The ideal palliative procedure for biliary obstruction should be effective in relieving jaundice, have minimal morbidity, be associated with a short hospital stay, have a low symptomatic recurrence and maintain quality-of-life. In patients with malignant distal biliary obstruction, there has been a trend recently towards
Fig. 6.4. Ultrasound image of an hepatic metastasis. Aloka SSD-2000, 7.5 MHz linear array probe.
nonoperative biliary drainage by either the endoscopic or transhepatic routes.34-41
Randomized trials have demonstrated a reduced hospital stay and similar early morbidity and mortality with endoscopic stent placement compared to surgical bypass.42,43 However, long term complications appear increased, with recurrent jaundice due to occluded or dislodged prosthesis and cholangitis occurring in 13-60% of cases.34,35,44,45 In patients who are expected to live longer than a few months these complications may make endoscopic palliation less than optimal.
Prior to the advent of minimal access surgery (MAS), open surgical drainage was the only palliative option to endoscopic or transhepatic stenting. Surgical drainage provides excellent relief of jaundice.10,11,45 Despite extensive controversy in the literature.10,11,34,36,45 both choledocho-enteric and cholecysto-enteric bypasses, if selected appropriately, have similar results with regards to reducing serum biliru-bin. In a recent analysis of our experience, we were not able to demonstrate any difference between these two methods of biliary diversion.11 Both procedures were associated with considerable morbidity with complications occurring in 18%. Others have reported similar figures.10,38 It is our clinical impression that particularly after a complicated postoperative course some patients never regain their preoperative performance status and commence a slow inexorable slide in their quality-of-life until death.
We perform a cholecystojejunostomy in selected patients. Patients with a patent cystic duct and at least 1 cm clearance from the upper extent of the tumor are candidates for this procedure. However, if it is determined that a cholecysto-jejunostomy would not be appropriate (i.e., prior cholecystectomy, diseased gallbladder, blocked cystic duct, low insertion of cystic duct, tumor encroachment on cystic duct or gallbladder), a standard surgical bypass to the common hepatic duct is performed.
The first series of animal experiments were reported by Nathanson and co-workers who utilized a sutured cholecystojejunostomy in a pig model.46 An intra-corporeal anastomosis was performed in six animals, five of whom subsequently underwent ligation of their common bile duct. In all cases, 4 weeks following this procedure the bilioenteric anastomosis was noted to be patent and bilirubin less than 5 mol/l. A combined biliary and gastric operation in a porcine model was examined by Patel and colleagues.47 They demonstrated the feasibility of such a procedure. A similar study by Rhodes et al48 showed that there is a 0% anastomotic stricture formation at 12 weeks if a 6 cm anastomosis was created. A combined biliary and gastric bypass procedure was investigated by Schob et al, who performed a double Roux-en-Y loop cholecystojejunostomy and gastroenterostomy in 10 pigs.49 On completion of the study only one animal was noted to have an anastomotic failure.
Clinical Experience with Laparoscopic Bypass
Cuschieri's group from Dundee University in 1992 was the first to report a series of biliary bypass procedures performed laparoscopically.50 In 5 patients with advanced pancreatic cancer a cholecystojejunostomy was performed. Four patients had an excellent result, recovering from the procedure with minimal morbidity and complete relief of their biliary obstruction. The authors felt that this procedure had merit in selected patients and may avoid the hazards of endoscopic stenting such as recurrent biliary obstruction or cholangitis. Fletcher and Jones also in 1992 reported a case in which they had used the endoscopic linear stapler to construct the complete anastomosis.51 At follow-up one month following the procedure the patient was neither icteric or symptomatic. Hawasli described a similar technique in two patients both of whom were discharged within 4 days following their procedure.52
The first report of laparoscopic gastroenterostomy for malignant duodenal obstruction was by Wilson and Verma from Edinburgh, Scotland.53 They reported on two cases in which duodenal obstruction was successfully relieved by means of an antecolic gastrojejunostomy. The nasogastric tube was removed on the first post-operative day and a regular diet was achieved by the forth day. Brune and Schonleben in 1992 reported their initial experience in two patients using a stapled anastomosis.54 They emphasized the operative complexity, need for expensive instruments and skilled surgical technique. Rangraj and coworkers reported a similar technique in 1994.55 In their case they used the laparoscopic stapler to complete the entire anastomosis rather than suturing the initial enterotomy/gastrotomy.
Combined biliary and gastric bypass was performed by Rhodes and coworkers on a series of 16 patients who presented with gastric outlet obstruction (n=8), an occluded endoscopic stent (n=4), or were found at staging laparoscopy to have metastatic disease (n=4).56 A cholecystojejunostomy was performed in 7, gastroenterostomy in 5, and a combined procedure in the remaining 3 patients. Median operative time was 75 minutes, and 14 patients were discharged from hospital within a week of surgery. One patient following a biliary bypass required a further surgical procedure for recurrent jaundice. The authors suggest that laparoscopic bypass is a viable option particularly for the patient with an occluded stent, duodenal obstruction, or in whom endoscopic stenting is not possible.
We believe that the indications for a laparoscopic cholecystojejunostomy are similar to the indications for the equivalent open procedure. Currently, we use the laparoscopic ultrasound to assess the relationship of the tumor to the cystic duct/ common bile duct. Those patients who are considered unsuitable for a laparoscopic procedure are converted to an open procedure and a standard bypass performed. If a laparoscopic bypass is performed the trocars used in the staging laparoscopy can be utilized. In order to accommodate a linear stapler the right upper quadrant 10 mm trocar is converted into a 12 mm trocar.
The procedure mimics the standard antecolic cholecystojejunostomy. A suitable loop of jejunum approximately 30 cm distal to the ligament of Treitz is brought to the gallbladder. Using an intracorporeal suturing technique, the jejunum is approximated to the gallbladder. Small incisions (0.5 mm) are made in the gallbladder and jejunum. Enteric leakage is minimal due to the increased intra-ab-dominal pressure enteric leakage is minimal. By using an EndoGIA/30 mm stapler (U.S. Surgical Corp. Norwalk, CT) inserted through the 12 mm RUQ port, and manipulated into the gallbladder and jejunum an anastomosis is created. The resultant enterotomy can be closed by using either a completely intracorporeal or laparoscopically-assisted approach. This technique allows for the construction of a 2.5 cm cholecystojejunal anastomosis without any bowel narrowing.
The technique for fashioning a laparoscopic gastrojejunostomy is similar. A proximal loop of jejunum which is brought in an antecolic position to the stomach. The left upper quadrant 5 mm laparoscopic trocar is converted to a 12 mm trocar. Enterotomies are made in both stomach and jejunum, an EndoGIA 30 mm stapler (U.S. Surgical Corp. Norwalk, CT) is inserted through the 12 mm LUQ port, and manipulated into both enterotomies. The instrument is positioned and fired. The stapler is removed and reloaded, being returned into the anastomosis and refired. This creates an anastomosis approximately 5 cm in length. The anterior defect then can be closed in a similar fashion to the cholecystojejunostomy. Any defects in the anastomosis can be repaired with individual 3/0 sutures.
To date, we have used the techniques described above in 12 patients with unresectable pancreatic cancer. Five patients underwent a cholecystojejunostomy, 2 underwent a gastrojejunostomy and 2 received both a biliary and gastric bypass. Eleven patients had a satisfactory result. In one patient with obstructive jaundice who underwent a cholecystojejunostomy, bilirubin levels did not decrease post-operatively. An endoscopic stent was subsequently placed. The ERCP demonstrated a long biliary stricture with an occluded cystic duct. At the time of the original procedure, the cystic duct and common bile duct junction were not identified and laparopscopic ultrasonography was not available.
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