Bile duct resection and reconstruction
- Jennifer F Tseng, MD, MPH
Jennifer F Tseng, MD, MPH
- Utley Professor of Surgery and Chair, Boston University School of Medicine
- Surgeon-in-Chief, Boston Medical Center
Even with the rising popularity of endoscopic and interventional radiology techniques to divert or restore biliary flow [1-3], operative bile duct resection and reconstruction (BDRR) remains a common procedure. Approximately 67,000 patient admissions for BDRR were recorded by the Nationwide Inpatient Sample Discharge database from 2004 to 2011, with an average of over 8000 patients per year .
Surgical aspects of BDRR, including preoperative preparation, techniques, and postoperative management, as well as outcomes will be discussed here. The management of common bile duct stone and bile duct injury, and surgical treatment of cholangiocarcinoma, are covered elsewhere. (See "Common bile duct exploration" and "Repair of common bile duct injuries" and "Surgical resection of localized cholangiocarcinoma".)
Bile duct resection and reconstruction (BDRR) is performed for a variety of indications, including benign and malignant tumors; complications from biliary and gallbladder disease or surgery; and more rarely, traumatic, infectious, or inflammatory processes involving the biliary tree. In a large retrospective study of 67,160 patients who underwent BDRR, 2.5 percent of procedures were performed for congenital anomalies, 37.4 percent for malignant neoplasms, 2.3 percent for benign neoplasms, 9.9 percent for biliary injuries, and 47.9 percent for other nonmalignant diseases .
Malignant tumors — BDRR can be performed for various forms of cancer, including cholangiocarcinoma (extrahepatic and intrahepatic), hepatocellular carcinoma, and metastatic disease to the liver or the porta hepatis (rare). Intrahepatic cholangiocarcinomas and tumors at the biliary bifurcation may require concomitant liver resection with BDRR. Pancreatic cancer or periampullary cancers involving the distal common bile duct are generally treated with pancreaticoduodenectomy (Whipple operation). (See "Surgical resection of localized cholangiocarcinoma" and "Surgical management of potentially resectable hepatocellular carcinoma" and "Surgical resection of lesions of the head of the pancreas".)
Benign tumors — BDRR can also be performed to excise premalignant tissue or correct aberrant bile flow that may predispose to inflammation and subsequent dysplasia or cancer. Examples of benign lesions that can be removed with BDRR include choledochocele (image 1), which carries a lifetime cancer risk of 30 percent [5-10], sclerosing cholangitis , and ampullary lesions such as adenomatous polyps and carcinoma in situ [12,13]. (See "Biliary cysts" and "Primary sclerosing cholangitis in adults: Management" and "Treatment of ampullary adenomas".)
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- Malignant tumors
- Benign tumors
- Complicated biliary disease
- PREOPERATIVE PREPARATION
- Endoscopically accessible lesions
- Endoscopically inaccessible lesions
- SURGICAL TECHNIQUES
- - Ampullary resection
- - Midportion bile duct resection
- - Perihilar resection
- Intraoperative frozen section analysis
- - Routine reconstruction
- - Special reconstruction
- Multiduct reconstruction
- Hilar duct reconstruction
- Minimally invasive approach
- POSTOPERATIVE MANAGEMENT
- Nasogastric tube
- Postoperative biliary access
- - Early complications
- - Late complications
- SUMMARY AND RECOMMENDATIONS