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Surgeries for Obstructive Jaundice

Ducts carry bile from the liver into the gall bladder and from the gall bladder into the small intestine. Blockage of any of the ducts can occur at several levels of the biliary system, leading to biliary obstruction. Causes are associated to intra-hepatic cholestasis or extra-hepatic biliary obstruction. Both are amenable to surgical treatment and hence also called surgical jaundice. Clinical grounds alone may not suffice in the diagnosis of obstructive jaundice. The disease is progressive, painless with associations to weight loss and anorexia. Malignant neoplasms can cause intra-cystic obstruction in which the gall bladder is palpable; while calculus diseases can cause shrinkage due to prior cholecystitis, and the gall bladder is not palpable.

Malignant diseases of obstructive jaundice include cholangiocarcinoma, Klastin tumour, carcinomas of the: pancreatic head, duodenum, Ampulla of Vater, gall bladder and lymph nodes at the porta. Benign diseases are CBD, biliary stricture, choledochal cyst, stenosis of the papilla, Mirizzi’s syndrome and extra-hepatic biliary atresia.

CBD exploration: After the exploration of the common bile duct, cholecystectomy is accomplished. Routine cystic duct cholangiography is conducted along with pre-exploratory size of the stones and their location. A supra-duodenal incision is made to attain either:

  • Simple closure: when there is patency of the distal duct system

  • T-tube drainage: which is followed by an antibiotic prophylaxis

  • Biliary enteric procedures: when there are indications of biliary-enteric anastomosis. Procedures are:

    • Choledochoduodenostomy for CBD > 1.5 cm

    • Trans-duodenal sphincteroplasty for patients with low CBD stricture and impacted stone in ampulla

    • Choledochojejunostomy for CBD that can be mobilized completely

Biliary calculus disease:

  • Therapeutic endoscopy: Endoscopic sphincterotomy for retained stones after cholecystectomy. ERC or endoscopic retrograde cholangiography is done after a cholangiogram shows the size, location and number of the stones. The procedure also involves cannulation of the ampulla. Stones’ extraction is done with balloon dilation and basket extraction.

  • Laparoscopic cholecystectomy is carried out along with trans-cystic CBD exploration. The cystic duct is dilated following a cholecystectomy and the stones are extracted with baskets.

Extra-hepatic biliary atresia: There are three different types: atresia of the CBD, common hepatic duct and right and left ducts. A pre-operative percutaneous liver biopsy is done and a resection of the biliary tract is done thereafter. A Roux-en-y loop is conducted as reconstructive surgery.

Ampullary tumours: Small tumours < 2 cm are excised locally. These usually arise from the Ampulla of Vater or biliary duct. Follow-up endoscopy is essential in about 6 months post-operatively.

Choledocholithiasis surgery: Several midline incisions are made. The peritoneum is opened and adhesions are divided. First, the liver is retracted upwards. Then the colon and duodenum are retracted downwards. The peritoneal fold is incised and a blunt dissection defines the CBD and the cystic duct. An intra-operative cholangiography is carried out and the cystic duct is ligated and cut.

Dr. Deepak conducts surgeries for obstructive jaundice after conducting ERCP, PTC and EUS procedures.

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