Ascending cholangitis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anila Hussain, MD [2]
Overview
Surgical or endoscopic drainage may be needed in addition to the medical therapy in patients with moderate to severe ascending cholanitis or those with mild cholangitis not responding to medical treatment. Different procedures of biliary drainage include ERCP, PTC, EUS- guided drainage and open surgical drainage. If attempts at an endoscopic papillotomy or percutaneous transhepatic drainage of the common bile duct are unsuccessful, surgical exploration should be carried out to control sepsis.[1] Clinical studies show that emergency surgery for patients suffering from acute cholangitis results in improved postoperative morbidity and mortality rates[2]
Ascending cholangitis surgery
Surgical or endoscopic drainage may be needed in addition to the medical therapy in patients with moderate to severe ascending cholangitis or those with mild cholangitis not responding to medical treatment. Different procedures of biliary drainage include ERCP, PTC, EUS- guided drainage and open surgical drainage.
Endoscopic drainage(ERCP):
- Endoscopic sphinceterotomy with stone extraction( via baloon extractor catheter or wire basket) with or without stent placement is the treatment of choice for drainge currently[3]
- Stent can be placed without sphinceterotomy to acheive urgent biliary decompression in patients with coagulopathy having acute suppurative cholangitis[4]
- Less risk of complications as compares to surgical drainage
- Lower the mortality and morbidity of patients with severe acute cholangitis[5]
- Endoscopic nasobiliary drainage is another method that can be used with or without sphinceterotomy in patients with acute cholangitis[6]. It permits irrigation and biliary decompression by aspiration and can be used in those with coagulopathy, and those with large stones with inadequate drainage. It has the disadvantage of being uncomfortable for the patient[7]
Percutaneous transhepatic biliary drainage (PTBD):
- Procedure include inserting a needle into bile duct via transhepatic route
- Dilatation is obtained via baloon catheter and stones can be pushed into duodenum for removal by gut
- Percutaneus biliary drain can be attached to transhepatic cather to facilitate biliary drainage
- Reserved for patients with failed ERCP or contraindication to ERCP ( for example Bilroth II gastrectomy, Roux-en-Y anastomosis, peri-ampullary diverticulum etc)[8]
- Higher complication rate as compared to ERCP due to liver puncture. common complications may include sepsis,peritonitis by bile or hemobilia[9].
- Contraindicated in patients with ascites, coagulopathy and intrahepatic biliary obstruction[10]
Surgical drainage:
- Methods of surgical drainage include stone extraction, T-tube insertion, bilio-enteric bypass
- Used in patients with failed or contraindicated endoscopic or transcutaneous methods
- High mortality rate (20-60 percent) in case of urgent surgical decompression
References
- ↑ Himal HS, Lindsay T (1990). "Ascending cholangitis: surgery versus endoscopic or percutaneous drainage". Surgery. 108 (4): 629–33, discussion 633–4. PMID 2218872.
- ↑ Lai EC, Tam PC, Paterson IA, Ng MM, Fan ST, Choi TK; et al. (1990). "Emergency surgery for severe acute cholangitis. The high-risk patients". Ann Surg. 211 (1): 55–9. PMC 1357893. PMID 2294844.
- ↑ Chijiiwa K, Kozaki N, Naito T, Kameoka N, Tanaka M (1995). "Treatment of choice for choledocholithiasis in patients with acute obstructive suppurative cholangitis and liver cirrhosis". Am J Surg. 170 (4): 356–60. PMID 7573728.
- ↑ Hui CK, Lai KC, Yuen MF, Ng M, Chan CK, Hu W; et al. (2003). "Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis?". Gastrointest Endosc. 58 (4): 500–4. PMID 14520280.
- ↑ Lai EC, Mok FP, Tan ES, Lo CM, Fan ST, You KT; et al. (1992). "Endoscopic biliary drainage for severe acute cholangitis". N Engl J Med. 326 (24): 1582–6. doi:10.1056/NEJM199206113262401. PMID 1584258.
- ↑ Leung JW, Cotton PB (1991). "Endoscopic nasobiliary catheter drainage in biliary and pancreatic disease". Am J Gastroenterol. 86 (4): 389–94. PMID 2012035.
- ↑ Nagino M, Takada T, Kawarada Y, Nimura Y, Yamashita Y, Tsuyuguchi T; et al. (2007). "Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 68–77. doi:10.1007/s00534-006-1158-5. PMC 2799047. PMID 17252299.
- ↑ Köcher M, Cerná M, Havlík R, Král V, Gryga A, Duda M (2007). "Percutaneous treatment of benign bile duct strictures". Eur J Radiol. 62 (2): 170–4. doi:10.1016/j.ejrad.2007.01.032. PMID 17383840.
- ↑ Liu CL, Fan ST. Acute cholangitis. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: https://www.ncbi.nlm.nih.gov/books/NBK6921/
- ↑ Ahmed M (2018). "Acute cholangitis - an update". World J Gastrointest Pathophysiol. 9 (1): 1–7. doi:10.4291/wjgp.v9.i1.1. PMC 5823698. PMID 29487761.