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General Surgery
Choledochal Cyst and Benign Biliary Strictures
Built from Maingot's Abdominal Operations
What’s inside
14 sections · 175 slides
Overview
- Scope and terminology
- Two disease groups compared
Choledochal cyst
Focal or diffuse dilations of the biliary tree
- Definition and consequences of a biliary cyst
- 1 in 13,000
- Age and sex distribution
Classification
Alonso-Lej, Todani, and what the five types mean
- Development of the classification
- Alonso-Lej and Todani classification of choledochal cysts
- Classification of choledochal cysts as tabulated in the source
- Todani types IA, II and III illustrated
- Todani types IVA, IVB and V illustrated
- Type I and type II cysts
- Type III cyst, the choledochocele
- Type IV and type V cysts
- Controversy about the classification
Pathogenesis
Three theories, and the long common channel
- Ductal plate and obstruction theories
- Pancreaticobiliary maljunction
- Pancreaticobiliary maljunction on cholangiography
- Consequences of a long common channel
- Sphincter pressure and cyst wall pathology
Presentation and diagnosis
From the classic triad to MRCP
- Presentation in children and adults
- Differential diagnosis and first-line imaging
- Type IA cyst on computed tomography
- Type IVA cyst on computed tomography
- MRCP and the role of cholangiography
- Percutaneous cholangiogram of a large type I cyst
- Choosing between PTC and ERCP
- Type IVA cyst drained by bilateral percutaneous catheters
Cancer risk and operative management
Why every cyst is taken out, and how
- Preoperative priorities and malignancy risk
- 2.3%
- Cancer risk by cyst type
- Rationale for complete cyst excision
- Molecular changes, and long-term follow-up
- First steps and the plan for reconstruction
- Laparoscopic resection
- Exposure and distal dissection of a type I cyst
- Exposing the cyst and dividing it distally
- Posterior dissection up to normal duct
- Dissecting up to normal duct
- Completed excision and Roux-en-Y reconstruction
- Roux-en-Y hepaticojejunostomy
- Sequence of a type I cyst excision
- Type II excision and indications in type III
- Type III cyst: surgical technique
- Type IV cysts: operation and the liver
- Malignancy and type V (Caroli's disease)
Results after cyst excision
Complications, follow-up and summary
- 9-41%
- Complications and long-term outcome
- Summary of choledochal cyst disease
Benign biliary strictures
Diverse causes, one common consequence
- Definition and clinical importance
- Congenital and postoperative causes of benign biliary stricture
- Inflammatory and other causes of benign biliary stricture
- Main causes of a benign biliary stricture
Postoperative biliary stricture
Incidence, mechanism and prevention
- Modes of presentation after bile duct injury
- 0.2-0.3%
- Reported incidence data
- Persistence of the injury rate after the learning curve
- Patient and anatomic factors that raise the risk
- Technical factors in laparoscopy
- Classic laparoscopic bile duct injury
- Mechanism of the classic laparoscopic injury
- Frequency and cognitive basis of the classic injury
- Role of intraoperative cholangiography
- Intraoperative cholangiogram showing a clipped common bile duct
- Critical view of safety
- Blood supply of the bile duct, and ischaemia
- Fibrosis after bile duct injury
- Other operations that injure the duct
- Interval from first repair to recurrent stricture
- Timing of recurrent stricture
Classifying and recognising the injury
Bismuth levels, Strasberg classes and presentation
- Minor and major injuries
- Bismuth levels of bile duct stricture
- Bismuth classification of bile duct stricture
- Strasberg classes of biliary injury as tabulated in the source
- Strasberg classification of biliary injury and stricture
- Timing of recognition and intraoperative clues
- Early presentation: the bile leak
- Consequences of intraperitoneal bile
- Biloma on computed tomography after bile duct injury
- Missed leaks, and late presentation
- The laboratory picture
- First-line imaging
- MRCP after a cystic duct leak
- Cystic duct leak on endoscopic cholangiography
- Complete duct transection on endoscopic cholangiography
- Endoscopic and percutaneous cholangiography compared
- Percutaneous cholangiogram in complete duct transection
- Associated arterial injury
Repairing the injured duct
Control sepsis, define anatomy, then reconstruct
- Control sepsis first
- Pitfalls of early re-exploration
- Managing a postoperative bile leak
- Preoperative sequence, early and late
- Aim of the repair
- Injury found during the cholecystectomy
- Ligation versus repair of small ducts
- Primary repair over a T-tube
- End-to-end repair over a T-tube
- Limits of primary repair and the biliary-enteric alternative
- Injury found in the first days after surgery
- Planning a definitive stricture repair
- Tailoring the repair to the Bismuth level
- Debate about transanastomotic stents
- Hepaticojejunostomy over a transhepatic stent
- Completed Roux-en-Y hepaticojejunostomy
- Technique: exposure and duct preparation
- Technique: stents and anastomosis
- Cholangiogram after hepaticojejunostomy
- Postoperative stent care
- Hepp-Couinaud approach and hilar exposure
Non-operative treatment and results
Dilation, stents, and how repairs perform
- Percutaneous balloon dilation
- Balloon dilation of a mid-bile duct stricture
- Risks, limits and evidence for dilation
- A longer follow-up series
- Endoscopic dilation and stenting
- Choosing a stent, and endoscopy versus surgery
- 1.7%
- Mortality, surgeon experience and survival
- Morbidity after repair
- Detail from 200 reconstructions
- Reported results of surgical repair of postoperative strictures
- Results of surgical repair of postoperative bile duct strictures
- Determinants of a successful repair
- Effect of the repairing surgeon
- Results after repair of laparoscopic cholecystectomy injuries
- Surgical repair of laparoscopic cholecystectomy bile duct injuries
- Long-term results from the 1990s
- Quality of life after repair
- Summary of postoperative strictures
Inflammatory causes of stricture
Pancreatitis, stones, parasites and the sphincter
- Inflammatory strictures, and chronic pancreatitis
- Chronic pancreatitis: frequency and presentation
- Long tapering stricture of the intrapancreatic bile duct
- Chronic pancreatitis: imaging and treatment
- Chronic pancreatitis: ineffective options
- Mirizzi's syndrome
- Mirizzi's syndrome: pitfalls and management
- Strictures from stones in the duct
- Handling the distal duct at exploration
- Recurrent pyogenic cholangitis
- The cycle in recurrent pyogenic cholangitis
- Cholangiogram in cholangiohepatitis
- Imaging and treating recurrent pyogenic cholangitis
- Liver resection, hydatid disease and the sphincter
Primary sclerosing cholangitis
Progressive scarring of the whole biliary tree
- Definition of primary sclerosing cholangitis
- Link with inflammatory bowel disease
- Bacterial, immunological and genetic evidence
- Secondary sclerosing cholangitis
- Presentation of primary sclerosing cholangitis
- Diagnosis
- Beading of the intrahepatic ducts in primary sclerosing cholangitis
- Medical management
- Monitoring and dominant strictures
- Surgical resection with stenting
- Survival after resection of the hepatic bifurcation
- Survival curve and natural history
- Liver transplantation
- Transplantation, cancer and summary
- Key points: choledochal cyst
- Key points: benign biliary strictures
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition