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Primary sclerosing cholangitis

Overview Primary sclerosing cholangitis (PSC) is a chronic, idiopathic cholangiopathy characterized histologically by peribiliary inflammation and fibrosis. PSC can progress to cirrhosis and is a risk factor for hepatobiliary and colonic carcinogenesis. The median liver transplant (LT) free survival time is approximately 15 years. Despite ongoing research over the past several decades, the etiopathogenesis of PSC remains poorly understood; as a result, effective pharmacologic therapy for…

Extrahepatic biliary atresia

Introduction Extrahepatic biliary atresia or biliary atresia (BA) is an obstructive fibroinflammatory disease that presents in infancy. First described in a case series of 49 patients by John Thompson in 1892, this disease is characterized by a destructive inflammatory cholangiopathy that can affect both the intrahepatic and extrahepatic biliary tree. If left untreated, the disease is progressive and leads to death from complications of biliary cirrhosis…

Intrahepatic stone disease

Overview Hepatolithiasis (intrahepatic stones) is defined as the presence of gallstones in the bile ducts peripheral to the confluence of the right and left hepatic ducts. These intrahepatic stones can simultaneously be present with stones in the common bile duct (CBD) and/or gallbladder. Hepatolithiasis, which is most prevalent in East Asia, is characterized by recurrent bouts of cholangitis and can lead to sepsis, biliary cirrhosis, and…

Cholecystolithiasis and stones in the common bile duct: Which approach and when?

Diagnostic considerations Imaging modalities: Why and when Determining the presence of cholecystolithiasis and choledocholithiasis can be challenging and often relies on indirect evidence of obstruction. For choledocholithiasis, clinicians use predictive models based on risk factors that include clinical features, abnormal liver function tests (LFTs), jaundice, and common bile duct (CBD) dilation. These are very sensitive (96%–98%) but not very specific (0%–70%). The Society of American Gastrointestinal…

Stones in the bile duct: Endoscopic and percutaneous approaches

Historical overview In the 1970s and 1980s, endoscopic retrograde cholangiopancreatography (ERCP) transformed the diagnostic approach to suspected biliary disease and jaundice (see Chapters 20 and 30 ). Similarly, in the years since it was first performed in humans, , endoscopic sphincterotomy (ES) has had a dramatic impact on the management of biliary disease, specifically in the treatment of common bile duct (CBD) stones. The widespread availability…

Stones in the bile duct: Minimally invasive surgical approaches

Introduction Epidemiology of choledocholithiasis The prevalence of cholelithiasis is approximately 15% in the general population, with up to 10% of patients having concomitant choledocholithiasis (CDL; for more information, see Chapter 33 ). The prevalence of gallstones is increased in the elderly population over 65 years of age, reaching up to 35% in women. Risk factors for gallstones include: obesity, type 2 diabetes and insulin resistance, genetic…

Stones in the bile duct: Clinical features and open surgical approaches and techniques

Overview The first successful common bile duct exploration (CBDE) by Thornton in 1889 and the introduction of catheter-based biliary decompression by Courvoisier and Kehr marked the initial efforts in treating choledocholithiasis. Open cholecystectomy and bile duct exploration were performed commonly as the standard treatment for patients with choledocholithiasis for many years with good success and low rates of morbidity and mortality ( Table 37A.1 ). During…

Cholecystectomy techniques and postoperative problems

Overview Cholecystectomy is one of the most frequently performed general surgery procedures in the United States (US) with over 500,000 being performed annually. There are many reasons for this, including the frequency of gallbladder disease and indications for intervention in the US population. The advent of laparoscopic cholecystectomy in the 1980s also resulted in a rapid rise in the number of cholecystectomies because of the reduced…

Percutaneous treatment of gallbladder disease

Overview The first reports of an operative cholecystostomy are attributable to Johannes Fabricius (1618) and Stalpert Von Der Wiel (1667) who described the procedure as occurring almost by happenstance upon the incision of an abdominal wall abcess. The following two centuries revealed further sporadic reports, until Marion Sims, an American surgeon in Paris, performed a clearly intentional cholecystostomy in 1878. Kocher and Tait formalized the procedure…

Cholecystitis

Overview Cholecystitis, a common condition usually resulting from complications of cholelithiasis, occurs in two forms: acute and chronic. Acute cholecystitis requires urgent intervention, typically with antibiotics and cholecystectomy. In the setting of acute cholecystitis, cholecystectomy is optimally performed within 72 hours of symptom onset. If urgent cholecystectomy is not feasible, cholecystectomy can be performed electively, provided symptoms have resolved with medical management. Chronic cholecystitis is the…

The natural history of symptomatic and asymptomatic gallstones

Introduction The aim of this chapter is to describe established and novel findings on the natural history of gallstones. Gallstones have been a scourge of humankind for millennia. Each year surgeons perform over 700,000 cholecystectomies in the United States alone, with an estimated annual cost of approximately $6.2 billion USD. , The annual rate of hospital admissions for acute cholecystitis and the associated hospital charges continue…

Bile duct exploration and biliary-enteric anastomosis

Overview Minimally invasive techniques to manage biliary pathology have reduced the need for open operative intervention. Although open exploration for biliary disease has become less common, specific situations like obstructive common duct stones not amenable to endoscopic therapy or restoration of biliary-enteric continuity following resection of bile duct tumors remain indications for surgical approaches. It is important to have a thorough understanding of biliary anatomy (see…

Radiologic hepatobiliary interventions

Radiologic hepatobiliary interventions Minimally invasive hepatic intervention is indicated in a wide range of pathologic conditions and can be generally divided into vascular, biliary, and hepatic parenchymal procedures. The objective of this chapter is to provide a broad overview of the spectrum of interventions that can be performed percutaneously using imaging guidance. Greater detail will be found in individual chapters devoted to each topic. Vascular procedures…

Interventional endoscopy for biliary tract disease: Technical aspects

Equipment needed for standard endoscopic retrograde cholangiopancreatography cannulation Before attempting cannulation of the biliary tree for standard endoscopic retrograde cholangiopancreatography (ERCP), the appropriate equipment must be assembled (see Chapter 20 ). At baseline that equipment should include : Side-viewing duodenoscope with biopsy channel of at least 3.2 mm to 4.2 mm Guidewire , : Hydrophilic or Hydrophilic tipped Diameter: 0.018, 0.025, and 0.035 inches. The 0.035…

The impact of hepatobiliary interventions on health and quality of life and health

The concepts of health and quality of life Promotion of health and restoration of quality of life is central to the delivery of healthcare. There is limited value in engaging in a medical intervention if there is no anticipated impact on health or improvement in quality of life. This chapter will explore the concepts and tools used to measure health and quality of life and will…

Postoperative complications requiring intervention: Diagnosis and management

Imaging and image-guided therapy of complications after pancreatectomy Imaging after pancreatectomy Computed tomography (CT) is the most common imaging modality for evaluation of the pancreas after surgery. Complications that can be detected on CT include anastomotic leak, abscess, fistula, and bleeding (see Chapters 62 and 117 ). Fluid collections, such as seromas, abscesses, and pancreatic pseudocysts, can be identified on CT ( Fig. 28.1 ). Rim…

Enhanced recovery programs in hepatobiliary surgery

Introduction In the 1990s, initial reports of fast-track surgical principles detailed their application to cardiac surgery patients with the goal of reducing intensive care unit (ICU) stay. Afterward, a novel multimodal approach to perioperative care was described by Kehlet and Mogensen, resulting in a dramatic reduction in length of hospital stay (LOS) after colectomy. , After overcoming much skepticism and scrutiny, the ensuing paradigm shift in…

Nutrition and perioperative critical care in the hepatopancreatobiliary surgery patient

Assessment of patient nutritional status and functional reserve allows surgeons to identify malnourishment and potential recovery before major abdominal surgery. Evolving nutritional and fluid management strategies, along with improving anesthesia, pain management, and hemodynamic monitoring, seek to minimize homeostatic alterations. Although specific surgical procedures, modalities, and disease states may each present specific challenges to perioperative management, these two efforts are now being understood to play a…

Liver and pancreatic surgery: Intraoperative management

Overview Improvements in patient selection criteria, advances in hepatopancreatobiliary (HPB) surgical techniques, and perioperative care have enabled increasing numbers of older and previously deemed inoperable patients to undergo HPB surgery. Despite this increase in comorbidities, recent studies have documented the progressive safety of liver and pancreas surgery ; nonetheless, morbidity remains significant even at tertiary care centers. , , This chapter addresses the unique perioperative anesthetic…

Intraoperative diagnostic techniques

Overview The management of hepatobiliary and pancreatic disease has evolved greatly since the 1990s. Today’s operative surgeon has several valuable adjuncts to aid in accurate preoperative evaluation and planning for benign and malignant disease. Advances in contrast-enhanced computed tomography (CT), endoscopic ultrasound (EUS), magnetic resonance imaging (MRI; see Chapter 13, Chapter 14, Chapter 15, Chapter 16, Chapter 17 ), and endoscopic retrograde cholangiopancreatography (ERCP; see Chapters…