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SURGICAL WEBSITES BREAST DISEASE LIVER ABSCESS Anatomy of liver SURGICAL WEBSITES KIDNEY SURGERY POSTGRADUATE SURGERY LINKS
BREAST DISEASE Breast cancer Breast lump Breast awareness Breast calcifications Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis
LIVER ABSCESS Anatomy of liver Physiology of liver Method of examination of liver Haematology of liver disease. Amoebic liver abscess .Pyogenic liver abscess. Percutaneous needle aspiration of liver abscess. Case study. Result Result continued Discussion
CHOLECYSTECTOMY Introduction Historical Review Anatomy of Gallbladder Physiology of Gallbladder Physiologic effects of pneumoperitoneum Pathology of Gallbladder Investigations Pre- operative preparation of laparoscopic cholecystectomy Contraindications Treatment modalities for gallstones. Anaesthesia
INGUINAL HERNIA HOW SURGICAL OPERATION IS DONE THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA BRONCHOGENIC CARCINOMA TETANUS AND ANAEROBIC INFECTIONS
INVESTIGATIONS FOR GALLBLADDER INVESTIGATIONS FOR GALLBLADDER.
A directed history and careful physical examination can usually detect the disease of the gall bladder. The object of investigation is to confirm the diagnosis, to rule out any concurrent illness. In this way make the patient fit for anaesthesia and surgery under given circumstances and to assess post-operative convalescence.
I- HAEMATOLOGICAL INVESTIGATIONS
a. COMPLETE BLOOD COUNT:
i. HAEMOGLOBIN ESTIMATION This is especially important in women who are mensturating and in elderly patients. Look for both polycythemia and anaemia.
ii. TOTAL LEUKOCYTE COUNT: In acute cholecystitis, empyaema of the gall bladder, cholangitis, and in perforation total leukocyte count found out to be high.
iii. DIFFERENTIAL LEUKOCYTE COUNT: Neutorophil percentage will be high in acute cholecystitis, cholangitis, perforation etc.
iv. ERYTHROCYTE SEDIMENTATION RATE: This will be raised in acute cholecystitis, cholangitis, empyaema and malignancy.
v. PLATELET COUNT
b. SERUM ELECTROLYTES:These should be estimated,
i. If the history suggests dehydration due to excessive vomiting etc.
ii. If the patient is on diuretics.
iii. In the presence of cardiac arrhythmia.
iv. If there would be prolonged postoperative intravenous infusion.
c. SERUM UREA:
i. the history suggests fluid or electrolyte disturbance
ii. if he is to be treated with drugs excreted by the kidneys which are potentially toxic ( e.g. gentamicin)
iii. If there is any renal or hepatic pathology.
d. SERUM CREATININE:
To exclude any renal pathology.
e. FASTING AND RANDOM BLOOD SUGAR:
i. the patient is diabetic
ii. there is a family history of diabetes mellitus
iii. if undiagnosed but symptoms and signs suggesting of diabetes mellitus
iv. if there is any suspicion of hepatic or pancreatic pathology like cirrhosis of liver etc.
f. LIVER FUNCTION TESTS:
i. SERUM BILIRUBIN [ CONJUGATED AND UNCONJUGATED]
These are done to exclude any acute or chronic hepatitis, biliary tract obstruction [cholangiolar, hepatic or common ducts]. It will be high in carcinomas
ii. SERUM ALKALINE PHOSPHATASE:
It is elevated in cholangiolar or hepatic duct obstruction due to stones, stricture or neoplasm
iii. SERUM GLUTAMIC PYRUVIC TRANSAMINASE:
To exclude any hepatic damage. As the liver function tests may suggest obstruction or hepatic insufficiency which sets a limit value of oral or intravenous cholecystography.
g. SERUM LIPID PROFILE:
It will be elevated in chronic hepatitis and biliary cirrhosis. It is also increased in obese patients therefore with its help there is preoperative evaluation whether to give injection heparin or not for the prevention of deep vein thrombosis.
h. SERUM TOTAL PROTEIN:
It is decreased in malnutrition in this way affect the postoperative healing process.
i. BLEEDING TIME AND CLOTTING TIME:
To exclude hepatic pathology and while the pre hand knowledge of its abnormality prevents intra operative bleeding.
j. PROTHROMBIN TIME AND PARTIAL THROMBOPLASTIN TIME:
If we want to start prophylactic injection Heparin then it is better to know the normal of the patient.
k. SERUM AMYLASE:
To rule out pancreatitis.
l. CARDIAC ENZYMES:
In patients with history of cardiac problem it should be done 73.
II- UROLOGICAL INVESTIGATIONS:
a. URINE D/R:
i. Gross Examination
ii. Microscopic Examination
iii. Chemical Examination
b. URINE CULTURE:
If the urine D/R shows pus cells and red cells.
III- STOOL EXAMINATION:
a. STOOL D/R
i. Gross Examination
ii. Microscopic Examination
iii. Chemical Analysis
b. STOOL CULTURE:
If the stool D/R shows evidence of infection.
IV- ELECTROCARDIOGRAM [E.C.G.]:
The indications for this investigation are:
i. evidence of cardiac failure;
ii. hypertension treated or untreated;
iii. an irregular pulse
iv. history of angina, myocardial infarction or congenital heart disease;
v. diabetes mellitus;
vi. Men over 50, or women over 60.
V- INVESTIGATIONS DONE ON STONES:
Chemical analysis of the gall stones
VI- RADIOLOGICAL INVESTIGATIONS
a. CHEST X-RAY:
P.A. view of the chest X-ray will be done and performed in the patients:
i. with acute respiratory symptoms;
ii. with suspected or established cardiorespiratory disease who have not have a chest X-ray in the previous twelve months;
iii. with suspected or established malignancy and possible metastasis;
iv. who had history of Tuberculosis, asthma, chronic bronchitis or any other pulmonary infection;
v. who is smoker or history of smoking.
b. PLAIN ABDOMINAL RADIOGRAPHS:
Abdominal X-ray will be done in erect and supine position. Gallstones of which 20-30% are radioopaque, are a mixture of cholesterol pigments, protein and calcium, the content of calcium determining the radiodensity. The densest gallstones are almost pure calcium carbonate, often mulberry shapes. These are characterised by lamination and they are often faceted. Calcium carbonate deposits may occur in the gall bladder as ‘biliary sand’ or ‘limy bile’. A ‘level’ is usually seen on the erect film rarely, a non opaque gall stone can be diagnosed on plain radiography by the presence of gas-containing clefts within it. The clefts are said to result from gas-forming organisms trapped within the stones. It is known as ‘ Mercedes Benz’ sign. About 20% of the patients with multiple gall bladder stones also harbour stones with in the common bile duct. Very rarely, the wall of the gall bladder affected by the chronic inflammatory disease may undergo calcification, resulting in a ‘Porcelain gall bladder’. If there is evidence of dilated intestinal loops, the diagnosis is almost certainly an Empyaema rather than a simple mucocoele of the gall bladder.
VII- INDIRECT CONTRAST STUDIES:
a. ORAL CHOLECYSTOGRAPHY:
Oral cholecystography, a relatively simple and effective test for diagnosing gall stones. While this test may actually permit visualisation of gall stones within the gall bladder, the critical function that is assessed in the absorptive ability of the gall bladder. Previously Telepaque tablets were used. Modern oral contrast media are Biloptin [ Sodium ipodate]and Solu-Biloptin [Calcium ipodate]. They are tri-iodinated benzene rings. A radio opaque iodine containing Halogenated dye is orally ingested by the patient. The dye is first absorbed by the gastrointestinal tract and extracted in the liver. The liver excretes the dye into the biliary ductular system, and the dye then passes through the cystic duct into the gall bladder. Ultimately, if there are no gallstones and if the gall bladder has normal mucosal function, the dye becomes concentrated through the physiological absorption of the water and solutes. A control radiograph is taken and then at about 18:00 hours on the day before the next radiograph the patient has a meal preferably containing some fat in order to empties the gall bladder. The medium is given by mouth, with water, at 21:00 hours. Nothing to eat or drink is taken thereafter. Oblique films of the right upper abdomen are taken in erect and supine positions at 09:00 hours the next day. A fatty meal or drink is then given to stimulate the gall bladder contraction and another radiograph is taken. The appearance of contrast in the gall bladder depends upon the following sequence of steps:
1. Ingestion of the contrast agent by the patient.
2. Adequate absorption of the contrast agent from the gut. Absorption may be delayed if the patient has achalasia of the oesophagus or pyloric stenosis, and adequate absorption may fail to occur in the presence of vomiting, diarrhoea or small intestinal disease.
3. Hepatic excretion of contrast agent in the bile. Excretion may be inadequate in the presence of the significant hepato cellular disease. The examination is contraindicated in the presence of jaundice. If the serum bilirubin is below 40.0 – 50.0 mmol/l then this technique can provide adequate visualisation.
4. Patency of the cystic duct. Contrast agent cannot reach the gall bladder if the cystic duct is blocked.
5. Concentration of the contrast agent in the gall bladder. This require both time and a normal gall bladder mucosa. All oral contrast agents also undergo enterohepatic recirculation.
It is still the excellent method of detection of gall bladder disease and is used when ultrasound examination is negative or inconclusive 74.
b. INTRAVENOUS CHOLANGIOGRAPHY:
Intravenous cholangiography has no routine role in the preoperative assessment in-patients undergoing elective cholecystectomy. In high-risk patients, alternative imaging techniques should be used 75.
There are four major reasons for this:
1. If cholecystectomy is contemplated, the bile ducts will usually be investigated by operative cholangiography.
2. In the symptomatic post cholecystectomy patient [the traditional indication for IVC] the examination is simply not reliable enough for stone or stricture of the duct to be confidently excluded. IVC has been replaced by ERCP [because of the therapeutic possibilities] or by PTC.
3. The extra hepatic bile ducts are frequently well visualised at oral cholecystography, especially after gall bladder contraction or if tomography is performed.
4. There is high incidence of complications.
TECHNIQUE:
A control film is taken to exclude air or opaque stone in the ducts. The contrast agent [typically 30 ml Biligram] is given by slow intravenous injection [5 min] or by infusion [10-15 min]. The medium appears in the duct about 20 minutes after commencement of injection and a coned low – kV film should be taken at this time, with the patient slightly prone oblique to through the duct clear of the spine. Tomography is required for the adequate visualisation. If the serum bilirubin is below 40.0 –50-. mmol then only adequate visualisation of gall bladder is possible.
INTERPRETATION:
The examination is normal if the following conditions are satisfied:
1. The duct calibre is less than 1 cm.
2. No filling defects are seen within it.
3. Contrast appears in the duodenum.
4. Contrast density in the duct is less on a film taken after 1 hour than on the 20 – minutes film. In junction to obtain 24 or 48 hours films “for the gall bladder” should be resisted strongly. The IVC is not an examination for the gall bladder.
COMPLICATIONS:
Hypersensitivity reactions are much more common.
The mortality rate is possibly as high as 1 in 3000.
In the post cholecystectomy patients contrast medium at IVC may pool in the duodenal cap mimicking the gall bladder. Direct cholangiography reveals the true state of affairs.
VIII. NON INVASIVE IMAGING:
The ability to image and visualise the gall bladder, liver and bile ducts with non invasive techniques, such as abdominal ultrasonography, computerised axial tomography, and magnetic imaging, has revolutionised our approach to patients with biliary tract disease. These tests permit us to identify the presence of stones, masses, biliary dilatation, and relation ship to other organs. Common to all three techniques is the concept that a sectional image is developed which physician then puts together with sequential images so as to be able to define anatomy and pathology.
a. REAL TIME ULTRASONOGRAPHY:
This is now the first-line investigation for biliary tract and pancreatic disease in most hospitals. A side from its non invasive nature and lack of any radiation exposure, ultrasound scanning can provide simultaneous information on the following:
1. Presence of the gall stones.
2. Presence of the gall bladder disease.
3. Dilatation of the biliary tract and hepatic parenchymal disease, e.g. tumour deposit.
4. Lesions in the pancreas.
Gall bladder wall thickness has a diagnostic significance but is also helpful in the management of the disease 76. Real time ultrasound in experienced hands can detect gallstones in over 90% of cases. However, its sensitivity for ductal calculi is much less and varies considerably from centre to centre [10-80%]. Gall bladder ultrasound scanning also detects gall bladder enlargement, thickening of the walls and tumours but is less sensitive in the diagnosis of adenomyomatosis than oral cholecystography. Ultrasound examination of the gall bladder has been advocated as the initial diagnostic procedure for acute cholecystitis since it enables the determination of tenderness over the sonographically identified gall bladder and is able to detect pericholecystic collections and gall bladder wall oedema/ thickening [ultrasonographic signs of cholecystitis] in addition to sludge and stones. However, the sensitivity and specificity of ultrasound in the diagnosis of acute cholecystitis is lower than that for gall bladder scintiscanning.
Ultrasound examination may prove unsatisfactory for technical reasons in the following:
i. Obese.
ii. Following previous surgery.
iii. Ascites.
iv. Gaseous distension of the upper abdominal viscera.
It is cheaper than other comparable examinations and cost a fraction of such sophisticated examinations such as CT scan 77.
b. CT SCANNING:
Can provide similar information on the biliary tree as ultrasonography but in view of cost and radiation exposure, it is usually held in reserve when ultrasound examination has failed [usually for technical reasons], in obese patients or in those with excessive bowel gas. Contrast enhancement [vascular or biliary] increases the diagnostic yield. CT scanning provides better detection of solid lesions in the extra hepatic bile ducts [e.g. cholangiocarcinoma], pancreas and liver. This test is not particularly sensitive for identifying gall bladder, but provides much information regarding the nature, extent, and location of biliary dilatation, and masses in and around the biliary tract and pancreas. In general this test provide more useful information when evaluating the jaundiced patients then does the ultrasound. Limiting factors includes patients exposure to ionising radiation and cost.
c. MAGNETIC RESONANCE IMAGING [MRI SCAN]:
Magnetic resonance imaging, also known as nuclear magnetic resonance, although this diagnostic test provides images that may appear similar to CT scans, the image results from the different magnetic properties of the tissues. A contrast material is used for this test: gadolinium. This material, which is administered intravenously, affects the magnetic properties of the tissues. Its role in the evaluation of patients with hepatobiliary diseases remains unclear at this time. The advantages of MRI are:
i. Excellent soft-tissue definition, particularly of the central nervous system because of the lipid/ water content.
ii. It can image in any plane [coronal, sagittal, transverse] without movement of the patients.
iii. It avoids radiation exposure.
iv. It carries no known biological hazard.
Already, MRI has replaced CT scanning for the delineation of soft tissue lesions.
The production of the multiplanar images of the pathological anatomy by MRI accounts for its usefulness in the detection of the site and cause of the obstruction in patients with cholestatic jaundice. Currently MRI is reserved when other methods of investigation have failed to produce the necessary information. However, MRI [if available] should be used in preference to CT in patients with suspected hilar cholangiocarcinoma and primary carcinoma of the gall bladder where it is superior to CT in assessing the presence and extent of extra mural invasion.
d. The Use of Magnetic Resonance Cholangiography (MRIC or MRC):
This emerging technology is being used with increasing frequency in surgical service to identify patients with choledocholithiasis. To date the specificity and accuracy of these studies is 98.2%. Unfortunately, it is an expensive study, and at this time it is only used in specific settings.
These settings are:
1 Patients post laparoscopic cholecystectomy or post-cholecystectomy with possible common bile duct stones.
2 Patients unfit or at high risk to undergo an ERC or ERCP.
e. MAGNETIC RESONANCE SPECTROSCOPY [MRS]:
The future potential, including the ability to obtain information on the chemical composition of the tissue being scanned, is great and has not been fully realised [MRS]. It is likely the MRS will be able to provide the best test of the liver function in the not too distant future. Already, it has been used successfully to identify specific inborn errors of metabolism due to specific enzyme deficiencies.
IX. BILIARY SCINTIGRAPHY:
The most widely used radiopharmaceutical compounds are 99mTc labelled compound of IDA [iminodiacetic acid] and EHIDA [diethyacetanilido- iminodiacetic acid]. These agents which are powerful gamma emitters are administered intravenously, whereupon they are selectively taken up by the hepatocytes and secreted into the bile. They are therefore ideal for the imaging of the biliary tree by a gamma camera, especially since their uptake by the liver and excretion into the biliary tract is not influenced by the presence of cholestasis.
EHIDA-cholescintiscanning is the most accurate test of acute cholecystitis irrespective of its nature (acute calculous obstructive, acalculous cholecystitis) and establishes the diagnosis within one hour of the intravenous administration of the radiopharmaceutical agent. A diagnosis of acute cholecystitis can be confidently made if the scintigram shows prompt excretion and a normal common bile duct and entry of isotopes into the duodenum, but the gall bladder is not imaged. The information is stored on magnetic tape / disc for more detailed computer analysis at a later stage. Cholescintiscanning has a sensitivity of 91-97% and a specificity of 87% for the diagnosis of acute cholecystitis. A normal gall bladder scinti scan is virtually 100% accurate in excluding cholecystitis. False-positives are encountered in:
- Chronic cholecystitis.
- Gall stone pancreatitis.
- Patient with alcoholic liver disease.
- Patients receiving parental nutrition.
The number of false positives results obtained by cholescintigraphy in the diagnosis of acute cholecystitis can be drastically reduced by the administration of the intravenous morphine before the procedure. It can also be used to evaluate the jaundiced patients with the bilirubin greater than 50mmol/l. Hepatocellular disease is diagnosed when poor liver excretion and intestinal activity are demonstrated after 18 hours of injection. Complete biliary obstruction is noted by the absence of any intestinal activity after 18 hours, and partial obstruction by normal liver excretion, dilated ducts and delayed intestinal activity. In jaundice, in neonate biliary scintigraphy and estimation of faecal radioactivity following the intravenous injection of the isotope is one of the routine tests used for the diagnosis of biliary atresia.
EHIDA-scintigraphy is also very useful for the functional evaluation of surgically constructed bilioenteric anastomoses. It is also used to quantitiate enterogastric reflux after the gall bladder contraction it is useful in documenting the presence and location of biliary leaks after cholecystectomy.
X. PROVOCATION TEST
Administration of exogenous cholecystokinin pancreozymin (CCK) will induce pronounced gall bladder contractions if given in infusion of 1 unit/kg over a five minutes period in a double blind test. The patient is asked to assess any induced pain by questionnaire and visual linear analogue. If the pain is induced by CCK infusion, resembles the presenting symptom of the gall bladder disease is likely.
XI. FINE NEEDLE ASPIRATION BIOPSY (FNA)
Fine needle aspiration biopsy for cytological examination can be taken percutaneously under computerised tomography or ultrasound guidance. The clinician must remember that a negative fine needle aspiration never reliably eliminates the possibility that the cancer is present.
XII. DIRECT CHOLANGIOGRAPHY
This term means the injection of the contrast medium directly into the biliary tree by needle or catheter. In general terms direct contrast studies are more accurate than indirect studies because a higher contrast density can be achieved and the volume and the concentration of the contrast medium can be varied at will.
a. INTRAOPERATIVE / PEROPERATIVE CHOLANGIOGRAPHY:
This investigation must be regarded as an integral part of cholecystectomy whether this is performed by the open or laparoscopic approach. It provides a road map of the biliary tree reduces the incidence of the bile duct injuries and indicates the need, or otherwise, for exploration of the common bile duct. Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate 78. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days 79.
Unsuspected stones are found by digitalised fluoroscopic cholangiography in normal sized ducts in 4-6% of the patients undergoing cholecystectomy. These stones would be missed if a selective policy for peroperaperative cholangiography is adopted and although some may pass spontaneously without any adverse sequelae, other will cause acute pancreatitis or cholangitis.
Anomalies of the biliary tract are encountered in some 8% of patients undergoing routine peroperative cholangiogram during cholecystectomy. Perhaps the most of these is an abnormal short cystic duct, which terminates in either the common hepatic or right hepatic duct. This anomaly if detected will reduce the risk of bile duct damage especially during the laparoscopic cholecystectomy where tenting of extrahepatic conduit is produced as a result of lateral and upward displacement of the gall bladder. If unrecognised this will result in or total compromise of the common hepatic or right common duct by the clip used to secure the medial end of cystic duct. This is the main reason for the increased incidence of stricture during laparoscopic cholecystectomy. Finally a selective policy for this procedure will not impart the experience needed to carry out the investigations expeditiously and the familiarity to interpret accurately the cholangiographic finding. In a prospective study by Birdi et al peroperative cholangiography (POC) was achieved in 25.4%. Major complications included deaths in0.9%, common bile duct (CBD) injury in 0.18%, 5.4% found to have CBD stones, which were cleared at ERCP, and three converted to open exploration. Cholecystectomy by any route is a major operation and it was conclude that careful case selection remains imperative. However, morbidity is favourable compared with open cholecystectomy and comparable with other reports using the laparoscopic technique. 56.2% who did not undergo perioperative CBD imaging with ERCP or POC and three of these developed early symptomatic retained stones. This group requires further follow up 80.
During conventional surgery, peroperative cholangiography is most often performed by means of cannulation of the cystic duct. During laparoscopic cholecystectomy, the most commonly used technique involves cannulation of the cystic duct after this is opened by fine curved micro-scissors. Although a variety of disposable purpose-designed catheter systems are available the best and most cost effective is the Cook ureteric catheter of Fr 5 size inserted inside a cholangiograsper. This instrument not only guides the catheter to the cystic duct lumen but its jaws allow the cystic duct walls to be grasped on the catheter once this is safely in the lumen of the cystic duct. Trans cholecystic cholangiography carried out by the direct puncture of the gall bladder, though easy is less favoured in view of the stone migration. Into the ductal system during injection. It is reserved for when dissection of the triangle of Calot proves difficult and in patients undergoing laparoscopy for jaundice due to inoperable pancreatic malignancy before laparoscopic bilio-enteric bypass is performed.
The important rules governing the performance and interpretation of peroperative cholangiogram are:
i. Rapid and over- filling of the ductal system must be avoided as aside from obscuring small ductal calculi, the resulting raise pressure may cause cholangiovenous reflex and bacteraemia.
ii. Unequivocal flow into the duodenum must be demonstrated in all cases.
iii. Both intra-and extrahepatic bile ducts must be visualised. Non-filling of the intrahepatic biliary tract, or part of it, is always pathological and cannot be ignored. In open surgery, aside from technical errors, the most common cause for failure of proximal duct filling is a hilar cholangiocarcinoma. During laparoscopic cholecystectomy, it may be indicative of common duct injury.
If doubt exists regarding the interpretation of any abnormalities, expert radiological advice should be sought.
COMPLICATIONS
Its complications are rarely encountered and are usually due to either hypersensitivity to the contrast material or to an excessive injection pressure. The later can result in cholangiovenous reflux and bacteraemia especially in patients with cholangitis.
b. CONTACT SELECTIVE CHOLANGIOGRAPHY
The technique of contact selective cholangiography provides detailed anatomical information on the lower end of the common bile duct it is not used routinely but is helpful in the delineation of the pathological anatomy of the Vaterian segment of the bile duct especially during secondary biliary intervention. The technique requires mobilisation of the duodenum and the head of the pancreas this is followed by the insertion of a sterile dental film behind these mobilised structures.
c. T-TUBE CHOLANGIOGRAPHY.
After surgical exploration, the duct is usually closed around a T- tube after 7-10 days, when any air introduced at surgery has been absorbed and any blood clots lysed, a T-tube cholangiogram is performed. The specific purpose of this examination is to exclude residual stones (which occur in 4-8%, of patients, despite duct exploration) or other abnormality. The criteria for a normal examination are the same as those listed for operative cholangiography 81.
A number of technical aspects need attention. A preliminary film should be obtained. The concentration of the contrast medium should initially be around 150 mgI/ml in order that small stones are not obscured. If the duct is considerably dilated, the contrast medium should be diluted further (as a rough guide, the agent should be diluted 50%) with saline for every 5 mm increase in diameter). The whole of the biliary tree must be visualised and this may necessitate turning the patient on the left side, and even on the head down, in order to pacify the ducts within the left lobe of the liver. A delay of a few seconds should be allowed between injection of the contrast agent and exposure of film to ensure that any stones are at rest during exposure.
XIII. PERCUTANEOUS TRANS HEPATIC CHOLANGIOGRAPHY (PTC):
This is a commonly used technique for the visualisation of the biliary tract in the jaundiced patient and can be modified to allow percutaneous transhepatic drainage and insertion of endoprosthesis. Therefore, the main indications for diagnostic PTC are,
i. Jaundice.
ii. Post cholecystectomy syndrome.
Its advantage over ERCP is its general availability in most radiology departments. In experienced hands, the success rate with PTC approximates to 100 in patients with dilated biliary tracts and exceeds 70% in the absence of the bile duct dilatation. The reported accuracy of PTC in detecting the level and cause of the biliary obstruction averages 90%. Nowadays the procedure is carried out under sedation using the Chiba 22G needle.
COMPLICATIONS:
The complications of PTC include:
i. Septicaemia.
ii. Bile leakage.
iii. Haemorrhage: Free bleeding into the peritoneal cavity and haemobilia.
iv. Bile embolization.
v. Intrahepatic arterioportal fistula.
vi. Pneumothorax.
vii. Contrast reactions.
The reported incidence of major complications with Chiba needle is 3-10% with mortality of 0.1-3%.
XIV. ENDOSCOPY:
Upper gastrointestinal endoscopy with a forward or oblique viewing pan endoscope should be performed in jaundiced patients as significant gastrointestinal pathology is encountered in 25% of the patients.
XV. ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY (ERCP):
ERCP which is performed through a side viewing endoscope, provides useful information in patients with cholestatic jaundice irrespective of whether ductal system is dilated or not. In experienced hands, successful cholangiography is achieved by ERCP in over 90% of the patients. In a recent study patients underwent early endoscopic retrograde cholangiography and laparoscopic cholecystectomy was performed after signs of clinical improvement 82. ERCP is shown in figure 21.
The advantages of ERCP over PTC include:
i. It permits concomitant endoscopic examination and biopsy of lesions encountered during the endoscopic examination. Although the examination of the stomach and duodenum is more difficult and less optimal than with a forward viewing endoscope.
ii. A pancreatogram can be obtained during the same investigation.
iii. Certain lesions can be treated or palliated during the procedure e.g. endoscopic stone removal.
ERCP is however, more difficult to perform PTC and requires special expertise. The procedure is well tolerated. Diagnostic ERCP has a very low morbidity largely due to pancreatitis (1.0%) and mortality (0.1%). The morbidity of interventional (therapeutic) ERCP, especially sphincterotomy is however, higher (6-10%).
TECHNICAL FAILURE:
Technical failure of an attempted ERCP examination may be due to:
i. Duodenal or pyloric stenosis.
ii. Previous Billiroth II gastrectomy.
iii. Duodenal diverticulum.
iv. Uncooperative patient.
v. Inexperience with the procedure.
Patient can have an exacerbation of abdominal pain after ERCP 83
XVI. CHOLEDOCHOSCOPY (OPERATIVE BILIARY ENDOSCOPY) (CHOLANGIOSCOPY):
Operative choledochoscopy is now well established in biliary tract surgery and is considered an integral part of common bile duct exploration. Shown in figure 22 to 26. Two types of choledochoscopes are available:
i. The flexible fibreoptic instrument.
ii. The rigid Berci-Shore Choledochoscope, which incorporates the Hopkin’s rod, lens system.
The choledochoscope is introduced through a small choledochotomy in the supraduodenal part of the common bile duct. The initial inspection establishes the pathology, e.g. stones, tumour, etc. removal of stones can be performed under vision. If the rigid instrument with the attached instrument channel is used. Either a biliary balloon catheter or a Dormia basket is introduced and the stone extracted under visual guidance. Once all the stones have been removed a completion choldochoscopic examination of the biliary tract is performed before the insertion of the T-tube.
ADVANTAGES:
The advantages of choledochoscopy are
i. It provides a better evaluation of intracholedochal pathology
ii. It allows biopsy of suspicious lesions.
iii. The rigid instrument with the attached stone forceps provides effective, safe and easy methods of dealing with the problem of impacted calculi.
iv. The routine use of completion choledochoscopy results in an almost negligible incidence of retained ductal calculi.
v. It reduces the incidence of trauma, especially to the lower end of the bile duct caused by the blind instrumentation metal sounds and forceps.
vi. The flexible endoscopes provide an effective method of stone extraction of retained ductal calculi through the T-tube tract.
Flexible choledochoscopy is used in the laparoscopic extraction of ductal calculi.
XVII. PEROPERATIVE POST EXPLORATORY CHOLANGIOGRAPHY:
A cholangiogram via a catheter or the T-drainage tube may be performed, after choledochotomy, to make sure that all stones have been removed, and there is no obstruction to the flow of bile into the duodenum.
XVIII. BILIARY MANOMETER
Biliary pressure studies can be performed peroperatively or endoscopically during ERCP using a special perfusion catheter. Various ways of measuring the biliary pressure are
i. PEROPERATIVELY
a. Radiomanometery
b. Mano-debimetry
ii. ENDOSCOPICALLY
i. PEROPERATIVE BILIARY MANOMETERY
It is not used routinely except in specialised centres. It can provide useful information on the rare disorder of the sphincter function (stenosis, spasm, and hypotonia) at the lower end of the bile duct. It also enhances the diagnostic yield of peroperative cholangiography 84. Biliary pressure and flow rates are recorded during cholecystectemy to determine the presence of bile duct stones 85.
a. RADIOMANOMETERY
It can be performed by the use of pressure transducer connected to the cannula, which is inserted in to the common bile duct via the cystic duct. The transducer is attached to a channel recorder, which gives an instant display of the biliary pressure. It permits the measurement of the basal (resting) pressure, and the filling pressure during the constant infusion of saline (5.0 ml/min). In addition, it demonstrates the sphincteric contractions.
b. MANO-DEBIMETRY:
This measures the passage (yield) pressure at the choledochal sphincter and the flow rate to through the common channel into the duodenum the technique was first by Caroli. The modern modification of the Caroli instrument is known as the Tondelli mano-debitometer. After measurement of the passage pressure, the upper limit of which 25.0 cm H2O the calibrated reservoir (filled with saline or contrast medium) is raised to a standard height of 30 cm above the level of common bile duct and the flow the rate through the common channel measures from the rate of emptying of reservoir per unit time. The normal flow rate measured in this way should exceed 12.0 ml/mm. A high passage pressure and a diminished flow rate are indicative of obstructive disease.
ii. ENDOSCOPIC BILIARY MANOMETERY:
It is now an established diagnostic procedure in specialised units. It is performed by the use of a special perfusion catheter attached to an external transducer and has been used in the investigations of patients with persistent symptoms and pain after cholecystectomy in an attempt to characterise abnormalities of the sphincter (stenosis, dyskinesia). The procedure measures the basal sphincter pressure, the rate and propagation of sphincteric contraction. In patients with dyskinesia, increased basal pressure, altered frequency and amplitude of phasic contraction, and reversal of the normal peristaltic direction (retrograde propulsion) have been reported. Patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from laparoscopic cholecystectomy in the majority of cases. Those who remain symptomatic after laparoscopic cholecystectomy may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal 86.
XIX. HISTOPATHOLOGY
The specimen obtained by any method either by open cholecystectomy or laparoscopic cholecystectomy should be sent for biopsy to rule out the carcinoma.
XX. FROZEN SECTION:
If peroperatively or on the table there is suspension of malignancy then frozen section should be sent to confirm the diagnosis of malignancy and to see the clearance of the area.
Washington, DC Registry
Last modified: Monday, 29-Nov-2004 07:07:18 EST |
