الفهرس 
ANATOMY OF THE BILIARY TRACT AND PANCREATIC DUCTOnly 14 pages are availabe for public view
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Abstract
Obstructive jaundice is a common problem frequently encountered by the general surgeons. The management of this problem has greatly advanced in the last decades.
Causes of obstructive jaundice are classified into benign and malignant causes. Benign causes include choledocholithiasis, chronic pancreatitis, benign strictures of bile ducts (post operative and primary sclerosing cholangitis), choledochal cysts and parasitic infestations of the bile ducts. Malignant causes of obstructive jaundice include cancer head of pancreas, cholangiocarcinoma, ampullary carcinoma, hepatocellular carcinoma and liver metastasis.
Obstructive jaundice is a common surgical emergency needing urgent interventional management for diagnosis and treatment.
Lab investigations of these patients reveal direct hyperbilirubinemia, elevated alkaline phosphatase, increased gama-glutamyl transferase, elevated aminotransferases (only if there is hepatocellular damage), prolonged PT and PTT and elevated tumor markers such as CA.19-9 in pancreatic cancers.
Transabdominal ultrasound is the first choice image. CT is more accurate than US especially in malignant cases. ERCP has evolved from a largely diagnostic to a largely therapeutic modality, because of its high complication rate (pancreatitis, duodenal perforation, duodenal hemorrhage, infection, stent migration and others) and the availability of other accurate, safe and noninvasive diagnostic modalities e.g. MRCP and EUS. MRCP is a new, safe and noninvasive technique that can accurately asses all involved structures such as bile ducts, vessels and hepatic parenchyma with a very high sensitivity and specificity and without contrast material. Endoscopic ultrasound is a new, safe, accurate technique that allows visualization of the extrahepatic bile ducts and pancreas. EUS-FNA can be used for staging of neoplasms of pancreaticobiliary tract. PTC is indicated only when ERCP fails in managing of complex biliary strictures. Intraoperative cholangiography can identify CBD stones, however, routine IOC has been found to yield little benefit over selective approach. Operative choledochoscopy is considered an integral part of CBD exploration allowing evaluation of CBD pathology and extraction of CBD stones.
IN treatment of CBD stones, ERCP is the first choice technique in cases with high probability of CBD stones allowing removal of stone and sphincterotomy. Laparoscopic CBD exploration has replaced to a large extent open CBD exploration especially during laparoscopic cholecystectomy. Two techniques of LCBDE are available, transcystic LCBDE (via the cystic duct) and transcholedochotomy LCBDE which is indicated in patients with dilated CBD, big stone, multiple stones, impacted stone, failed TC-LCBDE and in intrahepatic stones. Open CBD exploration is done only when endoscopic and laparoscopic techniques failes to remove CBD stones. Primary closure of common bile duct without stent has been proved to be at least as safe as T-tube drainage in both open and laparoscopic common bile duct exploration.
Chronic pancreatitis can be treated medically, endoscopically or surgically. ERCP is indicated for treatment of symptomatic stones, strictures of pancreatic ducts and pancreatic pseudocysts by ductal decompression, sphincterotomy or stent placement relieving pain in most patients. Surgical treatment is needed only when medical and endoscopic treatment fails.
In traumatic injury of the bile ducts, if injury is recognized intraoperatively, an immediate reconstructive procedure should be done. If this is impractical the proximal end of the duct should be anastomosed to a Roux-en-Y limp of the jejunum. If injury is discovered late, biliary decompression is done followed later (6-8 weeks) by operative exploration and management.
Treatment of sclerosing cholangitis is unclear. Liver transplantation gives excellent results in patients with P.S.C. and end stage liver disease.
In choledochal cysts, surgical excision with a roux-en-y anastomosis is the treatment of choice and gives much better results than drainage procedures.
In cancer head of pancreas, resectable lesions are treated with the classic Whipple procedure or Pylorus preserving pancreaticoduodenostomy with adjuvant leucovorine and fluorouracil chemotherapy. In locally advanced lesions, combined radiotherapy and fluorouracil-based chemotherapy offers better results than radiation therapy alone. In metastatic tumors, the use of gemcitabine improves the survival rate, pain and quality of life more than fluorouracil. Palliative treatment may be needed for pain, GIT obstruction, bile duct obstruction and pancreatic exocrine insuffeciancy.
Most patients with cholangiocarcinoma present with advanced unresectable disease. In resectable lesions; hilar cholangiocarcinoma requires a supraduodenal bile duct exploration, portal lymphadenectomy, cholecystectomy, bilioenteric reconstruction and in most cases partial hepatectomy. In distal cholangiocarcinoma, Hilar resection combined with pancreaticoduodenoctomy is done. Intrahepatic cholangiocarcinoma is treated with hepatic resection alone. Patients with distal extrahepatic tumors and cancer of ampulla of vater commonly treated with a pylorus preserving Whipple operation. Liver transplantation is indicated for locally unresectable disease, patients with biliary inflammation and patients with hepatic dysfunction. Survival with liver transplantation greatly exceeded that with surgical resection. Palliative therapy for biliary obstruction can be done through endoscopic biliary metal stenting, surgically or through percutaneous biliary drainage.