BILIARY RECONSTRUCTION

Document Sample
BILIARY RECONSTRUCTION Powered By Docstoc
					PERSONAL EXPERIENCE IN BILIARY RECONSTRUCTION
                         1986-2010      n=   824

                Choledocho/Hepatico-Jejunostomy 303
Transplant (live donors, pediatrics, inadequate bile duct)     175
Injury                                                          46
Curative cancer (pancreatic, cholangiocarcinoma)                43
Palliative cancer (pancreatic, duodenal, cholangiocarcinoma)    35
Choledochal cysts                                               4


                Choledocho-Choledochostomy                     485


                Choledocho-Duodenostomy                        27


                      Sphincteroplasty*                          9
KNOW ANATOMY             KNOW VARIANTS




               EXPOSURE




 FRIENDS AND ENEMIES   WHEN DOES HILUM START
KNOW ANATOMY             KNOW VARIANTS




               EXPOSURE




 FRIENDS AND ENEMIES   WHEN DOES HILUM START
KNOW ANATOMY             KNOW VARIANTS




               EXPOSURE



 FRIENDS AND ENEMIES   WHEN DOES HILUM START
KNOW ANATOMY           KNOW VARIANTS




               EXPOSURE



FRIENDS AND ENEMIES   WHEN DOES HILUM START
      BILIARY RECONSTRUCTION


INDICATIONS            OPERATIONS




Obstruction             -Duodenum


   Leak                  -Jejunum


 Congenital           Sphincteroplasty


 Transplant               Others



                                         SVera
       BILIARY OBSTRUCTION

         Bilirubin fractions,    Liver enzymes
              excretion


            Intrahepatic obstruction



Biliary dilatation              Cholangiography
ETIOLOGY OF JAUNDICE
Infants        Adolescents
ETIOLOGY OF JAUNDICE
Young Adults   The Elderly
                   ADMISSION WITH JAUNDICE
                            n=749




University hospital
General and tertiary care
1.2 million service population
L-C Injury


             DISTRIBUTION OF REFERRAL
                      DELAYS
                  n=67; 23% males; 20y follow up
L-C Injury
L-C Injury



             BISMUTH LEVEL OF INJURY

     HJ (2 or 3 ducts)
                                Right HJ




             HJ
L-C Injury
L-C Injury
L-C Injury



             LONG TERM RESULTS

  • Excellent             62

  • Medium                 2

  • Poor                   3
L-C Injury
L-C Injury
                                 ?
               Transection                 H-J, drain
             Cystic duct leaks            Stent, drain

 WELL DONE HEPATICO-JEJUNOSTOMY
             WORKS
Transection of small duct        Cholangiogram, ligation, drain
Lateral w/o thermal injury            Repair, stent, drain
      >50% of duct                    Repair, stent, drain

                  Referral to biliary surgeon
                             Drain
                             Stent
  CHOLEDOCHO-DUODENOSTOMY


 Benign distal CD stricture           CD>2.5 cms
Unable to retrieve all stones          Thick wall
  Primary ductal stones            Normal duodenum
                                    Running suture
                        SUMP
                      SYNDROME

                           Rare
               Latency 1-28years (m=6 y)
           Pain, fever, elevated liver enzymes
                Sphincterotomy curative
    TRANSDUODENAL SPHINCTEROPLASTY




Benign ampullary stricture        CD<2 cms
Unable to retrieve stones    Interrupted sutures
  Primary ductal stones        Suture mucosas
Benign ampullary tumors



      AVOID PANCREATIC DUCT
    DO NOT CUT DUODENAL WALL
                  REMEMBER
•   Well vascularized bile duct
•   Tension free
•   Approximate tissues before tying knot
•   Precise suturing (mms)
•   Segment IV retraction, bring liver down
•   Retro-colic is shorter
•   Stent, drain reconstructions after injury
•   Cholangiography after multiple anastomosis
•   Interrupted 5-0 vicryl (slick), Running 5-0 PDS
 OPERATIONS ON THE BILE DUCT
60                                Open chole
            Open CDE
50

40
                               1990
30
          1979
20

10                                                  Open CDE
                                      2002
                 2001                              1990
 0                                                        2002

     Govmt Database (x1,000)     ACGME               ACGME

                  UT residents CD surgery 2005-9
                            Range 0-6
                           Average 1.8
BACTERIOLOGY


               E.coli, Klebsiella sp

               Enterococcus, Strep.
               viridans
               Anaerobes

               Clostridium
         % INFECTED BILE

    70
    60
    50
    40
%   30
    20
    10
     0

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:21
posted:10/31/2011
language:English
pages:39