Surgical paper IX
Several special problems in diagnosis and treatment of biliary tract surgery
Abstract In the realm of biliary surgery, unique anatomical deviations and pathological transformations often necessitate unconventional approaches to achieve therapeutic success and minimize unintended harm. This article delves into the surgical procedures and outcomes of a curated selection of cases from a pool of 456 biliary surgeries. Through a retrospective evaluation, this study seeks to enhance both the diagnostic and therapeutic strategies for managing biliary disorders.
Traditional approaches to biliary surgery, well-versed among surgeons, have been progressively refined to better manage conditions like intrahepatic stones and biliary strictures . However, the nature of challenges that arise during such procedures can be incredibly diverse, and not all can be addressed through standard methodologies or by adhering to a one-size-fits-all surgical protocol. The eventual outcome of the intervention holds significant implications for patient prognosis. This study delves into an array of unique challenges encountered in a collection of 456 biliary surgical cases . It aims to shed light on their pathological underpinnings, surgical strategies employed, and the resulting clinical outcomes, serving as a repository of insights and lessons for future reference.
The patient is a 42-year-old female farmer, medical record No. 13317, who has been experiencing recurrent right upper abdominal colic for eight years. B-ultrasound indicated the presence of gallstones and stones at the left hepatic margin. She underwent surgery in our hospital on December 2, 1986. The surgical findings aligned with the B-ultrasound report. Intraoperative cholangiography displayed normal and unobstructed grade 1 to 3 biliary ducts but failed to reveal clusters of stones on the lower margin of the liver’s left outer lobe. The surgical approach included a cholecystectomy and a partial hepatectomy for stone removal, capped off with sub-hepatic drainage. Bile duct exploration and drainage were not performed, and the patient recovered smoothly without the need for a blood transfusion. She was discharged 12 days post-surgery, fully recovered.
The insights from this case underscore the utility of combining B-ultrasound and intraoperative cholangiography for a more nuanced understanding of the pathology, thereby aiding in the selection of the most appropriate surgical technique. The chosen procedure in this case was minimally invasive and effectively addressed the lesion.
While pre-operative examinations like PTC and ERCP are invaluable, their absence can make it challenging to fully comprehend the intrahepatic bile duct conditions, even when bile duct exploration is performed during the surgery, including choledochoscopy. Intraoperative cholangiography delivers direct imaging of the biliary tree, thus providing valuable guidance and mitigating some of the operative uncertainties.
In this specific case, however, the intrahepatic stones weren’t visualized in the cholangiography. This could have been due to the patient’s positioning during the imaging or perhaps due to obstruction caused by a narrow biliary tract. Thankfully, the diagnosis was confirmed through liver surface palpation, emphasizing the need for a comprehensive evaluation in similar cases.
The patient is a 64-year-old male worker, medical record No. 12928. He was diagnosed with the pentalogy of ACST and underwent emergency surgery in our hospital on April 18, 1986. During the operation, the common bile duct was opened and a pigmented gallstone with a diameter of 2 cm was removed. Microscopic analysis of the bile revealed pus cells, and a culture indicated the presence of E. coli. The gallbladder was found to be atrophic, measuring 3 cm in diameter, and containing 23 mixed stones along with some white mucus. The cystic duct was occluded. Remarkably, the gallbladder had an internal fistula of 0.3 cm with the common hepatic duct, which was patent. To simplify the procedure, separate choledochotomy and cholecystostomy were performed. Angiography on the 19th day post-operation showed normal intrahepatic and extrahepatic bile and pancreatic ducts, and the gallbladder-common hepatic duct fistula was also patent. The patient recovered well and had no symptoms upon a 10-month follow-up.
This was a high-risk case that required immediate surgical intervention, primarily focused on relieving biliary obstruction and draining infectious materials. The operation was straightforward, but the condition of the gallbladder—non-functioning and a disease focal point—posed a dilemma: to remove or not to remove.
The authors argue that the presence of a patent internal fistula would ensure proper drainage, essentially serving as a biliary diverticulum. This is considered harmless, especially given the emergency nature of the surgery and the complexities of the local anatomy that could potentially lead to additional complications, such as stenosis of the main bile duct or biliary leakage. Therefore, opting not to remove the gallbladder was deemed appropriate. Although the gallbladder could have been repaired, the recent inflammation and edema were inhibitory to proper drainage. As a safety precaution, a cholecystostomy was performed instead.
The patient is a 64-year-old female teacher, with medical record No. 4417. She was diagnosed with gallstones based on her medical history and B-ultrasound. A cholecystectomy was performed on October 16, 1984. During the surgery, 23 cholesterol gallstones were discovered in the gallbladder. The common bile duct, measuring 0.7 cm, appeared normal upon inspection and matched the B-ultrasound report. Since there was no history of jaundice, the common bile duct was neither explored nor puncture-confirmed. While removing the gallbladder, a cystic duct of 0.3 cm was found, which gradually tapered and extended away from the hepatic pedicle. The duct was ligated, and attention was then turned to the gallbladder artery. After 75 minutes, the surgery was successfully completed with no postoperative bile leakage and grade A incision healing. However, on the third postoperative day, progressive jaundice was observed. Serum bilirubin levels rose to 8.8 mg% on the 20th postoperative day, suggesting obstructive jaundice.
A follow-up B-ultrasound revealed generalized dilation of both intra and extrahepatic bile ducts, with the common bile duct measuring 1.1 cm in diameter. The patient refused further tests like PTC, and a second surgery was conducted on November 9, 1984. Despite exhaustive efforts, the common bile duct was not located, and no ligated end of the bile duct was found to be enlarged. The surgery lasted six hours, and due to the length of the procedure, no additional enterohepatic drainage was attempted. A catheter was placed for external drainage from the left intrahepatic bile duct, with postoperative bile discharge measuring 150 ml per day. Unfortunately, the jaundice did not resolve significantly. A follow-up after two months showed the intrahepatic bile ducts had thinned and become branch-like. A subsequent surgery on February 10, 1985, resulted in multiple organ failure, and the patient passed away on the fifth postoperative day.
This case underscores the complexity and unpredictability often encountered in biliary tract surgeries. Even when initial surgeries seem successful, complications like postoperative jaundice can emerge. Multiple interventions may not always resolve the issue, emphasizing the importance of thorough preoperative evaluations and planning. The case also draws attention to the limitations of relying solely on imaging for diagnosis, particularly when surgical intervention is involved. Furthermore, the case reiterates the need for cautious decision-making, especially when surgeries stretch on for extended periods, as excessive duration can elevate the risks of complications and unfavorable outcomes.
1. Anomalies in Extrahepatic Biliary Tract
Extrahepatic biliary variations can occur in up to 85% of cases, but the rare variation observed in this case has not been previously reported. The absence of a typical common hepatic duct and common bile duct was noted. Instead, a 0.2 cm duct entering the upper left corner of the gallbladder functioned as the common hepatic duct, and an extended 0.3 cm cystic duct served as the common bile duct. When the gallbladder was removed due to gallstones, the extrahepatic biliary tract was inadvertently damaged. Mistakes in pre- and post-operative B-ultrasound measurements, confusing the common bile duct with the portal vein, also contributed to this issue. Therefore, in such anomalies, exploration of the common bile duct is crucial, and the relationships among the three bile ducts should be thoroughly understood to avoid unnecessary damage.
2. Importance of Preoperative Testing
For surgical jaundice, it is crucial to conduct preoperative PTC and/or ERCP to obtain a clear image of both the intra- and extrahepatic bile ducts. This aids in the surgical planning. In this case, had a high-level biliary obstruction been diagnosed earlier, a lifesaving enterohepatic internal drainage could have been performed during the second surgery. However, repeated delays and long-term obstructive jaundice led to significant liver and multi-organ damage, rendering subsequent surgeries difficult and ultimately futile. This serves as a critical lesson.
3. Limitations of B-scan Ultrasonography
While B-scan ultrasonography is a relatively new and non-invasive diagnostic method, its diagnostic accuracy is 94% for gallstones and 64% for common bile duct stones. However, the modality is often prone to errors due to interference from intestinal gas and large blood vessels. Thus, clinicians should exercise caution when relying solely on B-ultrasonography for diagnosis. In this case, the two B-ultrasound images of the common bile duct were clearly incorrect, significantly contributing to the repeated diagnostic delays.
- Li Mingjie: “Choledocho-Intestinal Drainage.” Proceedings of Symposium on Biliary Tract Surgery, Ministry of Transportation, 37, 1987.
- Li Mingjie: “Left Lateral Hepatectomy for Intrahepatic Calculi.” Domestic Medical Abstracts, 1980; #161.
- Wang Yu: “Journal of Practical Surgery,” 1984; 4(5): 235.
- Chief Editor of China Medical University: “Regional Anatomy.” Beijing People’s Publishing House, 1979; 142.
- Liu Guoli: “Chinese Journal of Surgery,” 1984; 22: 669.
This article was originally published in Proceedings of the Second Academic Conference on Health Care Along the Yangtze Riverthe (27), Dec. 1988；27 Changhang Hospital, Li Mingjie