COMMON BILE DUCT EXPLORATION

Transcription

1 COMMON BILE DUCT EXPLORATION

2 DEVELOPMENTS IN SURGERY J.M. Greep, H.A.J. Lemmens, D.B. Roos, H.C. Urschel, eds., Pain in Shoulder and Arm: An Integrated View ISBN B. Niederle, Surgery of the Biliary Tract ISBN J.A. Nakhosteen & W. Maassen, eds., Bronchology: Research, Diagnostic and Therapeutic Aspects ISBN X R. van Schilfgaarde, J.C. Stanley, P. van Brummelen & E.H. Overbosch, eds., Clinical Aspects of Renovascular Hypertension ISBN G.M. Abouna, ed. & A.G. White, ass. ed., Current Status of Clinical Organ Transplantation. With some Recent Developments in Renal Surgery ISBN A. Cuschieri & G. Berci, Common Bile Duct Exploration ISBN X A. Cuschieri & G. Berci, Common Bile Duct Exploration in combination with video tape, Operative and Postoperative Biliary Endoscopy ISBN

3 COMMON BILE DUCT EXPLORATION Intraoperative investigations in biliary tract surgery by Professor A. CUSCHIERI, MD, ChM, FRCS (Eng), FRCS (Ed) Professor and Head of Department of Surgery, Ninewells Hospital and Medical School University of Dundee, Dundee, Scotland Consultant Surgeon to the Tayside Health Board G. BERCI, MD, FACS Associate Director of Surgery, Cedars-Sinai Medical Center and Clinical Professor of Surgery, UCLA School of Medicine With contributions from J.A. HAMLIN, MD Staff Radiologist, Chief, Section of G.!. Radiology Cedars-Sinai Medical Center, Los Angeles, USA MARGARET PAZ-PARTLOW, MA, MFA Research Assistant, Section of Surgical Endoscopy Department of Surgery Cedars-Sinai Medical Center, Los Angeles, USA 1984 MARTINUS NIJHOFF PUBLISHERS... a member of the KLUWER ACADEMIC PUBLISHERS GROUP,_ BOSTON / DORDRECHT / LANCASTER ~

4 Distributors for the United States and Canada: Kluwer Academic Publishers, 190 Old Derby Street, Hingham, MA 02043, USA for the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited, Falcon House, Queen Square, Lancaster LA1 1 RN, England for all other countries: Kluwer Academic Publishers Group, Distribution Center, P.O. Box 322, 3300 AH Dordrecht, The Netherlands Library of Congress Cataloging in Publication Data Cuschieri, Alfred. Common bile duct exploration. (Developments in surgery) Includes index. 1. Bile-ducts--Surgery. I. Berci, George, II. Title. III. Series. [DNLM: 1. Cholangiography- Handbooks. 2. Biliary tract diseases--surgery--handbooks. 3. Surgery, Operative--Handbooks. WI DE8s WI 3!i C984c] RD546.C ' ISBN-13: : / e-isbn-13: Copyright 1984 by Martinus Nijhoff Publishers, Dordrecht. Softcover reprint of the hardcover 1 st edition 1984 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publishers, Martinus Nijhoff Publishers, P.O. Box 163, 3300 AD Dordrecht, The Netherlands.

5 CONTENTS 1. Introduction 2. Review of existing problems in biliary tract surgery 3 3. Surgical approach and principles 7 1. Introduction 7 2. Prophylactic measures Infectious complications Haemorrhagic complications Renal failure 8 3. Pre-operative biliary decompression in the jaundiced patient 9 4. Operative principles Surgical access Patient positioning Appropriate incision Illumination of the operating field Packing Exposure of relevant anatomy Drainage of the supracolic compartment after biliary operations Operative cholangiography (in cooperation with l.a. Hamlin and M. Paz-Partlow) Introduction Common bile duct explorations Unsuspected stones Cannulation techniques Initial and/or completion cholangiograms Standard technique Technique and equipment Patient's positioning Scout film Injected volume Contrast material Coordination of exposure Mobile C-arm fluoroscope Fluoro-cholangiography Easy positioning of the patient Optimal beam collimation Shorter exposure time Automatic exposure control 23

6 VI 7.5. Minimal technician activity Control of the exposure sequence Serial films Decreased examination time Indirect radiography Anomalies of surgical importance Short cystic duct Drainage of cystic duct in the right hepatic duct Aberrant ducts Ductal diverticula and choledochocele The acute or emergency case General aspects Radiation protection The cystic duct Cholecysto-cholangiogram The choledocho-cholangiogram Direct needle puncture Butterfly needle puncture Special needle clamp T-tube insertion Contact selective cholangiography Reason for failure for operative cholangiography Overfilled ducts Underfilled ducts Poor quality films Improper positioning Obscured field Artifacts Complications of operative cholangiography Reformed calculi Complications of T-tube removal in the post-operative period Results of operative cholangiography Advantages Disadvantages Operative biliary endoscopy (cholangioscopy) (in cooperation with M. Paz-Partlow) Introduction Instrumentation Accessories Technique Mobilization of the duodenum Endoscopic appearance The cystic stump remnant Endoscopic anatomy and pathology Normal findings Cholangitis Calculi Ampullary stenosis Neoplasms 58

7 4.6. Miscellaneous Repeated cholangioscopy Complications General aspects Sterilization Maintenance Evaluation of results Conclusions Biliary manometry and debimetry Introduction Usage Pharmacolgy of the sphincter of Oddi (SO) Effect of hormones and peptides Effect of pharmacological agents Biliary pressure indices Resting (initial, interdigestive) pressure Passage (yield, opening) pressure Filling pressure curves Residual pressure Flow rate (debimetry) Incremental pressure and recovery time Dynamic (transducer) manometry Endoscopic sphincter zone activity Technique of operative biliary manometry Disorders of the sphincter of Oddi Iatrogenic stricture Papillitis/Oedema Papillary stenosis (choledocho-duodenal junctional stenosis) Functional disorders Exploration of the common bile duct Introduction Technique of CBD exploration Mobilization of duodenum and head of pancreas Exposure of the CBD Choledochotomy Cholangioscopy Additional procedures Insertion of T-tube Closure of choledochotomy wound Trans-duodenal exploration od CBD Intta-hepatic calculi Assessment of terminal end of the CBD and sphincteric region Post-operative removal of T-tube Conclusion Postoperative removal of retained stones through the T-Tube tract (in cooperation with I.A. Hamlin) 89 VII

8 VIII 1. Introduction Stone extraction via the T-tube Endoscopic method Preparation for stone extraction Technique Results Complications Discussion 91 Index of Subjects 99