The SAGES Manual of Biliary Surgery [1st ed. 2020] 978-3-030-13275-0, 978-3-030-13276-7

Table of contents :
Front Matter ....Pages i-xi
Introduction to Biliary Manual (Dimitrios Stefanidis)....Pages 1-4
Biliary Anatomy (Daniel J. Deziel, Benjamin R. Veenstra)....Pages 5-23
Basic Principles of Safe Laparoscopic Cholecystectomy (Zachary M. Callahan, Shanley Deal, Adnan Alseidi, Michael J. Pucci)....Pages 25-38
Preoperative Optimization for Elective Cholecystectomy (Denise W. Gee)....Pages 39-48
Preoperative Imaging in Patients Undergoing Cholecystectomy (Sofiane El Djouzi)....Pages 49-63
Choosing the Best Timing for Cholecystectomy (Kohji Okamoto, Tadahiro Takada)....Pages 65-80
When to Perform a Cholecystectomy After Percutaneous Cholecystostomy Tube Placement (Neelakantan Prakash, Edward D. Auyang)....Pages 81-90
Intraoperative Cholangiography (IOC): Important Aid in Biliary and Common Bile Duct Surgery (George Berci, Brian R. Davis)....Pages 91-105
Intraoperative Indocyanine Green During Cholecystectomy (Fernando Dip, Mayank Roy, Matthew Roche, Armando Rosales, Emanuele Lo Menzo, Raul J. Rosenthal)....Pages 107-117
Laparoscopic Biliary Ultrasound (Steven P. Bowers)....Pages 119-128
The Difficult Cholecystectomy (Nathaniel Stoikes, L. Michael Brunt)....Pages 129-150
Non-operative Management of Common Bile Duct Stones: ERCP and Other Techniques (Lithotripsy) (Andrew T. Strong, Jeffrey L. Ponsky)....Pages 151-190
Common Bile Duct Exploration (Andrew Lambour, Byron F. Santos)....Pages 191-212
Management of Common Bile Duct Injury (Marc G. Mesleh, Horacio J. Asbun)....Pages 213-231
Operative Management of Bile Duct Injury in the Presence of Prior Roux-en-Y (Mihir M. Shah, Alisha Gupta, Juan M. Sarmiento)....Pages 233-240
Management of Common Bile Duct Stones in the Presence of Prior Roux-en-Y (Andrew T. Strong, Matthew Kroh)....Pages 241-263
Advanced Biliary Procedures (Eugene P. Ceppa, Thomas K. Maatman, Patrick B. Schwartz)....Pages 265-285
Back Matter ....Pages 287-294

Citation preview

The SAGES University Masters Program Series Editor-in-Chief: Brian Jacob

The SAGES Manual of Biliary Surgery Horacio J. Asbun Mihir M. Shah Eugene P. Ceppa Edward D. Auyang Editors

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The SAGES Manual of Biliary Surgery

Horacio J. Asbun  •  Mihir M. Shah Eugene P. Ceppa  •  Edward D. Auyang Editors

The SAGES Manual of Biliary Surgery

Editors

Horacio J. Asbun Chief of HPB - Miami Cancer Institute Miami, FL USA Eugene P. Ceppa Associate Professor of Surgery Indiana University School of Medicine Indianapolis, IN USA

Mihir M. Shah Assistant Professor of Surgery Winship Cancer Institute Division of Surgical Oncology Department of Surgery Emory University School of Medicine Atlanta, GA USA Edward D. Auyang Department of Surgery University of New Mexico School of Medicine Albuquerque, NM USA

ISBN 978-3-030-13275-0    ISBN 978-3-030-13276-7 (eBook) https://doi.org/10.1007/978-3-030-13276-7 © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

Although benign biliary disease is an area in which many surgeons have experience, there are many nuances to providing the highest quality of surgical care. The biliary anatomy is unique, asymmetric and can be distorted by benign pathology. Biliary surgery has been one of the earliest adaptors of minimally invasive techniques in the late 1980s. However, surgical technique has continued to evolve due to advanced fellowship training and improvement in surgical technology. The expertise, sage, and knowledge of the members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) have prioritized the creation of this manual on modern biliary surgery. Many leaders and innovators in the field of biliary surgery have served as authors to the comprehensive and authoritative descriptions in the chapters included in this manual. This text will provide the standard for the current state of biliary surgery in the twenty-first century. Both for the surgical trainee and senior surgeon, this manual will provide great insight into the modern evaluation and management. The highlights will emphasize what is both feasible and safe from a minimally invasive approach in biliary surgery. The concept of safe cholecystectomy will be defined and expounded in great detail. The most difficult cholecystectomies will be given ample coverage to include management of intraoperative bile duct injury, indications and techniques of subtotal cholecystectomy, and special attention to intraoperative diagnostic imaging that serves as adjuncts, including cholangiog-

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raphy, ultrasound, as well as indocyanine green biliary fluorescence. We will review the updated international Tokyo Guidelines from 2018 for acute cholecystitis. Furthermore, the evolution of treatment of choledocohlithiasis has evolved the most in recent years and thus requires an extensive discussion of the non-operative and operative management of bile duct stones. This text will serve as an important contribution to the medical literature sponsored by SAGES, an international leading authority in gastrointestinal surgery with a keen interest in safe and proficient biliary surgery. Leaders in the field of biliary surgery will impart their profound insight and considerable experience in the chapters planned for this manual. The intent for this manual is to be the cited resource for high-quality and applicable knowledge for the treatment of benign biliary disease. The authors and editors hope you will find this all to be true. Miami, FL, USA Atlanta, GA, USA Indianapolis, IN, USA Albuquerque, NM, USA

Horacio J. Asbun Mihir M. Shah Eugene P. Ceppa Edward D. Auyang

Contents

1 Introduction to Biliary Manual�������������������������������������   1 Dimitrios Stefanidis 2 Biliary Anatomy�������������������������������������������������������������   5 Daniel J. Deziel and Benjamin R. Veenstra 3 Basic Principles of Safe Laparoscopic Cholecystectomy�������������������������������������������������������������  25 Zachary M. Callahan, Shanley Deal, Adnan Alseidi, and Michael J. Pucci 4 Preoperative Optimization for Elective Cholecystectomy�������������������������������������������������������������  39 Denise W. Gee 5 Preoperative Imaging in Patients Undergoing Cholecystectomy�������������������������������������������������������������  49 Sofiane El Djouzi 6 Choosing the Best Timing for Cholecystectomy �������  65 Kohji Okamoto and Tadahiro Takada 7 When to Perform a Cholecystectomy After Percutaneous Cholecystostomy Tube Placement �������������������������������������������������������������  81 Neelakantan Prakash and Edward D. Auyang 8 Intraoperative Cholangiography (IOC): Important Aid in Biliary and Common Bile Duct Surgery�����������������������������������������������������������  91 George Berci and Brian R. Davis vii

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Contents

9 Intraoperative Indocyanine Green During Cholecystectomy������������������������������������������������������������� 107 Fernando Dip, Mayank Roy, Matthew Roche, Armando Rosales, Emanuele Lo Menzo, and Raul J. Rosenthal 10 Laparoscopic Biliary Ultrasound��������������������������������� 119 Steven P. Bowers 11 The Difficult Cholecystectomy������������������������������������� 129 Nathaniel Stoikes and L. Michael Brunt 12 Non-operative Management of Common Bile Duct Stones: ERCP and Other Techniques (Lithotripsy) ������������������������������������������������������������������� 151 Andrew T. Strong and Jeffrey L. Ponsky 13 Common Bile Duct Exploration ��������������������������������� 191 Andrew Lambour and Byron F. Santos 14 Management of Common Bile Duct Injury��������������� 213 Marc G. Mesleh and Horacio J. Asbun 15 Operative Management of Bile Duct Injury in the Presence of Prior Roux-en-Y ��������������� 233 Mihir M. Shah, Alisha Gupta, and Juan M. Sarmiento 16 Management of Common Bile Duct Stones in the Presence of Prior Roux-en-Y��������������� 241 Andrew T. Strong and Matthew Kroh 17 Advanced Biliary Procedures��������������������������������������� 265 Eugene P. Ceppa, Thomas K. Maatman, and Patrick B. Schwartz Index����������������������������������������������������������������������������������������� 287

Contributors

Adnan Alseidi, MD, EDM  Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA Horacio  J.  Asbun, MD Chief of HPB - Miami Cancer Institute, Miami, FL, USA Professor of Surgery - Mayo Clinic, Jacksonville, FL, USA Edward D. Auyang, MD, MS, FACS  Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA George  Berci, MD Department of Surgery, Cedars Sinai Medical Center Los Angeles, Los Angeles, CA, USA Steven  P.  Bowers, MD Department of General Surgery, Mayo Clinic Florida, Jacksonville, FL, USA L. Michael Brunt, MD  Section of Minimally Invasive Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, MO, USA Zachary  M.  Callahan, MD Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University Hospital, Philadelphia, PA, USA Eugene P. Ceppa, MD, FACS  Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA Brian  R.  Davis, MD Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA Shanley  Deal  Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA ix

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Daniel  J.  Deziel, MD, MS Department of Surgery, Rush University Medical Center, Chicago, IL, USA Fernando Dip, MD  Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA Sofiane El Djouzi, MD, MS, MBA  Division of GI/Minimally Invasive Surgery, Loyola University Medical Center, Chicago, IL, USA Denise  W.  Gee, MD Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA Alisha  Gupta, MD Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA, USA Matthew  Kroh, MD Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Andrew  Lambour, MD Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Thomas  K.  Maatman, MD  Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA Emanuele  Lo  Menzo  Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA Marc  G.  Mesleh, MD Department of Surgery, Advocate Christ Medical Center, Oak Lawn, IL, USA Kohji  Okamoto, MD, PhD  Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Fukuoka, Japan Jeffrey  L.  Ponsky, MD Department of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA Neelakantan  Prakash, MD Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA Michael  J.  Pucci, MD Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University Hospital, Philadelphia, PA, USA

Contributors

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Matthew  Roche, MD Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA Armando  Rosales, MD Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA Raul  J.  Rosenthal, MD Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA Mayank  Roy  Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA Byron  F.  Santos, MD Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Juan  M.  Sarmiento, MD, FACS Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA Division of Gastrointestinal and General Surgery, Emory University, Atlanta, GA, USA Patrick B. Schwartz, MD  Department of Surgery, University of Wisconsin School of Medicine, Madison, WI, USA Mihir M. Shah, MD  Assistant Professor of Surgery, Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA Dimitrios  Stefanidis, MD, PhD Department of General Surgery, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA Nathaniel  Stoikes, MD Section of Minimally Invasive Surgery, University of Tennessee  – Memphis, Memphis, TN, USA Andrew  T.  Strong, MD Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA Tadahiro Takada, MD, PhD  Department of Surgery, Teikyo University, Shiniyuku-ku, Tokyo, Japan Benjamin  R.  Veenstra, MD Department of Surgery, Rush University Medical Center, Chicago, IL, USA

Chapter 1 Introduction to Biliary Manual Dimitrios Stefanidis

Since its introduction approximately 30  years ago, laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease due to its low morbidity and quick patient recovery [1]. Despite this, up to 8% of patients undergoing LC develop a complication, a rate that has not changed significantly in the past 30  years [2]. Importantly, an increase in the bile duct injury rate has been observed in patients undergoing LC compared to the era of open cholecystectomy [3]. At the present time, biliary complications after laparoscopic cholecystectomy occur in approximately 1  in 100 patients, while 2–4 out of 1000 patients experience a major biliary injury that requires biliary reconstruction [2]. Considering that approximately 90% of the 1,000,000 cholecystectomies each year are performed laparoscopically in the USA, this rate translates into approximately 3000 or more major biliary injuries in the USA annually.

D. Stefanidis (*) Department of General Surgery, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_1

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Patients sustaining bile duct injuries require numerous re-­ interventions and hospitalizations, suffer a diminished quality of life, and have an up to 8.8% increased risk of mortality [4, 5]. These injuries are the most common reason for medicolegal litigation against general surgeons and place a significant economic burden on our healthcare system with an estimated annual cost of more than 1 billion dollars [6, 7]. Given the frequency of this operation and a rate of bile duct injury that has not decreased despite accumulating experience with laparoscopy over time, improving the safety of laparoscopic cholecystectomy is an important priority in surgery. To address this issue and bring it to the attention of the surgical community, the Society of American Gastrointestinal and Endoscopic Surgery (SAGES) formed the Safe Cholecystectomy Task Force in 2014 with the mission of enhancing a universal culture of safety in LC in order to reduce biliary injuries. The group has created numerous educational materials and initiated several projects aiming to improve the safety of the laparoscopic cholecystectomy (https://www.sages.org/safe-cholecystectomy-program) [8]. More recently, with the introduction of the SAGES Masters program that aims to address existing needs of practicing surgeons for lifelong learning after training completion by providing them with the tools to achieve maintenance of certification, a biliary pathway has been created [9]. This pathway aims to educate surgeons in biliary tract surgery by offering curricula and educational material addressing three levels of performance (competency, proficiency, and mastery). Each level incorporates an anchoring procedure that is meant for training and assessment of surgeons. The biliary manual you have in your hands provides you with an excellent resource for essential knowledge relevant to the care of patients with gallbladder disease. It is organized according to the levels of the SAGES Masters biliary pathway and addresses in-depth laparoscopic cholecystectomy and other related procedures all general surgeons should be familiar with when caring for this patient population. In Sect. 1, at the competency level of the Masters program, the surgical anatomy of the biliary tree and the principles and

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technique of safe cholecystectomy are described. Further, selection of appropriate preoperative imaging, patient optimization approaches for elective procedures, and optimal timing of cholecystectomy for acute cholecystitis, including use of cholecystostomy tubes, are addressed. At the proficiency level, the technique, advantages, and disadvantages of intraoperative biliary imaging (including cholangiogram, ultrasound, and ICG) are discussed, while at the mastery level, the management of common bile duct stones is described (including endoscopic and surgical approaches). In Sect. 2, the management of bile duct injuries is addressed, and a description of the indications and technique of advanced biliary procedures is provided. We are confident that this biliary manual, written by experts in the field, will provide you with the requisite knowledge to offer excellent care to your patients with gallbladder disease and assist you in the development of mastery with biliary tract procedures.

References 1. Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy: the new gold standard. Arch Surg. 1992;127(8):917–23. 2. Pucher PH, Brunt LM, Davies N, the SAGES Safe Cholecystectomy Task Force, et  al. Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis. Surg Endosc. 2018;32(5):2175–83. 3. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 1991;324(16):1073–8. 4. Törnqvist B, Strömberg C, Persson G, Nilsson M.  Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ. 2012;345:e6457. 5. Zong ZV, Pitt HA, Strasberg SM, et  al. Diminished survival in patients with bile leaks and ductal injuries: management strategy influences survival. J Am Coll Surg. 2018;226(4):568–576.e1. 6. Kern K.  Malpractice litigation involving laparoscopic cholecystectomy: cost, causes, consequences. Arch Surg. 1997;132:392–8.

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7. MacLean TR. Monetary lessons form litigation involving laparoscopic cholecystectomy. Am Surg. 2005;7:606–12. 8. The SAGES Safe Cholecystectomy Program. https://www.sages. org/safe-cholecystectomy-program/. 2015. 9. Jones DB, Stefanidis D, Korndorffer JR Jr, Dimick JB, Jacob BP, Schultz L, Scott DJ.  SAGES University MASTERS program: a structured curriculum for deliberate, lifelong learning. Surg Endosc. 2017;31(8):3061–71.

Chapter 2 Biliary Anatomy Daniel J. Deziel and Benjamin R. Veenstra

Introduction Cholecystectomy is one of the most frequently performed operations by general surgeons. Correct identification of the anatomy is requisite to its safe performance. Variations in biliary anatomy are common, both natively and as the result of pathologic conditions. A detailed understanding of hepatobiliary anatomy has been derived from classic studies based on cadaver dissection, corrosion casting, and direct cholangiography, as well as from contemporary imaging studies using 3D computed tomography (CT) and magnetic resonance (MR) reconstructions [1–12]. This chapter will highlight some of the variations in bile duct and vascular anatomy that are regularly encountered during cholecystectomy and that have practical significance for the avoidance of bile duct and vascular injury.

D. J. Deziel (*) · B. R. Veenstra Department of Surgery, Rush University Medical Center, Chicago, IL, USA e-mail: [email protected]; [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_2

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Terminology In order for anatomic concepts to be properly understood and communicated, the terminology must be correct, consistent, and standard. The lexicon of hepatobiliary anatomy has historically been confused by descriptions that use different nomenclatures and imprecise eponyms. Therefore, a few remarks on the terms used in this chapter are relevant to avoid misunderstanding. The hepatocystic triangle is the roughly triangular area bounded by the cystic duct and gallbladder, the common hepatic duct, and the edge of the liver (Fig. 2.1). This is a critical area where right hepatic ducts and the right hepatic artery can be located. This is a region often obscured by the effects of acute or chronic inflammation. This is the high-priced real estate where bile duct and vascular injuries are prone to occur. This is the area that must be cleared for anatomic identification by the critical view of safety. The size and shape of the triangle will change during the stages of dissection and with the direction of retraction. The hepatocystic triangle is not synonymous with the triangle of Calot. The triangle of Calot is a triangle bounded by the cystic duct, the common hepatic duct, and the cystic artery. It was described

Figure 2.1  The hepatocystic triangle and critical view of safety

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by Jean-Francois Calot in his 1890 doctoral thesis as an area of concern during the early era of cholecystectomy. “Calot’s’” triangle has become ensconced in the surgical vernacular. However, the term is not anatomically precise as it is commonly used. Moreover, the triangle is not consistently present, since it is defined by the location of the cystic artery which can be entirely outside of this region. Hepatocystic triangle is the preferred terminology for this important anatomic area. The critical view of safety is a method for identification of the cystic duct during cholecystectomy. It is not the only method for identification, but it is the method felt to be less subject to error than others [13]. The critical view of safety is defined by three criteria: (1) the hepatocystic triangle is cleared of connective tissue, (2) the gallbladder is dissected off of the liver demonstrating an ample portion of the cystic plate, and (3) two structures, the cystic duct and cystic artery, are seen to join the gallbladder (Fig. 2.1). The critical view cannot always be obtained, either because of natural anatomic differences or as the consequence inflammation. In these situations, the surgeon must have safe alternatives for correct identification of the cystic duct as are discussed in other chapters. Extrahepatic bile ducts that are arranged differently from the most typical configuration are often referred to as “accessory,” “anomalous,” or “aberrant” ducts. Although alliterative, such terminology is generally incorrect. An accessory duct implies true embryologic duplication of drainage from the same hepatic area; such ducts are rare, if even existent. Michels noted that “every duct drains a definite segmental area of the liver” [6]. Use of the terms “anomalous” or “aberrant” suggests that variations are unusual, unexpected, not easily classified, or divergent from the natural type [14]. It is incorrect to apply these terms to many bile duct variations, which, in fact, are natural and well recognized and present with sufficient frequency that they should be anticipated by the watchful surgeon. Hence, variant duct is the preferred terminology. The anatomic divisions of the liver have been conceptualized differently over time, and the terminology assigned by different anatomists has created confusion. We will use the nomenclature

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of the Brisbane 2000 system that is based on the intrahepatic distribution of the bile duct and hepatic artery [15]. This divides the liver into two sides, then into four sections, and then into eight segments. The corresponding ducts from the second and third level divisions are referred to as sectional ducts and segmental ducts. The anatomic divisions of the right liver are the same in the Brisbane and Couinaud systems; the only difference is that Couinaud termed the secondary divisions “sectors”/“sectorial ducts” instead of sections [5]. For the left liver, the two systems differ both in anatomic concept and terminology, but this is not applicable to our considerations for cholecystectomy. A description of the anatomical and historical basis of these differences is beyond the scope of this chapter, but an informed discussion can be found in references by Strasberg [16] and Bismuth [17].

General Landmarks for Anatomic Orientation During laparoscopic operations, it is possible to develop “tunnel vision,” to be so specifically focused on such a narrow field that the wider anatomic perspective is lost. Prior to commencing dissection for cholecystectomy and as the case proceeds, it is therefore useful to pause and to note the location of certain adjacent anatomic structures. Appreciation of these landmarks can aid proper orientation and prevent straying off course into danger zones (Fig. 2.2). The falciform ligament is between hepatic segments 3 and 4. The common hepatic duct (CHD) is near the midplane of the liver between segments 4 and 5. If dissection is too close to the plane of the falciform ligament, it is on the wrong side of the extrahepatic ducts. Rouviere’s sulcus1 is a fissure in the liver that usually contains portions of the right portal pedicle. It is located underneath, or dorsal, to the gallbladder and anterior to hepatic segment one. It can be recognized in 75–80% of cases [18]. The sulcus demarcates the ventral-dorsal (anterior-posterior)  Described by French anatomist Henri Rouviere in 1924. The sulcus was called the incisura hepatis dextra by Gans in 1955. Hence, it is sometimes referred to as the incisura of Gans.

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Figure 2.2  Anatomic landmarks for orientation. Note the location of the falciform ligament (a), of Rouviere’s sulcus (b), and of the duodenum (c) and the apperance of the epicholedochal plexes of vessels on the common bile duct (d)

plane of the common bile duct. Dissection must be ventral (anterior) to the sulcus to avoid injury to the bile duct or to vascular structures that are located within the sulcus. While retracting the gallbladder, the location of the duodenum should be noted in relation to any ductal structure identified. A duct that courses directly behind the duodenum is the common bile duct (CBD), not the cystic duct. The blood supply to the supraduodenal segment of the CBD is primarily axial and is based on a plexus of vessels that is anchored by marginal anastomotic arteries, referred to as the 3 o’clock and 9 o’clock vessels. These anastomotic vessels run between the retroduodenal artery (a branch of the gastroduodenal artery) and the RHA. The epicholedochal plexus produces a characteristic vascular pattern on the CBD that is useful to visually distinguish it from the cystic duct.

Anatomy of the Right Hepatic Ducts In the most common arrangement, the right anterior (RA) sectional hepatic duct (from segments 5 and 8) and the right posterior (RP) sectional hepatic duct (from segments 6 and 7)

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unite to form the right hepatic duct (RHD), which joins the left hepatic duct to form the common hepatic duct (CHD) (Fig.  2.3). This “typical” anatomy occurs in 57–72% of individuals [3, 5, 8]. The corollary is that approximately one-­third to one-half of individuals will have variations in the anatomy of the extrahepatic ducts. Substantial portions of these variations involve right hepatic ducts located near the field of cholecystectomy.

Figure 2.3 Intraoperative cholangiogram demonstrating what is termed “typical” anatomy of the bile ducts

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The most frequent and important variation in the right hepatic ducts occurs when the RA and RP ducts do not join to form a common RHD. Instead, each sectional duct has a separate junction with the CHD or the left hepatic duct. Some version of this occurs in 15–30% of people [1, 3, 5, 8]. Segmental ducts, usually from segments 5 or 6, can also drain into the CHD separately from other segmental ducts. The junction of a separate right hepatic duct with the other extrahepatic ducts can be at a variable distance along the vertical hepatoduodenal axis. A separate RP duct tends to join the CHD further down from the hepatic hilum than a separate RA duct. Thus, the mean distance between the insertions of the cystic duct and a separate RP duct is shorter than the mean distance between the cystic duct and a separate RA duct [8]. Such anatomy brings the RP duct in close proximity to the gallbladder and the cystic duct (Fig. 2.4). Furthermore, in 1 out

Figure 2.4 Intraoperative cholangiogram demonstrating separate junctions of the right anterior and right posterior sectional ducts with the common hepatic duct. Note the junction of the cystic duct near the separate right posterior sectional duct

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Figure 2.5  Intraoperative cholangiogram demonstrating the cystic duct joining a separate right sectional hepatic duct

of 50 cholecystectomies, or 2% of individuals, the cystic duct joins a separate right sectional duct (or occasionally even the main right hepatic duct) rather than the CHD [5, 8, 9] (Fig. 2.5). These right duct variants court injury if not recognized. A subvesical duct is another structure that is pertinent to understand for safe cholecystectomy. These are ducts located superficially in the gallbladder bed, just under Glisson’s tunic.

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Figure 2.6 Intraoperative cholangiogram demonstrating a ­subvesical duct that joins the right anterior sectional hepatic duct

Although they can originate from different liver areas, they most frequently represent segmental ducts from segment 5, and they most frequently drain into the RA sectional duct, RHD, or CHD [3, 20] (Fig. 2.6). Subvesical ducts are considered to be the most common source of postoperative bile

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leakage from the liver bed. This is best avoided by keeping the plane of dissection outside of the liver when possible. Subvesical ducts have been observed in about one-third of human specimens [3, 20, 21]. Healey and Shroy made the germinal observations that, unlike other bile ducts, subvesical ducts were not accompanied by a branch of the portal vein, and, in no instance, did they drain into the gallbladder [3]. True hepatocystic ducts, between the liver and gallbladder, have been described, but they are rare, certainly much more so than subvesical ducts. It is a misnomer to refer to either subvesical ducts or hepatocystic ducts as the eponymic “ducts of Luschka.” German anatomist Hubert von Luschka, in 1863, described two microscopic tubular structures in the gallbladder wall that were present on both the peritoneal and liver surfaces of the gallbladder. These are best understood today to have represented intramural glands and lymphatics [19].

Anatomy of the Cystic Duct The cystic duct usually joins the CHD.  The location of the junction can be anywhere from the hepatic hilum to the preampullary area: 80% are supraduodenal and 20% are retroduodenal or retropancreatic [2, 20]. The course of the cystic duct relative to the CHD and the pattern of union are variable. In the textbook configuration, the cystic duct has an angular entry at the right lateral aspect of the CHD; classic dissection studies noted this in 75% of specimens [2, 20, 21]. About 20% of cystic ducts course parallel to the CHD, sharing a common sheath of connective tissue. The length of a parallel course can be short (< 5  cm) in 11–15% or long (>5  cm) in 4–6% [2]. The parallel formation has long been recognized as a risk factor for bile duct injury. Five to 10% of cystic ducts take a spiral course and cross either ventral or dorsal to the CHD with a medial, posterior, or anterior confluence [2, 9, 20, 21] (Fig. 2.7). A study by intraoperative cholangiography found that the frequency of cystic duct patterns often differed from what is commonly appreciated and

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b

Figure 2.7 Intraoperative cholangiograms demonstrating cystic ducts that are parallel to the common hepatic duct: (a) short and (b) long with spiral course

included a spiral course in 35%, a long parallel course in 7%, a posterior union with the CHD in 41%, and a direct lateral union in only 17% [7]. Two alterations in cystic duct anatomy are particularly important as risk factors for bile duct injury. The first is when the cystic duct is fused to the CHD.  This can be present natively, as mentioned above, but commonly results from inflammatory fusion of the CHD with the cystic duct and neck of the gallbladder [22]. A second high-risk situation is when the cystic duct is “short,” which is also usually due to inflammatory contraction (Fig. 2.8). The cystic duct has sometimes been described as “absent.” However, this appearance is almost certainly the result of an acquired inflammatory condition. Congenital absence of the cystic duct has not been documented in compiled series of anatomic dissections [20].

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Figure 2.8 A wide, so-called “short,” cystic duct resulting from inflammatory contraction

Anatomy of the Cystic Artery The cystic artery (CA) is a single vessel 75% of the time. It usually has two branches: a superficial or inferior branch on the peritoneal surface of the gallbladder and a deep or superior branch on the hepatic side. The CA can divide on the gallbladder wall or at a variable distance away from it. When the division is near the source vessel, the branches may appear to be two separate arteries in the hepatocystic triangle (Fig.  2.9). The CA originates from the right hepatic artery (RHA) 70% of the time. The location of the RHA is dorsal (posterior) to the CHD 85% of the time. When the CA comes from a source vessel other than the RHA, as it does in nearly one-third of cases, it may not be found in its anticipated location within the hepatocystic triangle. In particular, CAs that originate from the proper hepatic artery, middle hepatic artery2, left hepatic artery, or  The middle hepatic artery is usually a branch of the right or left hepatic artery. Although it is often not mentioned, it is consistently present in anatomic dissections [1].

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Figure 2.9  Dorsal view of the cystic artery dividing into its deep (lower branch in photo) and superficial (upper branch in photo) branches early in the hepatocystic triangle

gastroduodenal artery are often in positions that are anterior to the CHD or CBD or anterior and inferior to the cystic duct. Twenty percent of the time, there is an anterior CA that, if not properly identified in this location, is subject to injury. Multiple CAs exist in one out of four people (Fig.  2.10). When there are two CAs, the vessel supplying the liver surface of the gallbladder still typically comes from the RHA.  However, the vessel on the peritoneal surface may come from various sites and may be in an anterior location relative to the ducts as noted above. The arterial anatomy that we expect to encounter during cholecystectomy is actually not the norm when all of the variations are taken into consideration. Michels found that only 43% of individuals had a single cystic artery that originated from the RHA and was also located within the hepatocystic triangle [1]. In 10% of specimens, there is no CA within the hepatocystic triangle. Hence, Calot’s triangle cannot exist [1, 10].

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Figure 2.10 Two cystic arteries originating from the right hepatic artery that has a parallel course along the gallbladder wall. The superficial cystic artery has been clipped and divided. The deep cystic artery is displayed intact

The CA or its branches are most safely ligated and divided directly at the gallbladder wall. The first reason for this is to avoid compromise of a proximate RHA. When the RHA is situated low in the hepatocystic triangle, the CA that emanates from it can be very short; proximal clips can impinge on the RHA [23]. The second reason to divide the CA as near the gallbladder as possible is to prevent interruption of CA branches that provide flow to other areas. Separate hepatic branches can come off of the CA. The deep CA itself can actually be a liver vessel that gives off a number of small branches to the gallbladder before proceeding into the liver [1, 6] (Fig. 2.11). A portion of the CBD can also derive its blood supply from the CA. On occasion, the anastomotic vessels that anchor the epicholedochal plexus are essentially absent, and the plexus is supported by branches from the CA [24].

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Figure 2.11 Gallbladder bed following cholecystectomy demonstrating a “cystic artery” that gave off multiple branches to the gallbladder and then became a liver vessel. The clipped structure on the far right in the figure is the cystic duct. The three other clipped structures to the left of this are arterial vessels to the gallbladder that branched off of the source vessel that can then be seen to enter the liver in the region of the gallbladder fundus

Anatomy of the Right Hepatic Artery The RHA most typically originates from the proper hepatic artery in the hepatoduodenal ligament and crosses toward the hepatocystic triangle dorsal to the CHD. Variations in the anatomy of the RHA amplify the operative risk for bleeding or major vascular injury with resultant hepatic ischemia. The RHA can be closely applied to the gallbladder, either natively or as the result of inflammatory fusion. The vessel

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has a characteristic caterpillar-like loop that takes a serpentine course near the cystic duct and gallbladder. In relation to the cystic duct and gallbladder neck, the loop can descend dorsally or ventrally and can end cephalad or caudad to these structures [1, 23]. When the CA comes from a looping RHA, it can be very short if originating from the ascending portion of the loop (as previously noted). Alternatively, if the CA comes from the descending portion of the loop, it can cross the ascending portion adjacent to the gallbladder, CD, and CBD.  Both of these circumstances pose increased risk for operative injury. The RHA can branch and give the appearance of two larger vessels or of two RHAs in the hepatocystic triangle [1]. The RHA can run parallel to the gallbladder body wall before entering the liver (Fig. 2.10). Twelve percent of RHAs are anterior to the CHD (Fig.  2.12). Seventeen percent of RHAs originate from the

Figure 2.12 The right hepatic artery crossing ventral (anterior) to common hepatic duct rather than in its more usual dorsal (posterior) location

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Figure 2.13  Rouviere’s sulcus

superior mesenteric artery (SMA) and are termed replaced RHAs. In 2% of individuals, the entire hepatic arterial blood supply is replaced from the SMA [1, 4]. A replaced RHA is located lateral and dorsal to the CBD and is often close to its junction with the cystic duct. When present, a replaced RHA is the usual source of the deep CA. Branches of the RHA enter a fissure in the liver underneath the gallbladder known as Rouviere’s sulcus (Fig. 2.13). Two or three larger branches to the fissure often come off a replaced RHA from the SMA. While these vessels are usually more deeply situated, they can be mistaken for the CA as they lie behind and parallel to the cystic duct [1]. Probing in the plane of the sulcus is dangerous.

Summary Variations in bile duct and arterial anatomy are common and should be anticipated during cholecystectomy. Recognition of the more frequent variations, as discussed in this chapter, is vital to the safe conduct of the operation.

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References 1. Michels NA. The hepatic, cystic and retroduodenal arteries and their relations to the biliary ducts. Ann Surg. 1951;133:503–24. 2. Moosman DA, Coller FA. Prevention of traumatic injury to the bile ducts: a study of the structures of the cystohepatic angle encountered in cholecystectomy and supraduodenal choledochostomy. Am J Surg. 1951;32:132–43. 3. Healey JE, Schroy PC. Anatomy of the biliary ducts within the human liver. AMA Arch Surg. 1953;66:599–616. 4. Michels NA. Blood supply and anatomy of the upper abdominal organs. Philadelphia: Lippincott; 1955. 5. Couinaud C.  Le Fois: Etudes Anatomogiques et Chirurgicales. Paris: Masson; 1957. 6. Michels NA. New anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg. 1966;112:337–47. 7. Berci G, Hamlin JA.  Operative biliary radiology. Baltimore: Williams and Wilkins; 1981. 8. Yoshida J, Chijiiwa K, Yamaguchi K, et  al. Practical classification of the branching types of the biliary tree: an analysis of 1,094 consecutive direct cholangiograms. J Am Coll Surg. 1996;182:37–40. 9. Kwon AH, Uetsuji S, Ogura T, Kamiyama Y.  Spiral computed tomography scanning after intravenous infusion cholangiography for biliary duct anomalies. Am J Surg. 1997;174:396–402. 10. Suzuki M, Akaishi S, Rikiyama T, et al. Laparoscopic cholecystectomy, Calot’s triangle, and variations in cystic arterial supply. Surg Endosc. 2000;14:141–4. 11. Vakili K, Pomfret EA.  Biliary anatomy and embryology. Surg Clin N Am. 2008;88:1159–74. 12. Furusawa N, Kobayashi A, Yokoyama T, et al. Biliary tract variations of the left liver with special reference to the left medial sectional bile duct in 500 patients. Am J Surg. 2015;210:351–6. 13. Strasberg SM, Brunt LM. The critical view of safety: why it is not the only method of ductal identification within the standard of care in laparoscopic cholecystectomy. Ann Surg. 2017;265:464–5. 14. Mirriam-Websters Collegiate Dictionary, 10th edition. Springfield: Mirriam-Webster; 2001. 15. Terminology Committee of the IHPBA (authors). Terminology of liver anatomy and resections. HPB Surg. 2000;2:233–9.

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16. Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepato-Biliary-Pancreat Surg. 2005;12:351–5. 17. Bismuth H. Revisiting liver anatomy and terminology of hepatectomies. Ann Surg. 2013;257:383–6. 18. Hugh TB, Kelly MD, Mekisic A. Rouviere’s sulcus: a useful landmark in laparoscopic cholecystectomy. Br J Surg. 1997;87:1253–4. 19. Schnelldorfer T, Sarr MG, Adams DB.  What is the duct of Luschka?  – a systematic review. J Gastrointest Surg. 2012;16:656–62. 20. Kune GA.  Current practice of biliary surgery. 1st ed. Boston: Little, Brown and Company; 1972. 21. Kune GA. The anatomical basis of liver surgery. Aust NZ J Surg. 1969;39:117. 22. Strasberg SM, Eagon CJ, Drebin JA.  The “hidden cystic duct” syndrome and the infundibular technique of laparoscopic cholecystectomy – the danger of the false infundibulum. J Am Coll Surg. 2000;191:661–7. 23. Stremple JF. The need for careful dissection in Moosman’s area during cholecystectomy. Surg Gynecol Obstet. 1986;163:169–73. 24. Parke WW, Michels NA, Ghash GM. Blood supply of the common bile duct. Surg Gynecol Obstet. 1963;117:4755.

Chapter 3 Basic Principles of Safe Laparoscopic Cholecystectomy Zachary M. Callahan, Shanley Deal, Adnan Alseidi, and Michael J. Pucci

Introduction Laparoscopic cholecystectomy is a common surgical procedure for the management of a variety of gallbladder and biliary pathologies. It is generally regarded as a routine general surgery operation. However, the proximity of the gallbladder to critical vascular and biliary structures warrants a high degree of vigilance. The persistent incidence of complications associated with this operation, both major and minor, emphasizes this concept [1–4]. Surgeons must remain steadfast in adhering to the culture of safety in cholecystectomy in order to minimize complications [5]. This requires a “safety first”

Z. M. Callahan · M. J. Pucci (*) Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University Hospital, Philadelphia, PA, USA e-mail: [email protected] S. Deal · A. Alseidi Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_3

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mentality, always cognizant that this operation is done for a benign disease. Thus, persistence in the face of difficult operative conditions is not necessary, as other satisfactory “bail-­ out” procedures are available. The critical view of safety (CVS) has been widely adopted to diminish bile duct injuries and is the basis of completing safe laparoscopic total cholecystectomy [5]. Instituting intelligent operative planning, strategic retraction, careful dissection, and basic surgical principles assists surgeons in achieving the CVS and ultimately a safe cholecystectomy.

 oom Setup, Patient Positioning, and Surgical R Team Orientation After appropriate patient selection has occurred, the first consideration is optimal operating room setup and patient positioning. Obviously, each operating room is unique and may require a different setup to achieve the operation. Two video monitors are positioned at the head of the bed, one on each side of the patient, for the surgeon and operating room team. Additional operative and anesthesia equipment is oriented to facilitate fluoroscopic C-arm entry from the patient’s left side, if possible. The patient is positioned supine with both arms extended (or with either arm tucked, per surgeon preference or to facilitate C-arm entry). A footboard may be useful, especially for the obese patient, as more extreme reverse Trendelenburg positioning may be required. The operating surgeon and second assistant typically stand on the patient’s left side, while the first assistant and scrub tech/nurse stand on the patient’s right side. Care is taken to assure that the back table is either at the bottom of the bed or off to the patient’s right to allow for C-arm entry. However, adjustments may be necessary based on the actual room setup. The actual operating room bed must be capable of reverse Trendelenburg positioning and able to accommodate fluoroscopic equipment in case cholangiography is performed. An alternative setup is for the sur-

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geon to stand between the legs of the patient as described as the French technique. Regardless of the setup, it is most important to preserve the key safety factors of the technique.

Port Placement A common method of port placement is outlined here; the exact port placement varies per surgeon, and many orientations may be sufficient as long as the emphasis remains on triangulation of ports around the infundibulum of the gallbladder. We typically prefer an open Hasson method through the umbilicus for initially entry. In the obese patient, the traditional umbilicus-centered port placement may not be ideal. In this case, the xiphoid process is identified and marked. A 12 mm optical trocar [1] is introduced 15 cm caudal from the xiphoid process and slightly off to the patient’s right side. A 5 mm port [2] is then placed far laterally and often a couple centimeters superior to the camera port. A grasper retracts the gallbladder fundus superiorly and toward the right shoulder. At this point, the infundibulum should be visible (as this is the goal of the setup to this point). On the skin, the position of the infundibulum is identified and marked. A line is drawn connecting the gallbladder infundibulum and the camera port. This makes triangulation of the last two ports easily identifiable. A 5 mm [3] subxiphoid port is placed at the level of the infundibulum in the midline with care being taken to enter on the correct side of the falciform ligament. Lastly, a 5 mm [4] port is placed lateral to the camera port-­infundibulum line with care taken to avoid being in line with the camera or the lateral-most port (Fig. 3.1).

Principles of Dissection Standard surgical principles, such as gentle tissue handling, minimizing bleeding, and adequate understanding of surgical anatomy are critical to a safe and successful cholecystectomy.

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15 cm

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X mark infundibulum on skin Retract Fundus

Retract Fundus

3

X

3

X

4 2

1

same height as infundibulum

2

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camera port-infundibulum line

Figure 3.1  Recommended port placement. Note this setup is used in the obese patient; otherwise, placement of the camera [1] port is performed through or around the patient’s umbilicus

Arguably, the most important safety principle during dissection is that ligation of any ductal structure must not occur unless clear ductal anatomy is present. One of the most dreaded complications of a laparoscopic cholecystectomy is bile duct injury (BDI). This typically occurs when the common bile duct is mistaken for the cystic duct and is clipped or ligated. The “classical” bile duct injury also involves a ­resection of a variable segment of the common hepatic duct, as the surgeon must “get back into the correct plane” to remove the gallbladder. The critical view of safety (CVS) was developed in an attempt to prevent this error and has three requirements: exposure of the bottom third of the cystic plate,

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Table 3.1  The three criteria of the critical view of safety Exposure of at least the bottom third of the cystic plate Clearance of fibrous and adipose tissue within the hepatocystic triangle Generally, only two structures seen entering the gallbladder

clearing all fat and fibrous tissue within the hepatocystic triangle, and identifying two and only two structures entering the gallbladder (Table 3.1). The CVS should be visible in both the anterior and posterior view. The CVS mimics the method of ductal identification used in classic “open” cholecystectomy, where the incidence of bile duct injury is significantly lower. Ultimately, the goal of dissection is to safely achieve the CVS (Fig.  3.2). Thus, only when the CVS has been achieved should ligation of the cystic duct occur. While the authors generally believe the CVS can be achieved in the majority of cases, there may be times when it is not possible. In these circumstances, the surgeon can either perform a bailout procedure (discussed later in this book) or use a different method of cystic duct identification. These “alternate” methods of cystic duct identification are safe, yet may require additional training and, at times, may be difficult to interpret. Intraoperative cholangiography is useful in identifying appropriate anatomy and minimizing the severity of bile duct injuries [6]. The surgeon must be able to clearly identify appropriate hepatic ductal anatomy with all the possible “variant” anatomy. Additionally, the biliary system must be accessed in order to perform cholangiography. Intraoperative ultrasound is another useful adjunct that requires surgeons to be trained on how to use and interpret this modality. Nearinfrared cholangiography is another method to assist in ductal identification, yet its applicability is still being studied. In addition to the “classical” bile duct injury, there are multiple other injuries/complications possible during dissection as the gallbladder is positioned close to hepatic vascular and biliary structures. Thus, careful dissection and cautious use of electrosurgical energy is paramount to avoid inadver-

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Gallbladder

Liver

Cystic plate

Cystic artery Common bile duct

Cystic duct

Gallbladder

Cystic artery Liver

Cystic plate

Cystic duct

Figure 3.2  Critical view of safety demonstrated in both the anterior and posterior view

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Table 3.2  Intraoperative “triggers” for a safety pause Unable to “find” Cholecysto-enteric fistula gallbladder Gallbladder mass

Unexpected bile leakage

Unanticipated bleeding

Surgeon suspicion of bile duct injury

Concern for aberrant vascular anatomy

Unable to obtain critical view of safety

Concern for aberrant biliary anatomy

Abnormal or incomplete cholangiogram

Dense adhesions preventing safe dissection

Hepatocystic triangle without clear planes (woody or fibrous inflammation)

Hemodynamic instability

Severe acute infundibular inflammation Mirizzi’s syndrome

Choledochal cyst #

tent injury to surrounding structures. Additionally, when unexpected bleeding or bile leakage occurs, the anatomy must be carefully identified before clipping or energy use is attempted. Certain situations should be triggers for a “safety pause” (Table 3.2). When these triggers are encountered, the operating surgeon should stop operating and consider adjuncts to improve safety. Some of these adjuncts include obtaining a second opinion from a colleague, a phone consult with a biliary surgeon, an intraoperative cholangiogram, converting to an open operation, or aborting the procedure and transferring to a tertiary care center with expertise in biliary surgery.

Technique Before beginning dissection, certain surface anatomical landmarks should be identified. Rouviere’s sulcus (which is an external landmark of the right-sided portal structures) is

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Figure 3.3  Identifying Rouviere’s sulcus as the inferior border of dissection protects important vascular and biliary structures

present in the majority of patients and serves as a good inferior boundary for safe dissection. Dissecting below this boundary puts the porta hepatis and common bile duct at risk. Additionally, dissecting below Rouviere’s sulcus can lead the operating surgeon to misperceive the biliary anatomy, namely, mistaking the common bile duct for the cystic duct (Fig. 3.3). Dissection should never occur to the patient’s left of the umbilical fissure. The choledochal vascular plexus may be visible on both the common hepatic and bile ducts and may serve to identify these structures (as it is absent on the cystic duct). After external anatomy is confirmed, dissection begins with fully exposing the gallbladder. Adhesions from the greater omentum, colon, or duodenum are often partially covering the gallbladder, especially in situations where significant inflammation has occurred and/or is present. These should be carefully and bluntly separated while attempting to stay as close to the gallbladder wall as possible. Particular care should be taken to avoid duodenal injury as it may be intimately adherent to the gallbladder. Exposure may also require appropriate liver retraction in patients with enlarged livers. Additional ports may be helpful, and surgeons should

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never resist placing more ports to help with exposure and dissection. The fundus of the gallbladder is then retracted cephalad and toward the patient’s right shoulder. Care must be taken to avoid excessive force that can lead to capsular tears of the liver or inadvertent slippage of a grasper off the gallbladder and into the diaphragm. With the gallbladder appropriately elevated, the infundibulum is then identified and retracted laterally and slightly caudal. This not only opens the hepatocystic triangle but also brings the cystic duct perpendicular to (or out of alignment with) the common hepatic and bile duct, which by itself may prevent BDI. Sufficient, but careful, tension created by this retraction is critical for adequate dissection (Fig. 3.4). Dissection should start with a superficial incision of the overlying peritoneum from the lateral then medial midportion of the gallbladder body (or vice versa). This is typically

Figure 3.4  Insufficient lateral retraction of the infundibulum aligns the cystic duct (CD) with the common bile duct (CBD) predisposing to misidentification of anatomy and potential bile duct injury. CHD common hepatic duct

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accomplished with electrosurgery, using the “L” hook instrument. These two lines of incision will connect at the infundibulum. It is important to take this peritoneal incision up the gallbladder body enough to be able to expose at least the bottom third (although we will routinely expose the bottom half) of the cystic plate. This appears to be a common error and a leading reason why the CVS is not adequately achieved as the gallbladder is insufficiently retracted away from the porta hepatis. After the peritoneum is adequately opened, the surgeon can work either within the hepatocystic triangle or start to expose the cystic plate. If the surgeon chooses to dissect and expose the cystic plate first, this begins on the lateral (patient’s right) side to separate the lower gallbladder body away from the cystic plate. After the lateral aspect of the gallbladder is released from the cystic plate, medial dissection can begin and will complete the posterior window. If clearance of the cystic plate is performed after dissection of the hepatocystic triangle, the dissection should be continued posteriorly along the gallbladder. Extra care is taken to stay directly on the gallbladder, allowing the midportion of the gallbladder body to be elevated away from the liver. The authors believe each method is useful in certain instances. However, we will generally expose the cystic plate first, if possible, as it will allow for more mobility of the gallbladder and ultimately safer dissection of the hepatocystic triangle. After the peritoneal incision around the infundibulum is complete, the hepatocystic triangle is dissected. It is important to have adequate mobility of the infundibulum prior to beginning dissection to avoid working too closely to the porta hepatis. This is one of the reasons we recommend exposing the cystic plate prior to dissection within the hepatocystic triangle (Fig.  3.5). In this way, the bottom aspect of the ­gallbladder can be safely retracted away from critical portal structures. The goal of dissection within the hepatocystic triangle is to clear all fat and fibrous tissue from this space. Dissection can be done bluntly or with electrosurgery, though care must be taken to avoid thermal spread and inadvertent biliary or vascular injuries. Thermal injury is particularly

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Figure 3.5  Dissection of the hepatocystic triangle can be pursued before or after (as pictured here) elevating the lower third of the gallbladder from the cystic plate

troublesome, as the injury may not manifest until the postoperative period. For this reason, electrosurgery should be used sparingly and at the lowest acceptable power setting when working close to the hepatoduodenal ligament. The previously discussed principles of staying above Rouviere’s sulcus, as well as staying close to the gallbladder body, should be honored. For adequate clearance of the hepatocystic triangle, both the anterior and posterior triangle must be dissected. As the hepatocystic triangle is dissected, the cystic artery and duct will become apparent. When isolating these structures, be careful to identify additional or aberrant branches. Dissection does not need to be carried down to the common hepatic duct or right hepatic artery. The ultimate goal of dissection is achieving the three components of the critical view of safety. At this juncture, consider an intraoperative “time out” with doublet photographic documentation of the CVS (anterior and posterior photographs). In the authors’ opinion, a total cholecystectomy should only be performed when the CVS is achieved. Alternative maneuvers are discussed later and should be employed if the critical view cannot be safely achieved.

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Prior to ligation of the cystic duct, additional intraoperative imaging, such as cholangiography, ultrasound, and/or infrared cholangiography, may be used according to the surgeon’s preference and training. Secure ligation of the cystic duct may be performed with gentle, precise application of surgical clips or suture with care taken not to shear or tear the duct. If the cystic duct is too large to accommodate clips, an “endoloop” suture may be used assuming it has clearly been identified as the cystic duct. Similarly, the cystic artery is then clipped and ligated. With both structures ligated, the remaining gallbladder is removed from the liver using electrosurgery and the princi-

Table 3.3  Common laparoscopic cholecystectomy pitfalls Port placement  Placing the camera at the umbilicus in the obese or tall patient (view too low)  Placing the xiphoid trocar too low or not perpendicular to the abdominal wall (too much port “tension” that limits fine motor movements)  Placing the surgeon’s left-hand port in line with camera view or the lateral retraction port Dissection  Not releasing the gallbladder from the liver by not incising enough peritoneum  Insufficient retraction of infundibulum inferiorly and laterally (may align the cystic duct and common hepatic/bile duct in the same plane)  Excessive electrosurgical energy, use of clips, or ligation of ductal structures before adequately defining the anatomy  Not fully exposing the bottom third of the cystic plate (the CVS is not achievable unless this is performed)  Inadequate dissection of the hepatocystic triangle to clearly identify the cystic duct and artery  Attempting total cholecystectomy when the CVS is not achievable (must utilize a bail-out maneuver)

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ples of tension and counter tension. Dissection should remain on the gallbladder to prevent liver parenchymal injury. Liver injury may result in bleeding or bile leakage. After the gallbladder is completely removed, gentle irrigation of the operative field may be performed. A thorough review of the liver bed to inspect for hemostasis and bile leakage should occur. Additionally, the integrity of the clips or sutures should be confirmed without dislodgement (Table 3.3). The gallbladder can be removed from the peritoneal cavity with use of a bag to minimize the risk of infectious complications. After the gallbladder is removed, all ports can be removed while watching carefully for any abdominal wall bleeding. Larger fascial incisions should be closed. Postoperatively, the patient should be monitored for any early bleeding or other immediate complications. Bile leakage or bile duct injury usually manifests with vague symptoms after 2–3  days. All post-cholecystectomy abdominal pain should be taken seriously by the surgical team and investigated if sufficient concern is present.

Conclusion Laparoscopic cholecystectomy is a common surgical procedure. While it remains as one of the most performed operations in the United States, surgeons should remain steadfast in pursuit of safety and vigilant in avoidance of major bile duct injury by adhering to safety principles described in this chapter.

References 1. Barrett M, Asbun HJ, Chien HL, Brunt LM, Telem DA.  Bile duct injury and morbidity following cholecystectomy: a need for improvement. Surg Endosc. 2018;32(4):1683–8. https://doi. org/10.1007/s00464-017-5847-8. 2. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101–25.

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3. Santos BF, Brunt LM, Pucci MJ. The difficult gallbladder: a safe approach to a dangerous problem. J Laparoendosc Adv Surg Tech A. 2017:571–8. https://doi.org/10.1089/lap.2017.0038. 4. Pucher PH, Brunt LM, Davies N, et  al. Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis. Surg Endosc. 2018;32:2175. https://doi.org/10.1007/s00464-017-5974-2. 5. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010;211:132–8. 6. Ludwig K, Bernhardt J, Steffen H, Lorenz D.  Contribution of intraoperative cholangiography to incidence and outcome of common bile duct injuries during laparoscopic cholecystectomy. Surg Endosc. 2002;16(7):1098–104.

Chapter 4 Preoperative Optimization for Elective Cholecystectomy Denise W. Gee

The key to performing a safe laparoscopic cholecystectomy in the elective setting is a thorough preoperative assessment of the patient. There are certain patient conditions and diseases that may be predictive of a difficult operation, and these need to be considered before entering the operating room. The surgeon must always be prepared for the possibility of a difficult gallbladder. The main principle to abide by is “safety first.” This can be achieved by reviewing acute and chronic comorbid conditions, identifying potential red flags during the work-up, and considering other patient factors such as obesity, prior upper abdominal surgery, or pregnancy. The key is to know when to operate and when not to operate and to be able to consider nonoperative management strategies when appropriate.

D. W. Gee (*) Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA e-mail: [email protected]; [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_4

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This preoperative algorithm can be summarized into four areas: 1. Indication for cholecystectomy: the suspected indication for cholecystectomy based on a thorough review of history, exam, and diagnostic studies. 2. Review of comorbid medical conditions: the patient should be assessed for possible medical contraindications or surrogates such as an ASA class, anticoagulation, severe cardiopulmonary disease, or pregnancy. 3. Assessment for other hepatopancreatobiliary disease: look for evidence of more extensive hepatobiliary disease that includes acute cholecystitis, biliary obstruction, cholecystoenteric fistula, cirrhosis/portal hypertension, malignancy, or Mirizzi’s syndrome. 4. Assessment for possible technical limitations: assess for factors that may prove to be technically challenging in the operating room such as morbid obesity, pregnancy, presence of abdominal wall mesh, or previous upper abdominal surgery. This chapter will focus on many of the conditions and diseases mentioned above and on ways to identify and safely manage them. Acute cholecystitis and biliary pancreatitis will be discussed in more depth in Chap. 6.

Acute Cholecystitis Patients with acute cholecystitis typically present with acute right upper quadrant abdominal pain that may radiate to the epigastrium, across the upper abdomen, to the right flank and/or right shoulder, or to the back. They may also have fever and a positive Murphy’s sign. Laboratory studies may indicate an increased white blood cell count and possibly a mild increase in liver function tests (LFTs). Ultrasound is the gold standard imaging study and may demonstrate gallbladder wall thickening and pericholecystic fluid. A number of risk factors have been identified for a difficult cholecystectomy. These include prolonged symptoms preoperatively

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over 72–96 h, a white blood cell count of over 18,000, a palpable gallbladder, increased age and comorbidities, and suspected gangrenous gallbladder [1]. In high-risk patients or those with severe inflammation and prolonged symptoms, nonoperative management should be considered. Commonly, broad-spectrum intravenous antibiotics targeting gram-negative and anaerobic bacteria are started immediately, and if there is a lack of improvement over a short period of time, then a percutaneous cholecystostomy tube by interventional radiology is preferred in medically frail patients. This allows for decompression of the bactibilia resulting from obstruction of the cystic duct or infundibulum. Once the infection and resulting acute inflammatory process has subsided several weeks later, a safer operation can be performed in many cases [2, 3]. If one is in the operating room with a severely inflamed gallbladder, special operative strategies may need to be employed that will be reviewed in Chap. 5.

Mirizzi’s Syndrome Mirizzi’s syndrome is defined as a compression of common hepatic duct by a large stone impacted in gallbladder neck or cystic duct [4]. It may also be associated with a cholecystobiliary fistula which can be a challenging surgical problem to manage [5]. The diagnosis of Mirizzi’s syndrome requires increased clinical suspicion as symptoms usually mimic acute cholecystitis. Patients may present with fever and chills and other signs of infection. Jaundice is also possible if there is biliary obstruction [6]. Laboratory studies often demonstrate an increase in white blood cell count with abnormal LFTs [7]. Ultrasound and CT scan are helpful in this diagnosis and typically show a large impacted stone in the gallbladder neck or in the cystic duct with a dilated proximal hepatic duct [8]. In the presence of Mirizzi’s syndrome, severe inflammation and difficult operative conditions are likely. As a result, these cases often require hepatobiliary surgical expertise. A preoperative CT scan can help rule out malignancy, and a

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preoperative cholangiography with ERCP can help determine the presence or absence of a fistula [8]. An ERCP can be both diagnostic and therapeutic. ERCP may allow stenting to relieve a proximal biliary obstruction. MRI/MRCP with Eovist is another valid diagnostic study in case of suspected Mirizzi’s to determine anatomy and presence of a fistula when the patient has contrast dye allergies or no availability for ERCP [9].

Cirrhosis and Portal Hypertension Patients with cirrhosis and portal hypertension may have known liver disease or other signs of systemic illness. There may be a myriad of findings on history and exam such as right upper quadrant pain, bleeding, ascites, symptoms of biliary stasis, intermittent colic, or cholangitis. However, the patient could also be asymptomatic. Laboratory studies can help make the diagnosis and assess the degree of liver dysfunction [10]. Common labs to obtain are LFTs, a coagulation panel, renal function tests, viral hepatitis panel, and levels of hepatotoxic agents, such as acetaminophen, if suspected. On imaging, abdominal ultrasound and CT scan can demonstrate cirrhosis or other signs of portal hypertension. For example, a preoperative CT scan can help identify potential varices in the abdominal wall or a recanalized umbilical vein. An MRCP can also be obtained to help evaluate the biliary tree for stones, strictures, or any other pathology. Abnormal findings are warning signs that there may be other underlying pathology. Proceeding with surgery, in these cases, should be carefully considered based on risks, benefits, and available resources. It is important to keep in mind that acute hepatitis or cirrhosis can actually mimic symptoms of cholecystitis or biliary colic and, in these patients, an operation may not be indicated. However, acute cholecystitis is not uncommon in this population and should be carefully evaluated. Patients with cirrhosis and portal hypertension who go to the operating room are at considerably higher risk of liver

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failure, and as such, the Child’s class or the MELD score should be determined as a preoperative assessment of risk [11]. Child A and B class patients can undergo laparoscopic cholecystectomy when clinically appropriate. In higher-risk patients (Child C cirrhosis or increased collaterals from portal hypertension), nonoperative management may be preferable [12]. A preoperative MELD score>13 is associated with a higher complication rate [13]. Consultation from hepatology or transfer to a tertiary care center should be considered for such difficult cases. Liver function should be optimized preoperatively. These patients are also at significant risk for bleeding from thrombocytopenia and coagulopathies which should be corrected preoperatively, and they should always have a type and screen available [10].

Suspicion of Malignancy Patients in whom malignancy is suspected usually present with unexplained pancreaticobiliary obstruction, fistula, weight loss, or a mass on imaging. These patients may present with painful or painless jaundice with or without the signs of infection. If biliary obstruction is present, liver function tests should be elevated. Serum tumor markers should be sent once a potential malignancy is suspected including AFP, CEA, and CA19-9 [14]. Imaging findings that should raise a suspicion of possible malignancy include the presence of a solid or eccentric mass, evidence of liver invasion, a porcelain gallbladder, or asymmetrical gallbladder wall thickening. If the patient is jaundiced, it is critical to determine the cause of jaundice and rule out an underlying malignancy which usually requires a preoperative CT or MRI to better delineate the hepatobiliary anatomy. Patients at high risk for malignancy may benefit from consultation with a surgeon experienced in gallbladder cancer and liver resection. As such, referral to an HPB surgeon early in the management process is highly encouraged. In the acute setting, the cholecystectomy may need to be delayed until the work-up is complete. Management should

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consist of percutaneous decompression of the gallbladder and antibiotic therapy if indicated. Cholecystostomy tube is to be avoided when malignancy is suspected. If a gallbladder polyp is seen on imaging and is less than 10  mm, it can be followed with serial ultrasound exams. Indications for cholecystectomy in the setting of small gallbladder polyps include patients with biliary colic-type symptoms, patients who might be lost to follow-up, or those with age greater than 50  years [15]. In the setting of gallbladder polyps, other risk factors for malignancy include history of primary sclerosing cholangitis, Indian ethnicity, or a sessile polyp [16].

Pulmonary Hypertension/Heart Failure Pulmonary hypertension or heart failure can mimic gallbladder disease. In patients with pathologically elevated central venous pressure that can lead to what is described as a nutmeg liver, as a result diagnostic imaging studies may demonstrate gallbladder abnormalities [17]. These patients generally do not have gallstones but have diffuse wall thickening, pericholecystic fluid, and large caliber hepatic veins and inferior vena cava which are suggestive of a right-sided heart failure. These patients can develop abdominal pain thought to be biliary colic. If the patient does not have an obvious infection or biliary obstruction, it is important to note that symptoms attributed to the gallbladder should resolve with treatment of the underlying disease. These are patients on whom you should not operate.

Pregnancy Recent literature and SAGES publications [18] have indicated that laparoscopic cholecystectomy is safe in any trimester of pregnancy, especially in patients with accelerating symptoms. In fact, a delay in treatment may actually lead to additional morbidity and mortality. With varying levels of

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evidence, safe imaging techniques in pregnancy include ultrasound, MR without contrast, and nuclear imaging studies. Intraoperative cholangiography may be done with appropriate shielding. The decision to operate should be based on clinical judgment and a discussion with the patient and her obstetrician regarding risks and benefits.

Morbid Obesity Obese patients have a higher prevalence of gallstones, and morbid obesity can lead to increased complications following cholecystectomy, including a higher rate of conversion from a laparoscopic to an open procedure [19]. Weight loss prior to surgery may reduce the risk of the operation. Some studies advocate adherence to an 800-kcal diet for 2 weeks preoperatively to reduce the bulk of the fatty liver and decrease risk of the operation [20, 21].

Immunocompromised Patient Immunocompromised patients may not present with a history and physical exam consistent with the amount of inflammation they could be harboring intraabdominally. As such, careful preoperative assessment with appropriate imaging techniques and laboratory studies is imperative prior to going to the operating room. The surgeon must always have a high index of suspicion and be prepared for a potentially difficult operation. In these cases, while laparoscopic cholecystectomy may be feasible, nonoperative management with a percutaneous cholecystostomy tube may be warranted [12].

Summary When the appropriate preoperative assessment is complete, the fundamental question is: Does the patient need to go to the operating room?

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If the answer is yes, then proceed with a laparoscopic cholecystectomy  – with open cholecystectomy reserved for patients in whom a laparoscopic approach is not feasible or possible. If the answer is no, this could be because there is no gallbladder pathology (i.e., in cases of pulmonary hypertension or acute hepatitis), another complex HPB disease exists needing further work-up, or to allow for further medical optimization or resolution of acute symptoms in a frail patient. In these instances, options include antibiotics, percutaneous cholecystostomy tube, and decompression of the biliary tree with ERCP or percutaneous transhepatic cholangiography in the setting of common bile duct obstruction. Preoperative assessment is crucial before taking a patient to the operating room for a laparoscopic cholecystectomy. The timing of the operation depends on indications and patient factors. Understanding the alternatives to immediate cholecystectomy and when to apply them is critical. One should seek guidance especially in difficult situations when there is concern or doubt of the safety in performing a cholecystectomy. Finally, in the absence of contraindications, a prompt cholecystectomy when indicated is designed to ameliorate the patient’s active symptoms but also to prevent recurrent episodes, unnecessary readmissions, and increased morbidity because of the development of more severe gallbladder disease.

References 1. Hirota M, et  al. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo guidelines. J Hepato-Biliary-Pancreat Surg. 2007;14(1):78. 2. Gomi H, et al. Tokyo guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):3. 3. Mori Y, Itoi T, Takada T, et  al. Tokyo guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):87–95.

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4. Testini M, Sgaramella LI, De Luca GM, et  al. Management of Mirizzi syndrome in emergency. J Laparoendosc Adv Surg Tech A. 2017;27(1):28. 5. Csendes A, Díaz JC, Burdiles P, Maluenda F, Nava O.  Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg. 1989;76(11):1139. 6. Ibrarullah M, Mishra T, Das AP. Mirizzi syndrome. Indian J Surg. 2008;70(6):281. 7. Ibrarullah M, Saxena R, Sikora SS, Kapoor VK, Saraswat VA, Kaushik SP. Mirizzi’s syndrome: identification and management strategy. Aust N Z J Surg. 1993;63(10):802. 8. Becker CD, Hassler H, Terrier F. Preoperative diagnosis of the Mirizzi syndrome: limitations of sonography and computed tomography. AJR Am J Roentgenol. 1984;143(3):591. 9. Yun EJ, Choi CS, Yoon DY, Seo YL, Chang SK, Kim JS, Woo JY. Combination of magnetic resonance cholangiopancreatography and computed tomography for preoperative diagnosis of the Mirizzi syndrome. J Comput Assist Tomogr. 2009;33(4):636. 10. Leandros E, Albanopoulos K, Tsigris C, Archontovasilis F, Panoussopoulos SG, Skalistira M, Bramis C, Konstandoulakis MM, Giannopoulos A.  Laparoscopic cholecystectomy in cirrhotic patients with symptomatic gallstone disease. ANZ J Surg. 2008;78(5):363. 11. Dolejs S, Ceppa EP, Kays J, Zarzaur BL.  The model for end-­ stage liver disease predicts outcomes for patients undergoing cholecystectomy. Surg Endosc. 2017;31:5192–200. 12. Brunt LM, Stoikes N.  Managing the difficult gallbladder. Waltham: UpToDate http://uptodate.com (Accessed on 26 Sept 2018). 13. Delis S, Bakoyiannis A, Madariaga J, Bramis J, Tassopoulos N, Dervenis C. Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child-Pugh classification in predicting outcome. Surg Endosc. 2010;24(2):407. Epub 2009 Jun 24. 14. Mehrootra, B.  Gallbladder cancer: epidemiology, risk factors, clinical features, and diagnosis. Waltham: UpToDate. http://uptodate.com (Accessed on 26 Sept 2018). 15. Sarkut P, Kilicturgay S, Ozer A, Ozturk E, Yilmazlar T. Gallbladder polyps: factors affecting surgical decision. World J Gastroenterol. 2013;19(28):4526. 16. Wiles R, Thoeni RF, Barbu S, et al. Management and follow-up of gallbladder polyps. Eur Radiol. 2017;27(9):3856–66. 17. Li YL, Lee KH, Cheng AK, Yu ML.  Nutmeg liver. Abdom Radiol (NY). 2018;43(5):1275–6.

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18. https://www.sages.org/publications/guidelines/guidelines-fordiagnosis-treatment-and-use-of-laparoscopy-for-surgical-problems-during-pregnancy/. Accessed 26 Sept 2018. 19. Paajanen H, Kakela P, Suuronen S, et al. Impact of obesity and associated diseases on outcomes after laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2012;22:509. 20. Jones AD, Waterland PW, Powell-Brett S, Super P, Richardson M, Bowley D. Preoperative very low-calorie diet reduces technical difficulty during laparoscopic cholecystectomy in obese patients. Surg Laparosc Endosc Percutaneous Tech. 2016;26(3):226. 21. Burnand KM, Lahiri RP, Burr N, Jansen van Rensburg L, Lewis MP. A randomised, single blinded trial, assessing the effect of a two week preoperative very low calorie diet on laparoscopic cholecystectomy in obese patients. HPB (Oxford). 2016;18(5):456.

Chapter 5 Preoperative Imaging in Patients Undergoing Cholecystectomy Sofiane El Djouzi

Introduction Radiology has empowered the different surgical subspecialties since its inception [1]. The imaging technology has evolved through the decades, and its developmental pace keeps growing exponentially [2]. Despite the human nature and the propensity to err [3], what would lead to questionable radiological diagnosis in the past has either evolved or vanished leaving the very competitive arena to much more sophisticated machinery [4]. Static or dynamic X-rays were at one point in time the only scheme for radiologically exploring the human body for answers. Physicians were thrilled and excited even with hazy results from such films. Decades have passed, and we have reached an era where a pregnant woman could safely see the fetal facial expressions through 4D ultra-

S. El Djouzi (*) Division of GI/Minimally Invasive Surgery, Loyola University Medical Center, Chicago, IL, USA © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_5

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sounds [5]. Such advancement parallels well the needs of modern medical practices, especially when it comes to preparing for surgical intervention. Despite some geographical and socioeconomical variations [6], benign gallbladder pathology remains one of the highest incidences worldwide [7]. Gallstones and biliary dyskinesia are the most recognized sources of patient’s complaints. There are guidelines and recommendations in the prevention, diagnosis, and management of such conditions [8–10]. These guidelines are based on ample evidence related to clinical symptomatology with the suspected underlying diagnosis confirmed by laboratory and imaging studies. In some instances, radiology is the sole determinant of the problem. Hence, it is important for every practitioner, especially surgeons, to learn these tools and apply them in the appropriate context.

Radiology for the Diseased Gallbladder The current imaging modalities are derived from various technologies. Considering the underlying machinery processing, some of these tools are more invasive than others. Few are only available at larger facilities or academic facilities (i.e., computed tomography with 3D reconstruction capabilities). That being said, in most instances, these radiologic modalities complement each other. Imaging means are primarily used in the context of the preoperative assessment. Some become adjuncts at the time of surgery (i.e., intraoperative cholangiogram during cholecystectomy) to either unveil variations in anatomical patterns or prevent and manage complications. Furthermore, imaging has also proven to be helpful in the postoperative follow-up, especially when it comes to elucidating diagnostic dilemmas (i.e., postcholecystectomy collections with bile leak). This chapter is dedicated to the preoperative workup; the following sections will only pertain to the preoperative use of radiology for the preparation of patients to cholecystectomy.

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X-Rays The X-radiation is electromagnetic radiation that is capable of causing ionization in the matter due to its high energy content. In human tissue, the ionization can cause damage to DNA and cells. It can also penetrate the body creating a noninvasive image of the internal anatomy. Although still being used for the diagnostic workup of abdominal conditions, it has shown meager yield when it comes to gallbladder disease with the exception for the visualization of radiopaque gallstones (Fig.  5.1) (only 20% of gallstones are radiopaque). The X-rays provide no valuable details on the morphology of the gallbladder wall or the surrounding structures. The X-rays are also denuded from help when it comes to addressing the duct caliber. If large enough, a radiopaque gallstone could be sighted away from the presumed gallbladder bed, which could suggest migration down the biliary ducts.

Ultrasound In contrary to X-rays, ultrasound is a process of imaging that uses high-frequency sound waves, beyond the range of human hearing, to image structures inside the body [11]. It is a readily available and economical technology that is regarded as being the essential imaging method in biliary exploration [12]. It is a transferable technology, and the most recent devices are easily portable. Hence, ultrasound is applicable in any setting including critically ill patients. Considering the noninvasiveness and yet the inherent accuracy [13] of the ultrasound imaging, it is considered as the best first test for the diagnosis of gallstones disease [14]. The existing procedures are multiple: gray scale, Doppler, intravenous contrast enhancement, elastography, and tridimensional ultrasonography – each of these contributes differently to assess the biliary symptoms [15]. It is of ideal use in pregnant or younger females. The most basic devices

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Figure 5.1  Gallstones seen on plain abdominal X-rays (as shown by the small arrows)

allow for a distinct demarcation of the intra-abdominal organs such as the liver as well as for the discrimination between cholestatic and obstructive jaundice [16]. It also allows the evaluation of the gallbladder wall characteristics when it comes to thickness and associated edema. Ultrasonography is well established to be the most sensitive and yet specific modality in defining gallstones and biliary dilatation [17]. Additionally, the Doppler flow permits the exploration of mucosal polyps (Fig.  5.2) and the portal venous system. Ultrasound technology also permits the evaluation of complicated cases of gangrenous or emphysematous cholecystitis, which would prompt emergent surgical interven-

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Figure 5.2  Gallbladder wall polyp seen on ultrasound (as shown by the small arrow)

tion. The sonographic images could also suggest the presence of gallbladder perforation or pericholecystic abscess. One of the most notable drawbacks to such technology is its possible limitation when it comes to obese patients [18] or when the bowel (i.e., colon) is inflated with air obscuring the visualization of the biliary anatomy. These situations render the films difficult to interpret. In these particular instances, other diagnostic modalities become necessary.

Computed Tomography (CT) CT technology has experienced one of the most enhanced innovations that the field of medical imaging has ever witnessed [19]. To the contrary of ultrasonography, CT employs invasive waves as the primary use is the in-depth exploration of the human body when diagnostic ambiguity is present. CT is a technology that uses X-rays to generate cross-sectional (axial) images. Dense structures such as metal and bone are displayed as white on CT.  Less dense structures are displayed as various shades of gray with the least dense structures (which contain gas) shown as black

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Figure 5.3  Computed tomography scan – axial view (small arrows delineating the IV contrast-enhanced gallbladder wall with associated pericholecystic edema)

[20]. It provides a good architectural understanding of the inflamed gallbladder as seen in the axial (Fig. 5.3) and coronal (Fig. 5.4) views. It also clearly shows the stigmata of any severe inflammatory processes. Considering this is a relatively expensive diagnostic tool, CT occasionally fails to show abnormalities in the face of acute cholecystitis [21]. In most instances though and especially in the US, “cold or asymptomatic” gallbladder pathology is incidentally discovered when scans are obtained for other nonrelated pathologies (i.e., appendicitis, etc.). The 3D reconstruction modality is also of valuable input when it comes to the definition of the biliary anatomy in relationship to the surrounding organs and vasculature [22]. That being said, it is a costly assessment dedicated mainly to the focused preoperative assessment of complex oncologic and surgical pathologies.

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Figure 5.4 Computed tomography scan  – coronal view (small arrows delineating the IV contrast-enhanced gallbladder wall with associated pericholecystic edema)

Magnetic Resonance Imaging (MRI) MRI is a study that is frequently conducted as complimentary to other more basic radiology investigations. The basic principles relate to a strong magnetic field that is created

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Figure 5.5 Magnetic resonance imaging (T2) with an axial view demonstrating choledocholithiasis (as shown by the small arrow)

by movement of current through series of helical coils. The body is traversed by the electromagnetic waves, which generate signals based on the properties of the tissues, in the presence of magnets. The receiving coil detects the signal, and after complex data processing, an image is displayed on the monitor [23]. Radiologists refer to T1 (Tesla 1) and T2 (Tesla 2) as being the physiological properties of the tissues after exposure to a series of pulses at predetermined time intervals. It could be conducted with and without IV contrast. Intuitively speaking, such a diagnostic modality is one of the most expensive tools available for biliary imaging. It is frequently dedicated for difficult (i.e., common bile duct stone) (Figs. 5.5 and 5.6) and complex pathology (i.e., biliary dilatation with distal suspicious obstruction) (Fig. 5.7).

 ndoscopic Retrograde Cholangiopancreatography E (ERCP) ERCP is a technique that uses a combination of luminal endoscopy and fluoroscopic imaging to diagnose and treat

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Figure 5.6  MRCP with a coronal view showing choledocholithiasis (the short arrow delineates the gallbladder contour and the long arrow points to a stone in the distal CBD)

conditions associated with the pancreatobiliary system [24]. This imaging modality has proven to be efficacious when it comes to the preoperative and the postoperative management of confirmed CBD stones [25]. Interestingly, ERCP and MRCP were found to be equivalent when it comes to the diagnosis of biliary obstruction [26] with ERCP allowing for handy access to therapy. Nonetheless, a widely accepted practice is to proceed with MRCP in the context of highly suspected CBD stones [27–29] recognizing that it is simply a diagnostic technique and choledocholithiasis once confirmed would require either ERCP or common bile duct exploration

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Figure 5.7  Magnetic resonance imaging (T2) with a coronal view showing ductal dilatation with mass effect at the head of the pancreas (as shown by the arrow)

at the time of cholecystectomy. Although invasive leading to potential complications (i.e., pancreatitis and duodenal ­perforation) [30] and not favored by some authors [31], routine preoperative ERCP for suspected choledocholithiasis has revealed to be convenient and effective in expert hands. In fact, Adam et al. [32] found some cost-effectiveness in the use of preoperative ERCP over the traditional MRCP.  The question of whether ERCP should be routinely used when CBD stones are suspected remains without a clear answer. Nevertheless, the current recommendations are to limit the application of ERCP to well-selected patients [33–35]. If applied in the right clinical and socioeconomical context, such proactive practice could alleviate the load on the MRI modality and allow the prompt tackling of those patients. Furthermore, radiation exposure is regarded as constraint to the wide application of ERCP in certain age-­defined populations. A new emerging technology has consisted of the upgrade of ERCP with non-radiating imaging [36]. Such technological advance will broaden the spectrum application of this technology to children and pregnant women.

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Hepatobiliary Iminodiacetic Acid Scan (HIDA) HIDA scan is a nuclear medicine imaging modality named after the first version of the radiopharmaceutical used in this exam. Like ultrasound, it may aid in establishing and excluding the diagnosis of acute cholecystitis. Despite the very blurred biliary anatomical delineations it provides, it is regarded as a physiologic study of the biliary system. The radiopharmaceutical is injected intravenously and is selectively taken up by the liver and the biliary system. Images of the right upper quadrant are obtained serially over time. Usually, the gallbladder fills with HIDA; this effectively excludes acute cholecystitis, because cystic duct obstruction is the hallmark of acute cholecystitis [37]. As any other diagnostic tool, false positive (i.e., when fasting for hours) and false negative (i.e., early acute cholecystitis without a complete obstruction of the cystic duct) could be encountered. Chronic cholecystitis is another particular pathologic entity that leads to an initial perception of positive test (false positive), but soon the radiotracer passes through the cystic duct. The addition of the cholecystokinin (CCK) helps to score the strength of the gallbladder contracture aiding in the diagnosis of biliary dyskinesia [38]. Ultrasound is a significantly better imaging modality when it comes to scrutinizing the underlying anatomy. Furthermore, the relative cost of HIDA scan is higher and requires longer processing time. It is also modulated by the availability of the injected tracer and the ease of obtaining the study, particularly after regular working hours. That being said, HIDA scan could be considered as a complementary diagnostic investigation, should the ultrasound prove to be of equivocal diagnostic value in selected patients.

Conclusion Technology is undoubtedly available to render the diagnosis of gallbladder disease less of a challenge. The different radio-

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logic modalities are very useful in the patient’s preoperative assessment. More robust and accurate testing capabilities have replaced plain X-rays. Ultrasound is the most common modality and usually available even in the most remote locations. Due to its overall accuracy and ease, it merits being the first modality to employ. HIDA scan and CT scan should be looked at as adjuncts when the diagnosis is challenging or the presentation is complex. MRI may be helpful in special circumstances. Understanding when and which imaging technologies are used and in which order is of critical value when it comes to evaluating symptomatic patients with biliary pathology.

References 1. European Society of R.  The future role of radiology in healthcare. Insights Imag. 2010;1(1):2–11. 2. Rego J, Tan K.  Advances in imaging-the changing environment for the imaging specialist. Perm J. 2006;10(1):26–8. 3. Brady A, Laoide RO, McCarthy P, McDermott R.  Discrepancy and error in radiology: concepts, causes and consequences. Ulst Med J. 2012;81(1):3–9. 4. Scatliff JH, Morris PJ. From roentgen to magnetic resonance imaging: the history of medical imaging. N C Med J. 2014;75(2):111–3. 5. Lebit DF, Vladareanu PD. The role of 4D ultrasound in the assessment of fetal behaviour. Maedica (Buchar). 2011;6(2):120–7. 6. Sharma RK, Sonkar K, Sinha N, Rebala P, Albani AE, Behari A, et  al. Gallstones: a worldwide multifaceted disease and its correlations with gallbladder carcinoma. PLoS One. 2016;11(11):e0166351. 7. Stinton LM, Shaffer EA.  Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012;6(2):172–87. 8. European Association for the Study of the Liver. Electronic address eee. EASL clinical practice guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. ­ 2016;65(1):146–81. 9. Warttig S, Ward S, Rogers G, Guideline Development G. Diagnosis and management of gallstone disease: summary of NICE guidance. BMJ. 2014;349:g6241.

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10. Ansaloni L, Pisano M, Coccolini F, Peitzmann AB, Fingerhut A, Catena F, et al. WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016. 2016;11:25. 11. Ihnatsenka B, Boezaart AP.  Ultrasound: basic understanding and learning the language. Int J Should Surg. 2010;4(3):55–62. 12. Badea R, Zaro R, Opincariu I, Chiorean L.  Ultrasound in the examination of the gallbladder  – a holistic approach: grey scale, Doppler, CEUS, elastography, and 3D.  Med Ultrason. 2014;16(4):345–55. 13. Pinto A, Reginelli A, Cagini L, Coppolino F, Stabile Ianora AA, Bracale R, et  al. Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature. Crit Ultrasound J. 2013;5(Suppl 1):S11. 14. Hwang H, Marsh I, Doyle J.  Does ultrasonography accu rately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital. Can J Surg. 2014;57(3):162–8. 15. Badea R, Zaro R, Tantau M, Chiorean L.  Ultrasonography of the biliary tract  – up to date. The importance of correlation between imaging methods and patients’ signs and symptoms. Med Ultrason. 2015;17(3):383–91. 16. Khandelwal N, Suri S, Katariya S, Malik N, Das KM, Garg K, et al. Ultrasound in obstructive jaundice. Indian J Gastroenterol. 1990;9(1):51–3. 17. Cohen SM, Kurtz AB.  Biliary sonography. Radiol Clin N Am. 1991;29(6):1171–98. 18. Neitlich T, Neitlich J.  The imaging evaluation of cholelithiasis in the obese patient-ultrasound vs CT cholecystography: our experience with the bariatric surgery population. Obes Surg. 2009;19(2):207–10. 19. Pelc NJ.  Recent and future directions in CT imaging. Ann Biomed Eng. 2014;42(2):260–8. 20. Goldman LW. Principles of CT and CT technology. J Nucl Med Technol. 2007;35(3):115–28; quiz 29–30. 21. Shakespear JS, Shaaban AM, Rezvani M.  CT findings of acute cholecystitis and its complications. AJR Am J Roentgenol. 2010;194(6):1523–9. 22. Kim SJ, Choi BI, Kim SH, Lee JY.  Three-dimensional imaging for hepatobiliary and pancreatic diseases: emphasis on clinical utility. Indian J Radiol Imaging. 2009;19(1):7–15. 23. Grover VP, Tognarelli JM, Crossey MM, Cox IJ, Taylor-­ Robinson SD, McPhail MJ.  Magnetic resonance imaging: prin-

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ciples and techniques: lessons for clinicians. J Clin Exp Hepatol. 2015;5(3):246–55. 24. Meseeha M, Attia M. Endoscopic retrograde cholangiopancreatography (ERCP). Treasure Island: StatPearls; 2018. 25. Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, et  al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013;(9):CD003327. 26. Kaltenthaler EC, Walters SJ, Chilcott J, Blakeborough A, Vergel YB, Thomas S. MRCP compared to diagnostic ERCP for diagnosis when biliary obstruction is suspected: a systematic review. BMC Med Imaging. 2006;6:9. 27. Bahram M, Gaballa G.  The value of pre-operative magnetic resonance cholangiopancreatography (MRCP) in management of patients with gall stones. Int J Surg. 2010;8(5):342–5. 28. Jendresen MB, Thorboll JE, Adamsen S, Nielsen H, Gronvall S, Hart-Hansen O. Preoperative routine magnetic resonance cholangiopancreatography before laparoscopic cholecystectomy: a prospective study. Eur J Surg. 2002;168(12):690–4. 29. Dalton SJ, Balupuri S, Guest J.  Routine magnetic resonance cholangiopancreatography and intra-operative cholangiogram in the evaluation of common bile duct stones. Ann R Coll Surg Engl. 2005;87(6):469–70. 30. Leerhoy B, Elmunzer BJ.  How to avoid post-endoscopic retrograde cholangiopancreatography pancreatitis. Gastrointest Endosc Clin N Am. 2018;28(4):439–54. 31. Alkhaffaf B, Parkin E, Flook D.  Endoscopic retrograde cholangiopancreatography prior to laparoscopic cholecystectomy: a common and potentially hazardous technique that can be avoided. Arch Surg. 2011;146(3):329–33. 32. Adam V, Bhat M, Martel M, da Silveira E, Reinhold C, Valois E, et al. Comparison costs of ERCP and MRCP in patients with suspected biliary obstruction based on a randomized trial. Value Health. 2015;18(6):767–73. 33. Hoyuela C, Cugat E, Bretcha P, Collera P, Espinos J, Marco C. Must ERCP be routinely performed if choledocholithiasis is suspected? Dig Surg. 1999;16(5):411–4. 34. Rubin MI, Thosani NC, Tanikella R, Wolf DS, Fallon MB, Lukens FJ.  Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: testing the current guidelines. Dig Liver Dis. 2013;45(9):744–9. 35. Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL.  Cost-effective management of common

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bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc. 2001;15(1):4–13. 36. Ofosu A, Ramai D, Sunkara T, Adler DG. The emerging role of non-radiation endoscopic management of biliary tract disorders. Ann Gastroenterol. 2018;31(5):561–5. 37. Johnson H Jr, Cooper B.  The value of HIDA scans in the initial evaluation of patients for cholecystitis. J Natl Med Assoc. 1995;87(1):27–32. 38. Krishnamurthy S, Krishnamurthy GT.  Cholecystokinin and morphine pharmacological intervention during 99mTc-HIDA cholescintigraphy: a rational approach. Semin Nucl Med. 1996;26(1):16–24.

Chapter 6 Choosing the Best Timing for Cholecystectomy Kohji Okamoto and Tadahiro Takada

In 2005, the first edition of our “Clinical Practice Guidelines for Acute Cholangitis/Cholecystitis based on Scientific Evidence” (in Japanese) was published [1]. In the process of developing these guidelines, Professor Takada, who is editor in chief of these guidelines, was aware of the scarcity of relevant evidence and sought advice from Professor Steven Strasberg (Washington University, USA), a highly knowledgeable medical scientist, renowned surgeon, and Takada’s respected friend. Prof. Strasberg advised supplementing the available evidence with shared scientific consensus, and in 2006 an international consensus on how to manage acute cholangitis/acute cholecystitis was achieved at an international conference in 2006. K. Okamoto Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Fukuoka, Japan T. Takada (*) Department of Surgery, Teikyo University, Shiniyuku-ku, Tokyo, Japan e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_6

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Expanding on our original publication, in 2007, the Tokyo Guidelines for the management of acute cholangitis/acute cholecystitis (TG07) were published in the Journal of Hepato-­ Biliary-­Pancreatic Sciences (JHBPS) as the world’s first international acute biliary infection guidelines. However, after the publication of TG07, a gap was found between the recommendations in TG07 and real-world clinical decisions and therapies. To address this gap, an updated version of the guidelines (TG13) was published in JHBPS in 2013 based on an updated international consensus accomplished in 2012, and, for the first time, the GRADE approach was used to assess the quality of available evidence [2]. To verify the recommendations in the guidelines by using a large database, Prof. Takada collected and analyzed the outcomes of cases managed according to TG13 in a joint research project conducted between Japan and Taiwan. In 2018, TG18 was created based on new evidence obtained through this joint research project and with the participation of Professor Steven Strasberg and many other experts from around the world. A major update in TG18 is the modification of the flowcharts for the management of acute cholecystitis (AC) [3]. The flowcharts provide a selection of strategies for the treatment of AC at each of three severity grades based on three risk factors: predictive factors, Charlson Comorbidity Index (CCI) score, and American Society of anesthesiologists physical status classification (ASA-PS) score. The decision to opt for cholecystectomy or gallbladder drainage can now be made by using the TG18 flowcharts.

Diagnostic Criteria for Acute Cholecystitis To date, no diagnostic criteria for AC have been published, other than those included in TG13 [4]. In TG18, these diagnostic criteria remain unchanged [5]. TG18 recommended combined use of clinical, laboratory, and imaging findings for the diagnosis of AC. Studies have found that diagnostic accuracy ranges from 60.4% [6] to 94.0% [7], when pathological samples are used for diagnosis. In the study by Yokoe

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et  al. [7], the sensitivity and specificity of the TG13/TG18 diagnostic criteria for acute cholecystitis were 91.2% and 96.9%, as opposed to 83.1% and 37.5% as reported in the study by Naidu et al. [6].

Severity Grading for Acute Cholecystitis Severity grades for AC were first presented in TG07 [8], where the severity of AC was classified into three grades: Grade I (mild), Grade II (moderate), and Grade III (severe). In that version of the guidelines, Grade III (severe) AC was defined as AC associated with organ dysfunction. These severity assessment criteria were adopted in TG13 with minor changes and have been included in TG18 without further changes (Table 6.1) [4, 5]. In TG13/TG18, Grade III (severe) AC is defined as AC associated with one or more organ dysfunction  – cardiovascular, neurological, respiratory, renal, hepatic, or hematological dysfunctions. For these patients, intensive care with respiratory and circulatory support should be initiated as first-line treatment. Grade II (moderate) AC is defined as AC without organ dysfunction but with the risk of developing organ dysfunction, accompanied by serious local complications for which cholecystectomy and biliary drainage are to be performed immediately. Grade I (mild) AC does not meet the criteria for Grade III (severe) or Grade II (moderate) AC, which is defined as AC in an otherwise healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder. Cholecystectomy is a safe and low-risk operative procedure in these patients.

 lowcharts for the Management of Acute F Cholecystitis An important update in TG18 is the inclusion of modified flowcharts for the treatment of AC based on recent evidence, reported since the publication of TG13 [3]. At all severity

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Table 6.1  TG18/TG13 severity grading for acute cholecystitis Grade I (mild) acute cholecystitis “Grade I” acute cholecystitis does not meet the criteria of “Grade III” or “Grade II” acute cholecystitis. It can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure Grade II (moderate) acute cholecystitis “Grade II” acute cholecystitis is associated with any one of the following conditions:  1. Elevated WBC count (>18,000/mm3)  2. Palpable tender mass in the right upper abdominal quadrant  3. Duration of complaints >72 h  4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis) Grade III (severe) acute cholecystitis “Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems:  1. Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 μg/kg per min, or any dose of norepinephrine  2. Neurological dysfunction: decreased level of consciousness  3. Respiratory dysfunction: PaO2/FiO2 ratio 2.0 mg/dL  5. Hepatic dysfunction: PT-INR >1.5  6. Hematological dysfunction: platelet count 18,000/mm3)  2. Palpable, tender mass in the right upper abdominal quadrant  3. Duration of complaints >72 h  4. Marked local inflammation including biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis

Severe (grade III)

The presence of any one of the following conditions:  1. Cardiovascular dysfunction (hypotension requiring treatment with dopamine at ≥5 μg/ kg/min, or any dose of dobutamine)  2. Neurological dysfunction (decreased level of consciousness)  3. Respiratory dysfunction (PaO2/FiO2 ratio 2.0 mg/dL)  5. Hepatic dysfunction (PT-INR > 1.5)  6. Hematological dysfunction (platelet count 3  mm), gallstones, and pericholecystic fluid [7]. The diagnostic criteria for acute cholecystitis have been recently updated in the Tokyo 18 guidelines [8]. These include (A) local signs of inflammation or right upper quadrant mass/

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Figure 11.3  Initial port access in an obese patient. The Veress needle is inserted in supraumbilical location 15 cm below the xiphoid

tenderness, (B) systemic signs of inflammation (fever, elevated C reactive protein, elevated WBC count), and (C) imaging findings of acute cholecystitis. Besides a positive Murphy’s sign on physical exam, this may also be elicited during ultrasound examination.

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The technical challenges of acute cholecystitis are primarily related to the inflammatory process that occurs. In more severe cases, an omental pack may encase the gallbladder and can lead to difficulty visualizing the gallbladder and increased bleeding in the operative field. Other complications of acute cholecystitis include a gangrenous gallbladder, emphysematous cholecystitis, and perforation with abscess. Because of the acute inflammatory process, visualization of the colon and duodenum may be obscured which may increase the risk of intestinal injury. Inflammation in the hepatocystic triangle can lead to inflammatory contraction of the cystic duct that may obscure the hepatic artery and common bile duct or lead to biliary inflammatory fusion (BIF). There can also be fusion of the posterior wall of the gallbladder to the liver bed that makes the body of the gallbladder difficult to mobilize. Variations in ductal anatomy combined with these inflammatory situations may further increase the risk of these procedures. In such cases, a bailout procedure as described below may be the best option. Prevention of these situations is best achieved by early intervention in acute cholecystitis with the goal of intervention within 72  h of symptoms. Multiple studies have shown that early intervention is associated with earlier discharge, less wound morbidity, and lower healthcare costs [9–14]. Roulin and colleagues [12] recently reported results from a prospective randomized trial of early vs. delayed cholecystectomy in 86 patients with symptoms present for >72 h. Patients who underwent early LC had lower overall morbidity, fewer unplanned readmissions, shorter duration of antibiotics and hospital stay, and lower costs. These results suggest that early intervention after onset of symptoms in appropriately selected patients may yield superior outcomes. Further details regarding early cholecystectomy are outlined in Chap. 6 that discusses the Tokyo Guidelines for managing acute cholecystitis. Technique: Several operative adjustments may need to be made in the patient with acute cholecystitis. Once ports are placed, the initial step should be to consider decompression

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Figure 11.4 Aspiration of a distended gallbladder in patient with acute cholecystitis

of the gallbladder with a needle suction device to allow the gallbladder to be more easily grasped and retracted (Fig. 11.4). Also, this step reduces the risk of perforation with spillage of bile and stones, which can make the subsequent dissection more difficult. If an omental pack is present, this must be taken off the gallbladder with either monopolar electrosurgical energy or an advanced energy device. If there is considerable inflammation in the hepatocystic triangle, it may be helpful to use a blunt Kittner type dissector. If a large stone is impacted in the gallbladder neck, it may be difficult to grasp, and so a grasper can be used to push the GB back and forth from side to side to facilitate exposure. Intraoperative imaging with conventional cholangiography, laparoscopic ultrasound, or infrared cholangiography may be especially important in difficult cases and to verify anatomy before clipping or cutting any structures. Finally, edematous tissue planes may reduce effectiveness and increase smoke generation associated with monopolar energy, in which case an ultrasonic coagulator may facilitate dissection of the gallbladder from the liver bed. Some groups have recommended a

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top-down approach in difficult [5] cases [15]. However, one should be cautious with this approach as the bile duct and hepatic artery can still be injured as the dissection proceeds toward the hepatocystic triangle due to the adherence in this area. Bailout techniques are a useful alternative and are described later in this chapter.

Chronic Cholecystitis Severe chronic cholecystitis with a shrunken, contracted gallbladder can result in considerable distortion of biliary anatomy. Dense fibrous or desmoplastic changes can occur in the hepatocystic triangle leading to scarring of the cystic duct to the common bile duct. Contraction of the gallbladder with a chronically thickened gallbladder wall may also cause difficulty in grasping and retracting the gallbladder (Fig.  11.5). Tissue planes may be obliterated in these situations as a result of the biliary inflammatory fusion that occurs.

Figure 11.5  Severe chronic cholecystitis with inflammatory fusion of hepatocystic triangle. This patient had a percutaneous cholecystostomy tube placed for severe acute cholecystitis 2 months earlier

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Identification of patients with chronic cholecystitis is key to being prepared to dealing with the intraoperative challenges. These patients tend to have had multiple prior attacks and are older and male gender. Liberal use of bailout techniques, conversion to open operation, and intraoperative imaging should be considered.

Mirizzi Syndrome Mirizzi syndrome is defined as extrinsic obstruction of the common hepatic duct due to a large stone impacted in the neck of the gallbladder [16]. The incidence of Mirizzi syndrome is low, occurring in up to 2.7% of all patients undergoing cholecystectomy [17, 18]. There are two main subtypes: type I in which there is extrinsic obstruction or impingement on the common bile duct due to a large gallstone and type II in which there is fistulization between the neck of gallbladder and the bile duct due to a large stone. Preoperative recognition of a Mirizzi syndrome is key as the presence of a fistula requires a hepaticojejunostomy potentially by a hepato-­ pancreato-­biliary (HPB) surgeon. Early recognition involves the identification of a large stone in the neck of the ­gallbladder with evidence of a dilated common hepatic duct on imaging coupled with elevated liver function tests. Magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) can be helpful in establishing the diagnosis preoperatively and should be used liberally if there is concern for a fistula. Complex cases should be referred to a tertiary center where there is advanced HPB expertise. While a Mirizzi gallbladder without a fistula can be attempted laparoscopically, it is typically a more difficult procedure with increased risk for conversion to an open operation. There may be no safe dissection plane due to chronic inflammation that obscures biliary anatomy (Fig.  11.6). A metaanalysis of ten studies has shown that the conversion rate in Mirizzi syndrome cases was 41% [19]. Complication rates were

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Figure 11.6  Mirizzi syndrome with fusion of the gallbladder (GB) and duodenum (D) and fistulization

20% and reoperations were 6%. If the CVS cannot be obtained, a subtotal cholecystectomy should be considered.

Cirrhosis Cirrhosis complicates cholecystectomy in multiple ways. First, there can be exposure issues because of difficulty retracting the fibrotic liver. Secondly, there may be increased collaterals from portal hypertension that increases the bleeding risk during and after the operation. Consequently, patients should undergo CT imaging with contrast preoperatively to determine the extent of collaterals in the liver bed and the possibility of a large, recanalized umbilical vein. Lastly, patients can develop hepatic failure secondary to anesthesia and the stress of surgery itself, particularly if there is increased blood loss. Preoperative work-up should include liver function tests to establish the patient’s MELD or Child’s classification and a

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complete blood count and INR to assess for anemia, thrombocytopenia, or coagulation abnormalities. The extent of liver disease is important to establish preoperatively to determine surgical candidacy and management expectations of outcomes. Patients with Child’s A or B cirrhosis can be considered for laparoscopic cholecystectomy, whereas Child’s C cirrhosis should be evaluated by transplant surgery and hepatology. MELD has been found to be more effective at predicting postoperative morbidity, and patients with a MELD score >13 have been found to be at increased risk for postoperative 0complications [20]. Machado reviewed 1310 Child’s A and B cirrhotics who underwent cholecystectomy and found the mortality rate was 0.45% and morbidity was 17% [21]. Conversion to open cholecystectomy occurred in 5%. In Child’s C cirrhotics, mortality rates have ranged from 50% to 80%. [21, 22] Laparoscopy is the preferred approach in well-selected patients. In one meta-analyses review, outcomes were superior with less blood loss and shorter hospital stays compared to open cholecystectomy [22]. Studies have also shown comparable outcomes regarding morbidity and mortality with improved length of stay and cosmesis compared to open cholecystectomy [23, 24]. For the operative approach in the cirrhotic patient, alternative initial entry strategies may be needed if a recanalized umbilical vein is present. Care must be taken to expose the hepatocystic triangle without damaging the liver. A liver retractor and extra ports may be necessary to retract viscera to gain exposure. Dissection of the gallbladder from the liver bed carries an increased risk of bleeding which can be substantial, and an advanced energy device (e.g., ultrasonic coagulator) may be helpful to enhance hemostasis. Lastly, good judgment must be exercised, and if conditions are unfavorable, a bailout technique or subtotal cholecystectomy (as discussed below) leaving the back wall of the gallbladder to avoid getting into the liver bed and any collaterals vessels may be indicated.

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 ole of Percutaneous Cholecystostomy Tube R Drainage In patients who are deemed to be high risk for cholecystectomy, alternative methods such as percutaneous cholecystostomy should be considered. As noted above, risk factors that increase the difficulty of operation include duration of symptoms more than 72–96 h, white blood cell count greater than 18,000/mm3, a palpable gallbladder, increased age and comorbidities, and a suspected gangrenous gallbladder (Table 11.2). If in such circumstances, the patient is deemed not to be a suitable operative candidate, then placement of a percutaneous cholecystostomy tube should be considered. Several studies have shown that acute symptoms and inflammatory signs resolve in a high percentage of cases [25–29]. Typically, the tube must be left in place until the cholecystectomy is carried out since there is often ongoing obstruction at the cystic duct. Therefore, this approach is best reserved for patients in whom the gallbladder conditions are deemed highly unfavorable or high-risk elderly and critically ill patients. It should be noted that laparoscopic cholecystectomy after a ­percutaneous cholecystostomy is still a more difficult procedure with conversion rates in the 9–16% range. Several groups have examined outcomes of percutaneous cholecystostomy in acute cholecystitis. In a study from a single Veterans Administration Medical Center, all patients with acute cholecystitis based on the Tokyo guidelines criteria were evaluated from 2001 to 2010 [30]. Cholecystectomy was carried out in 150 patients and 51 underwent percutaneous drainage. Patients who underwent percutaneous drainage were older and had a greater elevation in their white blood cell count and a more prolonged ICU stay. Complications were slightly higher in the percutaneous drainage group (2.9% vs. 1.9%), and readmissions were also higher (31.4% versus 13.3%). Another study using a university health system consortium database found that extremely ill patients undergoing percutaneous cholecystostomy had decreased morbidity, fewer intensive care unit admissions,

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shorter length of stay, and lower costs, compared to patients who had laparoscopic or open cholecystectomy [31]. In a second study, 42 consecutive ICU patients with acute cholecystitis treated by percutaneous drainage versus emergent cholecystectomy were analyzed [25]. In the emergent group, ten were approached laparoscopically and nine open. The conversion rate from laparoscopic to open was 20%. Morbidity with treatment was 8.7% in the percutaneous drainage group versus 47% in the emergent cholecystectomy group and included two bile leaks that required reoperation postoperative day 1. Recently, Dimou et  al. carried out a propensity score analysis of older patients with grade III cholecystitis and cholecystostomy tube placement using Medicare data from 1996 to 2010 [32]. Of 8188 patients with grade III cholecystitis, 565 (6.4%) had a cholecystostomy tube placed. Compared to 1689 propensity-matched patients without percutaneous cholecystostomy tube treatment, they found that patients who underwent percutaneous cholecystostomy were less likely to undergo cholecystectomy (33.4% vs. 64.4%) and had higher 30-day, 90-day, and 2-year readmission rate and higher 30-day and 2-year mortality (hazard ratio 1.26 and 1.19). El-Gendi et  al. reported results from a prospective, randomized trial that compared emergency cholecystectomy to delayed laparoscopic cholecystectomy 6 weeks after percutaneous cholecystostomy in patients with grade II acute cholecystitis [28]. The cholecystitis resolved quickly with both approaches. The early laparoscopic cholecystectomy group had a higher conversion rate (24% vs. 2.7%), longer operative times, higher blood loss, and longer duration of postoperative hospital stay than the percutaneous cholecystostomy group. Postoperative complications were also significantly more common in the early cholecystectomy group (26.7% vs. 2.7%), and these included an increased incidence of bile leak (10.7%). Taken together, these studies would suggest that percutaneous cholecystostomy tube placement improves outcomes in appropriately selected patients.

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 lternate or Bailout Procedures A in the Difficult Gallbladder In patients who are undergoing cholecystectomy and conditions deemed too difficult or hazardous to proceed with dissection in the hepatocystic triangle and/or when the critical view of safety cannot be achieved, an alternative or bailout procedure should be considered. One option would be simply to put a surgical cholecystostomy tube in and abort the operation. This would be indicated especially if it’s difficult to expose the entire gallbladder and only the dome is visible. One study reviewed 41 patients who had cholecystostomy tubes placed surgically due to severe adhesions or inflammation encountered at the operation [33]. Of these, 33 patients subsequently had their gallbladder removed at a median of 60  days post tube placement. These cases were completed laparoscopically in 28 cases, converted to open in 1 case, and 4 were initiated as open procedures. These findings suggest that patients in whom operative conditions are unfavorable can be managed successfully with cholecystostomy tube drainage followed by interval cholecystectomy at a more favorable time (≥2 months later) when the acute inflammation has resolved. Conversion to open cholecystectomy The conventional approach in difficult cases in which progress is not being made, the CVS cannot be reached, or there is concern for an injury has traditionally been conversion to an open operation. However, conversion to an open procedure does not protect against potential biliary injury, and the decision to convert should be made in the setting of that surgeon’s experience with the open procedure. In a multicenter Belgian study of 1089 patients surgically treated for acute cholecystitis by 53 different surgeons, conversion to open operation occurred in 116 patients (11.7%) [34]. The biliary complication rate was 13.7% in this group (16 patients), seven of which were major biliary injuries (6.0%). Three of

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these injuries were incurred after conversion to open. These findings highlight the biliary injury potential in high-risk patients. As a result, conversion to open operation may not be the best default option in a difficult case. Instead, if the appropriate expertise is not available for open surgery (e.g., inexperience with open cholecystectomy), then laparoscopic subtotal cholecystectomy may be a better approach, or one could end the procedure and refer that patient to a center with appropriate expertise. Certainly, an exception is in the setting of major bleeding that cannot be controlled laparoscopically, in which immediate conversion to an open operation is indicated. Subtotal cholecystectomy In conditions in which the hepatocystic triangle can be reached but cannot be safely dissected, consideration should be given to performing a subtotal cholecystectomy. Recently, our group has attempted to standardize nomenclature around subtotal cholecystectomy into two subtypes: fenestrating or reconstituting [35]. In the fenestrating cholecystectomy, the neck of the gallbladder is left open, and a surgical drain is placed. In the reconstituting type, the neck of the gallbladder is either stapled off or sutured closed leaving a closed remnant. The principles of subtotal cholecystectomy consist of opening the gallbladder above the hepatocystic triangle and leaving a “shield” or cuff off the gallbladder neck to protect the porta hepatis and biliary structures (Fig. 11.7). All stones must be removed and the front and sides of the gallbladder excised leaving the back wall, although one can completely excise the back wall of the gallbladder as well. Typically, the procedure is done with an advanced energy device (ultrasonic coagulator or advanced bipolar). If the cystic duct orifice is visible, a cholangiogram can be performed through the cystic duct. It can also be directly sutured closed. A drain should be routinely placed because of the risk of a bile leak. van Dijk et  al. reported a retrospective study of 191 patients from 4

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Figure 11.7  Subtotal cholecystectomy in a patient with severe acute cholecystitis. Note the line of resection (arrow) that leaves a cuff of the neck of the gallbladder (dashed circle) to protect the critical structures

teaching hospitals that underwent laparoscopic subtotal cholecystectomy [36]. The fenestrating technique was used in 53% of cases, reconstituting in 38%, and the remainder were ­indeterminate. Patients had a median follow-up of 6  years. Bile leaks occurred postoperatively in 18% in the fenestrating group versus 7% in the reconstituting group. However, recurrent biliary symptoms were more common in the reconstituting group (18%) as compared to fenestrating (9%). There was one bile duct injury in the reconstituting group. Of the patients who had bile leaks postoperatively, 13 were managed by ERCP, and some were self-limited and were discharged with a drain and subsequently resolved. Get Help Finally, an important concept in difficult cases is to get help from a colleague if practical or possible to obtain, even if it is just for a second opinion. Such an approach should never be considered as a sign of inexperience or incompetence, but rather this reflects good judgment. This is also one of the

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principles of the SAGES Safe Cholecystectomy program [3]. Getting help for difficult cases may be especially important if the dissection is stalled or the critical view of safety cannot be attained, the anatomy is unclear, there is concern for possible biliary injury, or there are other conditions deemed difficult.

References 1. Strasberg S, Hertl M, Soper N.  The analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101–25. 2. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010;211(1):132–8. 3. The SAGES Safe Cholecystectomy Program. https://www.sages. org/safe-cholecystectomy-program/. 2014. 4. Pucher PH, Brunt LM, Fanelli RD, et al. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc. 2015;29(11):3074–85. 5. Panni RZ, Strasberg SM.  Preoperative predictors of conversion as indicators of local inflammation in acute ­cholecystitis: strategies for future studies to develop quantitative predictors. J Hepatobiliary Pancreas Sci. 2018;25:101–8. https://doi. org/10.1002/jhbp.493. 6. Augustin T, Moslim MA, Brethauer S, et  al. Obesity and its implications for morbidity and mortality after cholecystectomy: a matched NSQIP analysis. Am J Surg. 2017;213:539. 7. Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358:2804. 8. Yokoe M, Hata J, Strasberg SM, et  al. Tokyo guidelines 2018: diagnostic criteria and severity of grading of acute cholecystitis. J HBP Surg. 2018;25:42–54. 9. Gutt CN, Encke J, Köninger J, et  al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013;258:385. 10. de Mestral C, Rotstein OD, Laupacis A, et  al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann Surg. 2014;259:10.

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11. Zafar SN, Obirieze A, Adesibikan B, et al. Optimal time for early laparoscopic cholecystectomy for acute cholecystitis. JAMA Surg. 2015;150:129. 12. Roulin D, Saadi A, Di Mare L, et al. Early versus delayed cholecystectomy for acute cholecystitis, are the 72 hours still the rule?: a randomized trial. Ann Surg. 2016;264:717. 13. Cao AM, Eslick GD, Cox MR.  Early cholecystectomy is superior to delayed cholecystectomy for acute cholecystitis: a meta-­ analysis. J Gastrointest Surg. 2015;19:848. 14. Wu XD, Tian X, Liu MM, et al. Meta-analysis comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2015;102:1302. 15. Cengiz Y, Dalenback J, Edlund G, et  al. Improved outcomes after laparoscopic cholecystectomy with ultrasound dissection: a randomized multicenter trial. Surg Endocsc. 2010;24:624–30. 16. Testini M, Sgaramella LI, De Luca GM, et  al. Management of Mirizzi syndrome in emergency. J Laparoendosc Adv Surg Tech A. 2017;27:28. 17. Erben Y, Benavente-Chenhalls LA, Donohue JM, et al. Diagnosis and treatment of Mirizzi syndrome: 23-year Mayo Clinic experience. J Am Coll Surg. 2011;213:114. 18. Kulkarni SS, Hotta M, Sher L, et  al. Complicated gallstone disease: diagnosis and management of Mirizzi syndrome. Surg Endosc. 2017;31:2215. 19. Antoniou SA, Antoniou GA, Makridis C.  Laparoscopic treatment of Mirizzi syndrome: a systematic review. Surg Endosc. 2010;24:33. 20. Delis S, Bakoyiannis A, Madariaga J, et al. Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child-Pugh classification in predicting outcome. Surg Endosc. 2010;24:407. 21. Machado NO. Laparoscopic cholecystectomy in cirrhotics. JSLS. 2012;16:392. 22. Puggioni A, Wong LL. A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis. J Am Coll Surg. 2003;197:921. 23. Currò G, Iapichino G, Melita G, et al. Laparoscopic cholecystectomy in Child-Pugh class C cirrhotic patients. JSLS. 2005;9:311. 24. Hamad MA, Thabet M, Badawy A, et  al. Laparoscopic versus open cholecystectomy in patients with liver cirrhosis: a prospective, randomized study. J Laparoendosc Adv Surg Tech A. 2010;20:405.

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25. Melloul E, Denys A, Demartines N, et  al. Percutaneous drainage versus emergency cholecystectomy for treatment of acute cholecystitis in critically ill patients: does it matter? World J Surg. 2011;35:826–33. 26. Hsieh YC, Chun-Ku C, Chien-Wei S, et al. Outcome after percutaneous cholecystostomy for acute cholecystitis: a single center experience. J Gastrointest Surg. 2012;16:1860–8. 27. Chang YR, Young-Joon A, Jang JY, et al. Percutaneous cholecystostomy for acute cholecystitis in patients with high comorbidity and re-evaluation of treatment efficacy. Surgery. 2014;155:615–22. 28. El-Gendi A, El-Shafei M, Emara D. Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients. J Gastrointest Surg. 2017;21:284–93. 29. Alvino DML, Fong ZV, McCarthy CJ, et al. Long-term outcomes following percutaneous cholecystostomy tube placement for treatment of acute calculous cholecystitis. J Gastrointest Surg. 2017;21:761. 30. Abi-Haidar Y, Sanchez V, Williams SA, et al. Revisiting percutaneous cholecystostomy for acute cholecystitis based on 10-year experience. Arch Surg. 2012;147:416–21. 31. Simorov A, Ranade A, Parcells J, et  al. Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study. Am J Surg. 2013;206:935–41. 32. Dimou FM, Adhikari D, Mehta HB, et  al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: a propensity score analysis. J Am Coll Surg. 2017;224:502–14. 33. Cherng N, Witkowski ET, Sneider EB, et al. Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis. J Am Coll Surg. 2012;214:196–201. 34. Navez B, Ungureanu F, Michiels M, et al. Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc. 2012;26(9):2436–45. 35. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ.  Subtotal cholecystectomy-“Fenestrating” vs “Reconstituting” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg. 2016;222(1):89–96. 36. van Dijk AH, Donkervoort SC, Lameris W, et al. Short and long-­ term outcomes after a reconstituting and fenestrating subtotal cholecystectomy. J Am Coll Surg. 2017;225(3):371–9.

Chapter 12 Non-operative Management of Common Bile Duct Stones: ERCP and Other Techniques (Lithotripsy) Andrew T. Strong and Jeffrey L. Ponsky

Common Bile Duct Stones Biliary stones form as accumulated precipitates of various components of bile that generally form in the presence of stasis or super concentration. Biliary stone is partially driven by diet and changes in weight especially rapid weight loss. However, familial clustering of patients with biliary stone disease suggests that genetic components play a role as well [1, 2]. Gallstones, forming in the gallbladder and traveling through the cystic duct, are the most common source of common bile duct stones in European and American populations. A. T. Strong Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA e-mail: [email protected] J. L. Ponsky (*) Department of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_12

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Within the United States, the prevalence of gallstone disease is at least 20 million American adults [3]. While only a subset of these patients have symptoms annually, this still accounts for more than 600,000 hospital admissions a year [3]. For patients with symptomatic gallstones, 10–20% have secondary choledocholithiasis [4–6]. While there is relatively reliable data about the natural history of gallstones, and their likelihood to migrate, cause symptoms, or cholecystitis, the natural history of common bile duct stones (CBDS) is less well characterized. What evidence does exist suggests that 10–30% eventually pass spontaneously into the duodenum [6–8]. Common bile duct stones may form de novo within the intraor extrahepatic bile ducts, known as primary choledocholithiasis. Primary choledocholithiasis is far more common in Asian populations compared to Western populations, again suggesting some degree of genetic predisposition [1]. Complications of choledocholithiasis are related to their ability to partially or completely occlude the common bile duct. Biliary obstruction gives rise to obstructive jaundice, cholangitis, hepatic abscesses, and pancreatitis, which may lead to systemic illness and death in some cases [5, 6]. These complications do not follow a time-wise or step-wise progression and can occur at any time. Thus, in general patients with either a high likelihood or image-proven, common bile duct stones should be offered extraction [5, 6, 9, 10]. Other chapters in this text discuss diagnostic techniques for choledocholithiasis, including noninvasive imaging, intraoperative imaging, and endoscopic techniques. For ­ patients with proven or suspected choledocholithiasis, management may be operative, non-operative, or a hybrid of both. Non-­ operative techniques to manage CBDS as discussed here fall into two main categories: endoscopic and percutaneous methods. In most cases endoscopic management is attempted first with percutaneous methods employed after endoscopic techniques have failed. Endoscopic management of CBDS generally implies endoscopic retrograde cholangiopancreatography, though some special scenarios are discussed as well. Percutaneous techniques may serve as a

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definitive therapy and as a bridge to surgical management or to facilitate a more successful endoscopic management, such as wire-guided rendezvous ERCP.

 ndoscopic Management of Common Bile E Duct Stones Endoscopic retrograde cholangiopancreatography is a collective term that includes both diagnostic and therapeutic maneuvers. Successful ERCP-based intervention relies upon the ability to cannulate the distal bile duct, and techniques to do this are discussed. Once biliary access is secured, a variety of techniques can be performed to clear the duct including sphincterotomy, balloon sphincteroplasty, lithotripsy, stenting, and others. Other endoscopic modalities that may be employed to manage CBDS include direct peroral therapeutic cholangioscopy, endoscopic ultrasound, and multimodality rendezvous techniques, which will be discussed briefly.

 ndoscopic Procedure Planning for Endoscopic E Management of Choledocholithiasis The primary goal of endoscopic intervention for choledocholithiasis is to clear the bile duct of the stone burden. To that end, procedures should be planned to optimize the likelihood that outcome can be achieved. Most commonly, ERCP is performed under conscious sedation. However, since up to 14% of patients undergoing ERCP with conscious sedation do not tolerate the procedure well, this may not be the best anesthetic plan for lengthy procedures to clear the common bile duct of stones [11]. Anesthesiologistdirected sedation appears to be associated with better success in terms of cannulation and bile duct clearance [12]. In our practice general anesthesia is generally performed, which reflects recommendations by some gastroenterology professional societies [5]. If general anesthesia is not avail-

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able, there is ample evidence that propofol administered by qualified non-anesthesiologists is safe for endoscopy procedures and may be the most appropriate option if anesthesiologist-directed sedation is not available [13, 14]. There does not seem to be a difference in ERCP outcomes based on procedure location (operating room vs. endoscopy suite), as long as patient monitoring, anesthesia, fluoroscopy, and trained endoscopy assistants are available. If general anesthesia is induced, patients are initially positioned supine. While ERCP is often performed with the patient rotated to either a prone, semi-prone, or left lateral decubitus position, large trials do not support different success rates in terms of patient position [15]. Prophylactic antibiotics are not recommended for ERCP but should be started and continued after the procedure if the common duct is incompletely cleared [16]. In the setting of cholangitis, antibiotics should be administered when the diagnosis is suspected and may be continued through the ERCP procedure.

Brief History of ERCP The first report of endoscopic cholangiogram was in 1968 in the United States, replicated the following year in Japan [17, 18]. These endoscopists used front-viewing fiber-optic endoscopes. Industry partners in Japan collaborated to develop a side-viewing duodenoscope with an elevator to facilitate finer control of biliary catheters, familiar to endoscopists today [18]. While the next decade was principally spent refining technique and improving cannulation rates of the ampulla of Vater, therapeutic advances were introduced as well. Various catheters were developed to accomplish papillotomy, which were first reported in 1975  in the United States and performed to allow passive passage of CBDS [18, 19]. Catheter-based baskets, balloons, wires, and stents intended for urologic or intracardiac use were adapted for use in the biliary tree to facilitate non-operative stone extraction and biliary drainage [18]. Thus the nascent history of ERCP was

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at least partially directed toward non-operative management of choledocholithiasis. Additional technologies over the next two decades that were introduced included computer-­ regulated electrosurgical units, the introduction of endoscopic ultrasound and its application to detecting choledocholithiasis, laser lithotripsy, self-expanding biliary stents, and papillary balloon dilation. Additionally, a rich conversation was fostered among several surgical and medical disciplines regarding the role of magnetic resonance imaging, percutaneous biliary access with or without endoscopy, and the timing of ERCP with respect to cholecystectomy. Increasingly, these conversations have happened in parallel with analysis of training, supervision, and patient outcomes especially as driven by volumes, quality, and cost.

Biliary Access Techniques Wire access to the distal common bile duct must be established in order to perform therapeutic maneuvers to clear the bile duct of stones. Cannulation success is determined by a combination of both operator factors (such as experience, training) and patient factors (position, anatomy). There are no definitive criteria for what makes cannulation difficult, though the presence of duodenal diverticula or stones impacted in the ampulla is patient factors that anecdotally make cannulation more difficult (Figs. 12.1 and 12.2). Studies that report rates of difficult or failed cannulation typically use arbitrary cutoffs of time spent attempting cannulation or number of cannulation attempts to define difficult ERCP. Thus, the proportion of difficult ERCP reported in a given study varies slightly, depending on the study definition. However, cannulation rates are generally >98% in most large series [20]. Two conventional techniques are typically used: contrast-assisted biliary cannulation and guide wire-assisted biliary cannulation. Pre-cut sphincterotomy, or access sphincterotomy, is also discussed as a third option, typically employed when the first two techniques fail.

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Figure 12.1  Cannulation of the ampulla in the presence of a duodenal diverticulum. (a) A cholangiogram during ERCP, where a duodenal diverticula can be seen by air contrast just inferior to where the catheter enters the ampulla. (b) The sphincterotome is just engaged at the edge of the mucosa of the ampulla prior to cannulation with the wire. As is typical when a duodenal diverticulum is present, the ampulla is usually sitting at the edge the diverticulum. The opening of the diverticulum occupies the top left of the image. (c) Following cannulation, a sphincterotomy being performed. The diverticulum is better visualized in this image

Technique of Contrast-Assisted Biliary Cannulation Once the ampulla is visualized using a side-viewing endoscope, the tip of a standard sphincterotome or biliary ERCP cannula is inserted in the papillary orifice just engaging the mucosal edge and angled toward the 11 o’clock position [20, 21]. Injection of a small volume of contrast with low pressure under fluoroscopic guidance defines the anatomy of the distal common bile duct, which often has a sigmoid course in the intramural portion of the common bile duct. The catheter can then be advanced through the intrapapillary bile duct directly. If a sphincterotome is used, the direction of the catheter tip may be adjusted by varying the tension on the cutting wire [21]. Steerable cannulas are often associated with better rates of successful cannulation compared to standard cannulas [20, 22]. Technique of Guide Wire-Assisted Biliary Cannulation Once the ampulla is visualized using a side-viewing endoscope, the ERCP cannula is inserted into the papillary orifice

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Figure 12.2 Common bile duct stones impacted in the ampulla requiring using a pre-cut or access sphincterotomy. (a) A pre-cut sphincterotome what was able to be advanced around an impacted stone to perform a sphincterotomy. (b) Stones eventually extracted from the common bile duct after the pre-cut sphincterotomy sitting in the dependent portion of the duodenum. (c) A different patients with a larger impacted stone. A needle knife technique was used to perform a biliary access sphincterotomy in this case. (d) Shows the stones that were eventually extracted from the common bile duct in that case

just engaging the mucosal edge. Under fluoroscopic control, the guide wire is advanced into the bile duct. Alternatively, the guide wire can be advanced 1–2 mm beyond the cannula tip and used to engage the papillary orifice directly and then advanced under fluoroscopic guidance [20, 21]. Studies have

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failed to show that different wire configurations are associated with improved cannulation rates. Specifically, angled versus straight wires and 0.035 in. versus 0.025 in. wire gauge result in similar biliary cannulation rates [20]. A 0.035  in. hydrophilic guide wire is likely the most commonly used, which is both easy to manipulate in the biliary tree and more radiopaque compared to a narrower wire gauge. While operator experience likely drives the preferred technique for biliary cannulation, these two techniques have been compared in multiple randomized controlled trials. The most recently published systematic review of these trials included 12 prior publications and 5 abstracts. There was a small but statistically significant association noted between successful cannulation and the guide wire technique, as well as a reduced need for pre-cut sphincterotomy [20, 23]. However, the study data used to come to that conclusion carry significant heterogeneity [20]. Technique of Pre-cut Sphincterotomy/Biliary Access Sphincterotomy Pre-cut sphincterotomy uses a needle knife instrument to create a small incision in the mucosa, in the direction of the bile duct with the goal to expose the underlying biliary sphincter and facilitate cannulation. This can either be performed starting from the biliary orifice (conventional technique) or from the roof of the papilla (fistulotomy technique). There is little data available comparing these two techniques, though several meta-analyses have concluded that early pre-cut sphincterotomy, as opposed to repeated attempts at biliary cannulation, may reduce the risk of post-ERCP pancreatitis and may result in higher rates of biliary cannulation [24, 25]. However, in the aggregate, these differences were not statistically significant. An alternative to the needle knife is pre-cut sphincterotomes or access sphincterotomes. An alternative to the needle knife is an access or pre-cut sphincterotome. These devices are similar to conventional sphincterotomes, with the exception that the electrosurgical wire originates at the tip of the catheter,

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rather than several millimeters proximal, allowing an electrosurgical current to be applied at the distal most aspect of the catheter. Figure  12.2 shows images of common bile duct stones impacted at the ampulla, where pre-cut sphincterotomy was used to evacuate common bile duct stones.

 RCP Techniques to Clear Common Bile Duct E Stones ERCP techniques to manage common duct stones have three simultaneous goals. The first goal is to clear the common bile duct of existing stones. The second goal is to ensue patency of the sphincter and adequate drainage of the biliary tree in the future. The third goal is to perform therapeutic maneuvers to accomplish the first two goals while minimizing the risk of post-ERCP pancreatitis and other complications such as duodenal perforation. There is no absolute size cut off below which a stone in the common bile duct will not cause obstruction. However, there is a direct relationship between increasing stone diameter (and overall stone burden) and the likelihood for it to occlude the maximal diameter of the biliary outlet. As such, division of the muscular fibers of the biliary sphincter to expand the biliary orifice has been the mainstay of non-­ ­ operative management of choledocholithiasis. Sphincterotomy may be performed alone, which may accomplish all three goals above. Sphincterotomy may also be employed in combination with other maneuvers to clear the common bile duct of stones and sludge. Adjunctive maneuvers include catheter-­based balloons to mechanically sweep the duct clear or catheter-based baskets to retrieve stones. Alternatively balloon catheters may be used to perform balloon sphincteroplasty to dilate the biliary orifice without electrocautery in lieu of sphincterotomy. Occasionally, large stones may not be possible to sweep through the papilla but can be fragmented using a lithotripsy device to enable endoscopic clearance.

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Technique of Sphincterotomy Biliary sphincterotomy is accomplished using a sphincterotome catheter. Sphincterotome catheters incorporate a 15–30 mm monopolar cutting wire at the distal tip, beginning a few millimeters from the end of the catheter. This wire is typically an uncoated monofilament wire, though numerous variations including braided wire and partial coverage with insulated coatings exist from various manufacturers. The catheters themselves are also highly variable in terms of maneuverability and length. Sphincterotome catheters may be fashioned with one, two, or three lumens, which allow for insertion of contrast, and/or guide wires without need to exchange the cannula. Catheter tips may be blunt, rounded, or tapered. The latter facilitates use of a smaller gauge guide wire, often easier cannulation, but at the cost of more frequent tissue trauma. Fluoroscopy is used to confirm deep biliary cannulation with a wire. The sphincterotome is advance under fluoroscopic guidance to ensure it travels in the same direction and to determine the depth of wire insertion. The tip of the sphincterotome is then slightly bowed by tensioning the wire to be just in contact with the roof of the papilla at the 11 o’clock to 1 o’clock position, where the risk of bleeding and perforation is reduced. Current is applied to the sphincterotome to complete the sphincterotomy. Allowing no more than 5 mm of cutting wire inside the papilla minimizes the amount of tissue cut with each application of current. While shorter sphincterotomies may be appropriate in the setting of malignancy where the only goal is to accommodate insertion of an endoprosthesis, a sphincterotomy for the purpose of clearing CBDS should be ~10 mm in length (Fig.  12.3). Extending the sphincterotomy beyond 10 mm increases the risk of perforation. The electrosurgical settings used to perform sphincterotomy are a topic of great debate, though arguably this is more a philosophical than a clinically important discussion. Historically, the sides of the debate pitted “cut” against “coagulation” currents to complete the sphincterotomy. Modern electrosurgical units typically employ a blend of

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Figure 12.3 Conventional sphincterotomy and clearance of small common bile duct stones. (a) A balloon occlusion cholangiogram shows a dilated extrahepatic common bile duct with at least three small radiolucent filling defects marked by the green arrow. (b) The extent of a biliary sphincterotomy (~10  mm) performed using a standard sphincterotome for the purpose of evacuation of common bile duct stones. Note the yellow-black striped guidewire within the catheter lumen. (c) A small cholesterol stone spontaneously passing through the ampulla immediate after the completion of the sphincterotomy. (d) Additional stones and debris are cleared from the common bile duct using balloon sweeps. (e) A completion cholangiogram shows a dilated extrahepatic common bile duct free of filling defects with a temporary plastic stent in place in the common bile duct

these two current waveforms, so pure “cut” and “coagulation” are less common. Furthermore, many endoscopists actually use both, initiating the sphincterotomy with a “cut” current, and complete with “coagulation” or blended current [20, 26]. Regardless of the mode used, the endoscopist should be aware of degree of thermal spread with each mode, and the potential for causing thermal injury that will only fully manifest as bleeding or perforation hours to days after the proce-

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dure is completed. In general, using the lowest required energy with the least thermal spread to accomplish the intended therapeutic effect is advised. Technique of Balloon Sphincteroplasty/Endoscopic Papillary Balloon Dilation Balloon sphincteroplasty is also termed as endoscopic balloon sphincter dilation (EBSD) and endoscopic papillary balloon dilation (EPBD). In some settings EPBD may be a therapeutic alternative to sphincterotomy or may be used in conjunction with sphincterotomy. Patients with choledocholithiasis of stones less than 8 mm in diameter with minimal stone burden may be considered for EPBD alone [20]. EPBD may be an appropriate alternative also for patients taking antiplatelet medications to minimize bleeding risk associated with sphincterotomy. Contraindications to balloon sphincteroplasty are biliary strictures, suspected or known malignancies, prior biliary surgery (excepting cholecystectomy), acute pancreatitis, acute cholangitis, and the need to perform pre-cut sphincterotomy [5]. The technique of EPBD was first described by Staritz and colleagues in 1983, who proposed it as an alternative to sphincterotomy [27]. Numerous studies have since been performed, which have been summarized in several meta-­analyses in the past decade [20, 28–30]. Early reports associated EPBD without sphincterotomy with higher rates of post-ERCP pancreatitis. However, the results of meta-­analyses suggest that for small stones (12 mm in a single ERCP session, which was similar to the 80.8% noted for conventional sphincterotomy (p = 0.131) [33, 35]. In the aggregated analysis of prospective and retrospective studies, performance of a sphincterotomy with EPBD was estimated to be 95.3% [35]. One unique subset of patients are those with large common bile duct stones (>10 mm). In this population, sphincterotomy plus EPBD results in more frequent duct clearance with less complications than sphincterotomy alone [5, 33]. The diameter of the balloon should not exceed the maximal diameter of the bile duct at the time of sphincteroplasty, up to 18 mm [5, 33]. Stepwise inflation of the balloons appears to minimize risk of perforation compared to an attempting full inflation of a large balloon at the outset. Technique of Balloon and Wire Basket to Clear Common Bile Duct Stones Following sphincterotomy or EPBD (or both), several devices may be used to clear stones. In many cases a Dormia basket can be passed and used to encapsulate and retrieve stones through the papilla under fluoroscopic guidance (Fig.  12.4). When stones are retrieved with a basket, there is a chance that they can become impacted in the papilla. Alternatives to baskets are occlusion balloons. A balloon catheter is passed into the bile duct nearly to the level of the bifurcation. The balloon is inflated to occupy the internal diameter of the duct and withdrawn, sweeping stones and stone fragments through the papilla and into the duodenum (Fig. 12.5). Together with sphincterotomy or EPBD, these techniques effectively clear 86–91% of CBDS [36].

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Figure 12.4  Basket extraction technique to clear common bile duct stones. (a) A round radiolucent object contained within a closed basket, still within the common bile duct. (b) Typical appearance of an open retrieval basket

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Figure 12.5 Balloon extraction technique to clear common bile duct stones. (a) An irregularly shaped radiolucent filling defect in the background of the injected radiopaque contrast, consistent with a common bile duct stone. (b) A balloon extraction catheter is advanced pasted the stone and inflated proximal to the stone. Withdrawing the balloon will typically evacuate the stone

Technique of Endoscopic Lithotripsy For stones larger than 8–10 mm, lithotripsy is often necessary to facilitate passage through the ampulla. In some cases, even 8–10 mm stones may need to be fragmented to facili-

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tate passage through narrowed retropancreatic bile ducts, in the setting of a small papillotomy, or when EPBD alone has been performed [37]. For large stones, lithotripsy is almost always necessary to prevent stones impaction. Overall success rates for bile duct clearance using endoscopic lithotripsy are 80–95% in retrospective series using a variety of techniques [38–40]. Mechanical lithotripsy is the most commonly used and most widely available technology. This was first described by Riemann and colleagues in 1985 [41]. A reinforced wire basket is passed into the bile duct and used to trap the stone. A crank handle tensions the wires around the stone, and the concentrated lines of stress fragment the stone (Fig.  12.6) [37]. In the setting of multiple large stones, the distal most stone is fragmented first. In some cases this technique is

Figure 12.6 Mechanical lithotripsy of a common bile duct stone. Ann irregularly shaped radiolucent filling defect in the common bile duct with the wires of a lithotripsy basket closed around it. Note the reinforced portion of the wire just proximal to the basket, compared to the conventional basket shown in Fig. 12.4

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employed to salvage an extraction of an impacted stone and basket as an alternative. A catheter is placed over the wire of the basket and a lithotripter handle used to advance the ­catheter onto the tines of the basket, turning a basket not initially intended for lithotripsy into a lithotripter basket. While this typically destroys the basket, it generally sufficiently fragments the stone enough to allow expulsion into the duodenum [37]. Success rates of mechanical lithotripsy are around 80%, though may be higher for small stones and substantially lower with very large stones [37, 42, 43]. Some subtypes of stones, in particular stones associated with recurrent pyogenic cholangitis, may be fragmented with a standard stone retrieval basket. Electrohydraulic lithotripsy is a technique borrowed from urology, first described in the 1950s as a treatment for bladder stones. Electrohydraulic relies upon high-frequency hydraulic pressure waves resulting from short high-voltage electrical discharge. As these waves are absorbed by stones, they fragment along natural areas of stress [44]. Electrohydraulic lithotripsy catheters may be fitted with an occlusion balloon proximal to the electrode tip. To perform electrohydraulic lithotripsy, the catheter is passed into bile duct from a side-­ viewing duodenoscope. The balloon is inflated to occlude the duct, with the catheter nearly in contact with the stone under fluoroscopic guidance. Contrast mixed with saline is an adequate electrolyte solution to allow the current passage from one electrode to the other. Application of electrical pulse is typically accomplished by a foot pedal, with cycles of ~100 Hz, for periods of 1–5  s at a time until the stone is fragmented. The occlusion balloon can then be deflated, advanced past the stone fragments, and re-inflated to sweep the fragments through the ampulla [45]. Electrohydraulic may also be completed under peroral cholangioscopic guidance to minimize risk of inadvertent ductal injury [44, 46]. Laser lithotripsy relies on pulses of electromagnetic radiation within the visible light spectrum to induced wave-­ mediated fragmentation [44]. The holmium:YAG laser is a solid-state laser most typically used for this purpose. Laser

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lithotripsy requires peroral cholangioscopy for guidance in most cases, as inadvertent contact with the wall of the bile duct may result in perforation [44]. Older systems to perform cholangioscopy were cumbersome mother/daughter systems that required two endoscopists and were beset by fragile choledochoscopes or poor visualization (Fig. 12.7) [5, 44]. Recent advancements in both durability and optical quality of small fiber endoscopes have increased used of this technology more recently, including the advent of single operative peroral cholangioscopy [47]. Most reports of laser lithotripsy are small cases series, with a success rate >90%, but there is likely significant selection bias present [48]. Because of equipment expense, these technologies are not widely available; when available they are reserved for large or otherwise difficult common bile duct stones. Of note, these technologies are also employed by urologists, who may be of assistance in managing difficult stones in the common bile duct [49].

Percutaneous Techniques for the Management of Common Bile Duct Stones In the endoscopic era, percutaneous techniques to manage CBDS have been largely relegated to three scenarios, all of which are relatively uncommon. In the first scenario, endoscopic expertise is not available, and radiologic-guided access is the only technique available to decompress the biliary system and/or treat cholangitis. The second scenario is in the palliative setting, where percutaneous access enables biliary drainage and easy access for biliary instrumentation and intervention without the need for anesthesia. Most often this is an appropriate technique for terminal malignancies originating from or impinging on the biliary system. Also, for particularly frail patients, this could be considered for common duct stones. The third situation is the most common of these scenarios – difficult endoscopic biliary access. Difficult endoscopic access could be related to postsurgical anatomic alterations, such as Roux-en-Y anatomy from prior hepatic,

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Figure 12.7  Mother/ daughter preoral direct choledochoscopy. (a) Fluoroscopic image showing a daughter choledochoscope passed through the mother’s side-viewing duodenoscope and advanced within the common bile duct to the level of the biliary bifurcation. (b) A choledochoscopic view of the biliary bifurcation

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bariatric, pancreatic, or duodenal operations (this specific scenario is discussed extensively in another chapter in this book: “Management of Common Bile Duct stones in the Presence of Prior Roux-en-Y”). Endoscopic access may also

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be difficult due to ampullary pathology, such as duodenal diverticula or impacted common duct stones. For the roughly 1–3% of ERCPs performed are unable to accomplish biliary cannulation, percutaneous access to the biliary tree can be vital in identifying and facilitating later endoscopic access to the distal biliary tree as a rendezvous technique, discussed at the end of the chapter. Interventions may also be directly performed percutaneously, including stone expulsion, lithotripsy, stenting, balloon sphincteroplasty, and direct ­ cholangioscopy.

Percutaneous Access to the Biliary Tree Percutaneous access to the biliary tree has the same goal as establishing endoscopic access: securely cannulate the common bile duct. While endoscopists are not often involved in the decision-making regarding location and technique of access, this can have significant implications for later patient management and comfort. The biliary system may be accessed from either the left of right side, and providers should be familiar with both techniques. Various imaging modalities, including ultrasound, fluoroscopy, and spiral computed tomography, may be used and depend on both equipment availability and preference of the proceduralist. For choledocholithiasis, typically unilateral access is sufficient. In the setting of intrahepatic biliary stones, bilateral access may be necessary. Conventionally, the right system is accessed through the intercostal position in the midaxillary line. This approach results in violation of the pleura in some cases. In the setting of current cholangitis, or a biliary tree that has had prior instrumentation, this may provide a path for bacterial seeding into the pleural cavity or cause pneumothorax [50]. If a drain is to remain in place for an extended period of time, this position may be more difficult for a patient to care for. The left system is typically approached with a puncture in the epigastrium. For long-term drain care, this places the drain in direct view for the patient, though it may be more difficult to hide beneath clothing. Instrumentation for access varies widely, but the Seldinger technique is employed universally.

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 ercutaneous Common Bile Duct Stone Expulsion P or Extraction Transhepatic retrieval of common duct stones may be technically feasible, but because this frequently results in parenchymal injury to the liver, emphasis is placed on techniques to clear stones through the ampulla [51, 52]. This technique was first described by Centola and colleagues in 1981 [53]. In that report, retained common duct stones had failed to be cleared operatively, by attempted heparin dissolution (no longer a recommended therapy) and percutaneous basket retrieval. The 4 × 6  mm stone was pushed through the ampulla following balloon dilation of the sphincter using a 6 mm balloon [53]. When percutaneous expulsion is attempted today, a two-­stage approach is utilized. In the first stage, percutaneous access is established, and a cholangiogram is obtained to determine the location, number, and size of stones present. A drain is placed to decompress the biliary tree and allow cholangitis to resolve if present [54]. After 3–4 days, a wire is passed through the drain into the duodenum and the drain removed. A sheath is advanced over the wire to a site just proximal to the stone. A balloon, typically an angioplasty balloon, is passed to the ampulla. The balloon diameter is matched to the diameter of the largest stone up to 10 mm [51, 54]. Holding for 1 min and up to 5 min until the waist of the balloon is reduced has been shown to be the safest technique. The balloon is desufflated, pulled back behind the stone, and re-insufflated. The sheath is used to support the balloon, and the stone is pushed into duodenum [51, 53, 54]. A Fogarty balloon catheter or occlusion balloon catheter may also be used for this step. For common duct stones larger than 10–12 mm, lithotripsy is performed using mechanical, electrohydraulic, or laser-guided techniques as outlined above [55–57]. Stone fragments are the pushed into the duodenum. In most cases a stent or drain is placed following attempted or successful percutaneous expulsion of the common bile duct. This is removed once contrast injection flows freely into the duodenum, and the biliary tree is

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free from filling defects [51]. In select centers, direct percutaneous cholangioscopy is available. Percutaneous cholangioscopy can be used to perform balloon sphincteroplasty, stone expulsion, or laser lithotripsy. Overall success of percutaneous expulsion of common duct stones ranges from 94% to 97% [52, 54, 58, 59]. However, in some series, as many as six sessions are needed to completely clear the common bile duct; clearance after a single session is nearer 60%. In the event of failure, a wire can be left in place and a rendezvous procedure planned (discussed below). Complications of percutaneous stone expulsion occur in roughly 5% of cases and include hemobilia, failure to clear the duct, cholangitis/sepsis, and parenchymal injury of the liver [54].

 hoosing a Technique for Management C of Common Bile Duct Stones It is often said that the most crucial decisions occur outside of the operating room; this adage is particularly true in the setting of benign biliary disease including common duct stones. The first decision point is operative vs. non-operative management and is largely dependent upon the presence of a gallbladder. In a cholecystectomized patient, decision-making is more straightforward, and ERCP is most frequently the initial attempted therapy. Decision-making about both the initial and salvage approaches should the initial attempt fail depends heavily on the provider to whom the patient originally presented and availability of equipment, facilities, and personnel.

 anagement of Common Bile Duct Stones M in the Setting of Cholangitis While the Tokyo Guidelines attempted to defined clear guidelines for the treatment of cholangitis, the role of

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e­ ndoscopy to clear stones versus only providing drainage was not clear. The Tokyo Guidelines are discussed elsewhere in this text. In general, endoscopic biliary drainage is indicated in mild cholangitis that fails to respond to antimicrobial therapy alone and for moderate and severe cholangitis. In a survey-­based study, compliance to these guidelines was low [60]. Many practitioners at these high-volume ERCP centers often performed ERCP more rapidly than was recommended by the Tokyo Guidelines. In the setting of mild and moderate cholangitis, endoscopists appeared more likely to perform maneuvers to clear the duct of stones and provide drainage in a single endoscopic session as opposed to drainage alone [60]. Nevertheless, in the setting of cholangitis, especially when classified as moderate or severe, emphasis should be placed upon decompression of the biliary tree in the most rapid way feasible. Once the cholangitis is beginning to resolve, a more definitive intervention can be planned to clear the common bile duct of stones.

 ndoscopic Stent for Incomplete Clearance E of the Biliary Tree Bacterial contamination of bile is a well-documented occurrence of endoscopic biliary instrumentation. For this reason, incomplete endoscopic duct clearance is a risk factor for cholangitis. Placement of a short-term endoscopic biliary stent is a safe and effective treatment mitigating this risk when an additional therapy is planned (Fig. 12.8) [61]. For a small group of particularly frail patients, long-term endoscopic stenting may be an acceptable alternative to extensive percutaneous, endoscopic, or surgical interventions. Larger diameter stents (10Fr) are associated with less occlusion. In retrospective studies, scheduled endoscopic stent exchange every 3  months, compared to the exchange when biliary symptoms presented, resulted in a much lower rate of cholangitis (7.6 vs. 35.8%) [62]. Overall clearance rate with this technique is around 60% [62].

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Figure 12.8  Common bile duct stones that are not amenable to endoscopic clearance. (a) An ERCP cholangiogram in a patient who had previously undergone a cholecystectomy. The common bile duct is dilated and contains numerous stones to the level of the bifurcation of the duct. In this case navigating a wire to reach the proximal extent of the stone disease would be impossible. (b) An ERCP cholangiogram in a patient with three large stones in the distal common bile duct, which would be difficult to extract endoscopically. (c) An illustration of the distal common bile duct stones and the position of a temporary plastic stent. In both cases the plastic temporary endoscopic stent was a bridge to later operative intervention to clear the bile duct of stones

 re-cut Sphincterotomy to Facilitate Extraction P of Impacted Common Bile Duct Stones Common bile duct stones impacted in the ampulla are likely one of the most common indications for pre-cut or biliary access sphincterotomy (Fig. 12.2). Our preferred technique is to use a needle knife and begin at the 12 o’clock position. Careful consideration should be made prior to attempting this, as the sphincterotomy should still not extend beyond 10 mm typically. If the impacted stone is larger than 1 cm, an access sphincterotomy may still be insufficient to release the stone.

 ybrid Laparoscopic and Endoscopic H Approaches to Common Bile Duct Stones When the gallbladder is intact, common duct stones are most frequently secondary stones from the gallbladder. In order to both treat current condition and hopefully prevent

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future secondary choledocholithiasis, cholecystectomy is an appropriate therapy. Specifics and techniques for cholecystectomy with concomitant management of CBDS are detailed elsewhere within this manual. Combining cholecystectomy with intraoperative cholangiogram, cholangioscopy or common bile duct exploration is an appropriate option. If the surgeon is either unsuccessful at clearing the common duct of stone burden during cholecystectomy or lacks requisite training or experience to do so, the nonoperative techniques discussed above may be employed as a secondary therapy. The timing of endoscopic or percutaneous interventions with respect to performing cholecystectomy has been an area of intense research focus for many years. These debates can be well coalesced into consideration of the most frequently combined therapies: cholecystectomy (generally laparoscopic) and ERCP.  Several hybrid approach options are ERCP first followed by cholecystectomy, ERCP and cholecystectomy in the same session, and cholecystectomy first followed by ERCP, which will each be discussed below.

ERCP then Cholecystectomy As laparoscopic cholecystectomy was popularized, patients with the potential for choledocholithiasis commonly underwent preoperative ERCP [63–67]. The presence of hyperbilirubinemia, clinical jaundice, abnormal liver function tests, dilated common bile ducts seen on ultrasound or other imaging examinations, and recent pancreatitis were common indication for preoperative ERCP.  However, it soon became clear that CBDS were found in only a small subset of these patients (~2% for all laparoscopic cholecystectomy patients, up to 26% for patients presenting with gallstone pancreatitis) [63–65, 68, 69]. When discovered, CBDS were successfully cleared in more than 90% of patients by ERCP [63–67]. For those without CBDS, ERCP was an unneces-

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sary diagnostic test that carried its own risk for morbidity (10%) and mortality (1%) and was thus not likely necessary in all cases [63–67, 70]. Routine application of preoperative ERCP also represented an exorbitant expense and overutilization of hospital resources. Recent work suggests that patients with worsening gallstone pancreatitis, cholangitis, and those with persistent jaundice are most benefited by preoperative ERCP. Figure 12.9 demonstrates a case where a patient was noted to have both cholecystolithiasis and choledocholithiasis, in the absence of cholecystitis. The patient underwent a preoperative ERCP followed by laparoscopic cholecystectomy.

I ntraoperative ERCP (ERCP with Cholecystectomy) From the earliest days of laparoscopic cholecystectomy, it seemed logical that intraoperative use of ERCP might be a practical way of managing common duct stones [71]. Depaulo in Brazil and Curet and colleagues in the United States suggested that antegrade transcystic passage of a sphincterotome to cut the ampullary sphincter and release the stones was a viable option, when visualized by a duodenoscope [72]. Conventional ERCP is an effective method when stones are present in the common bile duct proximal to the cystic duct bifurcation, where transcystic access is unlikely to be able to gain access proximal to the stone. In other cases, the diameter of the cystic duct prevents successful transcystic exploration (Fig. 12.10). However, intraoperative ERCP mandates the transport of endoscopic equipment, supplies, and personnel to the operating room. On the one hand, this represented a logistical and scheduling challenge that may be prohibitive in some cases. On the other hand, it may be a good rationale for surgeons to acquire ERCP skills, such that the same proceduralist could perform both procedures.

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Figure 12.9  Preoperative ERCP in a patient with both cholelithiasis and choledocholithiasis. (a) Transverse image of the gallbladder obtained during a right upper quadrant ultrasound. The gallbladder is distended with a hyperechoic object noted in the gallbladder fundus with characteristic posterior acoustic shadowing consistent with a gallstone. The walls of the gallbladder are of a normal thickness, and no pericholecystic fluid is noted. (b) With the patient in a left lateral decubitus position, the common bile duct is visualized using abdominal ultrasound. The green arrow points to a hyperechoic object with posterior acoustic shadowing within a normal caliber common bile duct consistent with a common bile duct stone. (c) The initial ERCP cholangiogram demonstrates a filling defect in the mid common bile duct consistent with the hyperechoic object noted on ultrasound. (d) Demonstrates the extent of the biliary sphincterotomy performed to clear the common bile duct of the stone. The patient subsequently underwent a laparoscopic cholecystectomy

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Figure 12.10 Intraoperative ERCP. (a) Shows an intraoperative cholangiogram with several small filling defects confined to the distal common bile duct. (b) Shows a cholesterol stone spontaneously passing through the ampulla prior to completion of the sphincterotomy. (c) Additional small cholesterol stones extracted during the ERCP

 ostoperative ERCP (Cholecystectomy then P ERCP) In most settings, currently, cholecystectomy is completed first unless there is definitive evidence of CBDS.  Intraoperative cholangiogram can then be used to identify cystic and common duct stones that may be better treated with lower morbidity by ERCP afterward. In such cases, again, the success rate is very high. ERCP can be safely performed several days after cholecystectomy. Although the ultimate success rate is very high, a good number of these cases may prove difficult, and multiple procedures may be required in some patients [63–67].

 ombining Laparoscopic Transcystic Drainage C and Postoperative ERCP While likely reducing procedure-related morbidity to its lowest possible level with a cholecystectomy followed by ­postoperative ERCP, the delay to clearance of the common duct introduced the potential for additional complications. In the interim, stone impaction is possible, which can lead to obstructive jaundice, cholangitis, and possible cystic duct leak. Also, bile duct cannulation fails in ~1–2% of ERCPs. Therefore,

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some have suggested leaving a small caliber tube in cystic duct at the conclusion of the cholecystectomy. The tube with its tip in the common bile duct is secured in the cystic duct with pretied ligatures and brought out through the skin much as a t-tube would be. Later, a wire may be introduced through the tube and passed into the duodenum to permit guidance of an endoscopic cannulation for sphincterotomy and stone retrieval. Prior to stone removal, the tube is left to drainage to prevent biliary obstruction and prevent cholangitis. Once the stone is removed, the tube may be tied off but must remain until a secure tract is formed, about 2 weeks. This bailout technique may make biliary cannulation more likely but obligates the patient to a biliary drain for several weeks. While in a logical solution, this technique is rarely used in practice.

Transcystic Stenting and Postoperative ERCP A newer extension to transcystic drainage is transcystic biliary stenting. This technique, originally proposed by Rhodes and colleagues [73], placed an internal plastic biliary stent transcystically. This allows biliary decompression but also facilitates endoscopic access to the bile duct. A biliary stent is passed over a guide wire using a pushing catheter through the cystic duct and into position across the ampulla under fluoroscopy at the time of cholecystectomy. This may be particularly advantageous if there is to be several days or weeks before an ERCP can be completed, during which time the patient can be at home, with internal biliary drainage. A needle knife sphincterotomy can be performed directly over the stent at the time of ERCP and stones removed using the techniques outlined above.

 nique Scenario: Common Bile Duct Stones U After Choledochoduodenostomy Operative choledochoduodenostomy may be performed end to side or side to side. Such an anastomosis may be encountered after a patient has undergone operative common bile

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duct exploration, after orthotopic liver transplantation or various biliary or hepatic resections. Side-to-side anastomoses are less common and may be associated with sump syndrome in ~2% of cases [74]. While the proximal bile duct is well drained by a patent choledochoduodenostomy, a side-to-­side anastomosis creates a small reservoir between the anastomosis and the native ampulla. Because the choledochoduodenostomy is widely patent, food particles may travel retrograde into the bile duct and fall into the more dependent reservoir. While biliary drainage is unlikely to be impeded, impacted particles can cause persistent pain, nausea, and vomiting. In particularly rare cases where biliary drainage is also compromised, cholangitis can develop [75, 76]. However, choledochoduodenostomy can be used refractory cases of primary CBDS when a patient has undergone multiple ERCP.

Emerging Techniques and Alternative Technologies for Non-operative Management Common Bile Duct Stones While the techniques discussed above will be effective in the vast majority of cases of common duct stones, some unique situations exist where other hybrid approaches may be used. In addition new endoscopic techniques have been developed and recently applied to clearance of common bile duct stones.

 ercutaneous Rendezvous Technique to Cannulate P the Papilla Percutaneous biliary access may be used to facilitate endoscopic biliary cannulation in the event of failed endoscopic cannulation. This technique can be used with transcholecystic or transhepatic techniques, depending upon the presence of a gallbladder. A wire is placed through the papilla and into the duodenum. A conventional front-viewing endoscope is advanced to the duodenum and a snare used to grasp the

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transpapillary wire. This wire is then externalized by drawing it either through the working channel of the scope or withdrawn with the scope. In the latter case, techniques are performed under fluoroscopy. Balloons or stents can then be advanced over the externalized wire [77, 78]. Laparoendoscopic rendezvous is another option, generally performed in the setting of cholecystectomy and simultaneous ERCP [79, 80].

Endoscopic Ultrasound Rendezvous Technique As endoscopic ultrasound has become more prevalent, there has been an increased effort to expand its therapeutic usage. Using a similar approach to the percutaneous rendezvous technique, endoscopic ultrasound can facilitate passage of a transpapillary wire and/or be used to directly intervene on the biliary tree. Various techniques exist, including intrahepatic, where dilated intrahepatic bile ducts are accessed under ultrasound guidance from the stomach lumen and extrahepatic techniques [81]. Transduodenal or transgastric is another way to categorize these techniques [82]. Systematic reviews demonstrate a technical success rate of biliary cannulation of 94.7%. Success rates of EUSassisted EPBD to clear CBDS are difficult to determine, but it has been reported as feasible [83]. Despite a large number of studies, in practice endoscopic ultrasound-guided techniques require a high degree of technical skill that is likely only present in select centers. In many centers, these techniques are only utilized in patients with surgically altered anatomy, such as Billroth II gastrojejunostomy or Rouxen-Y anatomy [84].

Balloon-Assisted Endoscopy Balloon-assisted endoscopy uses overtubes and balloons to either add a fulcrum or to telescope the intestine over the scope allowing for deep endoscopic access to the small bowel.

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Both single- and double-balloon systems are available and are primarily used by providers with advanced endoscopic training. These techniques have application in the setting of altered foregut anatomy. Historically, Billroth II type gastrojejunostomy would have been the most common surgical alteration complicating ERCP.  However, Roux-en-Y anatomy after hepatectomy, liver transplant, gastric bypass, gastrectomy, and others is becoming increasingly common. Balloon-assisted endoscopy typically restricts to the use of forward-viewing endoscopes, which limit utility in management of CBDS. However, there are series that report success in terms of both cannulation and therapeutic intervention of the common bile duct using balloon-based apparatus [85]. Our center has vast experience with intragastric surgery and laparoscopic-assisted transgastric access for endoscopic procedure, which allows for use of a conventional endoscope. We generally favor this approach over balloon-based techniques for deep endoscopy to preform biliary interventions in altered foregut anatomy.

Extracorporeal Shockwave Lithotripsy Extracorporeal shockwave lithotripsy is another non-­ operative technique that does not fit within the percutaneous, endoscopic, or hybrid approaches. Extracorporeal shockwave lithotripsy is a technology that continues to be used to treat renal stones. It was first adapted for fragmentation of biliary stones in 1986 by Sauerbruch and colleagues [86]. In those days, devices required patients to be placed under general anesthesia and placed in a water bath [87]. Newer machines allow conscious sedation and no longer require submersion. The largest series published comes from a center reporting the use of extracorporeal shockwave lithotripsy for biliary stones that could not be cleared endoscopically with baskets, balloon sweep, or mechanical lithotripsy. As long as sphincterotomy had been performed, patients were considered if they did not have coagulation disorders, had stones visible

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with radiographic or sonographic techniques, and window existed without the bone, lung, calcified vessels, or vascular aneurysms [87]. Out of 376 patients, this technique resulted in a 90.2% bile duct clearance rate, with the majority needing endoscopy to fully clear the duct. Many required multiple sessions (up to 12) to achieve this result, and stone size was not surprisingly positively correlated with the number of sessions required [87].

Conclusion Because of the risks associated with biliary obstruction, common bile duct stones remain an important aspect of general surgical practice. Increasing arrays of techniques have been developed to clear the common bile duct of stones and/or provide decompression of the biliary tree. As with any intervention, management strategy should take into account individual patient characteristics, including foregut anatomy, stone size and overall stone burden, the presence of a gallbladder, and general state of health. Planned interventions should be chosen to maximize likelihood of clearing the duct of stones while minimizing the risk of complications. As technology continues to evolve, no doubt additional non-­operative strategies will emerge, though the goal of clearing the duct from CBDS will likely never change.

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26. Neuhaus H. Chapter 16: Biliary sphincterotomy. In: ERCP. 2nd ed. Philadelphia: Saunders Elsevier; 2013. p. 129–40. 27. Staritz M, Ewe K, Meyer zum Büschenfelde KH.  Endoscopic papillary dilation (EPD) for the treatment of common bile duct stones and papillary stenosis. Endoscopy. 1983;15(Suppl 1):197–8. 28. Liao W-C, Tu Y-K, Wu M-S, Wang H-P, Lin J-T, Leung JW, et al. Balloon dilation with adequate duration is safer than sphincterotomy for extracting bile duct stones: a systematic review and meta-analyses. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2012;10(10):1101–9. 29. Weinberg BM, Shindy W, Lo S. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones. Cochrane Database Syst Rev. 2006;(4):CD004890. 30. Zhao H-C, He L, Zhou D-C, Geng X-P, Pan F-M.  Meta-­ analysis comparison of endoscopic papillary balloon dilatation and endoscopic sphincteropapillotomy. World J Gastroenterol. 2013;19(24):3883–91. 31. Liu Y, Su P, Lin S, Xiao K, Chen P, An S, et  al. Endoscopic papillary balloon dilatation versus endoscopic sphincterotomy in the treatment for choledocholithiasis: a meta-analysis. J Gastroenterol Hepatol. 2012;27(3):464–71. 32. Baron TH, Harewood GC.  Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of common bile duct stones during ERCP: a metaanalysis of randomized, controlled trials. Am J Gastroenterol. 2004;99(8):1455–60. 33. Kim TH, Kim JH, Seo DW, Lee DK, Reddy ND, Rerknimitr R, et al. International consensus guidelines for endoscopic papillary large-balloon dilation. Gastrointest Endosc. 2016;83(1):37–47. 34. Wang AY.  Reappraisal of endoscopic papillary balloon dila tion versus sphincterotomy for choledocholithiasis-time for a new trial. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2017;15(11):1671–3. 35. Kim JH, Yang MJ, Hwang JC, Yoo BM.  Endoscopic papillary large balloon dilation for the removal of bile duct stones. World J Gastroenterol. 2013;19(46):8580–94. 36. Seitz U, Bapaye A, Bohnacker S, Navarrete C, Maydeo A, Soehendra N. Advances in therapeutic endoscopic treatment of common bile duct stones. World J Surg. 1998;22(11):1133–44. 37. Leung JW, Tu R.  Mechanical lithotripsy for large bile duct stones. Gastrointest Endosc. 2004;59(6):688–90.

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38. Patel SN, Rosenkranz L, Hooks B, Tarnasky PR, Raijman I, Fishman DS, et  al. Holmium-yttrium aluminum garnet laser lithotripsy in the treatment of biliary calculi using single-­ operator cholangioscopy: a multicenter experience (with video). Gastrointest Endosc. 2014;79(2):344–8. 39. Sauer BG, Cerefice M, Swartz DC, Gaidhane M, Jain A, Haider S, et  al. Safety and efficacy of laser lithotripsy for complicated biliary stones using direct choledochoscopy. Dig Dis Sci. 2013;58(1):253–6. 40. Binmoeller KF, Brückner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy. 1993;25(3):201–6. 41. Riemann JF, Seuberth K, Demling L. Mechanical lithotripsy of common bile duct stones. Gastrointest Endosc. 1985;31(3):207–10. 42. Garg PK, Tandon RK, Ahuja V, Makharia GK, Batra Y. Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones. Gastrointest Endosc. 2004;59(6):601–5. 43. Shaw MJ, Mackie RD, Moore JP, Dorsher PJ, Freeman ML, Meier PB, et al. Results of a multicenter trial using a mechanical lithotripter for the treatment of large bile duct stones. Am J Gastroenterol. 1993;88(5):730–3. 44. Trikudanathan G, Arain MA, Attam R, Freeman ML. Advances in the endoscopic management of common bile duct stones. Nat Rev Gastroenterol Hepatol. 2014;11(9):535–44. 45. Siegel JH, Ben-Zvi JS, Pullano WE. Endoscopic electrohydraulic lithotripsy. Gastrointest Endosc. 1990;36(2):134–6. 46. Kamiyama R, Ogura T, Okuda A, Miyano A, Nishioka N, Imanishi M, et  al. Electrohydraulic lithotripsy for difficult bile duct stones under endoscopic retrograde cholangiopancreatography and peroral transluminal cholangioscopy guidance. Gut Liver. 2018;12:457–62. 47. Bhandari S, Sanghvi K, Sharma A, Bondade N, Maydeo A. Single-operator cholangioscopy-guided holmium laser lithotripsy: the new-age “rescue” lithotripsy. Gastrointest Endosc. 2016;83(5):1035–6. 48. Lv S, Fang Z, Wang A, Yang J, Zhang W.  Choledochoscopic holmium laser lithotripsy for difficult bile duct stones. J Laparoendosc Adv Surg Tech A. 2017;27(1):24–7. 49. Ponsky LE, Geisinger MA, Ponsky JL, Streem SB. Contemporary “urologic” intervention in the pancreaticobiliary tree. Urology. 2001;57(1):21–5.

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50. Winick AB, Waybill PN, Venbrux AC.  Complications of percutaneous transhepatic biliary interventions. Tech Vasc Interv Radiol. 2001;4(3):200–6. 51. Dowell JD, Weinstein J, Lim A, Guy GE. Chapter 9: Percutaneous methods of common bile duct stone retrieval. In: Hazey JW, Conwell D, Guy GE, editors. Multidisciplinary management of common duct stones. Cham: Springer International Publishing; 2016. p. 77–83. 52. Ozcan N, Kahriman G, Mavili E.  Percutaneous transhepatic removal of bile duct stones: results of 261 patients. Cardiovasc Intervent Radiol. 2012;35(4):890–7. 53. Centola CA, Jander HP, Stauffer A, Russinovich NA.  Balloon dilatation of the papilla of Vater to allow biliary stone passage. AJR Am J Roentgenol. 1981;136(3):613–4. 54. Kint JF, van den Bergh JE, van Gelder RE, Rauws EA, Gouma DJ, van Delden OM, et al. Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients. Dig Surg. 2015;32(1):9–15. 55. Rimon U, Kleinmann N, Bensaid P, Golan G, Garniek A, Khaitovich B, et  al. Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones. Cardiovasc Intervent Radiol. 2011;34(6):1262–6. 56. Schatloff O, Rimon U, Garniek A, Lindner U, Morag R, Mor Y, et  al. Percutaneous transhepatic lithotripsy with the holmium: YAG laser for the treatment of refractory biliary lithiasis. Surg Laparosc Endosc Percutan Tech. 2009;19(2):106–9. 57. Mo LR, Hwang MH, Yueh SK, Yang JC, Lin C.  Percutaneous transhepatic choledochoscopic electrohydraulic lithotripsy (PTCS-EHL) of common bile duct stones. Gastrointest Endosc. 1988;34(2):122–5. 58. Gil S, de la Iglesia P, Verdú JF, de España F, Arenas J, Irurzun J. Effectiveness and safety of balloon dilation of the papilla and the use of an occlusion balloon for clearance of bile duct calculi. AJR Am J Roentgenol. 2000;174(5):1455–60. 59. García-García L, Lanciego C. Percutaneous treatment of biliary stones: sphincteroplasty and occlusion balloon for the clearance of bile duct calculi. Am J Roentgenol. 2004;182(3):663–70. 60. Isayama H, Yasuda I, Tan D.  Current strategies for endo scopic management of acute cholangitis. Dig Endosc Off J Jpn Gastroenterol Endosc Soc. 2017;29(Suppl 2):70–7. 61. Yang J, Peng J, Chen W. Endoscopic biliary stenting for irretrievable common bile duct stones: indications, advantages, disad-

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74. Leppard WM, Shary TM, Adams DB, Morgan KA. Choledochoduodenostomy: is it really so bad? J Gastrointest Surg Off J Soc Surg Aliment Tract. 2011;15(5):754–7. 75. Qadan M, Clarke S, Morrow E, Triadafilopoulos G, Visser B.  Sump syndrome as a complication of choledochoduodenostomy. Dig Dis Sci. 2012;57(8):2011–5. 76. Abraham H, Thomas S, Srivastava A.  Sump syndrome: a rare long-term complication of choledochoduodenostomy. Case Rep Gastroenterol. 2017;11(2):428–33. 77. Tomizawa Y, Di Giorgio J, Santos E, McCluskey KM, Gelrud A.  Combined interventional radiology followed by endoscopic therapy as a single procedure for patients with failed initial endoscopic biliary access. Dig Dis Sci. 2014;59(2):451–8. 78. Kawakami H, Abo D, Kawakubo K, Kuwatani M, Yoshino Y, Kubota Y, et  al. Rendezvous biliary recanalization combining percutaneous and endoscopic techniques using a diathermic dilator for bile duct obstruction. Endoscopy. 2014;46 Suppl 1 UCTN:E460–1. 79. Tzovaras G, Baloyiannis I, Kapsoritakis A, Psychos A, Paroutoglou G, Potamianos S.  Laparoendoscopic rendezvous: an effective alternative to a failed preoperative ERCP in patients with cholecystocholedocholithiasis. Surg Endosc. 2010;24(10):2603–6. 80. La Barba G, Gardini A, Cavargini E, Casadei A, Morgagni P, Bazzocchi F, et  al. Laparoendoscopic rendezvous in the treatment of cholecysto-choledocholitiasis: a single series of 200 patients. Surg Endosc. 2018 81. Tyberg A, Desai AP, Kumta NA, Brown E, Gaidhane M, Sharaiha RZ, et  al. EUS-guided biliary drainage after failed ERCP: a novel algorithm individualized based on patient anatomy. Gastrointest Endosc. 2016;84(6):941–6. 82. Wang K, Zhu J, Xing L, Wang Y, Jin Z, Li Z.  Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review. Gastrointest Endosc. 2016;83(6):1218–27. 83. Iwashita T, Yasuda I, Doi S, Uemura S, Mabuchi M, Okuno M, et  al. Endoscopic ultrasound-guided antegrade treatments for biliary disorders in patients with surgically altered anatomy. Dig Dis Sci. 2013;58(8):2417–22. 84. Nakai Y, Kogure H, Yamada A, Isayama H, Koike K. Endoscopic management of bile duct stones in patients with surgically altered anatomy. Dig Endosc Off J Jpn Gastroenterol Endosc Soc. 2018;30(Suppl 1):67–74.

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Chapter 13 Common Bile Duct Exploration Andrew Lambour and Byron F. Santos

Introduction Surgical management of the biliary system, particularly within the context of choledocholithiasis, is a valuable skill set that can save patients from undergoing additional procedures and morbidity. It is important to note that common bile duct exploration (CBDE) was the dominant, gold standard technique in the “open” surgical era for the management of common duct stones, with ERCP playing only a secondary role in the care of these patients. The development of laparoscopic cholecystectomy, while ushering in a sharp decline in the utilization of open cholecystectomy with many benefits for patients, also has caused many surgeons to increasingly rely on ERCP for the management of common duct stones rather than on traditional common duct exploration. Laparoscopic common bile duct exploration (LCBDE), described since the

A. Lambour (*) · B. F. Santos Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_13

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early days of the laparoscopic era, is now a mature technique and in some centers remains the preferred technique for the management of many patients requiring cholecystectomy with concurrent common bile duct stones. However, despite studies showing that single-stage management (laparoscopic cholecystectomy plus CBDE) versus two-stage management (laparoscopic cholecystectomy plus pre- or postoperative ERCP) for the management of choledocholithiasis results in fewer procedures, decreased cost, and shorter hospital stay, widespread adoption of LCBDE has been limited [1–4]. The reasons for this are complex and historically have included the increased technical challenge of LCBDE, increased operating time required, the need for specialized instruments, limited exposure of surgical faculty and residents to LCBDE, and economic reasons such as inadequate surgeon reimbursement. However, recently there has been renewed interest in LCBDE as surgical leaders have realized that a single-stage approach to CBD stones is beneficial for patients, endoscope technology has evolved, surgical residents now have an increased comfort level with advanced laparoscopy and flexible endoscopy, simulators have been developed to teach LCBDE [5], and as new payment models gradually replace the traditional fee-for-service model and no longer incentivize a multistage approach to common duct stones. This chapter will describe a simplified approach to the management of patients with common bile duct stones, focusing on those patients who also require cholecystectomy (the most common scenario), utilizing LCBDE as the primary modality for stone clearance. Both transcystic and transcholedochal LCBDE will be described, but not open CBDE as it is now rarely performed and is beyond the scope of this chapter.

Patient Selection for LCBDE Patients with an indication for cholecystectomy should undergo routine evaluation including a history and physical exam to determine initial suitability for surgery. Patients

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should have routine laboratory testing including a liver function panel and pancreatic enzymes and noninvasive imaging (transabdominal ultrasound or computed tomography, if ultrasound is not available) as an initial evaluation for biliary disease. Patients with suspicious findings for malignancy on clinical evaluation (e.g., weight loss, painless jaundice) or after an initial workup (e.g., indeterminate ductal stricture, pancreatic mass, profoundly elevated direct hyperbilirubinemia, etc.) should undergo appropriate additional workup to rule out malignancy with appropriate treatment as indicated. Patients with hemodynamic instability from cholangitis or cholecystitis or who have severe biliary pancreatitis should generally not proceed initially to surgery but are rather better served with initial endoscopic drainage (ERCP) or percutaneous cholecystostomy as indicated with consideration of interval cholecystectomy once they have improved. Most patients, excluding these two groups, will be able to proceed to cholecystectomy without costly or invasive additional imaging such as MRCP (magnetic resonance cholangiopancreatography) or EUS (endoscopic ultrasound) when routine intraoperative imaging (cholangiography or ultrasonography) is planned. All patients should be informed of the possibility of LCBDE or need for postoperative ERCP since up to 40% of CBD stones will have been clinically silent prior to surgery.

Operating Room Preparation and Supplies The surgeon should perform the operation with a table/room compatible with C-arm fluoroscopy. Having the C-arm already setup in the room will expedite cholangiography and possible LCBDE.

Choledochoscope The flexible choledochoscope is a thin flexible endoscope (approximately 2.8 mm in diameter) that is used to traverse

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and visualize the biliary tree for diagnostic or therapeutic purposes. The surgeon maneuvers the choledochoscope using bi-directional flexion at the tip plus torqueing of the instrument. The scopes typically have a 1.2 mm diameter working channel with an attachment for saline irrigation and a working channel cap to allow passage of instruments while preventing pressurized saline from escaping. A pressurized saline bag is connected to the endoscope to allow distention of the bile ducts and to keep the field of vision clear of bile and debris (we recommend a 3 L saline bag connected to a pressurized infuser to maintain constant flow without having to exchange saline bags frequently). Recent improvements in choledochoscope technology include the development of video choledochoscopes with “chip-on-the-tip” technology and integrated LED (light-emitting diode) light source resulting in high-quality digital video images compared to older fiber-optic choledochoscopes that have a typical “honeycomb” appearance and would develop black dots on the image with broken fiber-optic bundles. Other improvements include increased bi-directional range of flexion to approximately 270° that improves maneuverability and access to the intrahepatic ducts (Fig. 13.1).

Figure 13.1  Newly developed 2.8 mm diameter flexible video choledochoscopes have integrated light cord with LED lighting and chip-on-­the-tip technology. They have improved 270-degree deflection and a 1.2  mm working channel. (©2018 Photo Courtesy of KARL STORZ Endoscopy-America, Inc)

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Video Equipment LCBDE requires multiple imaging modalities (laparoscopic, fluoroscopic, and endoscopic/choledochoscopic), making the use of integrated picture-in-picture or split-screen capable monitors with multiple inputs ideal. Many modern laparoscopic systems can be set up to provide these capabilities, but the alternative is to wheel in a separate laparoscopy cart for the choledochoscope. If using an older fiber-optic choledochoscope, a separate camera and light cord along ­ with its own laparoscopy tower will be required.

Supplies To facilitate “on-demand” LCBDE, we have found it critical to organize a “CBD cart” stocked with the supplies necessary for LCBDE, analogous to how a traveling endoscopy cart would be organized for flexible endoscopic procedures to allow rapid deployment of necessary supplies (Fig. 13.2). This cart should have supplies including a cholangiogram catheter, access sheath, various guidewires, retrieval baskets, extraction balloons, biliary stents, T-tubes, saline bags with tubing connectors, and other items as necessary (Table 13.1).

LCBDE Technique Cholangiography Routine intraoperative imaging with cholangiography (IOC) is recommended, as it not only detects CBD stones with a high sensitivity and specificity but also provides a road map with precise delineation of ductal anatomy and stone burden and keeps the surgeon and operating team facile with maneuvers required for LCBDE. Various methods for cholangiography have been described, but we prefer to pass and secure a 5F open-tip catheter using an Olsen cholangiography

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Figure 13.2 The author’s “CBD cart” containing items necessary for LCBDE including guidewires, baskets, stents, balloons, etc. Table 13.1  List of laparoscopic common bile duct equipment (LCBDE) used by the authors to serve as a potential starter for a case cart Description Comments Choledochoscope setup: Two laparoscopic video monitors w/ video inputs and picture-in-picture capability

Allows integration of choledochoscope and/ or fluoroscopic views with laparoscopic view

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Table 13.1 (continued) Description Comments Flexible video choledochoscope IMAGE1 S

Deflection of distal tip: 270° Working channel inner diameter: 3.6 Fr/1.2 mm Sheath size: 8.5 Fr/2.8 mm Working length: 50 cm

LUER-lock tube connector

Connects saline tubing to scope

Endoscopic seal

Scope working channel seal

Pressure irrigation unit

Pressurizes saline bag for continuous irrigation

Cystoscopy irrigation tubing

Connects to saline bag

Silastic tubing extension

Extension tubing to facilitate scope handling

3 L saline bag

1 L bag is acceptable but may have to be replaced more frequently

LCBDE accessories (have available): Fanelli cholangiography catheter Common bile duct exploration set

Includes:  Biliary wire guide (0.035 in. diameter, Teflon coated), (RFSPC-35-145)  Wire stone basket, straight (C-NTSE2.4-115-NCT4)  Angioplasty dilating balloon (C-ATB535-40-8-4.0-CDES)  Berci introducer set 12F (C-CDIS-4.015-BERCI)

High-pressure inflation device

For pressure-controlled inflation of angioplasty balloon

(continued)

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Table 13.1 (continued) Description Comments 0.025 in. VisiGlide guidewire

For difficult cannulations, smaller diameter but has same stiffness as 0.035 guidewire. Long length allows compatibility with other biliary devices commonly used for ERCP

14F red rubber catheter

For vigorous flushing of duct through transcholedochal approach

Segura hemisphere basket

2.4F × 90 cm stainless steel basket, has greater radial force to allow easier dislodgement and capture of stones in the papilla

3-lumen balloon extraction device

Multiple lumens allow contrast injection, balloon inflation, and use of guidewire to position balloon

7F Fanelli biliary stent

7F laparoscopic delivery system – transcystic delivery is possible

8.5F Advanix biliary stent

8.5F stent if necessary for improved drainage – transcholedochal delivery is easier than transcystic delivery given proximal tine on stent

T-tubes, 14F Laparoscopic instruments: Olsen cholangiography fixation clamp Berci grasping forceps (padded grasper)

For gentle choledochoscope handling if necessary

Berci microknife (pointed, retractable)

For making choledochotomy

4-0 vicryl suture on RB-1 needle

For choledochotomy closure

Similar products may be available from alternate manufacturers

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clamp. This method allows for fine control of the catheter tip and secure yet adjustable fixation with the clamp. A 5F catheter allows further passage of guidewires if necessary (unlike smaller diameter catheters) in cases of difficult cannulation or when transcystic LCBDE is necessary. Use of half-strength contrast is helpful especially in situations where the biliary tree is dilated so as to avoid obscuring small stones with a more radiopaque contrast. The cholangiogram should be performed in “cine” mode in two steps to allow precise interpretation and a video “replay” of the images. An initial cholangiogram is performed of the distal duct to examine the early filling phase. Stones may be seen as floating filling defects or sometimes as a subtle “meniscus sign” with or without emptying of contrast into the duodenum. The second cholangiogram should be a proximal view of the hepatic ducts. Once a filling defect has been identified, the options include observation, flushing maneuvers, transcystic LCBDE, transcholedochal LCBDE, or postoperative ERCP with or without intraoperative biliary stent placement.

Decision-Making Stones smaller than 3 mm will often pass spontaneously, and consideration of a watchful waiting approach is not unreasonable. Analysis of the GallRIKS database, however, has shown that even stones as small as 4 mm or less lead to complications in 16% of patients [6]. The first maneuver for small stones (3 mm or less) should be to flush the ducts with saline. If unsuccessful, a trial of 1 mg intravenous glucagon to relax the sphincter of Oddi in combination with flushing the ducts can be attempted. Avoid glucagon in patients who are on beta-blockers as this is a reversal agent for those medications (alternatively, a nitroglycerin infusion can be used in this situation). The surgeon is also cautioned to avoid flushing maneuvers and excessive contrast injection in patients with cholangitis as these can cause bacteremia in these patients. Flushing maneuvers for larger stones are unlikely to be suc-

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cessful and should be avoided as they may cause migration of the stone into the hepatic ducts. If a filling defect remains, one can then proceed with a biliary intervention. The surgeon will next need to decide on transcystic LCBDE, transcholedochal LCBDE, or postoperative ERCP.  Transcystic LCBDE is an appealing initial approach, as it does not require incising and closing the common bile duct and has a lower complication profile. However, it requires suitable cystic duct anatomy, a limited stone burden, and availability of adequate instrumentation. The surgeon should measure the diameter and course of the cystic duct, common bile duct, and the filling defect(s) with the Olsen clamp serving as a reference 5  mm diameter marker. The ideal situation is when the cystic duct is dilated to at least 5 mm in diameter with a straight course and without a spiral (inserting medially on the common bile duct) or parallel configuration and with a single, small distal stone. A duct that is smaller than 4 mm or that has a spiral course will be at risk of injury with dilation and also will not easily allow extraction of stones. A common bile duct with many stones or with large stones is also not feasible to clear through a transcystic approach. Size of the stone(s) should also be taken into consideration, as stones greater than 6mm may not be feasible to remove through the cystic duct approach. Transcholedochal exploration is generally the most versatile LCBDE approach and allows removal of any size stone in any location. From a technical standpoint, transcholedochal exploration actually requires fewer instruments than transcystic exploration and is used as the primary approach for LCBDE by some surgeons. Transcholedochal LCBDE also serves as a backup option in cases of failed transcystic exploration. Transcholedochal LCBDE does require advanced suturing skills, though, and has a higher risk profile than transcystic exploration. This approach should not be attempted without adequate training and experience. As such, some surgeons may opt for postoperative ERCP instead, which is a good alternative in most patients (except in cases of altered anatomy). Transcholedochal exploration should be avoided in bile ducts smaller than 7 mm as well as

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in situations of severe porta hepatis inflammation to minimize the risk of ductal stricture with closure or ductal injury, respectively. Patient anatomy will also limit this approach, as in patients with a large fatty liver or severe intra-abdominal obesity that limits exposure to the CBD. If the surgeon decides to proceed with postoperative ERCP, a biliary stent may be placed intraoperatively if cystic duct anatomy allows decompressing the biliary tree and making subsequent biliary cannulation by ERCP easier. This approach also allows the postoperative ERCP to be performed as an elective outpatient procedure.

Transcystic CBDE For transcystic LCBDE the ductotomy in the cystic duct used for IOC is used to access the cystic duct and common bile duct. Another ductotomy closer to the common duct may be necessary if the cystic duct is noted to be of inadequate size or there are valves that impair passage of the catheter. Clearance via a transcystic approach may include fluoroscopic-­ guided techniques such as the use of wire baskets through a catheter or choledochoscope-guided techniques. The authors prefer the use of the choledochoscope given the ability to directly examine the bile ducts to facilitate stone capture as well as to confirm clearance of the ducts. The initial step in transcystic CBDE is to gain wire access to the biliary tree using fluoroscopic guidance. Exposure is conveniently obtained by using a locking grasper on the fundus and retracting the fundus cephalad to straighten the cystic duct. This fundus grasper is secured to the patient’s skin or to the drape by using a penetrating towel clamp externally, freeing up the assistant. The surgeon moves to the patient’s right side, while the assistant moves to the patient’s left side. Transcystic maneuvers are performed using the existing mid-­ clavicular trocar as long as the trocar is high and lateral enough to allow an angle parallel to the course of the cystic duct (an additional 5 mm trocar may be inserted if necessary). Under fluoroscopy, the surgeon advances a guidewire (0.035-­

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in.) through the 5F cholangiogram catheter (secured by the Olsen clamp) into the CBD and across the papilla into the duodenum to reduce the risk of losing wire access. If the wire is difficult to pass through the papilla, a smaller, more maneuverable 0.025-in. guidewire may be used instead. Using a Seldinger technique, the cholangiogram catheter and clamp are then removed by the surgeon, while the assistant pins the wire in place at the cystic ductotomy site using an instrument through the epigastric trocar (Fig. 13.3). A cystic duct introducer sheath is then advanced over the wire serving to extend the length of the trocar and also to prevent loss of pneumoperitoneum. Cystic duct dilation should be used selectively, to facilitate insertion of the choledochoscope and also to make stone extraction easier with less risk of stone basket entrapment. Generally, the surgeon should avoid dilating the cystic duct to more than 2mm larger than its native diameter to reduce the risk of injury. Most ducts at least 6  mm can be safely dilated to 8  mm using a wire-guided angioplasty balloon. The balloon is positioned under fluoroscopy and then inflated with contrast under fluoroscopy (Fig. 13.4). Narrow

Figure 13.3  After removal of the cholangiogram clamp and catheter over the wire, the assistant pins the wire to prevent wire dislodgement

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Figure 13.4  The assistant stabilizes the balloon during inflation to prevent forward movement of the balloon. The surgeon also monitors balloon inflation under fluoroscopy by inflating the balloon with contrast

areas of the cystic duct will appear as a “neck” on the balloon and can be slowly dilated. Care should be taken to ensure the inflated balloon diameter is not larger than the diameter of the common duct to avoid injuries. The balloon is inflated for at least 2 min to slowly dilate the cystic duct. The balloon is then deflated and removed along with the guidewire. The C-arm can now be backed away from the field. The choledochoscope is then inserted through the cystic duct introducer sheath into the cystic duct. Saline is turned on to distend the ducts and facilitate visualization as the scope is advanced. It is important for the surgeon to recognize and minimize bowing of the scope by watching both laparoscopic and choledochoscopic views. Once a stone is visualized, the surgeon passes a wire basket through the working channel and uses it to capture the stone (Fig. 13.5). It is often helpful to decrease the flow of saline to reduce movement of the stone to facilitate capture. Once the stone is captured in the basket, the basket and scope are withdrawn together from the cystic duct. To prevent entrapment of the basket in the cystic duct, try to remove stones one at a time and do not try to remove stones

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Figure 13.5 A wire basket is used through the choledochoscope channel to capture a stone

Figure 13.6 A transcystic choledochoscope can sometimes be maneuvered proximally to visualize the hepatic ducts

that are too large (these are better removed via a transcholedochal approach or should undergo fragmentation first). Some small distal stones can sometimes be pushed with the tip of the choledochoscope into the duodenum. Inspection with the scope should confirm removal of all distal stones. Usually the 2.8 mm diameter scope can be maneuvered past the papilla, and sometimes the newer, more flexible scopes can also be retroflexed in the duodenum to examine the papilla and may also at times be maneuvered proximally to

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inspect the hepatic ducts if the angle of the cystic duct-common duct junction allows (Fig. 13.6). Transcystic exploration may fail if the stone(s) are too large to remove through the cystic duct, if stones are proximal, or if the stone cannot be captured/dislodged. In this situation the surgeon may convert to a transcholedochal approach where more robust options for stone removal are possible or plan for postoperative ERCP. A temporary plastic biliary stent may be left to facilitate ERCP, improve biliary drainage in cases of infection, or if there is concern for ampullary edema postoperatively. A completion cholangiogram should be performed to confirm stone clearance and to identify any extravasation that would indicate a biliary injury from manipulation. We recommend ligating the cystic duct with a ligating loop rather than with clips alone for a more secure closure given that the duct has undergone dilation. Attention can then be turned to completion of the cholecystectomy in the usual fashion.

Transcholedochal CBDE Transcholedochal LCBDE involves clearance of the biliary tree via a ductotomy in the common bile duct. Conditions that are favorable for this approach include larger stone size (>10 mm), dilated CBD (>7 mm), multiple stones, proximal CBD stones, narrowed or tortuous cystic duct, or failed transcystic approach. This is a more technically challenging option, and patient selection and surgical skill should factor into the decision-making. Good intracorporeal suturing skill is a prerequisite for this approach. Placing an extra trocar in the right lower quadrant will facilitate transcholedochal exploration. The surgeon operates from the right side and uses the right lateral trocar along with the extra trocar for two-handed maneuvers, while the assistant retracts the gallbladder cephalad using the subxiphoid trocar. The peritoneum covering of the hepatoduodenal ligament is incised and the anterior aspect of the supraduodenal CBD

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Figure 13.7 The surgeon flushes the bile duct through the ductotomy using the suction irrigator to flush out stones

exposed. Being mindful of the vascular supply to the CBD in the 3- and 9-o’clock positions, a longitudinal ductotomy 1–2 cm in length is made with either a laparoscopic knife or scissors. If the location of the common duct is not clear, aspirating bile with a narrow-gauge needle will confirm its location. Stay sutures are not routinely necessary. Once the ductotomy is made, the initial maneuver should be to flush the duct vigorously with the tip of the suction irrigator (Fig.  13.7). This will often cause the stone(s) to follow the flow of saline out of the ductotomy. A 14F red-rubber catheter may be passed into the duct and flushed as it is withdrawn to augment the flushing maneuver. Next, the choledochoscope is passed to inspect the ducts (Fig.  13.8). Again, it is helpful to place a 12 Fr plastic sheath through the mid-­ clavicular working port with the tip in close proximity to the ductotomy to facilitate handling and prevent bowing of the choledochoscope. If inspection reveals residual stone(s), wire baskets may be used to capture the stone(s). Stones that are lodged in the papilla may present more of a challenge than free-floating stones. If a nitinol basket fails to capture these stones, the surgeon may use a steel-wire basket with greater radial force to try to dislodge the stone. If this fails, the sur-

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Figure 13.8  The choledochoscope is withdrawn. Irrigation causes a stone to float toward the ductotomy which can then be removed with a grasper

geon may attempt to pass a guidewire past the stone, and then over the guidewire, use a balloon extraction device (commonly used for ERCP) to dislodge the stone. The device is passed beyond the stone into the duodenum and inflated. The balloon is then slowly deflated while withdrawing the device with a grasper until it is felt to pass the papilla, at which point it is reinflated and withdrawn to remove the stone (Fig. 13.9). If the stone is unable to be dislodged, there are fragmentation techniques (shock-wave lithotripsy or laser) which may be used, but they are rarely necessary and beyond the scope of this chapter. Once the biliary tree has been cleared distally and proximally with the choledochoscope, the duct is closed. If the surgeon is unable to clear the biliary tree, a biliary stent or T-tube should be placed to protect the closure. The biliary stent may be placed over a wire through the choledochotomy and is guided in position with fluoroscopy or with the choledochoscope (Fig.  13.10). Internal (with biliary stent) or external drainage (with T-tube) is also recommended in situations of infected bile or when there has been edema or manipulation of the papilla. Failure to drain the biliary system in these situations may result in persistent cholangitis or obstruction/pressurization of the bile duct from papillary edema or spasm placing the ductal closure at risk.

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Figure 13.9 A balloon extraction device visible through the ductotomy has dislodged a distal stone

Figure 13.10  A biliary stent is placed to provide internal drainage. In this case the stent is positioned alongside and is guided by the choledochoscope

Primary closure alone is acceptable in selected straightforward procedures and has been shown to be safe compared to traditional closure around a T-tube. Closure is performed using absorbable suture in a running or interrupted fashion. The authors prefer to use a 4-0 vicryl suture in a running technique (Fig.  13.11). Similar to the urinary tract system,

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Figure 13.11  The surgeon closes the ductotomy with a running 4-0 vicryl suture. One to 2  mm full-thickness bites are taken, and the suture is cinched between bites

avoiding permanent suture is recommended due to its lithogenic potential. As with the transcystic approach, a completion cholangiogram through the cystic duct should be obtained to confirm a water-tight closure, rule out biliary injuries, and confirm stone clearance. A closed-suction drain is routinely placed adjacent to the ductotomy and removed once the patient resumes a regular diet as long as no bile leak is noted.

Outcomes About 60–70% of cases in the authors’ experience will be amenable to transcystic exploration and will be successfully cleared. If the surgeon also performs transcholedochal exploration, success rate for stone clearance will approach 90–95%. Complications specific to LCBDE are infrequent and include pancreatitis (which in most cases is mild and self-limited, resulting from papillary manipulation), persistent cholangitis or biliary obstruction if drainage is inadequate, retained stones, bile leak (reported rate around 5–7% from choledochotomy site in large series), and biliary injury or strictures in

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less than 1% of cases. Length of stay typically depends on the operative indication, with cholangitis and pancreatitis patients typically having a longer length of stay than patients with unsuspected silent stones, which can usually be discharged after an overnight hospital stay. Postoperative ERCP can be used as a salvage maneuver for patients with retained stones or persistent obstruction/cholangitis. Biliary stents are typically removed 2–4 weeks postoperatively with a gastroscope utilizing a snare or forceps to grab the stent. A clear plastic cap on the gastroscope facilitates visualization of the stent and the papilla.

 dvice for Surgeons Wishing to Start Doing A LCBDE A good option for surgeons wishing to start performing LCBDE is to take a simulation-based course to familiarize themselves with the equipment and techniques under guidance from experienced surgeons. Prior to starting LCBDE at an institution, the surgeon is also advised to educate the operative team on the techniques and reasons for them and to organize a CBD cart to make the procedure smoother. Explaining to the OR staff that LCBDE can potentially save a patient from additional procedures is motivating and empowering to the OR team. Performance of routine cholangiography (if not already done) is also strongly recommended as this allows the surgeon to become facile with catheter and wire manipulation (in cases of difficult cannulation) and cholangiogram interpretation. Routine cholangiography also reveals asymptomatic stones, which are generally the most amenable to LCBDE.  Transcystic techniques are the easiest to start with and allow the surgeon to gain experience with straightforward LCBDE. It is important to remember that acquiring LCBDE skills is an incremental process and that ERCP is almost always a good backup option upon should LCBDE not be successful, especially early in the surgeon’s learning curve. The authors believe that most of

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today’s general surgeons have the skill set to successfully adopt transcystic LCBDE into their armamentarium. As the surgeon gains experience, and depending on individual skills and practice needs, more advanced techniques such as transcholedochal exploration can be incorporated. As a reference, we have included a list of the equipment that we use for LCBDE, which can serve as a potential starting point for a case cart (Table  13.1). Also included is an algorithm for CBDE that can be used for education and reference purposes (Fig. 13.12).

Intra-operative cholangiogram

Type of step: Cognitive/Decisionmaking

Insert catheter

Technical

Secure catheter

Endpoint

Interpret cholangiogram

Small stone or small CBD If successful: finish cholecystectomy

If successful: finish cholecystectomy

Transcholedochal approach

Attempt to flush stone

Choledochotomy

Attempt glucagon + flush Gain wire access to CBD

Insert choledochoscope

Insert balloon Dilate cystic duct Insert choledochoscope Repeat until clear

Turn on irrigation Repeat until clear

Capture stone If stone is too large

Extract stone Prepare T-tube

Turn on irrigation Capture stone Extract stone

If CBD not clear

Large/Proximal stone and large CBD

Transcystic approach

Insert T-tube Select suture

Closing cholangiogram

Close choledochotomy

Transect cystic duct

Externalize T-tube

Ligate cystic duct

Closing cholangiogram

Finish cholecystectomy

Finish cholecystectomy

Figure 13.12  Intraoperative algorithm for the management of choledocholithiasis. (Figure used with permission from: Springer)

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Summary LCBDE is an elegant technique that allows the general surgeon to manage most cases of choledocholithiasis in patients also requiring cholecystectomy. Most patients can be treated in a single-stage fashion, and we believe that most general surgeons possess the basic skill set that is required for learning to perform CBDE: basic laparoscopic skills, wire-guided fluoroscopic skills, and flexible endoscopy skills. Increased adoption of LCBDE can lead to fewer procedures, decreased costs, and shorter hospital stays for patients [7].

References 1. Bansal VK, et  al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc. 2014;28(3):875–85. 2. Lu J, et al. Two-stage vs single-stage management for concomitant gallstones and common bile duct stones. World J Gastroenterol. 2012;18(24):3156–66. 3. Lu JX, Xian-Ze, Cheng Y, Lin Y-X, Zhou R-X, You Z, Wu S-J, Cheng N-S.  One-stage versus two-stage management for concomitant gallbladder stones and common bile duct stones in patients with obstructive jaundice. Am J. 2013;79(11):7. 4. Topal B, et al. Hospital cost categories of one-stage versus two-­ stage management of common bile duct stones. Surg Endosc. 2010;24(2):413–6. 5. Santos BF, et al. Development and evaluation of a laparoscopic common bile duct exploration simulator and procedural rating scale. Surg Endosc. 2012;26(9):2403–15. 6. Moller M, et al. Natural course vs interventions to clear common bile duct stones: data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). JAMA Surg. 2014;149(10):1008–13. 7. Schwab B, et  al. Single-stage laparoscopic management of choledocholithiasis: an analysis after implementation of a mastery learning resident curriculum. Surgery. 2018;163(3):503–8.

Chapter 14 Management of Common Bile Duct Injury Marc G. Mesleh and Horacio J. Asbun

Introduction Since the laparoscopic cholecystectomy (LC) was first introduced in the 1980s, the adoption of minimally invasive surgery for gallbladder disease has widely been accepted as the standard of care. Approximately 700,000 laparoscopic cholecystectomies are performed annually in the United States [1]. While the frequency of major bile duct injury (BDI) during LC is relatively rare, because of the total volume of this case being performed, the incidence of injury is still significant. For example, the SAGES Safe Cholecystectomy Task Force estimates a BDI rate of 0.3%. Based on the number of total LCs performed, this translates to an incidence of 2100 Common Bile Duect (CBD) injuries per year in the United States [2]. The following chapter presents the guiding principles for identification and management of BDI.  The identification M. G. Mesleh (*) Department of Surgery, Advocate Christ Medical Center, Oak Lawn, IL, USA e-mail: [email protected] H. J. Asbun Chief of HPB - Miami Cancer Institute, Miami, FL, USA Professor of Surgery - Mayo Clinic, Jacksonville, FL, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_14

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of injury is extremely important, and the surgical management depends on the training and the experience of the surgeon. When a surgical complication occurs, it is critical to recognize the injury and think rationally. There is a risk of making a bad situation worse when attempting to fix a problem one is not proficient at handling. Outcomes for patients with CBD injuries have been shown to be improved in high-volume centers with hepatopancreatobiliary (HPB) surgeons.

Recognizing an Injury LC is performed with such frequency that often the steps become routine. However, the following intraoperative findings should raise the level of suspicion for a BDI: dividing structures without achieving a critical view of safety, presence of unexplained bile in the operative bed, incomplete intraoperative cholangiogram, identification of a second structure after the cystic duct is clipped, or a double lumen encountered when the cystic duct is clipped and transected. The “Critical View of Safety” (CVS) is defined by three criteria. First, all fibrous and fatty tissue is cleared off of the hepatocystic triangle. Secondly, the lower third of the gallbladder is dissected off the liver to expose the cystic plate. Finally, two and only two structures should be seen entering the gallbladder. Please see Chap. 3 for further discussion of this definition. Whenever structures are divided before achieving the CVS, the surgeon must ensure that the anatomy is clearly defined. When there is suspicion for a BDI, efforts should be made to rule out the presence of an injury even if consultation with another surgeon is needed. The presence of an unexplained source of bile in the operative field raises the suspicion for a BDI. Occasionally, a rent in the gallbladder will cause bile spillage on the liver hilum. However, when no gallbladder injury was created and bile is present in the hilum, the surgeon must suspect a CBD or common hepatic duct injury causing leakage.

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Intraoperative cholangiography is a very useful adjunct to define anatomy in LC. The inability to visualize the distal or proximal biliary tree on cholangiogram is a possible manifestation of BDI. This could indicate the CBD was transected or clipped. It could also indicate that the structure cannulated for the cholangiogram is actually the CBD, rather than the cystic duct. After transection of the cystic duct and cystic artery, there should not be any additional ductal structures identified and divided. When a second duct is identified during further hilar dissection, there has to be a significant concern for BDI  – specifically that the second duct is actually the common hepatic duct. Finally, when the cystic duct is transected and a double lumen is visualized, this is worrisome for BDI. An extremely short and inflamed cystic duct may allow for the common bile duct itself to be tented up and divided (Fig.  14.1). This scenario is a BDI until proven otherwise. If a biliary injury is suspected or confirmed, surgeons must also ensure there is no associated vascular injury. Due to their proximity, a BDI can also have an adjacent hepatic artery injury. This may change the type of reconstruction needed or affect postoperative care.

Confirming an Injury It is important for the surgeon to assess the degree of BDI, but there is no indication to convert to an open operation unless the surgeon has the training and experience to repair the injury. Care must be taken during any open operation, because BDI can still occur during a difficult open dissection. Therefore, surgeons should not have a false sense of security during open cholecystectomy, and the same dissection principles apply. When an injury is suspected, but not confirmed, there are several laparoscopic options to consider. A cholangiogram catheter can be placed through the cystic duct or the opening

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B1

B2

Figure 14.1  Example of various locations of BDI.  Including how the CBD can be tented up and a double duct seen after clip and transection

in the ductal structure. This can help define the anatomy and assess for leak or occlusion of the CBD or common hepatic duct. For example, if the cholangiogram does not fill the proximal hepatic ducts, this could indicate a complete obstruction of the common hepatic duct (Fig. 14.2). Laparoscopic ultrasound may also be useful to define the anatomy. This is most useful for surgeons who routinely use it, as the utility is user dependent. This tool can be used to assess biliary anatomy and also ensure normal arterial flow at the hilum. (Refer to Chap. 10 in this manual for a detailed description of Laparoscopic Ultrasound technique during LC.)

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Figure 14.2 Intraoperative cholangiogram showing no proximal common hepatic duct. The cholangiogram catheter was placed directly into the CBD, thinking that this was the cystic duct

If an injury is suspected, the surgeon should consider calling for assistance from a surgical colleague. Often a fresh perspective on the visualized anatomy can confirm an injury or delineate a proper dissection. Surgeons should carefully consider whether or not they should convert to an open operation when an injury is suspected or to better define the anatomy of the injury. If the surgeon does not have the experience to repair a bile duct injury, it is preferable to simply place a drain and transfer the patient to a highvolume HPB center with surgical expertise. When an injury has occurred, it is not the time for a surgeon who does not perform HPB surgery routinely to venture into repairing the duct.

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Classification of Injury Multiple classification schemes have been developed to describe CBD injuries. This has been very useful in standardizing discussions and research regarding the incidence of injuries and the outcomes of repair. The most common is the Strasberg classification of injury [3]. Injuries are classified A-E (Fig. 14.3). Groups A, B, C, and D represent partial biliary injury and rents in the CBD which result in biloma and postoperative infections. Group E represent more complex injuries involving the CBD. This group includes complete CBD transection and tissue loss of the CBD, as well as injuries near the hepatic duct bifurcation. These injuries are the most complex to manage and are optimally repaired by a surgeon with HPB expertise. The ATOM classification is an all-inclusive classification system that is very descriptive method of categorizing BDI [4]. This is a nominal classification scheme that defines injury by three categories: anatomy of the injury (A), time of detection (TO), and mechanism of injury (M). For example, the mechanism of injury component can be A

E1

>2 cm

E2

B

C

D

E3

E4

E5

2cm from the Hepatic Duct Bifurcation. E2 - Bile Duct Injury 72 h from the initial operation. PTC is an extremely important intervention in these patients. This is immediately therapeutic to decompress the biliary system and allow the hepatic function to improve and prevent further sepsis. The PTC can also define the proximal anatomy of the injury by giving useful information regarding how far the injury is from the hepatic duct bifurcation and the number of hepatic ducts which require repair (Fig. 14.12). As mentioned, an MRI/MRCP study is also of great utility in assessing BDI and the presence or absence of vascular injury and for planning the repair (Fig. 14.13).

Figure 14.12  PTC revealing complete occlusion at the hilum of the liver

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Figure 14.13  MRCP revealing complete occlusion at the hilum, just below the bifurcation of left and right hepatic ducts

Often, MRCP with eovist can be very helpful for the surgical planning. This also gives information regarding the number of hepatic ducts that require management – anastomosis/ repair (Fig. 14.13). Definitive repair should be delayed for approximately 4–6  weeks [7]. By waiting, the postoperative inflammation will be decreased, and the biliary tree will be more suitable for repair. Also, there is decreased risk for causing additional vascular injuries in the delayed setting. As it has been previously discussed, the definitive surgical repair should be done at a high-volume HPB center. Most often the repair is a Roux-en-Y hepaticojejunostomy (Fig. 14.14). There are several unique considerations to this operation. It is important to ensure that the transected/occluded duct has good vascular supply. Anastomosis to an ischemic duct can cause significant postoperative biliary leak and increase the risk for future stricture of the bilio-enteric anastomosis. If there is any concern for bile duct ischemia intraoperatively, the dissection should be carried higher and the duct trimmed more proximally where the duct is better perfused.

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Figure 14.14  Typical anatomy of Roux-En-Y hepaticojejunostomy used for reconstruction

In cases where the injury is close to or at the hepatic duct bifurcation, it is critical to ensure all ducts are identified and drained. Preoperative planning with PTC and MRCP are essential in these cases. There are commonly normal variants of this anatomy, and these must be identified. Each duct may require a separate anastomosis, or adjacent ducts can be sutured together and drained in one larger anastomosis. Occasionally, the PTC can be positioned across the anastomosis during surgery. This may potentially decrease leakage and future strictures. Additionally, contrast can be injected into the drain to study the duct and anastomosis postoperatively prior to removal. Small duct openings should be spatulated to avoid strictures.

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Conclusion LC is often the most common operation a general surgeon does, but the risk for BDI is not zero. It is critical that surgeons have a plan if an injury is detected intraoperatively and even more important if there is a delay in identification of an injury. This chapter describes the consideration and management options in various situations. The best patient outcomes, with decrease in morbidity and long-term complications, are achieved when the CBD repair is addressed at a high-volume center with an experienced multispecialty team.

References 1. McKinley SK, Brunt LM, Schwaitzberg SD.  Prevention of bile duct injury: the case for incorporating educational theories of expertise. Surg Endosc. 2014;28:3385–91. 2. Buddingh KT, Weersam RK, Savenije RA, van Dam GM, Nieuwerhuijs VB.  Lower rate of major bile duct injury and increased intraoperative management of common bile duct stones after implementation of routine intraoperative cholangiography. JACS. 2011;213:267–74. 3. Strasberg SM, et  al. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101–25. 4. Fingerhut, et al. ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy. Surg Endosc. 2013;27:4608–19. 5. Frilling A, Li J, et al. Major bile duct injuries after laparoscopic cholecystectomy: a tertiary center experience. J Gastrointest Surg. 2004;2004:679–85. 6. Mercado MA, Pineda K, Garcia-Badiola A.  Surgical management of major bile duct injury. ACS Multimedia Atlas of Surgery: Liver Surgery Volume. 2014. 7. Walsh RM, Henderson JM, Vogt DP, Brown N. Long-term outcome of biliary reconstruction for bile duct injures from laparoscopic cholecystectomies. Surgery. 2007;142:450–7.

Chapter 15 Operative Management of Bile Duct Injury in the Presence of Prior Roux-en-Y Mihir M. Shah, Alisha Gupta, and Juan M. Sarmiento

Introduction Roux-en-Y (RNY) procedure was first described by the surgeon Cesar Roux of Lausanne, Switzerland [1]. Its use has increased significantly due to the expansive practice of bariatric surgery (laparoscopic Roux-en-Y gastric bypass  – LRYGB-) [2]. Patients operated for malignancy of the

M. M. Shah Assistant Professor of Surgery, Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA A. Gupta Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA, USA J. M. Sarmiento (*) Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA Division of Gastrointestinal and General Surgery, Emory University, Atlanta, GA, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_15

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stomach sometimes undergo a RNY for the reconstruction of the gastrointestinal tract, and their survival has increased with the new perioperative chemotherapeutic options. It is anticipated that patients with RNY will be seen more frequently in surgical practices. The incidence of bile duct injury is 0.4–0.6% with laparoscopic cholecystectomy [3, 4]. Based on the available literature, the computed number of cases from bile duct injury (BDI) after laparoscopic cholecystectomy in Roux-en-Y gastric bypass (RYGB) patients will be 22–33 cases within the next 4  years, with an increase in the number beyond 4 years [5]. One may anticipate that surgeons managing bile duct injuries will encounter this altered anatomy at some point in their career. We aim to describe the operative reconstruction options to manage a bile duct injury in the setting of prior RNY anatomy.

Operative Reconstruction Options The typical RYGB anatomy is illustrated in Fig.  15.1. The Roux-limb is approximately 75–200  cm in length after LRYGB and usually 40–60  cm in patients undergoing gastrectomy. The biliopancreatic limb is approximately 20–50 cm in length from the ligament of Treitz to the jejunojejunostomy. The alimentary limb distal to the jejunojejunostomy is defined as the common channel.

Hepaticoduodenostomy BDI usually occurs at the common hepatic duct rather than the common bile duct, i.e., proximal to insertion of the cystic duct. A generous Kocher maneuver is performed in an attempt to create a tension-free hepaticoduodenostomy (HD), as seen in Fig.  15.2. This goal may be difficult to achieve due to some anticipated tension at the anastomosis given the proximal nature of the biliary injury. Therefore, our

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Original anatomy Gastric pouch

Gastric remnant

Roux-limb

BP limb Common channel

Figure 15.1  Roux-en-Y gastric bypass anatomy

preference is to perform a hepaticojejunostomy (HJ). It may be more likely to create a tension-free HD in case of injury to the distal bile duct. One may anticipate earlier oral nutrient intake as the functional alimentary limb has not been disrupted [5].

Hepaticojejunostomy Two straightforward possibilities exist for the creation of the HJ. One consists of the division of the jejunum (Roux-limb) proximal to the jejunojejunostomy as illustrated in Fig. 15.3, and the other entails the division of the jejunum (common channel) distal to the jejunojejunostomy as highlighted in Fig. 15.4.

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Resection

Reconstruction

Figure 15.2  Reconstruction with hepaticoduodenostomy Resection

Reconstruction

Figure 15.3  Reconstruction with hepaticojejunostomy (Roux-limb divided)

In the first option (Fig.  15.3), it is imperative to ensure adequate length of the Roux-limb and assess the potential reach for the HJ prior to the division of the jejunum. Once divided, the distal segment of the divided Roux-limb is passed

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Reconstruction

Figure 15.4 Reconstruction with hepaticojejunostomy (common channel divided)

in a retrocolic fashion to create the HJ, and the proximal segment of that Roux-limb is anastomosed to the common channel, i.e., the jejunum distal to the jejunojejunostomy. In the latter option (Fig. 15.4), the jejunum is divided distal to the jejunojejunostomy. The distal segment of the divided common channel is passed in a retrocolic position to build the HJ, and the proximal segment is anastomosed distally as illustrated in Fig. 15.4 [5].

 epaticojejunostomy with Reversal of Gastric H Bypass This is a complex operation and should be considered in an elective setting in a highly selected group of patients. Specifically, this option is reserved for patients who may need repeated endoscopic access to the pancreas or to the pancreatic duct (e.g., intraductal papillary mucinous neoplasm) and for patients suffering from malnourishment as a consequence of the gastric bypass. This technique is well illustrated in Fig.  15.5, where the Roux-limb is detached from the gastric pouch and passed in

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Resection

Reconstruction

Figure 15.5  Reconstruction with reversal of gastric bypass

a retrocolic position to create the HJ. The gastric pouch is re-­ anastomosed to the gastric remnant, resulting in a configuration of RNY HJ, similar to that in a patient with no prior history of RNY anatomy. It may be prudent to place a gastrostomy tube in this setting for potential enteral access or decompression of the previously nonfunctional gastric remnant [5].

Discussion These illustrations on reconstructive options have been previously reported by the authors [5]. It is critical to be familiarized with these techniques for surgical reconstruction during intraoperative decision-making to meet the needs of each individual patient. Some of these illustrations have been reported as case series previously [6–8]. In a case report by Chang et  al., a shown reconstructive option involves biliogastric anastomosis, which is not an optimal choice due to the problems associated with bile gastritis, and not having endoscopic access to the gastric remnant [9]. In the same report, the Roux-limb

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is mobilized to form the HJ without division or disruption. This is a less than optimal option due to the potential kinking of the Roux-limb and the bile reflux with the consequent risk of cholangitis due to passage of food through the HJ. In addition, a leak from the HJ in this scenario would essentially render the Roux-limb nonfunctional due to the inability of the patient to ingest food until adequate resolution of the leak. Using the common channel instead of the Rouxlimb in this fashion would be faced with similar potential problems. The reconstructive options illustrated in this chapter are basic concepts that can be applied to any biliary tract operation requiring reconstruction in the setting of prior RNY anatomy, as well as for some pancreatic operations for benign diseases like chronic pancreatitis. In addition to an expert hepatobiliary surgeon, in this particular scenario, patients may benefit from the expertise of a bariatric surgeon involved with revisional and reoperative surgery.

References 1. Vauthey JN, Maddern GJ, Gertsch P. Cesar Roux – Swiss pioneer in surgery. Surgery. 1992;112(5):946–50. 2. Nguyen NT, DeMaria E, Ikramuddin S, Hutter MM. The SAGES manual: a practical guide to bariatric surgery. New York: Springer; 2008. 3. Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg. 1997;184(6):571–8. 4. Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, Knuiman MW, Sheiner HJ, Edis A.  Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann Surg. 1999;229(4):449–57. 5. Shah MM, Martin BM, Stetler JL, Patel AD, Davis SS, Lin E, Sarmiento JM.  Biliary reconstruction options for bile duct stricture in patients with prior Roux-en-Y reconstruction. Surg Obes Relat Dis. 2017;13(9):1629–34. https://doi.org/10.1016/j. soard.2017.05.023.

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6. Alqahtani MS, Alshammary SA, Alqahtani EM, Bojal SA, Alaidh A, Osian G. Hepaticojejunostomy for the management of sump syndrome arising from choledochoduodenostomy in a patient who underwent bariatric Roux-en-Y gastric bypass: a case report. Int J Surg Case Rep. 2016;21:36–40. https://doi.org/10.1016/j. ijscr.2016.02.009. 7. Peeters G, Himpens J.  A hybrid endo-laparoscopic therapy for common bile duct stenosis of a choledocho-duodenostomy after a Roux-en-Y gastric bypass. Obes Surg. 2009;19(6):806–8. https:// doi.org/10.1007/s11695-009-9829-3. 8. Yaqub S, Mala T, Mathisen O, Edwin B, Fosby B, Berntzen DT, Abildgaard A, Labori KJ. Management of injury to the common bile duct in a patient with Roux-en-Y gastric bypass. Case Rep Surg. 2014;2014:938532. https://doi.org/10.1155/2014/938532. 9. Chang J, Walsh RM, El-Hayek K.  Hybrid laparoscopic-robotic management of type IVa choledochal cyst in the setting of prior Roux-en-Y gastric bypass: video case report and review of the literature. Surg Endosc. 2015;29(6):1648–54. https://doi.org/10.1007/ s00464-014-3937-4.

Chapter 16 Management of Common Bile Duct Stones in the Presence of Prior Roux-en-Y Andrew T. Strong and Matthew Kroh Roux-en-Y (RNY) intestinal anatomy is becoming increasingly common among several different unique patient populations. Roux-en-Y gastric bypass for weight loss is the prototypical example. More than 40,000 of these operations are performed annually in the United States, and a significant proportion of revisional bariatric cases are converted to RNY anatomy [1, 2]. Both obesity and the rapid weight loss following bariatric surgery are independent risk factors for the development of cholelithiasis. Compared to nonobese adults, obese adults have a five- to sevenfold greater burden of choledocholithiasis, which translates to an incidence as high as 25% [3–5]. Stone burden prior to RNY gastric bypass notwithstanding, in the first few months after A. T. Strong Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA e-mail: [email protected] M. Kroh (*) Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates e-mail: [email protected]; [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_16

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bariatric surgery, early alterations in cholesterol and bile salt secretion alters cholesterol concentration in the bile to a solution more in favor of gallstone formation [4]. This leads to more than 50% of patients post-gastric bypass to develop gallstones in the 1st year after surgery. While ursodiol prophylaxis is effective in preventing most gallstones in the first several months after a bariatric operation, when the velocity of weight loss is greatest, it’s efficacy does not reach 100% [6]. This physiology is replicated for all patients with RNY anatomy, even if surgical procedures are not performed for weight loss. Other surgeries with RNY reconstruction include gastric malignancies, recalcitrant gastroesophageal reflux disease, gastroparesis, peptic ulcer disease, complications of other surgical procedures, and others. RNY foregut anatomy precludes facile transoral access to the papilla by endoscopic retrograde cholangiopancreatography (ERCP), and alternative techniques to access routes must be established. In general, if it is known that the sum length of a Roux and biliopancreatic limb are >150 cm, endoscopy is associated with decreased likelihood of successfully completing per-oral papillary or biliary interventions [7]. Evaluation of a patient with suspected choledocholithiasis with RNY anatomy is similar to patients with unaltered foregut anatomy. Patients may present with nausea, and often right upper quadrant abdominal pain, especially after a fatty meal. However, given that fatty meals are not well tolerated in patients with RNY anatomy, this may be less common. Atypical symptoms including chronic abdominal pain, or mid back pain, and vague abdominal pain are not uncommon. Ultrasonographic, computerized tomographic, and magnetic resonance imaging is used to assess for cholelithiasis and ­specifically choledocholithiasis. There may be a greater requirement to have radiographic documentation of bile duct stones prior to intervention, since typically interventions are multistep, or involve more invasive approaches to management compared to patients where transoral access in the non-RNY patient is available.

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Earlier identification of choledocholithiasis when no secondary complications have occurred makes more therapeutic options available. The technique used for management of choledocholithiasis in the presence of RNY depends on several factors, including the clinical stability of the patient, stone size, local equipment availability, and technical expertise of proceduralists with necessary training. Endoscopic, percutaneous, surgical, and various hybrid techniques are available. The decision to proceed down a primarily endoscopic route is largely dependent on personnel’s experience and equipment. When a surgical approach is taken to manage choledocholithiasis in the presence of prior RNY, the first decision branch point occurs if the gallbladder is present or absent. Given an intact gallbladder, a laparoscopic or open cholecystectomy can be performed with all other conventional surgical options available. This includes techniques detailed elsewhere in this text, including transcystic common bile duct exploration and laparoscopic bile duct exploration with choledochotomy, choledocoscopy, and definitive bilioenteric anastomosis. Apart from the likely presence of additional adhesions from prior foregut surgery, all of these options can be performed with prior RNY anatomy with little or no change in technique. The one caveat is the bowel should be evaluated for the present of occult internal hernias when undergoing these operations, since the incidence of asymptomatic internal herniation is as high as 40% [8, 9]. When the gallbladder has been previously resected, several other options exist. Some interventions require serial procedures to dilate access points and allow fistulae to mature, which would be inappropriate to undertake in an acutely unstable patient. Most of the techniques detailed below are various ways to establish intraluminal access such that an ERCP can be performed. The authors reinforce that open common bile duct exploration is also an appropriate technique to manage common bile duct stones, where experience with these procedures is not available.

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Nonoperative Management of Choledocholithiasis in a Patient with RNY Anatomy A number of nonoperative approaches exist for management of choledocholithiasis for a patient with RNY anatomy. These solutions often take expertise from multidisciplinary teams that include bariatric or foregut surgery, interventional radiology, and gastroenterology. Some solutions can be viewed as permanent solutions, and others are intentionally temporary until eventual definitive therapy. However, in centers where equipment or expertise is not available, these temporary solutions may prevent cholangitis and subsequent biliary sepsis and allow transfer to an appropriate center. See the end of this chapter for more emerging technologies in this arena that have yet to be fully vetted or reach widespread use.

Percutaneous Transhepatic Cholangiography for Drainage or Stone Extraction Ultrasound- or computed tomographic-based percutaneous procedures to access the intrahepatic bile ducts can provide an access point for stone extraction, or drainage and decompression of the biliary tree. In the United States, interventional radiologists typically perform these procedures. Biliary drainage can be routed internally, externally, or both. Successful cannulation of the intrahepatic bile ducts is simplest when intrahepatic biliary dilation is present, though this is not a requirement [10, 11]. Wires are used to cannulate intrahepatic ducts and passed into the common bile duct. In the presence of a large stone, it may not be possible to establish wire or catheter access though the papilla. In that ­scenario cannulating as deeply as possible into the biliary tree with external drainage with reduction in obstructive hyperbilirubinemia and diminished likelihood of cholangitis may

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be an appropriate course. In an unstable patient, this may be the quickest therapy to accomplish biliary decompression. In a medically frail patient, this may be considered a definitive therapy. Ideally wire and catheter access would be able to pass completely through the papilla and into the duodenum. A pigtail tip on a catheter can help secure drainage into the duodenum. With this configuration, bile can be drained either internally or externally. Percutaneous techniques to access the bile ducts can also be therapeutic. Once catheter access is established, several options exist for management of choledocholiths. Small stones may be able to be flushed into the duodenum. Serial dilation of the tract over 3–7  days can accommodate larger catheters and balloon-based or net-based systems to remove stones. Typically it is easier to push stones into the duodenum than remove them transhepatically. With large stones, mechanical lithotripsy or laser lithotripsy may effectively lyse the stones such that they can be pushed through the papilla [12, 13]. This can also be combined with percutaneous balloon sphincteroplasty. While multiple sessions may be necessary, this can be a highly effective treatment. Direct visualization and removal of choledocholiths by transhepatic cholangioscopy were first reported in the early 1980s [14]. This technique can be either fluoroscopically guided or be performed with small caliber choledochoscopes [15]. The latter procedure typically requires a tract that has matured around an eight to ten French biliary drain for a minimum of 2  weeks and up to 6 weeks if large stones are expected [15]. When this approach is taken, clearance of stones occurs in 80–100% of cases, though data specific to the post-gastric bypass population is limited [13, 15–17]. Percutaneous techniques may be employed as a first-line therapy or a rescue after other failed methods to clear the common duct of stone disease. Percutaneous transhepatic wires can also be a useful tool in establishing wire access through the papilla in the setting of a difficult ERCP.  A percutaneous wire can be grasped or fed into the endoscope to facilitate endoscopic access to the biliary tree [18].

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Balloon Enteroscopy-Assisted ERCP Selected case reports and small case series report successful double-balloon enteroscopy. However, these reports are isolated to centers with significant advanced endoscopic expertise [19–21]. Even in expert hands, double-balloon enteroscopy is typically only possible with a forward viewing endoscope that lacks an elevator with the precise control often required to cannulate the distal bile duct. Thus, therapeutic double-­ balloon endoscopy is difficult or not possible. In reported series, the ampulla is identified in the majority of cases, and there is a greater than 85% chance of cannulation once the ampulla is identified [20, 22]. Lack of available enteroscopes and personnel with training to perform balloon-assisted ERCP are the limiting factors for more widespread adoption. Compared with surgical- or radiological-assisted procedures detailed below, balloon-assisted ERCP is also associated with a higher rate of technical failure [23].

 urgical Management of Choledocholithiasis S in a Prior RNY As mentioned above, surgical management of choledocholithiasis in the presence of RNY anatomy can be managed by conventional surgical techniques detailed elsewhere in this text. Reviewed here are surgical techniques to allow luminal access for an endoscope through a surgically created orifice.

Overview of Transgastric ERCP There are multiple techniques to establish a gastrostomy in the remnant stomach to allow endoscopic access to the duodenum. This first time this was reported was in 1975  in a patient with an esophageal stricture, and this technique was adapted to a patient status post RYGB in 1998 [24, 25]. In both those cases, an open Stamm-style gastrostomy was cre-

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ated, dilated, and then used for passage of a duodenoscope days later. A laparoscopic-assisted transgastric ERCP (TGERCP) was reported in 2002. Several case reports [14, 26–34], small case series [8, 9, 35–40], and two multicenter studies [41, 42] have been reported since that point.

Percutaneous Gastrostomy with Serial Dilation In centers that lack laparoscopic expertise to access the gastric remnant, percutaneous access is a viable option. Percutaneous gastrostomy technique was reported for the first time in 2006 [43, 44]. Since those reports, additional techniques using ultrasonographic, spiral computed tomography or fluoroscopic-image guidance have been developed. If wire access can be secured to the remnant stomach, typically a small caliber catheter can be inserted into the remnant stomach [45, 46]. If this is the approach taken, the placement of T-fasteners is recommended, while the fistula tract is maturing. Over days to weeks, stepwise dilation of the site will allow a mature fistula tract to accommodate a standard side-­ viewing duodenoscope. From a logistical standpoint, scheduling may be simpler since a single proceduralist is required at any given time, though repeated visits may be an inconvenience to the patients. Successful percutaneous placement of a gastrostomy into the gastric remnant is >90% [45–47]. Technical success rates in terms of identifying the papilla and cannulating and completing an ERCP are on par with laparoscopic-­assisted techniques discussed below.

Laparoscopy-Assisted Transgastric ERCP Surgery to facilitate intraluminal access to the gastrointestinal tract is the most common method to perform ERCP in a patient after RNY.  Surgeries can be performed open or laparoscopically, with the latter being most common. Access can be secured either through the remnant stomach or jejunum to perform

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ERCP in a retrograde fashion. The remnant stomach is the preferred access point if available since this places the duodenoscope in a more conventional position and has a relatively low risk of significant postoperative leak since there is minimal flow of gastrointestinal contents and low intraluminal pressure. Laparoscopy-assisted TGERCP is performed in the operating room, and the patient must be able to tolerate general anesthesia. Prior to the procedure, consideration should be made to room setup, since the extra endoscopy and fluoroscopy equipment may occupy a large amount of space. The room diagrams (Fig.  16.1) below assume portable towers for all equipment, since this is likely the most common configuration, rather than boom-mounted equipment. Carbon dioxide insufflation should be available for both laparoscopic and endoscopic equipment. Patients are positioned supine on an operating table equipped with a footboard. At least the left arm is tucked. If the patients were not already receiving antibiotics, prophylactic antibiotics in accordance with the Surgical Care Improvement Project were administered prior to incision [48]. Abdominal access is performed with either Veress needle or 5 mm optical entry trocar. Following visual inspection of the abdomen, a 5 mm and a 10 mm trocar is placed with the final configuration as depicted in Fig. 16.2. The excluded stomach is lysed from any adhesions, until a portion of the midbody can be mobilized to the anterior abdominal wall without tension. This often requires mobilization of the gastro-­hepatic ligament. Once mobility to the anterior abdominal wall is verified, a free needle is used to place three gastropexy sutures in a triangular configuration, with the ends retrieved trans-facially using a laparoscopic suture passer (see Fig.  16.3). A 15  mm trocar is introduced into the abdomen between the stay sutures. Monopolar electrocautery is used to create a small gastrotomy in the anterior wall of the stomach between the gastropexy sutures. This should be done under laparoscopic vision to reduce the risk of an inadvertent gastrotomy in the posterior stomach wall. The 15 mm laparoscopic trocar is then placed through the gastrotomy and introduced into the lumen of the excluded stomach (see Fig. 16.4). This may be easier to

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Figure 16.2 Port placement for laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography (TGERCP). A 5 mm port is placed first followed by an addition 5 mm and 10 mm trocar. The 15 mm trocar is placed last, lateral to the remnant stomach, and is utilized for the transgastric endoscopy

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Figure 16.3  Stay suture placement – stay sutures are placed laparoscopically and passed to a suture passer to be fixed externally

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accomplish if the pneumoperitoneum is reduced. Securing the stay sutures with hemostat clamps maintains apposition of the excluded stomach to the abdominal wall. Prior to completely releasing pneumoperitoneum, an atraumatic, non-crushing bowel clamp is placed across the proximal jejunum just distal

Figure 16.4 Apposition of the gastric remnant and trocar insertion  – with the stay sutures secured, the 15  mm trocar is passed through the gastric remnant gastrotomy

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to the Ligament of Treitz to limit the extent of small bowel insufflation. A sterile drape is placed across the field with a small hole surrounding the 15 mm trocar to maintain sterility of the operative field. Some centers place a non-sterile duodenoscope through a sterile ultrasound probe cover attached to the trocar (see Fig.  16.5). In some cases laparoscopic and/or

Figure 16.5  Completion of transgastric endoscopic retrograde cholangiopancreatography (TGERCP)  – TGERCP being performed through 15 mm trocar

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fluoroscopic assistance may be useful to assist in directing passage of the duodenoscope toward the duodenum. The ERCP can then be completed, being cognizant that the scope position will be slightly different as the patient is supine. Based upon the pathology found during ERCP and need for stent placement, an intraoperative decision is made to either place a gastrostomy tube or close the gastrotomy. When a gastrostomy tube is placed, a balloon type 20–24Fr tube is typically used, and the transfascial sutures are tied in position. When the gastrotomy is closed, the transfascial sutures are removed, and the gastrotomy is closed using a running suture or stapler. The port sites are then closed and the patient awoken from anesthesia. Laparoscopic-assisted ERCP has a high rate of technical success. A recent multicenter retrospective study of 590 cases reported a 98% technical success rate with laparoscopic-­ assisted ERCP [42]. This was similar to a systematic review that included previously reported transgastric ERCP ­(laparoscopic assisted, endoscopic ultrasound assisted, open surgical) that reported an aggregate 98.9% ampullary access rate, a 98.5% biliary cannulation rate, and a 98.5% ERCP completion rate [49]. Overall complications occur in 10–14% of cases, with the majority being relatively mild [42, 49]. Most complications are surgical site infections or gastrointestinal leaks from the gastrostomy site/gastrostomy tube. As is typical of per-oral ERCP, the rate of ERCP related complications is 2–7% [42, 49]. One published series that included only patients with choledocholithiasis reported much more ­frequent complications (37%) [50]. It is unclear whether this is a result of different classification schema and definitions or reflective of the underlying pathology being treated.

Laparoscopy-Assisted Transjejunal Retrograde ERCP Some patients with REY anatomy lack a remnant stomach, such as the case of gastrectomy for gastric malignancy. In

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other cases, the remnant stomach will not be able to be sufficiently mobilized to reach the anterior abdominal wall, especially when a retrocolic technique was used for RY construction. In those cases the small bowel can be used to provide intraluminal access. Room setup and patient positioning are identical to the transgastric route. The biliopancreatic limb is chosen as an access point. A purse-string suture placed around the trocar will prevent longitudinal tearing of the bowel as the trocar is manipulated for the ERCP. Because access to the papilla is retrograde, a front- or side-viewing scope can be used. Following completion of the ERCP, the access site can be converted to a stapled enteroenterostomy or a large-caliber jejunostomy tube if repeated interventions are necessary. Only case reports have been published to date, but all were technically successful in completing the ERCP [51, 52]. Choosing a location of the initial enterotomy near the jejunojejunostomy allows the surgeon to potentially reconstruct the enteroenterostomy in the same location.

 ther Endoscopic Approaches to Establishing O Access to the Remnant Stomach Innovations in endoscopic devices and techniques have led to more recent developments of endoscopic approaches to establish access to the remnant stomach. In centers where laparoscopic assistance for transgastric or transjejunal ERCP is lacking, these may be alternative approaches to take. However, large-scale studies investigating the following interventions are lacking.

Endoscopic/Trans-prosthetic TGERCP Recent advances in endoscopy have introduced a technique known as percutaneous-assisted transprosthetic endoscopic therapy (PATENT). This technology, a self-expanding covered stent, is passed through the bowel and abdominal walls from

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within the lumen of the gastrointestinal tract using a push technique [53]. The lumen is coapted to the abdominal wall using t-fasteners [53]. The covered stent is then a corollary to a laparoscopic trocar, and endoscopy can be performed through the lumen without access through the abdominal wall. Once the endoscopy is completed, the stent is removed and a balloon enteral access tube is inserted [53]. This technique was adapted for using a patient with RNY anatomy, with results reported in a small case series [54]. A double-balloon endoscope was used to access the remnant stomach, and a covered stent placed into the remnant, followed by an ERCP in a single session [54]. This technique allows percutaneous endoscopic access to the remnant without the 3–4-week waiting period for tract maturation. Interestingly, the five patients included in the report all had suspected sphincter of Oddi dysfunction, for which urgent ERCP is not indicated. Another small case series reports using endoscopic ultrasound guidance to puncture and distend the gastric remnant, allowing placement of a direct percutaneous gastrostomy tube. The gastrostomy tube tract was then dilated, T- fasteners placed, and a fully covered self-­expanding metal stent placed into the remnant. Patients in that series did have choledocholithiasis without cholangitis [55].

 ndoscopic Ultrasound Guided Gastro-gastric E Fistula As endoscopic ultrasound (EUS) has become more prevalent, so also have the applications for it. In combination with lumen apposing stent, reports of the creation of an intentional gastro-gastric fistula with placement of a lumen apposing stent have been published. A conventional, per-oral ERCP was then completed, and the gastro-gastric fistula was closed using an endoscopic suturing device [56]. This has become known as EUS-directed transgastric ERCP (EDGE). Despite a provocative title with the initial publication, other authors quickly cautioned that this may not be ready for

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widespread application without greater study [57, 58]. While an iatrogenic gastro-gastric fistula is a novel approach, and facilitates transoral access to the biliary tree in someone with RNY anatomy, it does have significant disadvantages. Gastro-­ gastric fistula can cause anastomotic ulceration, pouch gastritis, bile reflux, and weight regain. Many times endoscopic suture or large endoscopic clip closures of gastro-gastric fistulae are not durable, and patients then typically need a difficult revision of the gastrojejunal anastomosis and resection of the gastro-gastric fistula. Moreover, this approach is not possible in patients with esophagojejunostomies, or who lack a remnant stomach. EDGE may play a role in management of biliary disease in the future for patients with RNY anatomy, but the therapy should not be taken lightly, and further validation with long-term follow-up is needed.

Conclusion Choledocholithiasis, whether related to cholelithiasis or primary bile duct stones, can be a challenging clinical scenario. Despite numerous innovations and evolving techniques to gain intraluminal access for the performance of an ERCP, conventional techniques in open or laparoscopic bile duct exploration are still valid in the patient with RNY anatomy, especially with an in situ gallbladder. The most common method is transgastric ERCP, either with laparoscopic assistance or through a previously placed percutaneous gastrostomy tube. Local experience and acuity of patient presentation should drive decision-making for these patients.

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14. Ahmed AR, Husain S, Saad N, Patel NC, Waldman DL, O’Malley W.  Accessing the common bile duct after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007;3(6):640–3. 15. Ahmed S, Schlachter TR, Hong K.  Percutaneous transhepatic cholangioscopy. Tech Vasc Interv Radiol. 2015;18(4):201–9. 16. Hazey JW, McCreary M, Guy G, Melvin WS. Efficacy of percutaneous treatment of biliary tract calculi using the holmium:YAG laser. Surg Endosc. 2007;21(7):1180–3. 17. Hwang MH, Tsai CC, Mo LR, Yang CT, Yeh YH, Yau MP, et  al. Percutaneous choledochoscopic biliary tract stone removal: experience in 645 consecutive patients. Eur J Radiol. 1993;17(3):184–90. 18. Mönkemüller K, McGuire B, Wilcox CM, Ramesh J, DuBay D, Eckhoff D.  Percutaneous balloon dilation and placement of endoscopic biliary stent by using the double-balloon enteroscopy ERCP rendezvous technique. Gastrointest Endosc. 2013;78(2):383–5. 19. Choi EK, Chiorean MV, Coté GA, El Hajj II, El Hajj I, Ballard D, et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc. 2013;27(8):2894–9. 20. Emmett DS, Mallat DB. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series. Gastrointest Endosc. 2007;66(5):1038–41. 21. Liu K, Joshi V, Saxena P, Kaffes AJ. Predictors of success for double balloon-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anastomosis. Dig Endosc. 2017;29(2):190–7. 22. Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et  al. A multicenter, U.S. experience of single-balloon, double-­ balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77(4):593–600. 23. Shao X-D, Qi X-S, Guo X-Z.  Endoscopic retrograde chol angiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: a meta-­ analysis. Saudi J Gastroenterol Off J Saudi Gastroenterol Assoc. 2017;23(3):150–60. 24. Schapira L, Falkenstein DB, Zimmon DS.  Endoscopy and retrograde cholangiography via gastrostomy. Gastrointest Endosc. 1975;22(2):103.

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25. Baron TH, Vickers SM. Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP.  Gastrointest Endosc. 1998;48(6):640–1. 26. Pimentel RR, Mehran A, Szomstein S, Rosenthal R. Laparoscopy-assisted transgastrostomy ERCP after bariatric surgery: case report of a novel approach. Gastrointest Endosc. 2004;59(2):325–8. 27. Ceppa FA, Gagné DJ, Papasavas PK, Caushaj PF. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007;3(1):21–4. 28. Nguyen NT, Hinojosa MW, Slone J, Lee J, Khiatani V, Wilson SE.  Laparoscopic transgastric access to the biliary tree after Roux-en-Y gastric bypass. Obes Surg. 2007;17(3):416–9. 29. Nakao FS, Mendes CJ, Szego T, Ferrari AP.  Intraoperative transgastric ERCP after a Roux-en-Y gastric bypass. Endoscopy. 2007;39(Suppl 1):E219–20. 30. Patel JA, Patel NA, Shinde T, Uchal M, Dhawan MK, Kulkarni A, et al. Endoscopic retrograde cholangiopancreatography after laparoscopic Roux-en-Y gastric bypass: a case series and review of the literature. Am Surg. 2008;74(8):689–93; discussion 693–694. 31. Dapri G, Himpens J, Buset M, Vasilikostas G, Ntounda R, Cadière GB.  Video. Laparoscopic transgastric access to the common bile duct after Roux-en-Y gastric bypass. Surg Endosc. 2009;23(7):1646–8. 32. Manassa E, Assalia A, Mahajna A. Laparoscopic intraoperative ERCP through a transgastric approach after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016;12(4):e43–5. 33. Sur A, Sur H, Khan MA.  Laparoscopic-assisted endoscopic retrograde cholangiopancreatography post bariatric surgery: how to overcome the technical challenges. J Surg Case Rep. 2015;2015(3):rjv011. 34. Melero Abellán A, Gumbau Puchol V, Mir Labrador J. Laparoscopy assisted transgastric endoscopic retrograde cholangiopancreatography for the management of choledocholithiasis in a patient with Roux-en-Y gastric bypass. Cir Esp. 2016;94(2):111–3. 35. Roberts KE, Panait L, Duffy AJ, Jamidar PA, Bell RL. Laparoscopic-assisted transgastric endoscopy: current indications and future implications. J Soc Laparoendosc Surg. 2008;12(1):30–6. 36. Gutierrez JM, Lederer H, Krook JC, Kinney TP, Freeman ML, Jensen EH. Surgical gastrostomy for pancreatobiliary and duo-

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denal access following Roux en Y gastric bypass. J Gastrointest Surg. 2009;13(12):2170–5. 37. Bertin PM, Singh K, Arregui ME.  Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc. 2011;25(8):2592–6. 38. Richardson JF, Lee JG, Smith BR, Nguyen B, Pham KP, Nguyen NT.  Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass: case series and review of the literature. Am Surg. 2012;78(10):1182–6. 39. Falcão M, Campos JM, Galvão Neto M, Ramos A, Secchi T, Alves E, et al. Transgastric endoscopic retrograde cholangiopancreatography for the management of biliary tract disease after Roux-en-Y gastric bypass treatment for obesity. Obes Surg. 2012;22(6):872–6. 40. Grimes KL, Maciel VH, Mata W, Arevalo G, Singh K, Arregui ME.  Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. Surg Endosc. 2015;29(7): 1753–9. 41. Snauwaert C, Laukens P, Dillemans B, Himpens J, De Looze D, Deprez P, et  al. Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Rouxen-Y gastric bypass patients. Endosc Int Open. 2015;03(05): E458–63. 42. Abbas AM, Strong AT, Diehl DL, Brauer BC, Lee IH, Burbridge R, et al. Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass. Gastrointest Endosc. 2018;87(4):1031–9. 43. Peters M, Papasavas PK, Caushaj PF, Kania RJ, Gagné DJ.  Laparoscopic transgastric endoscopic retrograde cholangiopancreatography for benign common bile duct stricture after Roux-en-Y gastric bypass. Surg Endosc. 2002;16(7):1106. 44. Martinez J, Guerrero L, Byers P, Lopez P, Scagnelli T, Azuaje R, et al. Endoscopic retrograde cholangiopancreatography and gastroduodenoscopy after Roux-en-Y gastric bypass. Surg Endosc. 2006;20(10):1548–50. 45. Goitein D, Gagné DJ, Papasavas PK, McLean G, Foster RG, Beasley HS, et  al. Percutaneous computed tomography-guided gastric remnant access after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006;2(6):651–5. 46. Shaikh SH, Stenz JJ, McVinnie DW, Morrison JJ, Getzen T, Carlin AM, et al. Percutaneous gastric remnant gastrostomy

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f­ ollowing Roux-en-Y gastric bypass surgery: a single tertiary center’s 13-year experience. Abdom Radiol N Y. 2017;43(6):1464–71. 47. Stein EG, Cynamon J, Katzman MJ, Goodman E, Rozenblit A, Wolf EL, et al. Percutaneous gastrostomy of the excluded gastric segment after Roux-en-Y gastric bypass surgery. J Vasc Interv Radiol JVIR. 2007;18(7):914–9. 48. Mangram AJ, Horan TC, Pearson ML, Christine Silver L, Jarvis WR.  Guideline for prevention of surgical site infection. 1999 [Internet]. Centers for Disease Control; 1999. [Cited 2016 Jul 14]. Available from: https://www.cdc.gov/hicpac/pdf/guidelines/ SSI_1999.pdf. 49. Banerjee N, Parepally M, Byrne TK, Pullatt RC, Coté GA, Elmunzer BJ. Systematic review of transgastric ERCP in Roux-­ en-­Y gastric bypass patients. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2017;13(7):1236–42. 50. Frederiksen NA, Tveskov L, Helgstrand F, Naver L, Floyd A.  Treatment of common bile duct stones in gastric bypass patients with laparoscopic transgastric endoscopic retrograde cholangiopancreatography. Obes Surg. 2017;27(6):1409–13. 51. Lopes TL, Clements RH, Wilcox CM.  Laparoscopy-assisted transjejunal ERCP in a patient with Roux-en-Y reconstruction following partial gastrectomy. J Laparoendosc Adv Surg Tech A. 2010;20(1):55–8. 52. Surdeanu IR, El Moussaoui I, Dika M, Des Marez B, Closset J, Mehdi A. Laparoscopy-assisted transjejunal ERCP in a patient with roux-en-Y gastric bypass. Acta Chir Belg. 2016;1–7. 53. Baron TH, Song LMWK.  Percutaneous assisted transpros thetic endoscopic therapy (PATENT): expanding gut access to infinity and beyond! (with video). Gastrointest Endosc. 2012;76(3):641–4. 54. Law R, Wong Kee Song LM, Petersen BT, Baron TH.  Single-­ session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series. Endoscopy. 2013;45(8):671–5. 55. Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K, Sharaiha RZ, et al. EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc. 2015;82(3):560–5. 56. Kedia P, Sharaiha RZ, Kumta NA, Kahaleh M.  Internal EUS-directed transgastric ERCP (EDGE): game over. Gastroenterology. 2014;147(3):566–8.

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Chapter 17 Advanced Biliary Procedures Eugene P. Ceppa, Thomas K. Maatman, and Patrick B. Schwartz

Introduction The comprehensive management of gallbladder disease includes not only understanding the principles of safe cholecystectomy, intraoperative cholangiography, and bile duct exploration but also the familiarity of the current endoscopic and surgical therapies for the known associated morbidities and special scenarios. In this chapter, we will review several advanced biliary procedures including both endoscopic and minimally invasive surgical bilioenteric anastomoses as well as transduodenal sphincteroplasty with contemporary approaches, indications, technical description, and existing supportive evidence.

E. P. Ceppa (*) ∙ T. K. Maatman Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA e-mail: [email protected]; [email protected] P. B. Schwartz Department of Surgery, University of Wisconsin School of Medicine, Madison, WI, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7_17

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Endoscopic Bilioenteric Anastomoses Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay for achieving biliary drainage in benign and malignant biliary obstruction in the modern era. ERCP can fail due to multiple factors including pathology, anatomy, or the experience of the provider. In the event of failed endoscopic relief of biliary obstruction, standard of care is a percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. However, accompanying these approaches are a higher morbidity and decreased quality of life when compared to endoscopic internal drainage. Percutaneous drainage is associated with patient discomfort, tube displacement, inadvertent removal, cholangitis, and bleeding. Surgical bypass often requires a major operation with inherent risk of bleeding, infection, anastomotic leak, and those risks associated with general anesthetic. As a result, there exists a need to develop further endoscopic therapeutic options in the setting of failed ERCP. The first endoscopic ultrasound-guided (EUS) bile duct puncture was performed in 1996, as reported by Wiersema et al. [10]. Giovannini et al. further advanced this technique with the description of a transduodenal approach to access the bile duct via endosonographic guidance, which proved a novel technique for biliary drainage [12]. The last decade has seen increasing experimentation and success with endoscopic bilioenteric anastomosis. Further, technological advances in endoscopes, ultrasound technology, endoscopic instruments, and stents have increased the feasibility of advanced ­endoscopic techniques. The result is a sparked interest in novel, alternative internal drainage techniques following failed ERCP. In the hands of experienced endoscopists, these techniques can now be performed with higher success rates and lower morbidity. In recent years, studies have shown endoscopic ultrasound-guided biliary drainage procedures to have equivalent outcomes when compared to PTBD and can be performed in a one-step procedure and obviate the need for external drainage [21].

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a

267

b

Figure 17.1 (a) Completion cholangiogram following endoscopic ultrasound-guided choledochoduodenostomy. (b) Cross-sectional imaging of endoscopic ultrasound-guided hepaticogastrostomy

Anastomotic techniques for endoscopic ultrasound-guided biliary drainage (EUS-BD) include choledochoduodenostomy (EUS-CDS, Fig. 17.1a) and hepaticogastrostomy (EUS-­ HGS, Fig.  17.1b). EUS-CDS uses ultrasound guidance to access the common bile duct and both create and stent a fistulous connection between the duodenum and common bile duct (“extrahepatic”). In the case of EUS-HGS, a fistulous connection is created between the left hepatic duct and lesser curve of the stomach (“intrahepatic”). Additionally, internal transmural gallbladder drainage with endoscopic ultrasound guidance is becoming an alternative to percutaneous cholecystostomy tube in select patients.

Indications Given the recent development of these techniques, no consensus guidelines exist for the indications of EUS-BD.  Generally accepted indications mirror those of ERCP; these newer, advanced techniques are used in the event of failed ERCP attempts in both benign and malignant biliary obstruction. Incidence of ERCP failure is reported as high as 5–10% [26]. Increased failure rates of ERCP are associated with altered anatomy from previous foregut surgery (Billroth II, Roux-en-Y, biliopancreatic diversion), periam-

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pullary diverticulum or mass, tumor infiltration of duodenum, gastroduodenal obstruction, tortuous bile ducts, or large impacted stones. Further, internal transmural gallbladder drainage is an option in the patient requiring percutaneous cholecystostomy tube who is otherwise not fit to undergo a cholecystectomy. Following percutaneous drainage and stabilization during the index admission for cholecystitis, the patient returns electively weeks later to undergo EUS-guided internal gallbladder drainage and removal of percutaneous drain. This is an excellent alternative to removing the drain, which is associated with recurrent cholecystitis [22], or leaving the drain in situ as definitive therapy, which is associated with decreased quality of life and repeat intervention. As these techniques become more widely applied, patients should be consented for EUS-BD at the same time as ERCP, and EUS-BD would be performed under the same anesthetic in the event of failed ERCP.

Technique In general, there are two technical aspects of these procedures in which the ideal approach remains unanswered: dilation of the fistula tract and choice of stent. Simple dilation with dilation catheter or balloon appears to be best at the present. Due to increased utilization of these techniques, development of one-step dilation devices that deploy a stent immediately following dilation would be ideal to decrease procedural bile leak. Fully covered stents would be most effective in decreasing bile leaks, yet these can occlude lower-­ order biliary duct radicles. Additionally, stents specifically for this indication are being developed in real time. Currently, a partially covered or fully covered metal stent appears the most durable; these provide the lowest bile leak potential with the best stent patency. However, cost remains high. An ideal stent has proximal and distal anchor flanges to prevent stent migration; an alternative is placing a double-pigtail plas-

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tic stent within the metal stent to act as an anchor. In its simplistic form, the steps to the procedure are as follows: access the biliary system, advance the guidewire to allow dilation of fistula tract, dilation, and stent deployment. Each individual technique carries a few nuances to improve success. In EUS-HGS, visualization of the biliary system, ideally the segment 3 bile duct, is obtained via insertion of the endoscope into the stomach followed by counterclockwise rotation. In this technique, increased hepatic parenchyma helps anchor the stent and decrease migration. In EUS-CDS, the common bile duct is best visualized by insertion of the scope into the duodenal bulb followed by downward and counterclockwise motion. Aspiration should always be performed to confirm bile return. The techniques discussed above regarding dilation and stent selection apply to both EUS-HGS and EUS-CDS.

Outcomes Given its recent conception, few studies evaluating outcomes from these techniques are available, and those available are small volume. However, the preliminary evidence during this innovation period is promising. A meta-analysis reviewing the current published data regarding the two techniques evaluated 10 studies published in the last 5  years; this provided a total sample size of 434 patients undergoing EUS-BD. This sample size displayed the novelty of the technique but provided insight into the feasibility and outcomes. A very high technical success rate was reported: 94.1% and 93.7% for EUS-CDS and EUS-HGS, respectively [27]. Complications in regard to biliary drainage are divided into procedural-related and drainage-related adverse events. Procedure-related events occur in the immediate periprocedural phase and include bile leak, cholangitis, hemorrhage, perforation, peritonitis, sepsis, and death [18]. Drainage-­ related events are those requiring medical treatment that occur >48  h from last intervention [23]. Both prospective

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randomized controlled trials and meta-analysis comparing EUS-BD to PTBD, reported a decreased incidence of procedure-related and drainage-related adverse events with EUS-BD [21, 23, 25, 26]. Furthermore, EUS-BD was associated with a decreased need for repeat intervention, hospital length of stay, and decreased cost. However, it should be reinforced that the available data is limited and further larger randomized trials are needed for definitive evidence documenting superiority of EUS-BD.  Little is known about the long-term outcomes related to EUS-BD, such as stent patency, need for late repeat intervention, and late complications. Stent patency in current literature ranges from 62 to 329  days [27]; recent years have seen an increased stent patency with metal stents when compared to plastic [26]. The need for repeat intervention to maintain biliary decompression is lower when compared to PTBD [25]. Long-term data specific to EUS-BD are needed, such as stent migration, stent erosion, and postoperative data in those undergoing operative intervention following EUS-BD.  With improving technology designed specifically for this procedure, there would be the expectation for improvement in long-term outcomes. The method of biliary drainage achieved via endosonographic assistance, be it EUS-­CDS or EUS-HGS, appears to not affect the rate of adverse events, yet EUS-HGS trends toward longer stent patency and decreased cholangitis. The current data and methodology would suggest performing whichever technique is technically feasible given the individual patient, with a slight preference toward EUS-HGS when able.

Conclusion EUS-BD has emerged as an excellent alternative to PTBD in the setting of failed ERCP. This technique currently remains isolated to specialty centers. EUS-BD has been reported to have a decrease in morbidity and cost while resulting in an increased quality of life when compared to PTBD, even during its period of inception and innovation. EUS-BD is

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expected to evolve as instruments and devices are modified leading to refinement of technique and presumed improved outcomes.

Minimally Invasive Bilioenteric Anastomoses Both historically and contemporarily, the vast majority of biliary surgery has been performed through an open approach, which is appropriate. However, the benefits of laparoscopic surgery have been established in numerous general surgical procedures. Currently, a paucity of data exists regarding the role of minimally invasive biliary surgery. Through the improvement of surgical skill (experience and fellowship training) and technology (optics, robotics, surgical staplers, and tissue sealing devices), surgeons have begun to challenge the standard of care in biliary surgery. Preoperative considerations focus mainly on surgeon experience. However, patient variables to consider when planning a MIS approach include comorbid conditions, past surgical history, body habitus, and hepatoduodenal ligament anatomy. Comorbid conditions play a role primarily as a function of length of anesthetic time and ability to clear carbon dioxide from the pneumoperitoneum. Patients with profound cardiopulmonary disease are particularly fragile if the length of anesthetic time is excessive in minimally invasive approaches. Portal hypertension or cirrhosis can be a major deterrent regardless of approach. Past surgical history alters surgeon’s decision-making in terms of peritoneal access, port placement, the ability to perform the jejunojejunostomy, and whether the small bowel will reach the porta hepatis. Ventral hernia repair with mesh is a special consideration for peritoneal access and contamination of synthetic mesh. Adhesions to the small bowel can prevent formation of an adequate conduit for reconstruction or increase operative times for the enterolysis. Body habitus is not a contraindication but deters some surgeons for multiple reasons. Super morbid obesity (BMI > 50) patients have steatotic livers as a result of fatty

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liver disease and are prone to lacerations (hemorrhage within the operative field significantly impairs image brightness) and fractures leading to further surgery to correct the problem. These patients should be considered for a preoperative liver reduction diets with protein supplementation (7–14 days prior) for a temporary reduction in liver size to optimize exposure and minimize tissue injury. Regardless if using an MIS or an open approach to bilioenteric anastomoses, the presence of bacteria in the bile, cholangitis, or biloma prior to biliary reconstruction implies the need for preoperative antibiotics, biliary endoprosthesis, or percutaneous biliary drains which alters the bile microbiota to higher concentrations of pathogenic biliary organisms. Patients with infection or insensible biliary losses typically are malnourished, dehydrated, possess electrolyte abnormalities, and are deficient in Vitamin K altering coagulation parameters. All of these should be corrected prior to surgery to diminish postoperative complications. Mastering the patient’s preoperative diagnostic imaging leads to improved intraoperative decision-making. Cholangiography provides an intraluminal roadmap of the biliary tree. Identification of cystic duct or cystic duct clips can be performed safely and provide intraoperative details about the location of the bile duct. Cross-sectional imaging with arterial and venous phases assists in determining the location of the hepatic arterial branches (if the right hepatic artery passes anterior or posterior to the common hepatic duct or replaced right or common hepatic arteries) to avoid inadvertent injury or ligation during mobilization of the bile duct.

Indications Advanced benign biliary disease includes iatrogenic bile duct injury and/or stricture, choledocholithiasis with large stones, Mirizzi’s syndrome, sphincter of Oddi dysfunction, duodenal diverticulum, and traumatic bile duct injuries. Most studies have found that a Roux-en-Y hepaticojejunostomy

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is the safest and most reproducible method of bilioenteric reconstruction possessing the best long-term patency rate. Choledochoduodenostomy, cholangiojejunostomy, and cholecystojejunostomy are other suitable biliary reconstructions that are performed as well in selected scenarios [14].

Technique This technical description will highlight laparoscopic Roux-­ en-­ Y hepaticojejunostomy as the preferred bilioenteric reconstruction for the treatment of benign biliary disease; robotic Roux-en-Y hepaticojejunostomy is nearly identical in technical steps. The critical skill set for this procedure is intracorporeal suturing. The patient is positioned supine with both arms out and undergoes a general anesthetic. Port placement can vary between surgeons, but Fig. 17.2 demonstrates one configura-

X

5

5 12

5 - 12

5 - 12

Figure 17.2  Port site placement of laparoscopic Roux-en-Y hepaticojejunostomy. *Camera port; X Optional incision/port for liver retractor

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tion. Our preferred port placement is a 5 mm right subcostal port, a 5 mm left subcostal port, a 12 mm right upper quadrant port (surgeon’s primary port), a 12 mm port in the umbilicus (primarily for the camera), and a 5 mm port in the left upper quadrant. The Roux limb is created first in the supine position. The ligament of Treitz is identified, and the small bowel is divided using a linear stapler with a 3.5 mm staple load 25–50 cm distal to the ligament of Treitz. The mesentery is divided evenly in order not to encroach on the arterial arcade on either side of the divided bowel to decrease undue tension on the mesentery. The bowel proximal to the staple line is the alimentary limb; an additional 50  cm of small bowel distal to the staple line is measured and referred to as the Roux limb (or biliary limb). A side-to-side jejunojejunostomy is fashioned with two 2-0 stay sutures. Enterotomies are created and an articulating 60 mm 2.5 mm staple load is introduced into the bowel to create the stapled anastomosis. The common enterostomy is oversewn with a 3-0 absorbable running suture to complete the jejunojejunostomy. The mesenteric defect is closed with a running 2-0 nonabsorbable suture to prevent future internal hernias. Avoid full thickness bites across the bowel mesenteric edge, which can lead to unnecessary hemorrhage, ischemia, or hematoma near your anastomosis resulting in bleeding, perforation, or obstruction postoperatively. Visualize the Roux limb mesenteric edge and travel down toward the root of the mesentery to ensure the mesentery is not twisted; worth double checking as peripheral visualization can be limited during laparoscopy. Create a defect in the transverse mesocolon to the right of the right branch of the middle colic vessels. Mobilization of the common bile duct within the hepatoduodenal ligament begins with a lateral to medial approach. The station 12p lymph node is just cephalad to the duodenum along the lateral border of the ligament to mark the location of the distal common bile duct. Incise the peritoneum of the anterior ligament to expose the bile duct, which will be lateral to the hepatic proper artery. The right hepatic artery travels anterior to the common hepatic duct in 10–15% of patients.

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Mobilize the ligament further by incising the peritoneum laterally and distally at the 12p lymph node; excision is helpful, as it will open the shared lateral border of common bile duct and portal vein. This will allow for less resistance when dissecting bluntly from medial to lateral posterior to the bile duct. Encircle the bile duct with a vessel loop. Pass a blunt instrument posterior to the bile duct for protection of the portal vein, and use the cautery to divide the bile duct. The cautery can be used to obtain hemostasis at the 3 and 9 o’clock arterial supple at the cut edge of the bile duct. The bile duct should bleed briskly, if it does not then consider shortening the bile duct proximally to the better-perfused tissue. The Trendelenburg position during the intracorporeal hepaticojejunostomy can take tension off the anastomosis by using gravity to bring the Roux limb closer. Reverse Trendelenburg position is useful in obese patients by using gravity to retract the hepatic flexure away from the porta hepatis. For dilated bile ducts, tie two separate 4-0 absorbable sutures together leaving it double-armed. Each suture is cut to a shorter length to 15–20 cm each in length but can be adjusted based on the size of the bile duct. For normal bile ducts, interrupted 4-0 absorbable sutures are used for the posterior and anterior rows. An enterotomy is made on the anti-mesenteric border of the Roux limb. A stay suture is placed at 12 o’clock on the bile duct for retraction of the anterior wall during creation of the posterior row. One arm of the 4-0 absorbable sutures is passed outside in on the bowel, followed by inside out on the bile duct (at 3 o’clock). The posterior row is created first by going inside out on the bowel and then outside in on the bile duct (Fig. 17.3a). Upon completion of the posterior row, tension is maintained on the posterior row. The 12 o’clock stay suture should be removed now to prevent confusion. Optional stenting the anastomosis would occur now with a 12Fr endoprosthesis. The anterior row is started with the other end of the doublearmed suture (at 3 o’clock) by going outside in on the bowel and then inside out on the bile duct. The anastomosis is

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a

b

Figure 17.3  (a) Posterior row of hepaticojejunostomy. (b) Anterior row of hepaticojejunostomy

completed by tying the two sutures on the outside at the 9 o’clock position (Fig. 17.3b). After completion of the anastomosis, the redundant Roux limb is pulled back through the mesocolon defect toward the jejunojejunostomy to prevent biliary stasis in the Roux limb. The limb is secured directly to the peritoneum at the mesenteric defect with 3-0 nonabsorbable suture to potentially decrease the risk of future herniation. Surgical drainage of the anastomosis is by surgeon preference.

Outcomes The majority of the postoperative management centers on bowel function and the advancement of the patient’s diet. The previously established overall complication rate for open hepaticojejunostomy is 10–20% and mortality of 1%. The principal complication for hepaticojejunostomy is the development of a biliary fistula (early) or biliary stricture (late). A previous systematic review reported 19 studies from 1992 to 2010 to date describing a collective experience with true laparoscopic choledochoduodenostomy, cholecystojejunostomy, or hepaticojejunostomy for benign or malignant biliary disease (Table  17.1); the authors reported a biliary fistula or early stricture rate that appears to be similar to that of the open approach [20]. When comparing laparoscopic and open

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Table 17.1 Comparison of laparoscopic and open biliary enteric reconstruction Laparoscopic Open Historical Patients N = 89 data Reviewa Conversion to open 2 (2%) N/A Early patency rate (90 days)

85 (96%)

>90%

Mortality

5 (6%)

1%

Morbidity

11 (12%)

15%

2 (2%)

2%

Biliary fistula Early biliary stricture (1 year)

2 (2%)

Long term patency rate (>20 years)

N/A

a

1% 70–90%

Data and table adapted from Toumi et al. [20]

reconstruction, it is important to note many surgeons with open biliary reconstruction currently do not internally stent nor drain externally their anastomosis. Surgical drainage of an anastomosis is optional. Although not common, it is possible to see bile in the surgical drain on postoperative day 1. Nevertheless, in limited experience with these biliary fistulas, they resolve in 2–3  days later and the majority prior to the date of discharge. If a prolonged fistula is seen, then the surgical drain is left in place at the time of discharge, and the bulb is changed to a bile bag. Prolonged fistulas are managed as an outpatient as long as the patient is asymptomatic and at each clinic visit the drain is retracted a short distance (2–3  cm) away from the fistula and secured to the skin. As long as the surgical drain is in place, rarely does a biliary fistula require intervention or lead to biliary sepsis. The primary outcome following bilioenteric reconstruction is long-term patency rate, which is 70–90% two decades following open Roux-en-Y hepaticojejunostomy; no data exists for long-term patency rate for minimally invasive biliary reconstructions.

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Conclusion Minimally invasive complex biliary surgery is feasible and safe in experienced hands. However besides the necessary HPB training, it does require advance laparoscopic skills, and the technique has begun to progress as readily as minimally invasive liver or pancreatic surgery.

Transduodenal Sphincteroplasty The transduodenal sphincteroplasty (TS) has been in the armamentarium of the general surgeon since it was first described by Jones and Smith in 1952 for either biliary or pancreatic drainage [6]. In an era with a proliferation of advanced biliary and pancreatic endoscopy, the role of TS has evolved as well. However, patients with altered anatomy due to prior surgery involving the stomach including those with a Billroth II or Roux-en-Y reconstruction, antegrade endoscopy becomes more difficult and advanced endoscopic techniques are required for endoscopic access. Double-balloon enteroscopy or laparoscopic-assisted gastrostomy tube access through the gastric remnant are possible, but not always successful nor necessarily lead to improved patient outcomes [17]. Furthermore, these endoscopic techniques are oftentimes only available in specialized tertiary referral centers. As a result, TS remains an important technique to understand conceptually and able to be performed from a technical aspect when endoscopic therapies fail.

Indications In the past, one of the principal indications for TS was obstructive biliary disease most commonly from a large impacted stone at the ampulla. Many of these patients will now be treated with either endoscopic sphincterotomy or sphincteroplasty. However, there is a role for TS for the

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t­ reatment of obstructive biliary disease when chronic inflammation from biliary stones or instrumentation leads to papillary stenosis as well as a need for acute biliary decompression when endoscopic therapies are not available. Although rare in North America, cystic echinococcosis disease occasionally presents as biliary obstruction amenable to TS for cyst clearance [7]. The entity formerly known as sphincter of Oddi dysfunction (SOD) has recently undergone reclassification with the recent Rome IV updates, but despite these changes those patients previously classified by the modified Milwaukee schema as Type I SOD (abdominal pain, dilated common bile duct (CBD) and elevated liver function tests) are thought to have an organic stenosis, and those thought to have Type II SOD (abdominal pain and dilated CBD or elevated liver function tests, but not both) likely have functional biliary sphincter disorder (FBSD) [24]. TS is indicated in Type I SOD and has a role in FBSD, especially if supportive evidence shows normal amylase or lipase, elevated sphincter of Oddi manometry, prolonged transit with hepatic scintigraphy, and absence of other organic causes [3, 24]. Pancreas divisum is one of the most common anatomic abnormalities of the pancreas, occurring in up to 7% of people, and is characterized by non-union of the main and accessory pancreatic ducts resulting in chronic pancreatitis in a small subset of people [16]. Anatomically, it is thought that primary drainage through the accessory duct of Santorini causes backpressure that has the potential to cause chronic pancreatitis. In such patients, TS is indicated with dual sphincteroplasty of both the duct of Wirsung and Santorini. Other causes of chronic pancreatitis, such as functional pancreatic sphincter disorder and idiopathic acute recurrent pancreatitis, have conflicting data supporting TS.

Technique The patient is brought to the operating room and placed supine on a radiolucent table. In those who have not

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­ndergone a cholecystectomy, this is performed in the u usual fashion. The hepatic flexure is retracted inferiorly, and the duodenum and pancreas are mobilized using an extended Kocher maneuver, taking care to expose down to the third portion of the duodenum. This allows for exposure of the papilla and releases strain on the duodenum for a tension-­free closure. Using a three to five French Fogarty catheter, the cystic duct stump is cannulated to access the common bile duct and is advanced antegrade through the duct and out the ampulla into the lumen of the duodenum [2, 8]. After retracting the catheter with the balloon inflated to confirm the exact location of the ampulla, an approximately 1.5  cm longitudinal incision is made over the balloon typically at junction of the second and third portion of the duodenum. A transverse incision is avoided to prevent inadvertent enlargement through retraction. The papilla is typically found on the medial wall and can be seen as a small, round, elevated protrusion. In cases of pancreas divisum where a dual sphincteroplasty is planned, the accessory papilla and duct of Santorini are located just cephalad to the major ampulla. If identification of the accessory duct is difficult, intravenous secretin (2  μg/kg over 1 min) can be administered to assist in identification via the production of bicarbonate rich effluent from the pancreatic duct. Once identified, the papilla may be exposed using an Allis clamp on the lateral aspect, avoiding the pancreatic duct medially, and stay sutures are placed to apply tension on the mucosa surrounding the ampulla [4]. A needle-tipped electrocautery is used to provide adequate hemostasis while creating the sphincterotomy. The biliary sphincterotomy is created by incision superiorly in the 11 o’clock direction for a length of, at most, approximately 1.5–2  cm proximally onto the distal common bile duct. Small, 5-0, nonabsorbable sutures with 2–3  mm bites are then used in an interrupted fashion to approximate duodenal mucosa to biliary mucosa circumferentially while preventing incorporation of the duct of Wirsung into the sphincteroplasty. Attention is then turned

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to the pancreatic duct sphincteroplasty, if required by the procedure, and another incision is used to open the duct of Wirsung along the 5 o’clock direction. In a fashion similar to the biliary sphincteroplasty, the pancreatic ductal mucosal is tacked to the bile duct and duodenal mucosa. A septoplasty is typically performed with the pancreatic sphincteroplasty by incising the septum and suture both sides of septum together in similar fashion. A pancreatic duct stent may be placed based on surgeon preference to decrease the incidence of postoperative acute pancreatitis. If a dual sphincteroplasty is being performed, the accessory duct of Santorini is then probed with a small blunt-tipped probe and opened in the cephalad-medial orientation. The ductal mucosa and duodenal mucosa are then approximated using small nonabsorbable sutures. The sphincteroplasty should be able to accommodate forceps, and any impacted or retained stones or sludge is systematically cleared from the duct. Following stone removal, the duct is irrigated with saline, and the lumen of the duodenum is inspected for hemostasis. The duodenum is then closed transversely in two layers with the first layer being a slowly absorbable suture in a purse-string fashion. Some authors have described an omega-loop closure for their first layer [1]. A second layer of nonabsorbable Lembert sutures is then used to complete the closure. The abdomen is inspected for any bleeding or traction injury from retraction, and the abdomen is closed using the standard technique. Surgical drain is placed, and an intra-abdominal omental patch is performed based on surgeon preference.

Minimally Invasive Transduodenal Sphincteroplasty The laparoscopic TS has been described in the literature and some details are noted here [5, 13]. The patient is placed supine and one author advocates for port placement as shown in Fig. 17.1 [13]. The case is started with a standard laparoscopic Kocher maneuver [5]. A surgical energy device is used to make the duodenotomy. The papilla can be

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found using the same transcystic approach and subsequently opened in the 11 o’clock direction using the harmonic device. A Fogarty balloon can be used to clear any stones and facilitates a trans-ampullary common bile duct exploration. 4-0 stay sutures can create traction between the duodenal and ductal mucosa to allow for choledochoscope passage, which can then be used in the typical fashion. The sphincteroplasty is created using interrupted 5-O PDS intracorporeal sutures. The duodenotomy is then closed with a running 3-0 absorbable suture and interrupted 2-0 Lembert sutures.

Outcomes A recent comparative study examining differences in TS techniques showed certain techniques have a significant effect on postoperative outcomes. The risk of pancreatitis can be minimized by exploring the CBD with a soft as opposed to hard probe, minimizing manipulation of the duct of Wirsung and avoiding transpapillary drainage [11]. Hemorrhage was reduced with use of a soft probe to explore the CBD and ensuring a mucosa-to-mucosa sphincteroplasty. Limiting the size of the duodenotomy minimized duodenal leakage. Finally, avoiding transpapillary drainage reduced early cholangitis. Large-scale follow-up data examining 25,541 TS procedures suggest few acute early complications include bleeding (0.65%), pancreatitis (0.60%), duodenal fistula (0.55%), and cholangitis (0.50%) [9]. Overall morbidity and mortality were found to be 2.3% and 0.8%, respectively. More recent series have found comparable results. In a study of 16 patients who underwent open TS for SOD after a previous Roux-en-Y gastric bypass found that 84.6% of patients had a substantial reduction of pain over the 28-month follow-up period [17]. Another series of 17 patients with long-term follow-up of TS for SOD showed sustained pain relief in all but 1 patient, and a median satisfaction with the procedure

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Table 17.2  Outcomes following open transduodenal sphincteroplasty Outcome Percentage Mortality 2.7 Overall morbidity

31.6 Pancreatitis

Response rate

11.0

Superficial SSI

9.0

Duodenal leak

1.3

Bile leak

1.3

Pulmonary complication

3.8

Urinary tract infection

2.4

DVT or PE

0.5

Excellent

62.3

Good

20.6

Fair

15.5

Poor

1.6

Data and table adapted from Madura et al. [15] SSI surgical site infection, DVT deep venous thromboembolism, PE pulmonary embolism

was 95% [19]. Two patients (11%) had post-procedural pancreatitis. The largest recent series was published by Madura et al. examining 446 patients who underwent TS for SOD or PD (Table  17.2) [15]. The overall mortality rate was 0.2%, and overall morbidity rate was 34.8%, with complications, including pancreatitis, duodenal or bile leak, wound infection, or abscess occurring in 21% of patients. A comparison of endoscopic and transduodenal sphincterotomy/sphincteroplasty showed endoscopic sphincterotomy related mortality and major morbidity did not differ from TS; however long-term complications appear to be higher after endoscopic sphincterotomy (10% vs. ~1%) [11]. Therefore, data would support use of TS when indicated with minimal postoperative complications.

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References 1. Duca S.  Sphincteroplasty in the treatment of biliary tract disease. A prospective study of 46 cases. Langenbecks Arch Chir. 1984;362(1):25–31. 2. Partington PF. Twenty-three years of experience with sphincterotomy and sphincteroplasty for stenosis of the sphincter of Oddi. Surg Gynecol Obstet. 1977;145:61–168. 3. Nakeeb A. Sphincter of Oddi dysfunction: how is it diagnosed? How is it classified? How do we treat it medically, endoscopically, and surgically? J Gastrointest Surg. 2013;17(9):1557–8. 4. Shah KN, Clary BM. Stones in the bile duct: clinical features and open surgical approaches and techniques. In: Jarnagin W, editor. Blumgart’s surgery of the liver, biliary tract, and pancreas. 6th ed. Philadelphia: Elsevier; 2017. p. 585–603. 5. Makary MA, Elariny HA.  Laparoscopic transduodenal sphincteroplasty. J Lap Adv Surg Tech. 2006;16(6):629–32. 6. Jones SA, Smith LL.  Transduodenal sphincteroplasty for recurrent pancreatitis; a preliminary report. Ann Surg. 1952;136(6):937–47. 7. Kourias BG, Tierris EJ.  Transduodenal sphincterotomy with strict indications. An evaluation of 113 cases. Am J Surg. 1966;112(3):426–31. 8. Jones SA, et al. Transduodenal sphincteroplasty (not sphincterotomy) for biliary and pancreatic disease. Indications, contraindications, and results. Am J Surg. 1969;118(2):292–306. 9. Negro P, et al. Surgical risk of the Oddi sphincterotomy. Results of an international survey (25541 cases). J Chir. 1984;121(2):133–9. 10. Wiersema MJ, et al. Endosonography-guided cholangiopancreatograph. Gastrointest Endosc. 1996;43(2):102–6. 11. Carboni M, et al. Transduodenal sphincterotomy in laparoscopic era. World J Surg. 2001;25(10):1357–9. 12. Giovannini M, et  al. Endoscopic ultrasound-guided biliodu odenal anastomosis: a new technique for biliary drainage. Endoscopy. 2001;33(10):898–900. 13. Novellino L, et  al. Laparoscopic transduodenal papillosphincteroplasty. Surg Endosc. 2003;17(11):1849. 14. Chowbey PK, et  al. Laparoscopic hepaticojejunostomy for biliary strictures. The experience of 10 patients. Surg Endosc. 2005;19:273–9.

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15. Madura JA, et al. Surgical sphincteroplasty in 446 patients. Arch Surg. 2005;140(5):504–11. 16. Morgan KA, et al. Transduodenal sphincteroplasty in the management of sphincter of Oddi dysfunction and pancreas divisum in the modern era. J Am Coll Surg. 2008;206(5):908–14. 17. Morgan KA, et  al. Sphincter of Oddi dysfunction after Roux-­ en-­Y gastric bypass. Surgery for obesity and related diseases. SOARD. 2009;5(5):571–5. 18. Weber A, et al. Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts. Eur J Radiol. 2009;72(3):412–7. 19. Roberts KJ, et al. Long-term symptomatic relief following surgical sphincteroplasty for sphincter of Oddi dysfunction. Dig Surg. 2011;28(4):304–8. 20. Toumi Z, et al. Role of laparoscopic approach to biliary bypass for benign and malignant disease: a systematic review. Surg Endsoc. 2011;25:2105–16. 21. Artifon E, et  al. Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-­guided choledochoduodenostomy versus percutaneous drainage. J Clin Gastroenterol. 2012;46(9):768–74. 22. McKay A, et  al. Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients. Surg Endosc. 2012;26(5):1343–51. 23. Nennstiel S, et al. Drainage-related complications in percutaneous transhepatic biliary drainage: an analysis over 10 years. J Clin Gastroenterol. 2015;49(9):764–70. 24. Cotton PB, et  al. Rome IV.  Gallbladder and sphincter of Oddi disorders. Gastroenterology. 2016. 25. Sharaiha RZ, et  al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis. Gastrointest Endosc. 2017;85(5):904–14. 26. Baars J, et  al. EUS-guided biliary drainage: a comprehensive review of the literature. Endosc Ultra. 2018;7(1):4–9. 27. Uemura RS, et al. EUS-guided choledochoduodenostomy versus hepaticogastrostomy: a systematic review and meta-analysis. J Clin Gastroenterol. 2018;52(2):123–30.

Index

A Aberrant ducts, 7 Accessory duct, 7 Acute cholecystitis (AC), 40, 41 ASA-PS score, 66 CCI score, 66 diagnostic criteria, 66, 67 difficult cholecystectomy, 135, 137, 139 grade 1 (mild) AC, 70 grade II (moderate) AC, 70, 71 grade III (severe), 72–74 optimal timing, 74, 75 predictive factors, 66 TG18 treatment strategy, 69 Acute inflammatory process, 41 Anomalous duct, 7 Aparoscopic cholecystectomy acute biliary pancreatitis, 76 acute cholecystitis (see Acute cholecystitis) percutaneous transhepatic gallbladder drainage, 75 transfer criteria, 75, 76 B Balloon assisted endoscopy, 180, 181 Balloon enteroscopy-assisted ERCP, 246

Balloon sphincteroplasty, 162 Bile duct injury (BDI), 3, 28 bile duct transection, 215, 218 classification, 218, 219 delayed identification complete CBD transection/occlusion, 227–229 cystic duct stump leak, 225 lateral/partial BDI, 226, 227 incidence, 234 intraoperative cholangiography, 215 intraoperative management no tissue loss, 219, 221 tissue loss, 221, 222 location, 215, 216 no proximal hepatic ducts, 216, 217 operative management hepaticoduodenostomy, 234, 236 hepaticojejunostomy, 236, 237 reversal of gastric bypass, 237, 238 Roux-en-Y gastric bypass anatomy, 233–235

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 H. Asbun et al. (eds.), The SAGES Manual of Biliary Surgery, https://doi.org/10.1007/978-3-030-13276-7

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288

Index

Biliary access techniques contrast-assisted biliary cannulation, 156 guide wire-assisted biliary cannulation, 157, 158 pre-cut sphincterotomy, 158 sphincterotomy, 158 Biliary anatomy critical view of safety, 7 cystic artery, 16, 18 cystic duct, 14, 15 epicholedochal plexus, 9 falciform ligament, 8 hepatocystic triangle, 6 right hepatic artery, 19, 21 right hepatic duct, 10, 11 Rouviere’s sulcus, 8 sectional ducts, 8 segmental ducts, 8 triangle of Calot, 6 variant duct, 7 Biliary pancreatitis, 76 Biliary sludge, 125 Biliary sphincterotomy, 160, 280 C Calot’s’ triangle, 7 Charlson comorbidity index (CCI) score, 66 Cholangitis, 171, 172 Cholecysto-cholangiogram, 95 Cholecystokinin (CCK), 59 Choledocholithiasis atypical symptoms, 242 non-obese vs. obese adults, 241 non-operative management balloon enteroscopyassisted ERCP, 246 percutaneous transhepatic cholangiography, drainage/stone extraction, 244, 245 patient evaluation, 242 surgical management

endoscopic/trans-­ prosthetic TGERCP, 255, 256 endoscopic ultrasound guided gastro-gastric fistula, 256, 257 laparoscopy-assisted TGERCP, 247, 248, 254, 255 percutaneous gastrostomy technique, 247 remnant stomach, 255 technique, 243 Chronic cholecystitis, 59, 139, 140 Cirrhosis, 42, 141, 142 Common bile duct exploration (CBDE), see Laparoscopic common bile duct exploration Common bile duct stones (CBDS), 98, 100, 125 endoscopic retrograde cholangiopancrea­ tography balloon and wire-basket, 163, 164 balloon sphincteroplasty, 162 biliary access sphincterotomy, 158 choledocholithiaisis, 153, 154 combined approach, 177 contrast-assisted biliary cannulation, 156 endoscopic balloon sphincter dilation, 162 endoscopic papillary balloon dilation, 162, 163 guide wire-assisted biliary cannulation, 157, 158 history, 154 intra-operative, 175, 177 lithotripsy, 164–166, 168 post-operative, 177, 178

Index pre-cut sphincterotomy, 157, 158 preoperative, 175, 176 sphincterotomy, 160, 161 transcystic drainage, 178 genetic components, 151 natural history, 152 non-operative management balloon assisted endoscopy, 180, 181 Endoscopic Ultrasound Rendezvous technique, 180 extracorporeal shockwave lithotripsy, 181 Percutaneous Rendezvous technique, 179, 180 operative choledochoduode­ nostomy, 178 operative management cholangitis, 171, 172 incomplete endoscopic duct clearance, 172, 173 pre-cut/biliary access sphincterotomy, 173 percutaneous techniques biliary tree, 169 difficult endoscopic biliary access, 167 expulsion or extraction, 170, 171 primary choledocholithiasis, 152 Common hepatic duct (CHD), 10, 11 Contrast-assisted biliary cannulation, 156 Critical view of safety (CVS), 7, 28–30, 130, 214 Cystic artery (CA), 16, 18 Cystic duct, 14, 15, 94 Cystic echinococcosis disease, 279 D Delayed bile duct injury

289

complete CBD transection/ occlusion, 227–229 cystic duct stump leak, 225 lateral/partial BDI, 226, 227 Difficult cholecystectomy acute cholecystitis, 135, 137, 139 alternate/bail-out procedures conventional approach, 145, 146 subtotal cholecystectomy, 146 chronic cholecystitis, 139, 140 cirrhosis, 141, 142 difficult access and exposure obesity, 134–136 prior abdominal surgery, 134 Mirizzi syndrome, 140 patient-related and disease-­ related categories, 133 percutaneous cholecystostomy tube drainage, 143, 144 Ductotomy, 206, 209 Duodenal diverticulum, 156 E Electrohydraulic lithotripsy, 166 Endoscopic balloon sphincter dilation (EBSD), 162 Endoscopic bilioenteric anastomoses endoscopic ultrasound-guided bile duct puncture, 266 EUS-BD, 267 EUS-CDS, 267 EUS-HGS, 267 indications, 267, 268 outcomes, 269, 270 technical aspects, 268 Endoscopic lithotripsy, 164 Endoscopic papillary balloon dilation (EPBD), 162, 163

290

Index

Endoscopic retrograde cholangiopancrea­ tography (ERCP), 56–58, 120, 266 balloon and wire-basket, 163, 164 balloon sphincteroplasty, 162 bile duct injury, 223, 224 biliary access sphincterotomy, 158 choledocholithiaisis, 153, 154 combined approach, 177 contrast-assisted biliary cannulation, 156 endoscopic balloon sphincter dilation, 162 endoscopic papillary balloon dilation, 162, 163 guide wire assisted biliary cannulation, 157, 158 history, 154 intra-operative, 175, 177 laparoscopy-assisted transjejunal retrograde, 255 laproscopic-assisted transgastric, 247, 248, 254 lithotripsy, 164–166, 168 post-operative, 177, 178 pre-cut sphincterotomy, 157, 158 sphincterotomy, 160, 161 transcystic drainage, 178 transgastric, 247 Endoscopic/trans-prosthetic TGERCP, 255, 256 Endoscopic ultrasound-guided biliary drainage (EUS-BD), 267 Endoscopic ultrasound guided choledochoduode­ nostomy (EUS-CDS), 267 Endoscopic ultrasound guided gastro-gastric fistula, 256, 257

Endoscopic ultrasound guided hepaticogastrostomy (EUS-HGS), 267 Endoscopic Ultrasound Rendezvous Technique, 180 Epicholedochal plexus, 9 Extracorporeal shockwave lithotripsy, 181 Extrahepatic bile ducts, 7 F Falciform ligament, 8 Favorable organ system failure (FOSF), 72 Flexible choledochoscope, 193, 194 Functional biliary sphincter disorder (FBSD), 279 G Gallbladder CT technology, 53–55 ERCP, 56–58 HIDA, 59 MRI, 55, 56 safe dissection, 32–35 electrosurgery, 34, 35 fundus, 33 hepatocystic triangle, 34 infundibulum aligns, 33 ligation, 36 removal, 37 thermal injury, 34 ultrasound, 51–53 X-radiation, 51, 52 Gallbladder polyp, 44, 53 Gallstones, 45 Guide wire-assisted biliary cannulation, 157, 158 H Heart failure, 44

Index Hepatico-cystic ducts, 14 Hepaticoduodenostomy (HD), 234, 236 Hepaticojejunostomy, 236, 237 Hepatobiliary iminodiacetic acid scan (HIDA), 59 Hepatocystic triangle, 6 I Immediate bile duct injury, 223 Indocyanine green (ICG) drug properties, 110–111 fluorescence biliary imaging, 115 near infrared fluorescent cholangiography accessory duct recognition, 113 accessory ducts identification, 113 advantages, 114 Calot’s and hepatocystic triangle, 110 Calot’s pre-dissection visibility level, 108 cystic duct identification, 112 extrahepatic bile ducts, 109 hepatic duct identification, 113 hepatocystic triangle, 113 ICG administration, 111 initial evaluation, 110 liver bed evaluation, 113 liver excretion, 108 NIR light and xenon light, 112 removal of adhesions, 112 single-site cholecystectomy, 108 visualization common bile duct, 112 Intraoperative biliary imaging, 3 Intraoperative cholangiography (IOC), 195, 199

291

advantages, 97–99 aparoscopic cholecystectomy, 96 cholecysto-cholangiogram, 94 common bile duct stones, 98, 100 components, 93 critical aspects, 94 cystic duct anatomy, 92, 95, 96 indications, 92 radiation hazard, 94 L Laparoscopic biliary ultrasound advantages, 120 anatomical biliary variation, 125 bile duct injury, 119 biliary tree, 124 CBD stone, 125 color flow mode/pulsed wave mode, 123 device set-up, 121 filling defects, 125 hepatic vascular anatomical variation, 123, 124 intraoperative, 120 intrapancreatic portion of duct, 123 postoperative biliary complications and reintervention, 119 SAGES Safe Cholecystectomy Task Force, 119 tilted Mickey image, 122, 123 Laparoscopic cholecystectomy (LC), gallbladder, 1 CT technology, 53–55 ERCP, 56 HIDA, 59 MRI, 55, 56 ultrasound, 51–53 X-radiation, 51, 52

292

Index

Laparoscopic common bile duct exploration (LCBDE) choledochoscope, 193, 194 GallRIKS database, 199 intra-operative algorithm, 211 intraoperative imaging with cholangiography, 195, 199 open approach, 191 outcomes, 209, 210 patient selection, 192, 193 postoperative ERCP, 200, 201 supplies, 195 surgical advice, 210 transcholedochal, 200, 205–209 transcystic, 200–205 video equipment, 195 Laparoscopy-assisted transjejunal retrograde ERCP, 255 Laser lithotripsy, 166, 168 M Mechanical lithotripsy, 165 Medico-legal litigation, 2 Minimally invasive bilioenteric anastomoses comorbid conditions, 271 indications, 272–273 intraoperative decision-­ making, 272 MIS or open approach, 272 morbid obesity, 271 outcomes, 276, 277 portal hypertension or cirrhosis, 271 preoperative considerations, 271 technical aspects, 273–276 ventral hernia repair with mesh, 271 Minimally Invasive transduodenal sphincteroplasty, 281

Mirizzi’s syndrome, 41, 140 Morbid obesity, 45 N Near infrared fluorescent cholangiography (NIRFC) accessory duct recognition, 113 accessory ducts identification, 113 advantages, 114 Calot’s and hepatocystic triangle, 110 Calot’s pre-dissection visibility level, 108 cystic duct identification, 112 extrahepatic bile ducts before dissection, 109 hepatic duct identification, 113 hepatocystic triangle, 113 ICG administration, 111 initial evaluation, 110 liver bed evaluation, 113 liver excretion, 108 NIR light and xenon light, 112 removal of adhesions, 112 single-site cholecystectomy, 108 visualization common bile duct, 112 O Obesity, 134–136 Occult calculi, 99 P Pancreas divisum, 279 Percutaneous cholecystostomy tube (PCT) algorithm, 88 complications, 87

Index drainage, 143, 144 indication, 82 management, 84–86 optimal timing, 84 postoperative, 89 timing of interval, 87, 88 Percutaneous gastrostomy technique, 247 Percutaneous Rendezvous technique, 179, 180 Percutaneous techniques biliary tree, 169 difficult endoscopic biliary access, 167 expulsion/extraction, 170, 171 Percutaneous transhepatic biliary drainage (PTBD), 266 Percutaneous transhepatic cholagiography (PTC), 223, 224, 228, 230 Percutaneous transhepatic gallbladder drainage (PTGBD), 75 Portal hypertension, 42 Pre-cut sphincterotomy, 157, 158 Pregnancy, 44 Primary choledocholithiasis, 152 Pulmonary hypertension, 44 R Reversal of gastric bypass, 237, 238 Right hepatic artery (RHA), 19, 21 Right hepatic duct (RHD), 10, 11 Rouviere’s sulcus, 8, 32 Roux-en-Y gastric bypass (RYGB) anatomy, 234, 235 Roux-en-y hepaticojejunostomy, 222–223, 229, 230 Roux-en-Y (RNY) intestinal anatomy choledocholithiasis atypical symptoms, 242

293

non-obese adults vs. obese adults, 241 non-operative management, 244–246 patient evaluation, 242 surgical management, 246–257 technique, 243 physiology, 242 ursodiol prophylaxis, 242 S Safe dissection bile duct injury, 28 choledochal vascular plexus, 32 critical view of safety, 28–30, 130 cystic artery, 131 cystic duct identification, 29 gallbladder dissection, 32–35 electrosurgery, 34, 35 fundus, 33 hepatocystic triangle, 34 infundibulum aligns, 33 ligation, 36 removal, 37 thermal injury, 34 hepatocystic triangle, 35 infundibulum aligns, 33 intraoperative ultrasound, 29, 31 method of identification, 130 patient positioning, 26 port placement, 27, 28 postoperative management, 37 room setup, 26 Rouviere’s sulcus, 31, 32 SAGES program, 132 surface anatomical landmarks, 31 surgical principles, 27 surgical team orientation, 27

294

Index

Safe laparoscopic cholecystectomy, elective setting acute cholecystitis, 40, 41 cirrhosis, 42 gallstones and morbid obesity, 45 immunocompromised patients, 45 malignancy, 43 Mirizzi’s syndrome, 41 portal hypertension, 42 pregnancy, 44 pre-operative algorithm, 40 pulmonary hypertension/ heart failure, 44 SAGES masters biliary pathway, 2 SAGES Masters program, 2 SAGES Safe Cholecystectomy Task Force, 119 Sphincter of Oddi dysfunction (SOD), 279 Sphincterotomy, 160, 161 Subvesical duct, 12, 14 Superior mesenteric artery (SMA), 21

T Temporary plastic biliary stent, 205 Transcholedochal common bile duct exploration, 200, 205–209 Transcystic common bile duct exploration, 200–205 Transduodenal sphincteroplasty (TS) indications, 278, 279 minimally invasive transduodenal sphincteroplasty, 281 outcomes, 282, 283 technique, 280, 281 Transgasric ERCP (TGERCP), 247 True hepatico-cystic ducts, 14 T-tube, 220 V Variant duct, 7