Gall bladder and Biliary tree

Dr. Vivek Mangla


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Gall bladder and Biliary tree

Gall bladder stones and bile duct stones

In modern societies, gall bladder stone is a significant public health problem. These are either cholesterol stones or brown pigmented stones. Most commonly patients have severe abdominal pain. Jaundice and/or associated fever suggests complications from the stones and mandates urgent treatment. Such patients should undergo a simple surgery called laparoscopic cholecystectomy. Sometimes the stone moves out from gall bladder to the bile duct. These patients are managed either with a two stage endoscopic bile duct stone removal (ERCP) followed by a laparoscopic surgery for removal of gall bladder, or a single stage laparoscopic procedure entailing removal of gall bladder as well the stone in the bile duct. The advantages of the latter procedure, in experienced hands, are that it is a single stage treatment and avoid risks associated with ERCP namely pancreatitis, cholangitis, perforation or bleeding. We have performed laparoscopic Bile duct exploration in such patients with stent placement or choledochoduodenostomy. Patients go back home free of any stones and associated problems with no recurrence. A detailed & accurate understanding of endoscopic procedures like ERCP, MRCP etc. is required for the best & safest management of such patients with quick recovery.

In fact, sometimes gall bladder infections if ignored can proceed to complications like perforation or gangrene of gall bladder. Surgery in such situation needs more expertise and higher level of care. We have managed patients whose gall stones have passed into intestine and caused obstruction. Sometimes emergency surgery needed to done & special antibiotics given when gas forming bacteria lead to emphysematous gall bladder. Similarly empyema (pus) gall bladder also needs emergency surgery depending on severity of illness at the time of presentation. Diabetic patients are at higher risk of such complications.

Benign biliary stricture

Benign Biliary stricture, also referred to as bile duct stricture, occurs when the bile duct gets smaller or narrower. Patients with mild biliary strictures may not show any symptoms. When symptoms develop, they may include jaundice (yellowing of the skin), itching, and lightening of stool colour.

Most biliary strictures arise in the setting of surgery for complicated gall stone disease where in there is inadvertent injury to the bile duct (bile duct injuries occur in 0.1% patients undergoing laparoscopic cholecystectomy worldwide). Other causes include instrumentation of gall bladder or biliary tree, infections and congenital conditions like choledochal cyst. High quality imaging is of paramount importance in accurate understanding of biliary diseases. Improperly treated, bile duct strictures may lead to long term irreversible changes in liver (cirrhosis) resulting in portal hypertension and liver failure. Though early surgical repair (in 72 hours of injury) is more cost effective in experienced hands, a certain group of patients have benefited from delaying the repair for controlling infection and improving nutrition. Very high success rate of > 90% has been reported for these injury related strictures in trained hands and care centre. See a patient review and video for details. The best chance of cure is at first attempt at correction and it is paramount that the treating surgeon is experienced in dealing with these cases and working in a well-equipped facility.

Gall bladder cancer

There are three common clinical scenarios for gall bladder cancer

  • Identified at biopsy after routine cholecystectomy
  • Discovered Intraoperatively
  • Suspected before surgery

Careful history taking and examination can point towards early detection of gall bladder cancer. This is important because primary resection remains the best choice for a good outcome. If the stone size is big (>3cm) or calcified gall bladder is seen on ultrasound or CT scan, surgeons’ suspicion for gall bladder cancer should be heightened. The team should be prepared for a definitive operation at the first attempt itself. This curative operation usually involves removal of gall bladder with a small amount of surrounding liver &surrounding lymph nodes. In experienced hands and well equipped facilities, this surgery can be performed quite safely. For those patients, whose gall bladder cancer is incidentally detected in the biopsy specimen of a normally performed cholecystectomy, we perform a completion cholecystectomy. The decision for further treatment in cases of incidentally detected gall bladder cancer depends on the extent of disease in the removed gall bladder and imaging as well as a number of other factors.

Bile duct cancer

The cancer of bile duct is also called cholangiocarcinoma. When cancer affects the bile ducts which are still in the liver (intrahepatic ducts) it is called intrahepatic cholangiocarcinoma (bile duct cancer). While cancer affecting the part of the duct where it joins the intestine is known as distal bile duct cancer. Hilar cholangiocarcinoma is a form of bile duct cancer which afflicts confluence of right and left hepatic duct. Infact hilar cholangiocarcinoma or Klatskins tumor is the most common form of bile duct cancer. In the absence of effective chemotherapy or radiation therapy, surgical resection remains the mainstay of curative treatment. The ability to perform a margin-negative R0 complete resection is critical. Unfortunately, some patients present at a stage that is not amenable to surgical treatment. This requires careful surgical planning entailing good quality imaging, preoperative preparation (which may need interventional radiology procedures like PTBD and Portal vein embolization).

Choledochal cyst

Have you been diagnosed with choledochal cyst on ERCP or MRCP? Don’t panic. It has to be excised because of the risk of subsequently developing cancer. This surgery can be done laparoscopically with very good results. See my video for detailed understanding.