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Surgery of the Extrahepatic Biliary Tract

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Mark Garneau

on 18 January 2011

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Transcript of Surgery of the Extrahepatic Biliary Tract

-The extrahepatic biliary tract (EHBT) defines the biliary system that lies outside of the liver starting with the hepatic ducts and ending at the major duodenal papilla
- Consists of: Hepatic and cystic ducts, the bile duct, gallbladder

- In the dog the CBD & pancreatic duct empty into major duodenal papilla
- The accessory pancreatic duct present & empties into minor duodenal papilla
- CBD approx 3mm in diameter
- Blood is supplied to the gall bladder and cystic duct by the left branch of the proper hepatic artery CAT
- In the cat CBD usually joins the major pancreatic duct & empties into major duodenal papilla
- The accessory pancreatic duct usually absent
- CBD approx 2-2.5mm in diameter - The gallbladder sits between the quadrate and right medial liver lobes, on the visceral surface of the liver (hepatic fossa) DISEASES OF THE EHBT:
- Extraluminal:
1. Pancreatic disease - Pancreatitis, abscessation, neoplasia
2. Duodenal or Pyloric neoplasia
3. Hepatic or biliary neoplasia
4. Diaphragmatic hernia
5. Congenital abnormalities
- Intraluminal:
1. Cholelithiasis, Choledocholithiasis
2. GB mucocele
3. Liver flukes (cats)
- Blunt or penetrating trauma
- Necrotizing cholecystitis
- can cause scar formation in or around the CBD or can compress the CBD
by inflammed tissue, abscesses, or cysts
- TREATMENT: usually consists of medical management.
If unsuccessful – cholecystoduodenostomy or cholecystojejunostomy
may be considered
- If animal not deemed stable enough to go to sx for EHBO can temporarily decompress GB w/ a foley catheter or a self-retaining accordion cath, pig tail cathters (to be discussed later on)
- Biliary, Pancreatic, Duodenal, Pyloric neoplasia
- Most common cause of EHBO in cats (along with inflammatory disease)
- Surgery generally unrewarding as these are mostly malignant tumors
- Cholecystojejunostomy +/- Bilroth II may be palliative
- Note that the obstruction may also be caused by biliary, intestinal, hepatic, or lymph node malignancy
- Prognosis is typically poor, patients w/ lymphoma may benefit from chemo
- Congenital abnormalities
- Duodenal FB PANCREATITIS NEOPLASIA CHOLELITHIASIS GB MUCOCELE - somewhat rare in dogs + cats (1% of animals w/ biliary dz)
- often an incidental finding w/ imaging or at necropsy
- older female small breed dogs predisposed
(notably mini schnauzers and mini poodles)
- Clinical signs usually associated with development of cholecystitis
- If obstructing the CBD – should be removed
- Cholecystectomy is the treatment of choice when clinical signs are secondary to cholelithiasis. If stones are in CBD the duct can be catheterized via the duodenum and the stones flushed into the GB
- Alternatively choledochotomy can be performed (incising into CBD) to remove the stones however this can cause stricture formation
- Canine gallstones usually contain bilirubin, calcium, and mucin
- An abnormal accumulation of inspissated mucus that distends the GB and often causes some degree of EHBO
- Typically cause a striated or stellate appearance on AUS w/ immobile bile ("kiwi gall bladder")
- Left untreated necrosis of the GB w/ subsequent rupture may occur
- Cholecystectomy is the preferred tx though sometimes medical management is possible
- Shetland Sheepdogs are predisposed
LIVER FLUKES - Platynosum fastosum – Florida, Hawaii, Caribbean
- Typically infects cats that eat lizards or toads (a 2nd intermediate host)
- May be found in liver, GB, bile duct – may be asymptomatic or cause fibrosis, obstruction or both
- Can be diagnosed on AUS or fecal sedimentation
- Therapy may be attempted w/ Praziquantel
- Others include Amphimerus pseudofelineus, Metorchis conjunctus, + Eurytrema procyonis
CHOLECYSTITIS - Cholecystitis usually involves the associated bile ducts, typically due to a bacterial infxn caused by bacteria ascending from the intestine via the CBD or via hematogenous spread
- Often cured w/ antibiotics but with chronic recurrent infxns cholecystectomy is usually curative
- Necrotizing cholecystitis occurs when a bacterial infxn severely damages the GB wall, sometimes rupturing it spilling bile into the abdomen producing a localized peritonitis
- Tx: cholecystectomy, ABs, supportive care
- Emphysematous cholecystitis: gas forming bacteria (eg- Ecoli, Clostridium perfringens) infect the GB and invades the wall
- Tympanic cholecystitis - gas fills the GB lumen
TRAUMA Rupture
- most commonly CBD, but can be anywhere
- most common site tends to be at CBD just distal to entrance of the last hepatic duct
- Treatment involves surgical repair of the ruptured duct or biliary diversion, cholecystectomy for ruptured GB, hepatic ducts can be ligated
ABNORMALITIES 1) Caroli’s disease
- congenital dilation of intrahepatic and extrahepatic bile ducts w/out obstruction
- generally less than 3.5yrs old
- usually vomiting, PU/PD, anorexia, ascites, and increased hepatic enzymes
- GB and CBD generally normal in size
- Renal fibrosis and cystic changes are common in affected animals
2) GB abnormalities are occasional
- Bile normally flows from the liver through 4 hepatic ducts
leading into the CBD
- Resistance to flow by the CBD (particularly the terminal sphincter mechanism) shunts bile through the cystic duct and into the gall bladder
- Bile is concentrated and stored in the GB for periodic emptying into the duodenum via GB contraction
- Rhythmic contractions of the Sphincter of Oddi at duodenem regulate bile flow (one-way valve)
1) Cholecystotomy
2) Cholecystectomy
3) Choledochotomy
4) Primary repair of the CBD
5) Bile Flow Diversion
- Choledochoduodenostomy
- Cholecystoenterostomy
- Cholecystoduodenostomy
- Cholecystojejunostomy

- rarely performed
- INDICATIONS: to remove some choleliths or inspissated bile (that is unable to be aspirated)
Pack the area + Place stay sutures in the GB
Remove contents + lavage
Catheterize CBD + flush to ensure patency
Close w/ one or 2 layer inverting pattern
- INDICATIONS: Cholelithiasis, Necrotizing cholecystitis,
GB rupture (spontaneous or traumatic), GB mucocele, Primary GB neoplasia
Expose GB, free from the liver via careful dissection
Identify CBD + take care not to damage
Cannulate CBD to the duodenal papilla (enterotomy)
Clamp and double ligate the cystic duct + cystic artery
Sever the duct + remove GB
Close the duodenal incision
Submit: Bile + a piece of GB wall for culture
Remainder of GB for histopath CHOLEDOCHOTOMY

- Direct incision into the CBD
- INDICATIONS: Obstruction of the CBD (generally chronic) where the duct is greatly dilated (choledocholithiasis or biliary sludge)
- An attempt should always be made to catheterize and flush the obstruction via cholecystotomy or enterotomy
Pack off the area surrounding CBD
Place traction sutures in the distended CBD
Make a small incision in the duct and remove the obstruction
Flush the duct + catheterize to ensure patency
Close the incision with small suture
If concerned about leakage, catheterize (from duodenal papilla)
Small leaks can be treated by stenting the CBD

- INDICATIONS: any injury to the CBD (depending on location and severitiy)
- Severely damaged CBD is very difficult to repair
- Incisional dehiscence, leakage, and stricture formation are common

- If the injury is distal to the entrance of the hepatic ducts - biliary diversion surgery should generally be performed
- If the duct has been cleanly severed and the lumen is >4-5mm in diameter (which is rare), then primary suturing and anstomosis is possible
- Proximal lacerations or perforations may be treated with primary suturing
- Identify the CBD, if necessary by cath from duod papilla
- Take care not to disrupt blood supply during manipulation
- Debride the transected ends of the CBD
- take care to leave adeq length to prevent tension
- Reappose ends of duct using small sutures
- Place a catheter from duod papilla to stent the suture line
- Suture the distal end of the catheter to the duodenum
using small absorbable suture
- As the suture dissolves the catheter will be pulled further
into the duodenum and will eventually pass into the feces
- Stenting is a controversial procedure (to be discussed)

- Altering the normal bile flow through the bile duct and into the duodenum
- With any injury to the CBD (trauma, obstruction), the damage is often irreversible
and necessitates bile flow diversion surgery
- When the CBD is damaged distal to the entry of the hepatic ducts, bile flow diversion
can be easily achieved
- INDICATIONS: CBD obstruction or severe trauma w/out GB involvement
1) Choledochoduodenostomy
2) Cholecystoenterostomy
- Cholecystoduodenostomy, Cholecystojejunostomy
3) Other: cholecystojejunoduodenostomy, sphincterotomy, sphincteroplasty
- COMPLICATIONS: chronic or recurrent cholangiohepatitis, stricture of stoma, recurrence of EHBO, pancreatic insufficiency, chronic vomiting
- Very rarely performed (little indication in dogs + cats)
- Primarily reserved for benign obstruction of the intramural portion
of the CBD with enough dilation of the CBD to sufficiently permit anastomosis to the duodenum with less risk of stricture
- Not recommended unless:
The gall bladder has been removed
The CBD is dilated to at least 1cm in diameter
A stoma of at least 2.5cm long can be made CHOLECYSTOENTEROSTOMY

- Cholecystoduodenostomy is preferred to -jejunostomy
- If -jejunostomy performed - should be done in proximal jejunum to prevent maldigestion
- Free the GB
- Place stay sutures approximately 3cm apart in GB
- Bring GB in apposition w/ the antimesenteric surface of the descending duodenum so that little or no tension exists on either side. Pack off the area
- Place a continuous suture line (~4cm) between the serosa of the GB and serosa of the duodenum
- Leave the suture ends long to allow for manipulation of the GB and intestine
- Drain the GB + make a 3cm in the GB parallel to the original suture line
- Occlude the duodenum proximal and distal to the suture line & make a smilar parallel incision into the duodenum
- Place a continuous suture line from mucosa of the GB to mucosa of the duodenum on either side
- Complete the stoma by closing the other side of the GB and duodenal serosa
- Stoma contraction can be expected to decrease the original stoma size by 50%


BILTROTH I = Pylorectomy w/ Gastroduodenostomy
- Indicated for gastric neoplasia, pyloric hypertrophy (causing gastric obstruction), ulceration of gastric outflow tract
- With neoplasia - >1-2cm margins
- If CBD has been damaged - cholecystoenterostomy

BILROTH II = Partial Gastrectomy w/ Gastrojejunostomy
- Indicated if the margin of the lesion precludes end-to-end anastomosis of the pyloric antrum to the duodenum
- Cholecystoenterostomy usually performed Choledochal tube stenting for decompression of the extrahepatic portion of the biliary tract in dogs: 13 cases (2002-2005) (JAVMA 2006 - Mayhew et al)

10 dogs EHBO – 6/10 pancreatitis
2 dogs – CBD rupture assoc w/ cholelithiasis
1 dog – prophylactic stent after Bilroth I for a perforated duodenal ulcer (to avoid swelling induced EHBO)

9/13 survived perioperative period and were discharged
No recurrence of EHBO or complications occurred in these dogs, median followup 13 mos
- in one dog the stent was removed endoscopically 10 mos after sx and EHBO occurred 9 mos later b/c of cholangitis
- in 4/9 of these dogs the stent was passed in feces in 1 to 11 mos


- Human medicine: self-expanding metal stents vs. polyethylene stents
- Metallic stents meant for more permanent placement in humans but are much more difficult to remove
- Polyethylene stents have a 30% rate of occlusion, but can be easily exchanged via endoscopy
- Research has shown that protein absorption to the stent wall followed by adherence of bacteria, plant, and food material (partly via duodenobiliary reflex) results in development of a protein biofilm that slowly narrows the lumen until complete occlusion occurs
- Most human patients are being treated for bile duct strictures secondary to alcohol-related chronic pancreatitis or malignancies which require long-term decompression
- Stents in dogs usually due to reversible condition (pancreatitis, CBD trauma)
- So in dogs use of nonmetallic stents is usually preferable (as they can be removed endoscopically and pass more readily in the feces)

- Initial Database:
CBC: possibly mild anemia, +/- stress or inflammatory leukogram (depending on condition)
Chemistry: - Elevated bilirubin
- Elevated liver enzymes: GGT, AlkPhos, ALT
- Possibly elevated amylase + lipase
- Hypokalemia
Urinalysis: bilirubinuria in both dogs + cats (mild bilirubinuria can be normal in dogs)
Survey Abd Rads: may see radio-opaque choleliths, masses, loss of abd detail w/ effusion
Chest rads: to R/O metastatic neoplasia


- CBD dilation (>5mm diagnostic in cats for obstruction)
- GB mucocele, Cholelithiasis
- Pancreatitis
Peritoneal fluid analysis:
- elev bilirubin concentration w/ bile peritonitis
- cytology + C/S
- Coag profile – may see elev PT/PTT ABDOMINAL US GB mucocele Cholelithiasis CBD dilation CLINICAL SIGNS OF EHBT DISEASE
Abdominal pain
Abdominal distention
GI signs: vomiting, diarrhea, anorexia lethargy
icterus Treatment of Pancreatitis Associated Extrahepatic Biliary Tract Obstruction by Choledochal Stenting in 7 Cats (JSAP 2008 - Mayhew et. al)

-All cats had pancreatitis based on biopsy sample (6) or surgical findings (1)
-At surgery all cats were found to have a mass like thickening in the area where the distal CBD joins the duodenum and at the major duodenal papilla
-3.5 to 5Fr red rubber catheter or 22g IV cath used for stent
-2/7 died in perioperative period
-5/7 survived to discharge: 3/5 died 7-24mos post op, 2 still alive at publication date
-Complications: asc cholangitis (1), chronic vomiting (2), reobstruction 1 week post op (2)
-One of the cats that reobstructed had a cholecystoduodenostomy 6 days post op, very thick bile sludge had occluded the stent; other cat was euthanized
-Conclusion: Stenting for pancreatitis associated EHBO is an alternative to biliary diversion surgery in select cases. May be greater morbidity as compared to dogs.
Minimally Invasive Cholecystotomy in the Dog:
Evaluation of Placement Techniques and Use in Extrahepatic Biliary Obstruction (Vet Surg 2007 Murphy et. al)

-Study to evaluate 4 methods of cholecystotomy catheter placement and to report on laparoscopic cholecystotomy for the management of EHBO in 3 patients
-Pigtail cholecystotomy catheters were inserted in 20 canine cadavers using US or lap guidance. Approach was either transhepatic or transperitoneal.
-Insertion success was 100% w/ Lap-transperitoneal approach, 0% with US-transperitoneal approach, US-transhepatic 3/5 successful placement. (2/3 penetrated the pleura)

- 3 clinical cases were treated by Lap-transperitoneal technique
-Lap-transperitoneal cholecystotomy resulted in marked improvement in 2 dogs, but the catheter became obstructed in the cat. One dog spontaneously regained common bile duct patency, and the remaining 2 animals had successful cholecystoenterostomy.

-Conclusion: Lap-transperitoneal cholecystotomy method superior to US guided methods. In 2 clinical cases the cholecystotomy catheter successfully provided biliary drainage for patient stabilization
Cholecystoenterostomy for Treatment of Extrahepatic Biliary Tract Obstruction in Cats: 22 cases (1994-2003) (JAVMA 2006 Buote et al)

- Retrospective study attempting to identify factors associated with outcome in cats w/ EHBTO that underwent biliary diversion surgery
- 13 cats w/ inflammatory dz (chronic hepatitis, cholangitis, pancreatitis, enteritis)
- 9 cats with neoplastic disease (biliary AC or pancreatic carcinoma)
- 9/13 inflammatory dz cats and 5/9 neoplastic dz cats survived to discharge (not statistically different)
- Median survival time for inflammatory dz cats was significantly longer than cats with neoplasia (447 days vs. 31 days)
- Complications in cats that survived surgery included recurrent cholecystitis, intermittent vomiting, and diarrhea secondary to pancreatic insufficiency
- Overall prognosis for cats w/ EHBTO undergoing cholecystoenterostomy is guarded to poor
- Previous studies have looked at cats having biliary diversion sx due to cholelithiasis: 75% survived to discharge + cats that were discharged lived on average 2 yrs and often died of unrelated disease
Considerations Prior to Surgery:
- IV fluids
- Antibiotic therapy
- Vitamin K
- Blood +/- Plasma Transfusion IMPLICATIONS:
-Endotoxemia + bacterial translocation are major contributers to mortality post-operatively in patients w/ EHBO
-Lack of luminal bile salts promotes intestinal bacterial overgrowth + permeability, also hepatic Kupffer cell function is reduced
-Oral lactulose, early enteral feeding, and enteric bile replacement have been shown to lower serum endotoxin levels, improve intestinal permeability within 5-21 days
- Providing pre-operative biliary drainage and supportive care measures = more stable patient going in to surgery
- How long? - In human medicine standard is 5-10 days Variables Associated with Outcome in Dogs Undergoing Extrahepatic Biliary Surgery: 60 cases (1988-2002) (Vet Surg 2004 Mehler et al)

-Retrospective study
-Diagnoses: Necrotizing cholecystitis (36/60), Pancreatitis (12/60), Neoplasia (5/60), Trauma (4/60), GB rupture w/out NC (3/60)
-Cholecystectomy in 37 dogs, Cholecystoduodenostomy in 14 dogs were most commonly performed procedures
-Cholecystojejunostomy in 7, cholecystotomy in 1, and hepatic duct ligation in 1
-43/60 (72%) survival, 17 nonsurvivors – 4 died, 13 euthanized (28% mortality rate)
-No statistical difference between cause of disease, though patients w/ CBD trauma all had a good outcome
-Presence of septic bile peritonitis, preoperative elevated creatnine, and immediate post-op hypotension are assoc with a poor clinical outcome (assessed 25 variables)
-Previous studies have reported leukocytosis, septic bile peritonitis, and presence of bands as higher risk factors
-Previous reported mortality rates 40-64%

CHOLEDOCHAL STENTS - CATS CONCLUSION - Patients with EHB disease are often very sick and require extended hospitalization
- Prognosis variable depending on type of disease, clinical signs, presence of bile peritonitis (+/-septic)
- Dogs in general fare better than cats
- Consider alternative techniques such as cholecystotomy catheters + stenting prior (or in place of) biliary diversion surgery in select cases
- A lot more research needed in this area Catheter end demostrating trochar tip Inner stylet and locking pull cord Catheter tip in the locked configuration Gallbladder Mucocele in Dogs: 30 cases (2000-2002)
(JAVMA 2004 Pike et al.)

- 30 dogs with GB mucocele
- 23/30 underwent cholecystectomy
- Perioperative mortality rate 21.7%
- Mortality rate was not significantly different for dogs w/ GB rupture
- All 18 dogs discharged from hospital had complete resolution of clinical signs
- Mean follow-up period was 13.9mos
- Conclusion: Cholecystectomy is an effective tx. for GB mucocele. Although peri-operative mortality rate is high, prognosis after discharge from the hospital is excellent. PROGNOSIS AND RISK FACTORS
Bacon NJ, White RAS: Extrahepatic Biliary Tract Surgery in the Cat: A Case Series and Review J Small Anim Pract. 44(5):231-5, 2003.

Buote et al: Cholecystoenterostomy for Treatment of Extrahepatic Biliary Tract Obstruction in Cats: 22 cases (1994-2003). JAVMA 228 (9):1376-82, 2006.

Dodham JR.: Hepatic and Gastrointestinal surgery, in Slatter et al: Textbook of Small Animal Surgery (ed 3). Philadelphia, PA, Saunders, 2003.

Eich CS, Ludwig LL. The surgical treatment of cholelithiasis in cats: a study of 9 cases. J Am Anim Hosp Assoc 38: 231-235, 2003.

Holt, D. Bile Duct Obstruction, Extrahepatic in Cote et al: Clinical Veterinary Advisor Dogs and Cats. St. Louis, MO, 2007, 130-132.

Fossum, TW: Surgery of the Extrahepatic Biliary System, in Fossum TW, Hedlund CS, Johnson AL, et al: (eds): Small Animal Surgery (ed 3). St. Louis, MO, Mosby, 2007, 560-572.

Gaillot et al: Ultrasonographic Features of Extrahepatic Biliary Obstruction in 30 Cats. Vet Rad & US 48 (5): 439-447, 2007.

Mayhew et al: Choledochal tube stenting for decompression of the extrahepatic portion of the biliary tract in dogs: 13 cases (2002-2005). JAVMA 228 (8):1209-1214, 2006

Mayhew et al: Pathogenesis and Outcome of Extrahepatic Biliary Obstruction in Cats. J Small Anim Pract 43: 247-53, 2002.

Mayhew et al: Treatment of Pancreatitis Associated Extrahepatic Biliary Tract Obstruction by Choledochal Stenting in Seven Cats. J Small Anim Prac 49:133-138, 2008

Mehler SJ, Bennett RA: Canine Extrahepatic Biliary Tract Disease and Surgery. Compendium, April 2006: 302-315.

Mehler et al: Variables Associated with Outcome in Dogs Undergoing Extrahepatic Biliary Surgery: 60 cases (1988-2002). Vet Surg 33:644-649, 2004.

Murphy et al: Minimally Invasive Cholecystotomy in the Dog: Evaluation of Placement Techniques and Use in Extrahepatic Biliary Obstruction. Vet Surg 36:675-683, 2007.

Pike et al: Gallbladder Mucocele in Dogs: 30 cases (2000-2002). JAVMA 224 (10): 1615-1622, 2004.

Willard MD, Fossum TW. Diseases of the Gallbladder and Extraheptic Biliary System in Ettinger SJ, Feldman EC, et al: Textbook of Veterinary Internal Medicine. (ed 6). St. Louis, MO, Elsevier, 2005, 1478-81.
Mark Garneau
Intern, 2009-2010
AAMC - Boston
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