discharged and are small enough to pass rectally, an uncomplicated cholecystoenteric fistula results. However, if stones are still present in the gallbladder or CBD, chronic symptoms may arise.

Image What are the most common sites of cholecystoenteric fistula?

In descending order of frequency, the duodenum, hepatic flexure of the colon, stomach, and jejunum.

Image What investigations are useful for diagnosing cholecystoenteric fistula?

Plain abdominal x-rays may show air in the biliary tree. Barium studies often reveal the site of communication.
The gallbladder does not opacify on oral cholecystography. Ultrasonography of the gallbladder can detect air in the biliary tree but not the site of the fistula. CT scans are less useful in detecting gallstones and fistulae, although they may show air in the biliary tree.

Image What problems can be caused by a cystic duct remnant in a patient who has undergone cholecystectomy?

In some patients, the cause of postcholecystectomy symptoms has been attributed to pathology in the cystic duct remnant. The described abnormalities include cystic duct stones, fistulae, granulomas, or neuromas. ERC is useful in delineating biliary anatomy in patients with suspected cystic duct remnant pathology. Treatment is cystic duct excision.

Image What is the false positive rate of detecting CBD stones with intraoperative cholangiogram?

3%–4%.

Image What tests should be performed in a patient with postcholecystectomy symptoms?

CBD stones are the most common cause of postcholecystectomy symptoms. Liver function tests, particularly alkaline phosphatase, may be elevated. Ultrasonography may reveal indirect signs, such as a dilated bile duct, but direct visualization of the stone is uncommon. ERC is an important diagnostic tool with which to confirm the presence of ductal stones and exclude the presence of bile duct stricture or tumor.

Image What other biliary cause of postcholecystectomy symptoms should be considered when CBD stones and cystic duct pathology have been excluded?

Sphincter of Oddi dysfunction, including papillary stenosis.

Image What is the differential diagnoses of cholangitis in a patient with a history of cholecystectomy?

Bile duct stricture and choledocholithiasis.

Image When is surgery recommended for benign biliary strictures?

Complete ductal transection, failed previous repair, and failure of endoscopic therapy.

Image True/False: It is possible to differentiate between choledocholithiasis and bile duct stricture on the basis of symptoms.

False.

Image What radiologic evaluations should be considered in a patient with a suspected bile duct stricture?

The evaluation should begin with ultrasonography to identify dilated ducts and/or a subhepatic fluid collection. In the early postoperative period, a 99mTc-labeled radionuclide scan may expeditiously and noninvasively demonstrate patency of the biliary tree and exclude bile leak. If these studies suggest bile duct injury, ERC is indicated to define and possibly treat the lesion.

Image If laparoscopic bile duct injury is suspected, what is the earliest time when an ERCP can be done?

If a biliary fistula is suspected immediately following laparoscopic cholecystectomy, diagnostic and therapeutic ERC can be performed as little as 6 hours postoperatively.

Image How is an intrahepatic bile leak treated?

These can be treated with biliary stents positioned below the leak.

Image What are potential consequences of stricture development following injury to the bile duct due to laparoscopic cholecystectomy?

Cholangitis, biliary cirrhosis, and eventual need for liver transplantation.

Image What options are available for removal of CBD stones if preoperative ERC fails?

If the stones are small and the laparoscopic surgeon is skilled in laparoscopic bile duct exploration, an attempt at this treatment procedure is made. If it is not successful or large stones are found, an open bile duct exploration is the treatment of choice.

Image In cases of laparoscopic bile duct injuries, what factor is associated with the best long-term results?

Immediate identification with immediate repair is associated with the best long-term results. Unfortunately, in one recent study, only 10% of ductal injuries were discovered and operated on in the first week. The vast majority (70%) were diagnosed within the first 6 months.

Image What is the best initial approach to take in patients with bile duct injuries and biliary peritonitis?

Biliary peritonitis is usually caused by infected bile. Percutaneous drainage is the best initial strategy. Definitive repair of the lesion can be done when the infection is treated.

Image In a patient with a recurrent bile duct stricture in whom a repeat attempt at operative bypass has failed or seems unwise, what option is available?

Consideration may be given to balloon dilation or possibly placement of metal stent across the stricture.

Image How long should a stent remain in place in a patient with a biliary fistula and concomitant stricture?

Biliary fistulas associated with bile duct strictures will require long-term stenting, preferably with large bore stents (10- or 11.5-French stents). These patients will need one or two 10-French stents placed with interval changes every 3 months for a mean of 10 months.

Image If a patient has an external biliary fistula, what test should be done first?

Fistulogram.

Image In what situation is the best result achieved when stenting a biliary stricture?

If the stenotic segment is short (< 1 cm) or if the stenosis is partial.

Image What is the usual closure time of biliary leaks in the absence of stricture?

The majority of biliary leaks (not associated with stricture) close within 7–10 days after ablation of the biliary sphincter or stent placement.

Image True/False: Surgery is indicated for patients with chronic pancreatitis and associated biliary strictures, which produce chronic cholestasis.

True. Surgery is indicated whenever a biliary stricture has produced chronic cholestasis or its complications. Persistent elevation of alkaline phosphastase levels, even with normal bilirubin levels, is a sufficient indication for surgery. If cholestasis is not relieved in this situation, secondary biliary cirrhosis may result.

Image List three outcomes of gallbladder perforation.

Localized perforation is most common and leads to a pericholecystic abscess. Next is free peritonitis followed by cholecystoduodenal or cholecystoenteric fistulae.

Image When is cholecystectomy indicated for patients who fail gallstone dissolution with ursodeoxycholic acid?

Cholecystectomy is recommended after the second failure.

Image Name the four most common sites of trauma to the extrahepatic bile ducts.

1. CBD (58.3%)

2. Common hepatic duct (23.6%)

3. Right hepatic duct (5.5%)

4. Left hepatic duct (2.8%)

Image Name the most common presentation and treatment approach for complete blowout rupture of the fundus of the gallbladder.

Progressive early bile ascites requires early laparotomy, whereas laparotomy can be delayed for an early seal of the perforation with delayed rupture.

Image Name the most common presentation and treatment approach for avulsion of the gallbladder from the hepatic fossa.

This usually results in hemoperitoneum requiring an early laparotomy.

Image Name the most common presentation and treatment approach for contusion or incomplete blowout of the gallbladder.

In general, minimal early symptoms occur. Late rupture of an ischemia-weakened fundus should be treated by laparotomy.

• • • SUGGESTED READINGS • • •

Kianicka B, Díte P, Piskac P, Korbicka J, Vlcek P, Zák J. Endoscopic approach in diagnosis and treatment of biliary complications after laparoscopic cholecystectomy. Hepatogastroenterology. 2011;58(106):275-280.

Kortram K, de Vries Reilingh TS, Wiezer MJ, van Ramshorst B, Boerma D. Percutaneous drainage for acute calculous cholecystitis. Surg Endosc. 2011;25(11):2642-2646.

Cantù P, Tenca A, Caparello C, et al. Role of symptoms, trend of liver tests, and endotherapy in management of post-cholecystectomy biliary leak. Dig Dis Sci. 2011;56(5):1565-1571.

Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg. 2006;93(2):158-168.