Stricture of the bile duct

      Benign Stricture 

      (1)Postoperative (80%)

 (2)  Inflammatory (20%)

 Malignant Stricture

Postoperative stricture

Postoperative strictures concern either the common bile duct or the common hepatic duct. In a few cases only the right hepatic duct is implicated. The stricture is the result of a preventable error in technique during the performance of cholecystectomy.

  Blind plunge application of a haemostat to a bleeding cystic or accessory cystic artery, or to the right hepatic artery, is likely to damage the common hepatic duct (Fig. 54.48). The prevention of this tragic happening is standardised. All unexpected haemorrhage in this region should be controlled initially by inserting an index finger into the foramen of Winslow, and pinching the free edge of the gastrohepatic omentum between the finger and thumb. Temporary compression of the hepatic artery in this way allows the bleeding point to be visualised and ligated securely (Hogarth Pringle’s manoeuvre).

  Should cholecystectomy be performed by dissecting from the fundus (fundus-first procedure) too much traction applied to the freed gall bladder may so tent the common bile duct that any forceps intended for the cystic duct grasp the angulated main channel (Fig. 54.49) (forceps should not, in fact, ever be used for grasping the cystic duct prior to ligature — Fig. 54.38).

  Failure to identify the anatomy in Calot’s triangle when there is much inflammation. The common hepatic duct is tied instead of the cystic duct.

  Ignorance of the anatomical anomalies of the bile ducts.

  Laceration of the common bile duct while exploring it for stones.

    In 3 per cent of cases of stricture of the common bile duct, injury occurs during related surgical procedures.

  About 15 per cent of injuries to the bile ducts are not recognised at the time of operation. In 85 per cent of cases the injury declares itself postoperatively by: (1) a profuse and persistent leakage of bile if drainage has been provided, or bile peritonitis if such drainage has not been provided; and (2) deepening obstructive jaundice. When the obstruction is incomplete, jaundice is delayed until subsequent fibrosis renders the lumen of the duct inadequate.

Radiological investigation of biliary strictures

     Ultrasonography

Cholangiography via I-tube, if present

ERCP

Transhepatic cholangiography

  Treatment

In the debilitated patient, temporary external biliary drainage may be achieved by passing a catheter percutaneously into an intrahepatic duct. Also, stents may be passed through strictures at the time of ERCP and left to drain into the duodenum. When the general condition of the patient has improved, definitive surgery can be undertaken. However, both of these methods may be complicated by cholangitis and are not recommended for all cases. For benign stricture or duct transection, the preferred treatment is immediate Roux­en-Y choledochojejunostomy by a surgeon well versed in managing benign postoperative strictures. For a stricture of recent onset through which a guidewire can be passed, balloon dilatation with insertion of a stent is an acceptable alternative provided that the services of an experienced endoscopist are available.

Primary sclerosing cholangitis

This is a chronic fibrosing inflammatory condition of the biliary tree which affects both intrahepatic and extrahepatic ducts, and may involve the gall bladder and pancreas. It is of unknown origin and must be distinguished from secondary sclerosing cholangitis associated with choledocholithiasis. It is associated with inflammatory bowel disease, usually ulcerative colitis, in 5 0—70 per cent of cases, and these patients may be at greater risk of developing a bile-duct carcinoma. The patients are commonly young, being less than 50 years old. They present with a progressive cholestatic disorder and right upper quadrant discomfort, jaundice, pruritis and fever. Investigation reveals a considerable elevation of the alkaline phosphatase, and on cholangiography stricturing and beading of the bile ducts (Fig. 54.50). As the majority of patients has both intrahepatic and extrahepatic biliary tree involvement, surgical treatment is not appropriate. Primarily, these patients are managed with antibiotics, vitamin K, cholestyramine, steroids and azothiaprine, but with little benefit. Repeated dilatation of the strictures is helpful. Many go on to develop cirrhosis due to obstruction. If liver failure supervenes these patients are suitable candidates for liver transplantation.

Parasitic infestation of the biliary tract

  Biliary ascariasis

The round worm, A. lumbnicoides, commonly infests the intestine of inhabitants of Asia, Africa and Central America. It may enter the biliary tree through the ampulla of Vater and cause biliary pain. Complications include strictures, suppurative cholangitis, liver abscesses and empyema of the gall bladder. In the uncomplicated case, antispasmodics can be given to relax the sphincter of Oddi and the worm will return to the small intestine to be dealt with by antihelminthic drugs. Operation may be necessary to remove the worm or deal with complications. Worms can be extracted via the ampulla of Vater by ERCP

Clonorchiasis (asiatic cholangiohepatis)

The disease is endemic in the Far East. The fluke, up to 25 mm long and 5 mm wide, inhabits the bile ducts, including the intrahepatic ducts. Fibrous thickening of the duct walls occur. Many cases are asymptomatic. Complications include biliary pain, stones, cholangitis, cirrhosis and bile-duct carcinoma. Choledochotomy and T-tube drainage and, in some cases, choledocho­duodenostomy are required. Because a process of recurrent stone formation is set up, a choledochojejunostomy with Roux loop affixed to the abdominal parietes is performed in some centres to allow easy subsequent access to the duct system.

Hydatid disease

A large hydatid cyst may obstruct the hepatic ducts. Some­times a cyst will rupture into the biliary tree and its contents cause obstructive jaundice or cholangitis, requiring appro­priate surgery (see Chapter 52).