Mechanical jaundice (MJ) of malignant genesis is a clinical syndrome caused by obturation of [621485]

INTRODUCTION
Mechanical jaundice (MJ) of malignant genesis is a clinical syndrome caused by obturation of
bile ducts due to malignant tumor growth. It is characterized by specific pigmentation of skin,
mucous membranes and sclerae due to increased accumulation of bilirubin in blood serum and
other fluids and tissues of the organism. Various immune disorders are detected in patients with
mechanical jaundice. Immune reactivity in mechanical jaundice is affected by toxic, infectious,
or tumor factors . (O. V. Smirnova, V. V. Tsukanov, N. M. Titova, B. G. Gubanov MEDICINSKAÂ IMMUNOLO GIÂ (2018 -01-
01) FEATURES OF CYTOKINE REGULATION IN PATIENTS WITH MECHANICAL JAUNDICE OF MALIGNANT GENESIS Journ al volume & issue
Vol. 20, no. 1 pp. 135 – 144 )
Obstructive jaundice is a symptom of malignant bile duct obstruction. Malignancies c ausing bile
duct obstruction include hepatocellular carcinoma, cholangiocarcinoma, gallbladder carcinoma ,
pancreatic cancer, ampullary carcinoma and metastatic tumors with consecutive compres sion of
the common bile duct . Patients with malignant biliary obstruction usually present fever,
abdominal pain, dyspepsia and jaundice . The diagnosis of malignancy is often dependent on the
measurement of tumor markers. High blood AFP is common in hepatocellular carcinoma, while
high blood CEA or CA19- 9 is associated with malignant pancreaticobiliary dis ease. Jaundice is a
main symptom of malignant bile duct obstruction, and increased jaundice may lead to severe
itching . (Zheng Zhou1,2*, Jingjing Li1*, Hua Liu1 , Deqing Wu1 , Yaping Xu1 , Yujing Xia1 , Jie Lu1 , Chuanyong Guo1 , Yingqun Zhou1
Quality of life and survival of patients with malignant bile duct obstruction fo llowing different ERCP based treatments Int J Clin Exp Med
2016;9(5):8821 -8832 www.ijcem.com /ISSN:1940 -5901/IJCEM0021536 )
Obstructive jaundice can be complicated with renal dysfunction, hemostasis impairment, hepatic
dysfunction, increased intestinal per meability, and other complications. ( Fekaj E, Jankulovski N and Matveeva N.
Obstructive Jaundice. Austin Dig Syst. 2017; 2(1): 1006. April 18, 2017)
The highest age incidence of obstructive jaundice was in the 50 – 80 years with maximum
incidence in the 6th decade. There was an increased incidence in female i.e. M: F=1:2.5. Most
common cause of obstructive jaundice is choledocholithiasis, followed by periampullary
carcinoma. Among periampullary carcinoma, Ca head of pancreas and Ca Ampulla of Vater are
the common causes. Jaundice is the most common presentation of surgical jaundice followed by
pain abdomen, nausea/vomiting, itching, loss of weight and f ever. (Srinidhi M, Ramesh Hosmani. “A Study of
Obstructive Jaundice with Focus on Predictive Factors for Outcome”. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue
29, July 21; Page: 8040 -8047, DOI: 10.14260/jemds/2014/3009 )

Incidence of malignancy in obstructive jaundice is 84%, which gradually increases with the
increasing age. The most common malignancy responsible for obstructive jaundice in female
patients is CA gall bladder (52%) and in male patients is CA head of pancreas (31%). (AZIZ, M.;
AHMAD, N.; , F. Incidence of malignant Obstructive Jaundice – a study of hundred patients at Nishtar Hospital Multan. Annals of King
Edward Medical University , v. 10, n. 1, 6 May 2016.)
The etiology and epidemiology of obstructive jaundice in Continental Croatia has been studied in
174 patients. The frequency of illness is higher among female population, and the most frequent
cause of obstructive jaundice are gallstones (54.1% of patients). In 29.8% of patients the primary
or secondary m alignant disease was the cause of blockage in gall flow and subsequent jaundice,
and the most frequent malignant cause of obstructive jaundice is pancreas cancer in 11.5% of
patients . (Gracanin AG, Kujundzić M, Petrovecki M, Romić Z, Rahelić D. Etiology an d epidemiology of obstructive
jaundice in Continental Croatia. Coll Antropol. 2013 Mar;37(1):131-3. PMID: 23697262.)
Klatskin tumor arises from the common hepatic duct and its bifurcation the bile ducts and is the
most common primary malignancy of the biliary tree. the location of the tumor and its close
relationship with vascular structures at the hepatic hilum have resulted in a low resectability and
high morbidity and mortality. Improvement of instrumental diagnostics and operative techniques
allows to perform extended resection and complex interventions on the liver, bile ducts and
vascular structures at the hepatic hilum. The role of chemoratiotherapy and photodynamic
therapy is not fully understood. thus, questions of treatment and prognosis of the disease are
remain relevant and require further study. (Czhao AV, Shevchenko TV, Zharikov YO. [View on the problem of
Klatskin tumor]. Khirurgiia (Mosk). 2015;(4):62- 67. Russian. doi: 10.17116/hirurgia2015462- 67. PMID: 26103646 .)
Gallbladder cancer remain s a relatively rare malignancy with a highly variable presentation.
Gallbladder cancer is the most common biliary tract malignancy with the worst overall
prognosis. With the advent of the laparoscope, in comparison with historical controls, this
disease is now more commonly diagnosed incidentally and at an earlier stage. However, when
symptoms of jaundice and pain are present, the prognosis remains dismal. From a surgical
perspective, gallbladder cancer can be suspected preoperatively, identified intraopera tively, or
discovered incidentally on final surgical pathology. (Wernberg JA, Lucarelli DD. Gallbladder cancer. Surg
Clin North Am. 2014 Apr;94(2):343- 60. doi: 10.1016/j.suc.2014.01.009. Epub 2014 Feb 18. PMID: 24679425.)

Obstructive Jaundice is a common surgical problem that occurs when there is an obstruction to
the passage of conjugated bilirubin from liver cells to intestine. It is among the most challenging
conditions managed by general surgeons and contributes signifi cantly t o high morbidity and
mortality . As patients with obstructive jaundice have high morbidity and mortality, early
diagnosis of the cause of obstruction is very important especially in malignant cases, as resection
is only possible at that stage. ( Chal ya PL, Kanumba ES, McHembe M. Etiological spectrum and treatment outcome of Obstructive
jaundice at a University teaching Hospital in northwestern Tanzania: A diagnostic and therapeutic challenges. BMC Res Notes . 2011;4:147. Published
2011 May 23. doi:10.1 186/1756- 0500- 4-147)

Purpose : bibliographic data synthesis regarding the methods of diagnosis and treatment of
malignant mechanical jaundice.
Objectives :
1. To highlight the malignant tumors manifested by the mechanical jaundice.
2. To analyze the diagnostic methods in the malignant mechanical jaundice.
3. To study the surgical methods of treatment in malignant mechanical jaundice.
4. To analyze the endoscopic and mini-invasive methods of palliative treatment
in malignant mechanical jaundice.

MATERIAL AND METHODS OF RESEARCH

In order to achieve the mentioned purpose and objectives, I performed the analysis of the
literature review between the years 2010 -2020. I have used the informational resources of the
Medical Scientific Library of the State University of Medicine and Pharmacy "Nicolae Testemitanu”, as well as the last -minute specialized publications, which are in the databases of
the electronic libraries PubMed, Medline, and Hinari, using the following keywords: “malignant mechanical jaundice”, “klatski n tumor”, “periampullary carcinoma”, “cancer of the head of
pancreas”, “gallbladder cancer”, “diagnosis of klatskin tumor”, “treatment of klatskin tumor”, “diagnosis of periampullary carcinoma”, “treatment of periampullary carcinoma”, “diagnosis
of cancer of head of pancreas”, “ treatment of cancer of head of pancreas”, “ diagnosis of
gallbladder cancer”, “ treatment of gallbladder cancer”, “ malignant mechanical jaundice
endoscopy”, “malignant mechanical jaundice palliative treatment”.

Chapter1. MALIGNANT MECHANICAL JAUNDICE
Obstructive jaundice is a surgical condition that occurs when there is an obstruction to the
passage of conjugated bilirubin from the liver cells to the intestine. It may be caused by a
heterogeneous group of diseases that include both Benign and Malignant conditions. Malignant
obstructive jaundice is a clinical picture in which jaundice develops as a result of mechanical
obstr uction of bile ducts from primary pancreaticobiliary malignancies or metastatic deposits.
(Shetty TS, Ghetla SR, Shaikh ST, et al. Malignant obstructive jaundice: A study of investigative parameters and its outcome.
J. Evid. Based Med. Healthc. 2016; 3(69) , 3752- 3759. DOI: 10.18410/jebmh/2016/803 )
Primary pancreatobiliary tract cancers and other local cancers that can cause compression of the
biliary tract (e.g., liver, gallbladder) account for approximately 80,000 new cancer cases and an
estimated 58,000 deaths in the United States.5 Despite advances in diagnosis and treatment, the
5-year survival rate of the most commonly encountered malignancies, pancreatic cancer, and
cholangiocarcinoma, remains dismal at Malignant biliary tract obstruction can also aris e from
gallbladder, duodenal, and ampullary cancers. ( Selvasekaran R, Nagalakshmi G, Anandan H. Clinical
Spectrum of Presentation of Obstructive Jaundice in Inflammation, Stone Disease and Malignancy. Int J Sci Stud
2017;5(4):10- 14.)
Among 50 cases studie d, 15 cases had a benign etiology and 35 cases had a malignant etiology
accounting for 70%. This shows the high morbidity and mortality of the disease (Table 2)

The most common complaint was yellowish discoloration of skin and sclera accounting for 54%.
Some patients had two chief complaints in combination such as abdominal pain and vomiting in
malignancies (Table 3).

Periampullary carcinoma appears to be the most common cause accounting for 34% of malignancies (Table 5)

The most common age group affected with obstructive jaundice appears to be 50- 60 years of age
accounting to about 38% and the mean age group affected is 52.5 years – youngest being 20
years and eldest being 85 years. The next most common age group appears to be 40- 50 years and

60-70 years with 24% and 16%, respectively. Thus, it appears to be a disease of elderly age
group. The most commonly affected sex is male.
Malignant disease appears to be most common in elderly males. About 22 cases, among 28 are
affected by malignant obstructive jaundice. The ratio of male:female appears to be 1.3:1. The
most common chief complaint appears to be yellowish discoloration of skin and sclera, i.e.,
jaundice in about 54% of patients. The next most common complaint is abdominal pain
accounting to a bout 40%. Some patients have two complaints in combination such as abdominal
pain and vomiting.
ETIOLOGY
The causes of malignant mechanical jaundice are Periampullary carcinoma, cancer of head of
pancreas, cancer of gallbladder and klatskin tumor.

1.1 PERIAMPULARRY CARCINOMA
Periampullary cancers are defined as cancers arising within 2 cm of the papilla of Vater and
include pancreatic, ampullary, biliary and duodenal cancers . The region of the ampulla is
anatomically complex because it is the area of co nvergence of the bile duct, pancreatic duct and
the duodenum . Pancreatic cancers represent the majority of cancers resected with a PD in most
series . (Chandrasegaram MD, Gill AJ, Samra J, Price T, Chen J, Fawcett J, Merrett ND. Ampullary cancer of intestin al origin
and duodenal cancer – A logical clinical and therapeutic subgroup in periampullary cancer. World J Gastrointest
Oncol 2017; 9(10): 407- 415)
Pancreatic cancer accounts for the majority of periampullary cancers resected with a PD in most
series, followed by ampullary 16% -50%, biliary 5% -39%, and duodenal cancer 3% -17%
(Table 1). The wide variation in the reported incidence and proportion of resec ted periampullary
cancers relates partly to difficulties in accurate determination of the primary tissue origin. This is
due to close anatomical proximity of the cancer subtypes and architectural distortion at time of
presentation.

Patients with resected duodenal and ampullary cancers have a better reported median survival
(29-47 mo and 22- 54 mo) compared to pancreatic cancer (13 -19 mo).
Incidence of periampullary carcinoma is low, approximately 0.5- 2% of all gastrointestinal
malignancies and 20% of all tumours of the extrahepatic biliary tree. Peri- ampullary carcinoma
arises around the confluence of the common bile duct with the main pancreatic duct and
therefore may have a different anatomical origin: at the level of the pancreatic head (60% of the
resected specimens), ampulla of Vater (20%), distal common bile duct (10%) and duodenum
(10%). In clinical practice, all these kind of periampullary carcinoma are joined by the
occurrence that they have a higher frequency of resectability compared to the pancreatic head
cancers, which represent as much as 90% of the tumours (both resectable and unresectable) of

the periampullary area. The clinical picture of periampullary carcinoma is mainly related in the
vast majority of patients to an early occurren ce of jaundice, thus contributing to the early
detection and a higher resection rat e. (Generoso Uomo Periampullary Carcinoma JOP. J Pancreas (Online)
2014 Mar 10; 15(2):213- 215 )
According to the microscopic classification, there are two main histological types of
periampullary carcinoma: the “intestinal type” (similar to tubular carcinoma of the stomach or
the colon and the “pancreatobiliary type” .

1.2 CANCER OF THE HEAD OF PANCREAS
Pancreatic cancer (PC), in spite of arising as a thirteenth cancer worldwide, is the fourth most
comm on cause of death due to cancer . The incidence and mortality rates of PC have been
increasing year by year worldwide. In 2015, there will be 367,411 new cases and 359,335 deaths from it globally . PC causes about 4.0% of a ll cancer deaths. In addition, it is an aggressive type
of cancer and 80% of patients have locally advanced or metastatic PC at the time of diagnosis.
There is also a continuous increase in PC incidence and mortality in China. According to the recent stati stics, it is the seventh most common cancer diagnosis in men and the fourteenth in
women and the sixth leading cause of cancer deaths in men and eighth in women. Figure 1
showed that 65,600 new cases of PC (39,200 men, 26,400 women) and 63,500 deaths (26,400 men, 25,800 women) occurred in 2012. And the rates of incidence and mortality from PC were
slightly higher in men than in women. (Qiubo Zhang, Linjuan Zeng, Yinting Chen, Guoda Lian, Chenchen Qian, Shaojie
Chen, Jiajia Li, Kaihong Huang, "Pancreatic Can cer Epidemiology, Detection, and Management", Gastroenterology Research and
Practice, vol. 2016, Article ID 8962321, 10 pages, 2016. https://doi.org/10.1155/2016/8962321 )

Figure 2 has shown geographical variations in PC. The age -standardized incidence and mortality
rates were calculated with the Asian model population of 2012. ASRs for PC were relatively low
in the southern part of Asia, such as State of Palestine, Bhutan, and China. In China, the age –
standardized incidence and mortality rates for men were 4.5 and 4.3 per 100,000, while for women they were 2.8 and 2.7. The northern part of Asia showed a considerably higher age –
standardized rate (ASR) than countries located in the southern part, for both incidence and mortality. The highest ASR was observed in Armenia, followed by Japan, and Kazakhstan.
Among both men and women, ASRs were 2- 3 times highe r in the north part of Asia. An
increasing gradient from the south to the north may suggest a protective factor for PC, which is vitamin D. The serum level of vitamin D among populations in the countries far from the equator
with insufficient UV solar radiation is relatively poor. Another possible reason for this difference
is the level of economic development. The accuracy of diagnosis for PC is higher in more
developed countries. (Qiubo Zhang, Linjuan Zeng, Yinting Chen, Guoda Lian, Chenchen Qian, Shaojie Chen, Jiajia Li,
Kaihong Huang, "Pancreatic Cancer Epidemiology, Detection, and Management", Gastroenterology Research and
Practice, vol. 2016, Article ID 8962321, 10 pages, 2016. https://doi.org/10.1155/ 2016/8962321 )

The possible risk factors for PC include gender, age, smoking, alcohol abuse, obesity, physical
activities, diabetes, chronic pancreatitis, vitamin D, genetic alterations, dietary, and reproductive
factors. For China, PC incidence is about 48% more common among men than women, as
shown in Figure 1. Estrogen and lifestyle habits such as smoking, alcohol abuse may be
responsible for the higher morbidity of PC among men than women.
The incidence of PC increases with age, with a slow increase before the age of 50. The median
age at diagnosis is 71 years in the United States and 72 years in England. An epidemiological
study of China in 2012 showed that 6572,700 had PC diagnosed and about 538,900 (0.8%) had a
diagnos is made before the age of 50 .
Studies have consistently confirmed that smoking can increase the risk of PC and one -quarter of
PC risk might be attributable to smoking. Epidemiological evidence suggest s that alcohol –
abusing group have a higher PC incidence and mortality than nondrinkers .

Dietary habits , particularly high- fat diets, resulted in a significant increase of cholecystokinin
(CCK). High release of CCK was frequently associated with the develop ment of intravascular
tumor emboli, which was correlated with increased vascular endothelial growth factor -A (VEGF –
A) . Besides, people who consume a diet high in animal fat are at higher risk for diabetes. A link
between diabetes and PC survival has also been suggested, but it remains inconsistent . On one
hand, it has been found that patients with long -term diabetes have a 1.5 -fold to 2.0- fold increase
in the risk of PC; on the other hand, the mean age of developing PC in these patients was significantly older than new -onset ones . Diabetes may even be considered to be a consequence
of PC.
Reproductive factors may be etiologically associated with PC through estrogen exposure.
Several studies, both in vivo and in vitro, have demonstrated that estrogen may lower women’s
risk of PC. A 100- fold increase in circulating plasma level of estrogen is observed during
pregnancy . Women with the higher parity have longer term exposure to high estrogen. And high expression of steroid hormone receptors is frequently found in both benign and malignant
neoplasm of pancreas .
1.3
GALLBLADDER CANCER
According to GLOBOCAN 2018 data, gallbladder cancer is the 22nd most incident but 17th most
deadly cancer worldwide . Gallbladder cancer is disproportionately deadly because it is rarely
found before it has advanced or metastasized. In fact, in the United States (US), only about 1 in 5
gallbladder cancers are diagnosed in the early stages . In 2018, about 219,000 people were
estimated to have been diagnosed with gallbladder cancer. This constitutes 1.2% of all cancer
diagnoses .
Gallbladder cancer is the only digestive system cancer that is more common among women than
men. In 2018, the estimated incidence was 97,000 for men and 122,000 for women. The
incidence in the US is lower tha n that around the world, with a rate of 1.4 per 100,000 among
women and 0.8 among men. ( Prashanth Rawla Tagore Sunkara Krishna Chaitanya Thandra and Adam
Barsouk Epidemiology of gallbladder cancer Clin Exp Hepatol . 2019 May; 5(2): 93– 102. Published online 2019
May 23. doi: 10.5114/ceh.2019.85166 )

Countries with t he top five highest age -standardized incidence rates per 100,000 for males in
2018 are Bolivia (12.8), Thailand (9.0), Republic of Korea (8.4), Chile (6.6) and Nepal (6.0).
Countries with the top five highest age -standardized incidence rates per 100,000 for females in
2018 are Bolivia (15.1), Chile (11.7), Bangladesh (7.3), Nepal (7.3) and Peru (6.0) . The
geographic differences in incidence are likely attributable to differences in environmental
exposures to various chemicals, genetic predisposition and regional intrinsic risk factors th at
predispose to carcinogenesis .
Gallbladder cancer rates become more common with age, likely because the malignancy takes
decades to develop. The average age of diagnosis in the US is 72. Gallbladder cancer is common
after the age of 60 years. The Surveillance, Epidemiology, and End Results (SEER) database
from the US from 2015 reveals that age -adjusted incidence rates (per 100,000) in 2015 rose from
0.2 for those aged 20- 49 years, to 1.6 for those aged 50- 64 years, to 4.3 for those aged 65- 74
years, and to 8.1 for individuals aged 75 years and older. This corresponded with mortality rates
(per 100,000), which increased from 0.1 for those aged 20- 49 years, to 0.7 for those aged 50 -64
years and to 2.1 for those aged 65- 74 ye ars. The highest mortality rate was 4.9/100,000, for
individuals aged 75 years and older .
Gallbladder cancer is more common in females than males . Women are two to six times more commonly affected than men. The female hormone estrogen is known to increas e the saturation
of cholesterol in bile, thus increasing the risk of gallstone formation. This pathogenesis is believed to be the primary culprit behind the greater risk of gallbladder cancer among females .
A family history of gallbladder cancer can increa se a person’s risk of developing gallbladder
cancer. Reports regarding the familial risk of gallbladder cancer have been contradictory.
Familial clustering of gallbladder cancer has been noted in some studies . A Swedish study
showed that the standardized i ncidence ratio (SIR) for gallbladder cancer in offspring of parents
diagnosed w ith gallbladder cancer was 2.47. But results from the Biliary Tract Cancers Pooling
Project recently did not show any association between family history of cancer and gallbladde r
cancer . Multiple genetic mutations have been implicated among gallbladder cancer cases,
including KRAS , P16 , c-erb-B2, and TP53 . Most are common oncogenes or tumor suppressor
genes implicated in many cancers; hence, it is not clear which are driving muta tions unique to
gallbladder cancer. Certain mutations are associated with other cancer risk factors; for instance,

gallbladder cancer in those with an anomalous pancreaticobiliary duct junction frequently
presents with KRAS mutations and relatively late on set of p53 mutations, while in patients with
cholelithiasis and chronic cholecystitis, KRAS mutations are rare and p53 mutations arise early .
Post-menopausal women undergoing oral estrogen or estrogen -progesterone therapy are at
increased risk of gallstones and gallbladder cancer, although the association between oral
contraceptives an d gallbladder cancer is unclear . Further studies have suggested that transdermal
estrogen replacement therapy presents with a lower risk for gallbla dder diseases than oral
therapy . Since oral estrogen is ingested, it likely finds its way into the liver and bile in greater
concentration than transdermal applications. Methyldopa and isoni azid have been impli cated in
biliary carcinogenesis .
Toxic substances that are ingested are often filtered by the liver and excreted into the bile,
where they come into contact with the lining of the gallbladder. Workers in rubber plants or
textile factories, or those exposed to nitrosamines, are at an incre ased risk of gallbladder cancer .
Those living in the Gangetic belt in India, an industrial region with a high load of pollutants,
have a nearly 10 -fold increased risk of developing gallbladder cancer rel ative to the average in
the country . Cigarette smoking has also be en associated with the neoplasm . A meta -analysis by
Bagnardi et al. of 8 studies showed that heavy drinking (> 50 γ of alcohol/day) was associated
with a RR of 2.64 for gallbladder cancer . Aflatoxin exposure has also been associated with an
increased risk of gallbladder cancer .
Obese people, those with a body mass index (BMI) > 30 kg/m2, have an increased risk o f
developing gallbladder cancer . Overweight and obese individuals have a 1.15 and 1.66 RR,
respectively, of developing gallbladder cancer. Potential biological mechanisms for the
association include an increased concentration of hormones such as estrogen or insulin, which
increases the formation of gallstones. The association is stronge r among women than men,
perhaps because women already have a higher level of estrogen in the circulation . A meta –
analysis of 15 studies with 5902 cases showed that the risk increased by 4% for each 1
kg/m2 increase in BMI above 25 kg/m2. In another meta -analysis of 20 studies it was found that
compared with nondiabetics, diabetic individuals had 1.56 times incre ased risk of gallbladder
cancer .

1.4 KLATSKIN TUMOR
Klatskin tumor (hilar cholangiocarcinoma or central bile duct carcinoma, KCC) is a rare type of
tumor, with an annual incidence of no more than 1: 100 000. It originates from the bifurcation of
the extrahepatic bile duct and was first described in 1965 by Gerald Klatskin who reported 15
cases and defined some featur es in these cholangiocarcinomas . Most KCCs are adenocarcinomas
with poor differentiation degree, spreading along the duct and nerve sheath. There are some risk
factors, including primary sclerosing cholangitis (PSC), liver fluke infection (C. sinensis and
Opisthorchis viverrini), and intrahepatic bile duct stones, but most KCCs are sporadic with no
obvious predisposing factors . The symptoms are usually fatigue, jaundice, and cachexia,
indicating metastatic or advanced tumors. Most patients have biliary symptoms, including
painless jaun dice. About 10% of patients also simultaneously present with cholangitis . (Zhang X,
Liu H. Klatskin Tumor: A Population -Based Study of Incidence and Survival. Med Sci Monit . 2019;25:4503- 4512.
Published 2019 Jun 17. doi:10.12659/MSM.914987)
Klatskin ident ified CCAs originating from the hepatic duct bifurcation and named these hilar
tumors as Klatskin tu mors . Klatskin tumors, or hilar CCAs, are bile duct tumors that involve the
common hepatic duct bifurcation but may arise from the intrahepatic (IHCCA) or e xtrahepatic
(EHC CA) portion of the biliary tree. (Sharma P, Yadav S. Demographics, tumor characteristics,
treatment, and survival of patients with Klatskin tumors. Ann Gastroenterol . 2018;31(2):231-236.
doi:10.20524/aog.2018.0233 )
Klatskin tumor is an advanced disease that usually occurs in patients over age 60 years, which is
similar to our results (median age: 71 years). Males and females were affected roughly equally in
our study, but some studies have shown that males have a slightly hi gher incidence. Globally, the
highest incidence of Klatskin tumor is in Southeast Asia, and the disea se is rare in the United
States .
The cause of Klatskin tumor is still unclear, but many risk factors have been identified. Infection seems to be closely related to the development of cholangiocarcinoma in Asian countries. Liver
flukes, including Clonorchis
trematode and Thai liver fluke, can chronically infect the bile duct
and cause the development of cholangiocarcinoma . Other risk factors related to Klatsk in tumor
include alcoholism, hepatitis B and hepatitis C viruses, chronic pancreatitis, primary sclerosing
cholangitis, choledochal cysts, and cholelithiasis . (Zhang X, Liu H. Klatskin Tumor: A Population –

Based Study of Incidence and Survival. Med Sci Monit . 2019;25:4503 -4512. Published 2019 Jun 17.
doi:10.12659/MSM.914987)
Current unresectable disease criteria include major portal vein involvement or encapsulation,
bilateral spread, bilateral hepatic artery involvement, unilateral liver arterial involv ement, and the
presence of distant lymph nodes or organ metastases. For patients whose tumors are operable, the current primary treatment is surgery. Several studies have shown that patients undergoing
resection have significantly longer survival than in non- surgical patients, and the overall 5 -year
survival rate for highly selected patients is close to 53%.
Klatskin tumors had the highest incidence among Asians and Pacific islanders, who had an age –
adjusted incidence rate of 0.48 per 1,000,000. Factors tha t explain this racial predisposition for
Asians to developing Klatskin tumors include the increased rate of hepatolithiasis and liver -fluke
infections among these patients. The highest prevalence of CCA has been reported from
Southeast Asia . The reason behind the increased predisposition to these tumors among Asians in
the United States who lack the usual risk factors may, however, suggest an alternative
pathogenesis. Our analysis noted that the incidence of Klatskin tumors increases with age, with a
peak b etween 60s -80s. It can affect all age groups, but the age distribution seen in our st udy is
similar to prior reports . We noted that no cases were reported in patients younger than 24 years,
which suggests chronic long -standing inflammation with advancing a ge leading to hyperplasia as
an underlying pathogenic mechanism. (Sharma P, Yadav S. Demographics, tumor characteristics,
treatment, and survival of patients with Klatskin tumors. Ann Gastroenterol . 2018;31(2):231-236.
doi:10.20524/aog.2018.0233 )
The overall age- adjusted incidence of Klatskin tumors between 2004 and 2013 was 0.38 per
1,000,000 per year (Table 1). There was a higher incidence of Klatskin tumors in males
compared to females (0.47 vs. 0.25 per 1,000,000 per year). These tumors were more common
among Asian and Pacific islanders, who had an age -adjusted incidence rate of 0.48 per
1,000,000. A gradual decline in the incidence was noted, with the highest incidence (0.44) in
2005 and the lowest (0.24) in 2010 (Fig. 1).

Incidence increased with age, with peak incidence between the ages of 80 to 84 years. No cases
were reported in patients younger than 24 years of age (Fig. 2).

Chapter 2 CLINICAL PICTURES AND METHOD OF DIAGNOSIS IN
MALIGNANT MECHANICAL JAUNDICE
A prospective clinical study consisting of 30 cases of obstructive jaundice was undertaken to investigate
the pattern of clinical presentation and lab parameters to study the cause of obstructive jaundice and
the different modes of treatment adopted. (: Prabakar A, Raj RS. Obstructive jaundice: a clinical study. J.
Evolution Med. Dent. Sci. 2016;5(28): 1423- 1429, DOI: 10.14260/jemds/2016/335)

Pain abdomen was present in 22 patients (73.33%) with 100% of patients with benign and 20%
of patients with malignant aetiology presenting with this symptom. This was found to be
statistically significant without any increase in risk for a malignant aetiology. Flatulent dyspepsia
which includes bloating, belching or heart burn was present in 18 patients (60%) with 70% of patients of benign and 70% of patients with malignant aetiology presenting with this symptom,
but was not statistically significant withou t an increase in risk . Jaundice was present in 20
patients (67%). Jaundice in benign condition 12 patients (60%) and in malignant condition 8 patients (40%). Jaundice had 3 times the risk for a malignant cause, however, not statistically
significant. Itchi ng was present in 16 patients (53%). In benign condition–50% and malignant

condition–60% with a 2 times increased risk for malignancy which was not statistically
significant.
High coloured urine was present in 20 patients (67%). In benign condition – 60% and malignant
condition, it was 80% prevalent with 3 times increased risk for the cause to be malignant, but not
statistically significant. Clay coloured stools was present in 16 patients (53%). In benign
condition, it was 40% prevalent and in malignant c ondition 80% with 6 times increased risk
which was statis tically significant. Nausea and vomiting was present in 16 patients (53%). In
benign condition, the prevalence was 60% and in malignant condition 40% prevalent with no increased ris k or statistical s ignificance. Fever was present in a total of 16 patients (53%) with
benign condition- 70% and malignant condition 20% prevalence with no increased risk or
statistical significance.
(: Prabakar A, Raj RS. Obstructive jaundice: a clinical study. J. Evolutio n Med. Dent.
Sci. 2016;5(28): 1423- 1429, DOI: 10.14260/jemds/2016/335)
Loss of appetite was present in 18 patients. In benign condition, it was 50% and in malignant condition it was 80% with 4 times increased risk of being malignant with no significant
difference among the 2 groups. Melena was present in 10 patients who were diagnosed as
obstructive jaundice with 36 times increased risk for malignancy with statistical p value <0.05. Pallor was present in a total of 16 (53%) patients with benign condition (4 0%) and in malignant
condition it was 80% with an increased risk for malignancy, but no significant difference was noticed between the 2 groups. Gallbladder was palpable in 10 patients (33%). In patients with
benign condition 10% and malignant condition 80 % prevalence with 36 times increased risk for
malignancy was noted with a p value .
A total of 116 patients of obstructive jaundice were enrolled. Of these, 50 (43.1%) were males
and females were 66 (56.9%) with a male to female ratio of 1:1.3. Their ages ranged from 12 to
78 years with a mean of 56.34 ± 16.42 years. The clinical presentation of obstructive jaundice for
both benign and malignant etiology is shown in Table 2. ( Chalya PL, Kanumba ES, McHembe M. Etiological spectrum
and treatment outcome of Obstructive jaundice at a University teaching Hospital in northwestern Tanzania: A diagnostic and therapeutic
challenges. BMC Res Notes . 2011;4:147. Published 2011 May 23. doi:10.1186/1756- 0500 -4-147)

All patients in our study presented with jaundice associated with clay colored stool (89.6%),
pruritis (77.6%), weight loss (61.2%), right upper abdominal pain (58.6%), scratch marks
(53.6%) and palpable abdominal mass (51.8%). Clay colored stool, weight loss and palpable
abdominal mass were more common i n malignant obstructive jaundice, whereas right upper
abdominal pain was more common in benign obstructive jaundice. Pruritis and scratch marks
were seen equally in both the benign and malignant cases. Similar clinical pattern was also
reported by others. The presence of right upper abdominal pain in patients with malignant
obstructive jaundice is probably due to advanced disease. The abdominal mass was appreciated
in 50.9% of the patients with malignancy due to the local spread of tissues and no mass was
palpable.
2.1 ERCP ( Endoscopic retrograde cholangiopancreatography)
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved into an almost
exclusively therapeutic procedure since its first description in the late 1960s as a diagnostic
techniq ue.1 By using moderate sedation , ERCP is performed with a side -viewing duodenoscope
that allows identification of the major papilla and the bile duct is cannulated under endoscopic
and fluoroscopic guidance. A variety of catheters, guide -wires, and stents are available to
perform the therapeutic interventions. Diagnostic ERCP is still used for facilitating manometry

in patients with suspected sphincter of Oddi dysfu nction and for establishing the diagnosis of
primary sclerosing cholangitis when other imaging techniques have been non- diagnostic .
(Mohammad Quamrul Hasan , Nelson Taposh Mondal , Mahbub Hossain , Irin Perveen Endoscopic Retrograde
Cholangiopancreatography (ERCP) Experience in a Tertiary Level Hospital in Bangladesh Journal of Enam Medical College Vol
9 No 1 January 2019 doi: https://doi.org/10.3329/jemc.v9i1.39898)
Now- a-days we mainly do ERCP with therapeutic intent in biliary tract disease for removal o f
common bile duct calculi, for palliation of malignant biliary obstruction, in management of
biliary leaks/damage complicating surgery, for dilatation of benign strictures and primary
sclerosing cholangitis. For pancreatic diseases, drainage of pancreatic pseudocysts and fistula are
done and pancreatic calculi are removed in selected cases .( Penman ID, Lees CW. Alimentary tract and pancreatic
disease. In: Walker BR, Colledge NR, Relston SH, Penman ID (eds). Davidson’s principles & practice of medicine. 22n d edn. London: Churchill
Livingstone, 2014: 837 –920)
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful procedure for the
evaluation and treatment of diseases of the gallbladder and pancreas. During most of the
intervening years, ERCP has be en invaluable as both a diagnostic and therapeutic procedure.
However, advances in noninvasive radiographic and less invasive endoscopic imaging have transformed ERCP into an almost exclusively therapeutic procedure.
(Rahman MM, Sharif MSB, Rahman
A, Khan MR, Mandal MA. Success and limitations of ERCP in the management of obstructive jaundice. KYAMC Journal 2017;
8(1): 38– 42.)
Stones within the bile duct during ERCP appear as filling defects and can be detected with a
sensitivity and specificity of approximately 95%.9 The therapeutic applications of ERCP have
revolutionized the treatment of patients with choledocholithiasis10 and other bile duct disorders.
Stones in the bile duct, when cause symptoms, tend to manifest as life -threatening complications
such as cholangitis and acute pancreatitis. Therefore, discovery of choledocholithiasis generally
should be followed by some types of interventions to remove the stones.
patients with biliary obstruction usually undergo initial evaluation with endoscopic retrograde
cholangiopancreatography (ERCP). ERCP is an outpatient procedure that combines
gastrointestinal endoscopy with fluoroscopy to evaluate the pancreatic and bile ducts. With the
patient under procedural sedation or general anesthesia, an endoscope is inserted into the oral
pharynx and is advanced into the second part of the duodenum to the level of the ampulla of
Vater, an anatomic landmark where the common bile duct (CBD) and pancreatic duct join and

enter the duodenum. The ampulla is cannulated and contrast is injected into the confluence to
opacify the CBD, pancreatic duct, and proximal bile ducts. After identification of a biliary
stricture, ERCP is used to obtain brush cytology or biliary biopsy, if the obstruction is more
distal (closer to the ampulla of Vater). The sensitivity of brush cytology is poor for diagnosing a
malignant cause of stricture (23 –56%); however, the s pecificity is quite high (95%).The
sensitivity is improved to 70% when brush cytology is combined with endobiliary biopsy with
high specificity (100%). Because ERCP allows for access to the intrahepatic and extrahepatic
bile ducts through natural orifices, patients with contraindications to percutaneous methods such
as significant coagulopathies, ascites, and polycystic liver disease can be safely evaluated with
this technique. ( Christopher R. Bailey and Kelvin Hong Malignant Obstructive Jaundice 10.1055/b -0038- 162883 )

(Garcea, Giuseppe & Ong, Seok & Dennison, Ashley & Berry, David & Maddern, Guy. (2009). Palliation of Malignant
Obstructive Jaundice. Dig Dis Sci. 54. 1184 -1198. 10.1007/s10620 -008-0479- 4.)

ERCP is the standard imaging study for patients with obstructive jaundice, who needed
intervention. and its great advantage is, in its ability to perform therapeutic interventional
procedures, like stone removal, stricture dilatation, and stent placement w hich will relieve
obstruction. It requires a highly skilled and experienced endoscopist. Technical limitations can lead to unsuccessful examination. It may fail to show biliary tree proximal to severe obstruction.
It is associated with significant post pro cedure morbidity and mortality. It cannot be performed
in critically ill patients .
(R Sundara Raja Perumal, Shaik Farid. Role of magnetic resonance cholangiopancreatography (MRCP) in the
evaluation of patients with obstructive jaundice. MedPulse – Internat ional Journal of Radiology. September 2019; 11(3): 107 -110.
http://www.medpulse.in/Radio%20Diagnosis/)

2.2 Ultrasound
Ultrasonography is a reliable imaging modality for diagnosing the cause and level of obstruction
in surgical jaundice. The sensitivity is adequate to aid the early institution of surgical
intervention, thereby preventing morbidity and mortality . Ultrasound is often the only readily
available method, with many of the other modalities being too expensive or unavailable to many patients. Furthermore, abdominal ultrasound is considered to be the first initial imaging
procedure in obstructive jaundice. Ultrasonography could al so be used for some imaging -guided
hepatobiliary interventions. With the patient in the supine position, a coupling gel was applied to the exposed abdomen in the right upper quadrant. Scanning was done in both longitudinal and
transverse planes. The patien t was then placed in the left posterior oblique or left lateral
decubitus position in order to scan the intra and extra -hepatic ductal systems. (Fadahunsi OO, Ibitoye
BO, Adisa AO, Alatise OI, Adetiloye VA, Idowu BM. Diagnostic accuracy of ultrasonography in adults with obstructive
jaundice. J Ultrason . 2020;20(81):e100-e105. doi:10.15557/JoU.2020.0016)

The study investigated the diagnostic accuracy of ultrasonography for reaching a definitive
diagnosis in patients with obstruction of the extra -hepatic biliary tree. We observed a good
correlation between the definitive diagnosis and sonographic diagnosis, wi th an overall
sensitivity of 76.6% and specificity of 98%.
Ultrasound provided significant information about the gallbladder and the biliary ducts and
usually differentiate between obstructive jaundice and non- obstructive jaundice, stones.
Ultrasound is s ensitive in detection of any liver parenchymal changes, also a useful tool to detect
any change in gallbladder wall, stones impacted in the common bile duct, tumor of the head of
pancreas In jaundiced patients, ultrasound can detect single nodular masses or any inflammatory
changes and also assesses liver size. (Moawia Gamersddin ,Rasha Abdalgaffar , Mohamed yousef IOSR Journal of
Nursing and Health Science (IOSR -JNHS) e -ISSN: 2320 –1959.p- ISSN: 2320 –1940 Volume 1, Issue 4 (May – Jun. 2013), PP
25-28)

Usually after laboratory investigations ultrasonography of the abdomen is considered the first
choice technique n the study of biliary obstructive disease, due to its accessibility, speed, ease of
performance and low cost. This has been even more so in re cent years, following the
technological evolution of US equipment which, thanks to Tissue Harmonic Imaging (THI), gives better visualization of fluid filled structures (such as the biliary structures), reduced
artifacts and enhanced contrast resolution. Di agnostic sonography has advanced at a breath
taking pace . Ultrasound has the advantage that the biliary tree is easily assessed, but the retro
pancreatic tissue are less well visualized, and bowel gas, periodically in the presence of an ileus
accompanying acute pancreatitis can partially or completely obscure the 4 pancreas . Ultrasound
is non- invasive, painless, does not submit the patient to radiation and can be performed 5 on the
critically ill patients . (
Kianai AA, Javaid RH, Ghaffar A, Khan S. Ultraso nography in obstructive
jaundice. Professional Med J Aug 2012;19(4):436- 441.)

2.3 CT (COMPUTED TOMOGRAPHY)
Computed tomography (CT) scanning technology has improved significantly over the past two
decades. The revolution has proceeded through several stag es, from conventional CT to helical
(or spiral) CT to new multidetector CT (MDCT), in which ultrafast detector rotation and
collimation can be combined to yield high- resolution image reconstructions of the liver,
pancreas, and related structures. MDCT's ab ility to obtain volume dataset with submillimeter
spatial resolution allows the optimal display of bile duct using multiplanar reconstruction (MPR)
and minimal intensity projection (MinIP) without compromising image quality. The combined
use of MPR and Min IP techniques significantly improves the images of the biliary ducts and
their site of confluence compared with those obtained by axial CT.These recent advances make
MDCT often sufficient for evaluating obstructive jaundice. To the best of our knowledge,
however, there are only few studies comparing the accuracy of MDCT and magnetic resonance
imaging (MRI) in assessment of cause and level of obstruction in obstructive jaundice. (Singh SS,
Shafi F, Singh NR. Comparative study of multidetector computed tomography and magnetic resonance
cholangiopancreatography in obstructive jaundice. J Med Soc 2017;31:162 -8 )

Figure 3: cholangiocarcinoma. Minimal intensity projection oblique coronal multiplanar
reconstruction image of the delayed phase mult idetector computed tomography scan showing
delayed enhancing mass (arrow) distal to confluence of dilated hepatic ducts.
For the diagnosis of malignant obstruction, accuracy of MDCT (94.2%) is comparable with or
slightly better than that of MRCP (91.2%). Accurately diagnosing malignant strictures require
high spatial resolution as the lesion behind the malignant stricture is usually small. Thin
collimation of the MDCT enables the acquisition of large volume of data, which in turn enable
multiplanar images with high Z -axis resolution. (Narayanaswamy I, Erasu AR, Prakash HV. The role of
multidetector row computed tomography in biliary tract malignancy. Cancer Res J 2015;3:104- 9. )

64 SLICE Multiphasic CT has ability to obtain volume dataset with sub- millimetre spatial
resolution allowing the optimal display of bile duct by using multiplanar reconstruction (MPR)
and minimal intensity projection (MinIP) and axial CT significantly improves the visualization
of the biliary ducts and their site of conflu ence . In cases of jaundice with high likelihood of
malignant biliary obstruction,a MDCT scan is recommended as the first line imaging method in this category. A contrast -enhanced multiphase spiral CT examination with multiplanar

reformation has high sensitivity to lesion detection and 70% accuracy in discrimination of
resectable and unrespectable disease and tumour staging.

Pancreatic carcinoma- On dynamic contrast enhanced MDCT the tumour is seen as a focal area
of poor enhanc ement in densely enhancing normal pancreatic tissue and this is classical direct
sign for tumour detection. For diagnosis of this lesion there are six indirect sign s : the
presence of (1 ) biliary duct dilatation,(2) pancreatic duct dilatation,(3) double duct sign
which may lead to ,(iv) focal atrophy of the gland. If mass is sufficiently large it will ( 5)
distort contour of the gland, and (6)loss of pancreatic lobulation is a subtle , but often early sign.
MDCT findings that indicate arterial invasion include soft tissue infiltration obscuring vessel
margin, calibre change, or contour deformity. Li et al assessed presence of circumferential
vessel contact with tumor to define vascula r infiltration( either arterial or venous) and opined
that a tumor -vessel contact >180 indicate invasion and <90 indicate low probability of
infiltration. (IOSR Journal of Dental and Medical Sciences (IOSR -JDMS) e -ISSN: 2279 -0853, p-ISSN: 2279 -0861.Volume
17, Issue 9 Ver. 7 (September. 2018), PP 18- 26 www.iosrjournals.org)

2.4 MRI (MAGNETIC RESONANCE IMAGING)
Magnetic resonance cholangiopancreatography (MRCP) is a non -invasive diagnostic technique
that can be used for imaging the entire biliary tree a nd pancreatic duct system. the positive rate of
anatomical diagnosis and the detection rate of bile ducts on the proximal side of obstruction are
100%. The diagnostic accuracy of malignant obstruction was 82.9%. MRCP was found to have
high diagnostic speci ficity for determining the location and extent of obstruction. Therefore,
concluded that MRCP had significance for clinical diagnosis of malignant obstructive jaundice.
The positive rate of localization diagnosis was 100%. Distinguishing the quality of obstruction
was also important. The diagnostic accuracy of MRCP for malignant obstructive jaundice was
remarkably higher. (Liang C, Mao H, Wang Q, Han D, Li Yuxia L, Yue J, Cui H, Sun F, Yang R. Diagnostic performance of
magnetic resonance cholangiopancrea tography in malignant obstructive jaundice. Cell Biochem Biophys. 2011 Nov;61(2):383 -8. doi:
10.1007/s12013- 011-9195- 3. PMID: 21567133.)
MRCP is a standard MR imaging technique that has revolutionized the imaging of biliary and
pancreatic ducts and has emerged as an accurate, noninvasive means of visualization of the
biliary tree and pancreatic duct without radiation and injection of contrast material.3 Since its
introduction by Wallner et al in 1991, MRCP has undergone a wide range of changes. It relies on
heavily T2 -Weighted image sequences that display stationary water as a high signal. Multiplanar
thin and thick section acquisitions are obtained using fast spinecho techniques. 4The latest imaging techniques for MRCP are Rapid Acquisition with Relaxation Enhancement (RARE) and
Half-Fourier Acquisition Single – Shot Turbo- Spin- Echo (HASTE).1 Using RARE and HASTE
sequences, image acquisition is possible within a few seconds, allowing MRCP to be performed comfortably during a single breath -hold thus markedly r educing the motion artifacts and
improving the quality of images Magnetic Resonance Cholangiopancreatography with its inherent high contrast resolution, rapidity, multiplanar capability and virtually artifact -free
display of anatomy and pathology, is provi ng to be imaging of choice in these patients.
MRCP shows the entire biliary tract and pancreatic duct without any intervention and use of oral
or IV contrast. The quality of images obtained is comparable with those of direct
cholangiography procedure like ERCP.6 The diagnostic accuracy of MRCP suggests that it has
the potential to replace the more invasive procedures like diagnostic ERCP, which should be
used only in cases where intervention is being contemplated. MRCP is very effective in

diagnosing calcul i within the CBD, level of stricture, Intrahepatic, extrahepatic biliary ductal
dilatation. In patients with malignant obstruction or stenosis of biliary -enteric anastomosis, this
non invasive imaging technique demonstrates the site and extent of the stenosis, the degree of
proximal dilatation, the presence and size of biliary stones, and associated findings.

MRCP has the highest accuracy for detecting cause of obstruction in both and malignant lesions. The sensitivity of MRCP is 94% but the specificity is high as 100%. Inspite of the high
sensitivity for USG, the specificity for the same is very low at 69% whe n compared to that of
CT’s 69% and MRCP’s 100%. Thus MRCP is a specific investigation for level and cause of obstruction in patients with obstructive jaundice. (Table No:3)

Three patients were diagnosed to have klatskins tumour, (Figure No:3) and the ac curacy of
MRCP remains 100%. MRI sections to it because of its non invasive nature, non ionization, No
use of contast media in most of cases, multiplanar capability, Non operator dependance, No post
procedure complication. MRCP and MRI can be done in crit ically ill patients. However, MRCP
and MRI abdomen cannot provide therapeutic options like ERCP. The study also has a few limitations. In the diagnosis of obstructive jaundice and to know the cause, site and extent of the
lesion MRCP being a non invasive, non ionizing procedure seems to be a better choice. The drawback of MRCP is, its limited availability and its high cost.
(R Sundara Raja Perumal, Shaik Farid. Role of
magnetic resonance cholangiopancreatography (MRCP) in the evaluation of patients with obs tructive jaundice. MedPulse – International
Journal of Radiology. September 2019; 11(3): 107 -110. http://www.medpulse.in/Radio%20Diagnosis/)

Chapter 3 SURGICAL TREATMENT IN MALIGNANT MECHANICAL
JAUNDICE
3.1 Radical Methods
3.1.1 Pancreaticoduodenectomy
PD remains the standard surgical treatment for resectable peri -ampullary tumors. The first PD
operation was reported by Codavilli in 1898 in a patient with an epithelioma of the pancreas, but
the patient died from cachexia on the 21st post -operative day. In 1946, Whipple described a one –
stage PD in which the pylorus was resected. The first report of pylorus preserving PD (PPPD)
was by Watson in 1944 for ampullary carcinoma but it did not gain popularity at that time.
In both the classic PD and PPPD, the head of pancreas, duodenum, and distal bile duct are
resected. The main difference is that in classic PD, the gastric antrum and pyl orus are resected with
the creation of a gastro -jejunostomy, while in PPPD, the gastric antrum and pylorus are preserved and
the line of resection is through the first part of duodenum and a duodeno -jejunostomy is performed
[Figure 1 a and b].

Figure 1: Pancreaticoduodenectomy, (a) classic, (b) pylorus preserving
(Faisal Alsaif Pylorus Preserving Pancreaticoduodenectomy for PeriAmpullary Carcinoma, Is It a Good Option The Saudi Journal
of Gastroenterology 2010 16(2):75- 8 DOI: 10.4103/1319- 3767. 61231)

The conventional pancreaticoduodenectomy, often referred to as a classic Whipple, includes a
distal gastrectomy and resection of the pancreatic head, common hepatic duct (CHD),
gallbladder, duodenum, and first portion of the jejunum. In comparison, a PPPD preserves the
distal stomach, pylorus, and first portion of the duodenum. Instead of a gastrojejunostomy for
gastric continuity, the duodenum is anastamosed directly to the jejunum (Fig. 1).

Figure 2: Classic versus pylorus -preserving pancreaticoduodenectomy.

(Garonzik Wang, Jacqueline & Doyle, Maria. (2015). Pylorus preserving pancreaticoduodenectomy: Pylorus Preserving
Pancreaticoduodenectomy. Clinical Liver Disease. 5. 10.1002/cld.463.)
A bilateral subcostal or midline incision provides adequate exposure. On entry, a thorough
exploration must be performed to rule out metastatic disease or local invasion precluding
resection. Next, the duodenum is extensively kocherized, and the duodenum, along with the head
of the pancreas, is mobilized and elevated medially. This maneuver allows for palpation of the
superior mesenteric artery (SMA) to rule out local invasion. Although not the standard of care, there are reports of en bloc resection and reconstruction of the S MA if invasion is present.
(He J,
Page AJ, Weiss M, Wolfgang CL, Herman JM, Pawlik TM. Management of borderline and locally advanced
pancreatic cancer: where do we stand? World J Gastroenterol 2014;20:2255- 2266.)
Next, the surgeon should identify the porta l vein (PV) and confirm that it is tumor free.
Mobilization of the gallbladder and subsequent identification and division of the CHD can aid in
PV visualization. Hepaticojejunostomy (HJ) is the preferred palliative bypass method, so CHD
divisi on is acceptable at this point. The gastroduodenal artery (GDA) can also be divided;
however, first the surgeon must temporarily occlude it and confirm continued pulsation in the hepatic artery. Patients with celiac axis stenosis are often reliant on the GDA for collat eral flow.
Ligation in these patients would be devastating. This is also an appropriate time to assess for aberrant arterial anatomy, specifically, a replaced or accessory right hepatic artery.
(Diener MK,
Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Kn aebel HP, et al. Pylorus -preserving pancreaticoduodenectomy (pp Whipple) versus
pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev
2011;(5): CD006053.)
After transection of the CHD and GDA, the pancreas can be mobilized from the anterior wall of
the PV. The superior mesenteric vein (SMV) should be identified as it crosses anterior to the third portion of the duodenum. A tunnel under the pancreas between the PV and SMV should be
created bluntly. If PV invasion is present, resection and reconstruction can be considered.
(He J,
Page AJ, Weiss M, Wolfgang CL, Herman JM, Pawlik TM. Management of borderline and locally advanced pancreatic cancer:
where do we stand? World J Gastroen terol 2014;20:2255- 2266.)

Table 1: Key Surgical Maneuvers in a Pylorus -Preserving Pancreaticoduodenectomy

Reconstruction proceeds first with a pancreaticojejunostomy (PJ). The jejunum is passed through
mesocolon, usually in a bare area to the right of the mesenteric vessels. There are many reported
PJ variat ions with similar outcomes. We prefer an end -to-side PJ consisting of a back layer of
interrupted silk sutures, an inner duct -to-mucosal layer, using 6- 0 PDS, and an outer layer of
interrupted silk sutures (Fig. 2). Some authors recommend routine utilization of a PJ stent; howeve r, there is no consensus. Next, an HJ is created approximately 5 -10 cm distal to the PJ.
Again, there are many reported techniques; however, we prefer an interrupted layer of 4-0 or 5- 0
absorbable sutures. Finally, a two- layer, handsewn end- to-side duodenojejunostomy is created
(Fig. 3). We usually perform this anastomosis antecolic, as there is some evidence this decreas es
delayed gastric emptying. The duodenum must be inspec ted prior to anastomosis to ensure it is
not dusky and still viable. If there is concern, a partial gastrectomy with gastrojejunostomy
should be performed. We routinely leave two drains near the PJ and HJ. (
Kennedy EP, Brumbaugh
J, Yeo CJ. Reconstruction f ollowing the pylorus preserving Whipple resection: PJ, HJ, and DJ. J
Gastrointest Surg 2010;14:408 -415.)

Figure 3: Pancreaticojejunostomy Figure 4: Duodenojejunostomy

3.1.2 Cholecystectomy
T1 TUMORS
Usually, incidentally diagnosed cancers on specimens resulting from cholecystectomy are T1a
tumors. These lesions are limited to the lamina propria and the performed cholecystectomy is
considered to be sufficient if obtained resection margins are negative. In cases with T1b tumors,
due to the 50% 1- year survival rate, a follow -up on the initial intervention with a resection of
IVb and V segments of the liver ( Figure 1) and limphadenectomy along the portal pedicle is
necessary. (Jayaraman S, Jarnagin W. Management of gallbladder cancer. Gastroenterology Clinics of North America.
2010;39(2):331 –342)

Figure 5: Resection of segment I Vb-V, “in block” with the tumoral gallbladder. Dissection of
the glissonian pedicles .
T2 TUMORS
For this type of tumors, simple cholecystectomy is not sufficient. Hepatic resection and loco-
regional lymphadenectomy is necessary. Major hepatic resections (right hepatectomy or
extended right hepatectomy) may be necessary if the invasion of the right branch of the portal vein occurs. Simple cholecystectomy performed in T2 tumors offers a 5- year survival rate of
40%, compared to an 80% 5- year survival rate for en bloc resections of the tumor. Given its
close anatomical relation with the gallbladder, the right branch of the portal pedicle is most
susceptible to tumoral invasion. In some cases, in order to obtain negative resection margins, it is
necessary to perform a bile duct resection and a biliodigestive anatomosis. Thus, an
extemporaneous examination of the cystic stump is vital for certifying oncologic radicality. It is
important that bile duct resection to be perfor med in attentively selected cases where the benefit
outweighs the complication rate of the necessary biliodigestive anastomosis . Lymphadenectomy is demonstrated to improve the prognosis if N1 lymph nodes are involved, whereas in patients
presenting N2 lym ph nodes involvement, lymphadenectomy will not bring certain benefits. Thus,

N2 lymph nodes involvement represents a negative factor in patient outcome . (Gani F, Buettner S,
Margonis G, Ethun C, Poultsides G, Tran T et al. Assessing the impact of common bi le duct resection in the surgical
management of gallbladder cancer. Journal of Surgical Oncology. 2016;114(2):176 –180.)
T3 TUMORS
As in the case of T2 tumors, for T3 tumors, simple cholecystectomy is not considered sufficient
from an oncological point of view. Hepatic resection and loco -regional lymphadenectomy are
necessary. If adjacent organs are involved, en bloc resection is necessary due to the difficulty in distinguishing, from a macroscopic point of view, between inflamed tissue and tumor invasion.
A 5-year survival rate between 30 and 50% is obtained in case of R0 resections. (Jayaraman S,
Jarnagin W. Management of gallbladder cancer. Gastroenterology Clinics of North America. 2010;39(2):331– 342)
T4 TUMORS
T4 classified tumors are in most cases unresectable without any oncologic radicality pretention.
In this stage, the palliative surgical approach combined with chemoradiotherapy is the only
therapeutic alternative. (Jayaraman S, Jarnagin W. Management of gallbladder cancer. Gastroenterology Clin ics of North
America. 2010;39(2):331– 342)
Open and laparoscopic cholecystectomy
Simple cholecystectomy is the surgical intervention whereby the gallbladder and a portion of the
cystic duct are removed. This can be performed either open or by laparoscopy. R egardless of the
approach, three types of cholecystectomy can be distinguished: retrograde, anterograde or
bipolar. In cases presenting with T1a gallbladder tumors, simple cholecystectomy is sufficient
for obtaining a radical resection. Cholecystectomy is usually performed with the patient placed in
a supine position with the arms abducted, the main surgeon being situated on the patient’s right
side. The laparotomy is usually done through a right subcostal incision. The cholecystectomy can
be performed eith er retrograde (with the primary dissection of the gallbladder pedicle at the level
of Calot triangle) or anterograde (with primary dissection of the gallbladder from its hepatic fossa). The anterograde cholecystectomy may be useful in cases where the primary dissection of
Calot triangle is difficult due to adhesions or anatomic modifications. ( Adrian Bartoș, Andrei Herdean
and Dana Monica Bartoș (April 26th 2017). Gallbladder Cancer: Surgical Management, Updates in Gallbladder Diseases,
Hesham Mohamed Abdel dayem, IntechOpen, DOI: 10.5772/67561. )

The most important moment in performing the cholecystectomy is the dissection of Calot
triangle, where the elements of the gallbladder pedicle are located. The isolation, ligation and
resection of the cystic duct an d artery are performed at this level. At this point in the procedure,
the prelevation of a sample from the cystic duct stump is necessary for performing the histopathological assessment of the resection margin. The next step of the procedure is the
dissect ion of the gallbladder from its hepatic fossa using the electrocautery. Following that, the
gallbladder extraction is performed through the subxiphoidian incision, with or without the enlargement of the aponeurosis. Given the high risk of spreading maligna nt cells into the
abdominal wall, the gallbladder is extracted using an endobag.( Adrian Bartoș, Andrei Herdean and Dana
Monica Bartoș (April 26th 2017). Gallbladder Cancer: Surgical Management, Updates in Gallbladder Diseases, Hesham
Mohamed Abdeldayem, IntechOpen, DOI: 10.5772/67561. )
RADICAL CHOLECYSTECTOMY
In cases with gallbladder tumors staged over T1a, the required surgical approach is radical
cholecystectomy, combined, in selected cases, with liver resections. Radical cholecystectomy is
defined as the removal of the gallbladder and the hepatic parenchyma corresponding to its fossa,
with a resection margin of minimum 2 cm. After exposing the subhepatic region, the liver
parenchyma corresponding to gallbladder fossa is marked using the electrocautery. The blood
loss from transected liver parenchyma can be m inimized by using recent generation surgical
instruments, as well as intra -anesthetic lowering the central venous pressure. The Calot triangle
dissection is performed in the same manner as for simple cholecystectomy. The specimen
obtained is sent for extem poraneous histopathological assessment of the resection margins. If the
margins are negative, a portal pedicle lymphadenectomy is performed. If the resection margins are positive, the resection must be completed by either resecting more liver parenchyma or by the
resection of the bile duct with performing a bilio -digestive anastomosis. If it is necessary to
resect more liver parenchyma, an anatomical resection of segments IVb and V is considered to
be appropriate
. (Kingham TP, D’Angelica MI. Cancer of the g allbladder. In: Jarnagin W, Belghiti J, Blumgart L (Eds).
Blumgart’s surgery of the liver, biliary tract, and pancreas. 5th ed. Philadelphia: Elsevier Saunders; 2012; 744.)
EXTENDED LIVER RESECTIONS
Extended liver resections are necessary especially if the tumor is localized at the level of body or
infundibulum of the gallbladder. Most frequently, it is necessary to perform an extended right

hepatectomy, due to the close anatomic relation between the gallbladder and the right portal
pedicle. In numerous cas es, it is difficult to distinguish between inflamed tissue and tumoral
invasion at the level of the right portal pedicle and it is necessary to perform the right hepatectomy to ensure a curative surgical attempt. The right hepatectomy is defined as the
removal of segments V, VI, VII and VIII of the liver. The extended right hepatectomy imply
additional resection of segment IV. After entering the peritoneal cavity through a right subcostal
incision (Kocher incision), the first surgical step is to mobilize th e liver by cutting the falciform,
right triangular and coronary ligament. After the liver is mobilized, a visual and manual
assessment of the liver is mandatory. (Maithel SK, Jarnagin WR, Belghiti J. Hepatic resection for benign disease and
for liver and biliary tumors. In: Jarnagin W, Belghiti J, Blumgart L (Eds). Blumgart’s surgery of the liver, biliary tract, and
pancreas. 1st ed. Philadelphia: Elsevier Saunders; 2012; 1461 –1511.)
BILE DUCT RESECTON
Extrahepatic bile duct resection is necessary either if a tumoral invasion of the common bile duct
is present or if at the extemporaneous histological assessment, malignant cells are revealed at the
level of the cystic duct stump. Once negative margins are obtained, t he continuity of the biliary
tract is restored through a Roux -en-Y hepaticojejunostomy .
LYMPHADENECTOMY
The status of the lymph nodes represents an important prognosis factor for all patients undergoing surgery for gallbladder cancer. Lymphadenectomy is ma ndatory in all cases of
tumors staged T1b and above, even if there are no macroscopic signs of lymphatic spread. The
prognosis in significantly improved in patients for which the lymphadenectomy is performed; the
5-year survival rate increases to 57%, comp ared to only 12% in cases where the
lymphadenectomy was not performed .( Birnbaum D, Viganò L, Russolillo N, Langella S, Ferrero A, Capussotti L.
Lymph node metastases in patients undergoing surgery for a gallbladder cancer. Extension of the lymph node diss ection and
prognostic value of the lymph node ratio. Annals of Surgical Oncology. 2014;22(3):811 –818.) The D1
lymphadenectomy is defined by the removal of lymph nodes situated at the level of the hepatic pedicle and the hepatico -duodenal ligament (cystic a rtery, hepatic artery, portal vein and
common bile duct) ( Figure 2). The extended lymphadenectomy (D2) consists of extending the
lymphadenectomy to the N2 classified lymph nodes: periaortic, celiac artery, superior mesenteric
artery and inferior vena cava nodes. This type of lymphadenectomy should be performed in cases

where this is possible without performing large scale surgical pr ocedures, which increase the risk
of postoperative complications. The only certain benefit of performing the D2 lymphadenectomy
is obtaining a more accurate staging; the patient survival rate is not significantly influenced . (Ito
H, Ito K, DʼAngelica M, Go nen M, Klimstra D, Allen P et al. Accurate staging for gallbladder cancer. Annals of Surgery.
2011;254(2):320– 325.)

Figure 6: Lymphadenectomy along the portal pedicle. PHA, proper hepatic artery, RHA, right
hepatic artery, LHA, left hepatic artery, CBD, common bile duct, PV, portal vein.
3.1.3 SURGICAL RESECTION OF KLATSKIN TUMORS
The anatomic schema is presented in Figure 1. This classification, based on the longitudinal
location of the bile duct cancer, defines the surgical strategy, including the operability and
curability. (Nobuhisa Akamatsu, Yasuhiko Sugawara, Daijo Hashimoto Surgical strategy for bile duct cancer: Advances and
current limitations World J Clin Oncol. Feb 10, 2011; 2(2): 94- 107 Published online Feb 10, 2011. doi: 10.5306/wjco.v2. i2.94)

Figure 7: Anatomic classification of cholangiocarcinoma. A: The majority of
cholangiocarcinoma (60% -70%) develop in the hilar bile duct and are called Klatskin tumors.
The distal bile duct is involved in 20% to 30% of cases, while intrahepatic cholangiocarcinomas represent 5% to 10% of the tumors originating from the biliary tract; B: Bismuth -Corlette
classification of hilar bile duct cancer. Type I, cholangiocarcinoma confined to the common bile
duct; Type II, cholangiocarcinoma involves the bi furcation of the common bile duct; Type IIIa,
cholangiocarcinoma involves the bifurcation and the right hepatic duct; Type IIIb, cholangiocarcinoma involves the bifurcation and the left hepatic duct; Type IV,
cholangiocarcinoma involves the bifurcation and extends to both the right and left hepatic ducts.

Preoperative Biliary Drainage Patients with HCCA typically present with jaundice [11] .
Obstructive jaundice affects liver functional reserve and reduces the regenerative capacity of the
liver after resect ion. Jaundice for these reasons, is considered a significant risk factor in patients
with HCCA requiring major liver resection. For optimal postoperative function and regeneration of the liver remnant, preoperative drainage of the biliary system is advised . In our experience,
percutaneous transhepatic biliary drainage outperformed endoscopic biliary drainage in patients with potentially resectable HCCA, showing fewer infectious complications and less drainage
procedures [12] . An additional advantage of the percutaneous route of biliary drainage is that the
biliary tubes are an aid to locate the bile ducts proximal of the tumor in the liver parenchyma and that after the resection has taken place, the tubes can be used as transanastomotic drains to
facilitate healing of the hepaticojejunostomies. The tubes are removed after control
cholangiography via the tubes 3–6 weeks later.
(Kloek JJ, van der Gaag NA, Aziz Y, Rauws EA, van Delden OM,
Lameris JS, Busch OR, Gouma DJ, van Gulik TM: Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar
cholangiocarcinoma. J Gastrointest Surg 2010;14:119 – 125.)
Radical resection of HCCA encompasses excision of the liver hilum en bloc with (extended)
hemihepatectomy including the caudate lobe, excision of the portal vein bifurcation when
involved and complete lymphadenectomy of the hepatoduodenal ligament [13] . This concept is based on a three -dimensional perception of the tumor located centrally in the liver. Tumor
extension occurs from the bile duct confluence to the right and left along the main hepatic and segmental bile ducts, but also anteriorly into segment 4 and posteriorly into the bile ducts
draining segment 1. It is therefore crucial that the central part of the liver along the
anteroposterior axis through segment 1 and segment 4 is removed with liver resection, whether
this would be a left -sided or right -sided resection. A right -sided resection therefore entails an
extended right hemihepatectomy including segments 4 and 1, and leaving only segments 2 and 3 as liver remnant. These are large resections in which a significant volume of liver parenchyma is sacrificed leaving only the left lateral segment (s2/3) which usually constitutes 20 –30% of total
liver volume.
(Thomas M. van Gulik Anthony T. Ruys Oliver R.C. Busch Erik A.J. Rauws b Dirk J. Gouma Extent of
Liver Resection for Hilar Cholangiocarcinoma (Klatskin Tumor): How Much Is Enough? Dig Surg 2011;28:141– 147 DOI:
10.1159/000323825 )
There is an advantage of a left -sided approach to resection since segment 4 is an anatomical part
of the left liver, hence preserving the whole right liver. For these reasons, a leftsided approach to

Bismuth type IV tumors provided the right hepatic artery is free, becaus e coming from the left,
there is a leeway to extend the resection including segment 5 and (part of) segment 8, while
preserving a higher volume of parenchyma than only segments 2 and 3.
Care is taken to control bile spill during resection in order to decr ease the risk of postoperative
seeding metastases. Firstly, after the common bile duct (CBD) is cut on the edge of the pancreas early during the operation, the stump of the CBD is meticulously closed to avoid bile spill.
Secondly, the proximal, segmental bile ducts are cut in the liver remnant, preferably as the final
step in the procedure, after the parenchymal transection has been completely executed and any
additional procedures such as portal vein reconstruction have been finished. Hence, the tumor is
removed with the specimen as soon as the proximal bile ducts have been cut minimalizing
exposure of the operative field to bile coming out of the affected bile ducts. The biliary -enteric
anastomosis is subsequently carried out by end -to-side anastomoses of the segmental ducts to a
Roux -en-Y jejunal loop
.( Kloek JJ, van der Gaag NA, Aziz Y, Rauws EA, van Delden OM, Lameris JS, Busch OR,
Gouma DJ, van Gulik TM: Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar
cholangiocarcinoma. J Gastrointest Surg 2010;14:119– 125.)
Parenchyma -Preserving Techniques of Extended Liver Resection The aim of parenchyma-
preserving techniques is to compromise between the extent of resection and the sparing of
functional liver tissue. While pe rforming extended right hemihepatectomy (segments 1, 4, 5, 6,
7, 8), the cranial part of segment 4 (4a) may be preserved depending on the level in which the bile duct of segment 4 (B4) drains into the left hepatic duct relative to the tumor. When B4 joins
the left hepatic duct just proximal to the confluence of right and left hepatic ducts, it is possible
to resect this junction with the tumor while preserving the proximal part of B4 and the associated
parenchyma of segmen t 4 ( fig 8 ) (
(Thomas M. van Gulik Anthony T. Ruys Oliver R.C. Busch Erik A.J. Rauws b
Dirk J. Gouma Extent of Liver Resection for Hilar Cholangiocarcinoma (Klatskin Tumor): How Much Is Enough? Dig Surg
2011;28:141– 147 DOI: 10.1159/000323825 )

Figure 8: Resection surface after modified extended right hemihepatectomy including segment 1,
in which the cranial part of segment 4 (4a) was preserved. The segmental duct openings of B2/3
and B4 are shown. The PTD cannula passing through B2/3 is cut for positioning through the
hepaticojejunostomy. LPV = Left portal vein; LHA = left hepatic artery; IVC = inferior vena
cava; RL = round ligament.
A separate biliary anastomosis with the subsegmental duct of 4 (B4a) is required in these cases,
in addition to the anastom oses with B2/3. Likewise, in tumors predominantly arising from the
left part of the biliary system (Bismuth type IIIb and IV), a modified extended left hepatectomy
can be performed by resecting segments 1, 2, 3, 4, 5 and part of segment 8, preserving B8 and
associated parenchyma on the cranial side ( fig. 9 ).

Figure 9 : Resection surface after modified extended left hepatectomy including segment 1, in
which on the right side, segment 5 was resected while preserving part of segment 8. The
segmental bile ducts were cut on the level of B8, B6 and B7. PTD = PTD cannula; MPV = main
portal vein; RHA = right hepatic artery; IVC = inferior vena cava. (van Gulik TM, Kloek JJ, Ruys AT,
Busch OR, van Tienhoven GJ, Lameris JS, Rauws EA, Gouma DJ: Multidisciplinary m anagement of hilar cholangiocarcinoma
(Klatskin tumor): extended resection is associated with improved survival. Eur J Surg Oncol 2011; 37:65– 71.)
3.2 PALLIATIVE METHODS
3.2.1 BILIODIGESTIVE ANASTAMOSIS
A hepaticojejunostomy is the surgical creation of a communication between the hepatic duct and
the jejunum. The major indications for hepaticojejunostomy are benign or iatrogenic strictures, and injuries to the biliary system. Roux -en-Y hepaticojejunostomy is sometimes perform ed for
biliary reconstruction ( Figure 1 ). For anastomosis to either the common bile duct or the
confluence of the hepatic ducts, it is necessary to fashion a Roux -en-Y jejunal limb. This limb is
identified and transected with a stapling device 30 -35cm from the ligament of Treitz. To achieve
a stable anastomosis, mucosal contact must exist between the bowel and the biliary tree. (
Felder SI,
Menon VG, Nissen NN, et al. Hepaticojejunostomy using short –limb Roux –en–Y reconstruction. JAMA Surg . 2013;148(3):253–
257; discussion 257– 258.)

Figure 10: Schematic representation of Roux -en-Y hepaticojejunostomy. Stomach (St),
duodenum (D), Roux limb or jejunal afferent loop (AL), jejunal eferent loop (EL),
hepaticojejunal anastomosis (black arrows), jejunojenunal anas tomosis (white arrows).
The two upper limbs of the Y represent: the proximal segment of stomach and the proximal
small bowel it joins with; and the blind end that is surgically divided off. And the lower part of
the Y is formed by the distal small bowel be yond the anastomosis. The alimentary limb remains
the primary recipient of food after the surgery, while the hepatobiliary or afferent limb that
anastomoses with the biliary system serves as the recipient for biliary secretions, which then
travel through t he excluded small bowel to the distal anastomosis at the mid jejunum (efferent
limb) to aid digestion. There are two anastomoses: a proximal hepaticojejunal anastomosis and a
distal jejunojejunal anastomosis. (Felder SI, Menon VG, Nissen NN, et al. Hepaticojejunostomy using short –limb
Roux –en–Y reconstruction. JAMA Surg . 2013;148(3):253 –257; discussion 257– 258.)
3.2.2 CHOLEDOCO JEJUNO ANASTAMOSIS
A right subcostal, upper midline, right paramedian, or bilateral subcostal “bucket
handle” incision may be used. The last of these is preferred in patients with unfavorable body
habitus, particularly when exposure remains poor after a right subcostal approach is attempted. A self-retaining retractor is placed if needed.
(Cholecystojejunostomy and choledocho/hepaticojejunostomy. Fischer
J, Ellison EC, Upchurch GR Jr, Galandiuk S, Gould JC, Klimberg VS, et al, eds. Fischer's Mastery of Surgery. 7th ed.
Philadelphia: Wolters Kluwer; 2018. Chap 115.)
Creation of the biliary -enteric anastomosis itself involves three main steps: exposure, dissection,
and establishment of biliary continuity. [ 5] Depending on the underlying pathology, lysis of
adhesions may be mandatory upon entry into the abdomen and dissection toward the area of the hepatoduodenal ligament. Blunt dissection is used to free the edge and undersurface of the liver.
After the peritoneal attachments lateral to the duodenum are divided, the Kocher maneuver is
used to mobilize the duodenum medially, furt her exposing the foramen of Winslow and the
portal triad .(Ellison EC, Zollinger RM Jr. Choledochojejunostomy. Zollinger's Atlas of Surgical Operations . 10th ed. New
York: McGraw -Hill; 2016. 278 -9.)
After careful dissection of the plane between the undersid e of the the right hemiliver and the
duodenum, the portal triad comes into view. Although in the majority of people, the hepatic artery lies to the left of the common bile duct (CBD), there are numerous potential anatomic

variations in this area that must be kept in mind. Most notably, a replaced right hepatic artery
(see the image below) may arise from the superior mesenteric artery and course to the right of
the portal vein, the common hepatic duct (CHD), and the CBD.
Once isolated, the CBD is encircled and transected above the level of obstruction. The distal
CBD is then doubly ligated. Bile cultures are taken at this time, and if appropriate, the duct is irrigated or explored for stone or debris. The proximal end is then inspected and trimmed to
healthy , even edges as needed.The CHD and CBD receive their blood supply from axial arteries
just lateral and medial to the duct (see the image below). These arteries originate from the
intrahepatic arterial collaterals feeding the biliary tree superiorly and fro m the gastroduodenal
artery inferiorly. With this in mind, skeletonization of the CBD should be avoided because it can
compromise the blood supply and lead to ischemic stricturing.
The ligament of Treitz is then identified, and a proximal loop of jejunum t hat comfortably
reaches the subhepatic space is identified. After the jejunal arcades are assessed for adequacy of
blood supply, this loop is transected with a gastrointestinal anastomosis (GIA) stapler.
Alternatively, if the jejunum is divided between bow el clamps, the distal end is closed with two
layers of interrupted silk suture. (Ellison EC, Zollinger RM Jr. Choledochojejunostomy. Zollinger's Atlas of Surgical
Operations . 10th ed. New York: McGraw -Hill; 2016. 278 -9.)
The distal jejunum is rotated through the avascular space just to the right of the middle colic
artery up into the porta hepatis. The proximal (afferent) divided end of the jejunum is then
sutured to the distal end of the jejunum 45 cm aborally from the di vided end where the
choledochojejunostomy will be created. After the choledochojejunostomy is complete, the defect in the transverse mesocolon is closed, and several interrupted absorbable sutures are used to
anchor the afferent limb to the mesocolon.
(Cho lecystojejunostomy and choledocho/hepaticojejunostomy. Fischer
J, Ellison EC, Upchurch GR Jr, Galandiuk S, Gould JC, Klimberg VS, et al, eds. Fischer's Mastery of Surgery. 7th ed.
Philadelphia: Wolters Kluwer; 2018. Chap 115.)
In the case of a much dilated CBD, the choledochojejunostomy may be performed in an end -to-
end fashion (see the image below).

Figure 11: End -to-end choledochojejunostomy.
The anterior wall is then completed by using the needles previously passed through the bile duct
wall. Starting at each corner, the needle is passed from outside in, tied, and cut, again with the
knot facing the lumen. The final few stitches at the center of the anterior wall are placed so that
the knot lies on the outside. The key to a successful choledochojejunost omy is creating a tension –
free anastomosis with direct mucosa -to-mucosa apposition at this stage. A few anchoring stitches
may be placed between the jejunum and surrounding structures of the hepatoduodenal ligament.
If internal stenting is desired, it is p laced through a separate opening in the bile duct or in a
retrograde manner through an opening in the duodenum (see the image below).

Figure 12: Retrograde stenting of choledochojejunostomy through an opening in the jejunum .