Cholecystoenterostomy

Surgery of the Biliary System
Surgery of the Biliary System
Dr. T. Németh, DVM
DVM,, Ph.D, DipECVS
 Surgical
anatomy
– gall bladder (between right. med.
and quadr. lobes)
– cystic duct
– hepatic ducts
– common bile duct (duodenum)
Associate Professor and Head of Surgery
Surgical anatomy
Surgical anatomy
Central division
Surgical anatomy
Surgery of the Biliary System
 (Cholecystotomy)
 Cholecystectomy
 Cholecystoenterostomy
 Bile duct
„stenting”
Surgery of the Biliary System
Cholecystectomy
 Indication
 (Cholecystotomy)
 Cholecystectomy
 Cholecystoenterostomy
 Bile duct
„stenting”
Cholecystectomy

– cholelithiasis
– rupture / perforation of gall bladder
– gall bladder tumour
– gen. primary liver disease!
Just in case
the common bile duct is patent or can be made patent !!!
Cholecystectomy
Surgical technique
–
–
–
–
antegrade or retrograde dissection of the gall bladder
catheterisation of the common bile duct
ligature of the cystic duct
covering of the „hepatic bed” (omentum, Surgicel,
Spongostan)
– drainage

Complications
– bleeding from liver
– „bile - peritonitis”
Cholecystectomy
Cholecystectomy
Cholelithiasis
Cholelithiasis
Cholecystectomy
Cholecystectomy
Cholelithiasis
Cholelithiasis
Anterograde duct. choled. catheterisation
Retrograde duct. choled. catheterisation (major papilla)
Cholecystectomy
Cholecystectomy
Cholelithiasis
Cholelithiasis
Cholecystectomy
Cholecystectomy
Perforation of the Gall Bladder
Perforation of the Gall Bladder
Cholecystectomy
Perforation of the Gall Bladder
Surgery of the Biliary System
 (Cholecystotomy)
 Cholecystectomy
 Cholecystoenterostomy
 Bile duct
Cholecystoenterostomy
Cholecystoenterostomy

In case
the common bile duct can’t be patent anymore !!!
Surgical technique
– cholecystoduodenocholecystoduodeno- or jejunostomy
– single layer “side“side-to
to--side” anastomosis
– „Roux
„Roux--en
en--Y loop”
 Indication
– obstructed common bile duct !
– obturation
– compression (pancreatitis !!!)
„stenting”

Complications
– bile
bile--peritonitis
– suture insuffitiency
– obturation
Cholecystoenterostomy
Cholecystoduodenostomy
Cholecystoduodenostomy
Cholecystoenterostomy
Cholecystoenterostomy
Cholecystoduodenostomy
Cholecystoduodenostomy
Cholecystoenterostomy
Cholecystoenterostomy
Cholecystoduodenostomy
Cholecystoduodenostomy
Cholecystoenterostomy
Cholecystoenterostomia
Cholecystoduodenostomy
Cholecystoduodenostomia
Cholecystoenterostomia
Cholecystoduodenostomia
Cholecystojejunostomy
Cholecystoenterostomy
Cholecystoenterostomy
Cholecystojejunostomy
Cholecystojejunostomy
Cholecystoenterostomy
Cholecystoenterostomy
Cholecystojejunostomy
Cholecystojejunostomy
Cholecystoenterostomy
Cholecystoenterostomy
Cholecystojejunostomy
Cholecystojejunostomy
Cholecystoenterostomy
Cholecystojejunostomy
„Roux--en
„Roux
en--Y” loop
cholecystojejunostomy
Cholecystoenterostomy
Cholecystoenterostomy
Cholecystojejunostomy
Cholecystojejunostomy
with „Roux„Roux-en
en--Y” loop
with „Roux„Roux-en
en--Y” loop
Cholecystoenterostomy

Surgical technique
– cholecystoduodenocholecystoduodeno- or jejunostomy
– single layer “side“side-to
to--side” anastomosis
– „Roux
„Roux--en
en--Y loop”

 (Cholecystotomy)
 Cholecystectomy
 Cholecystoenterostomy
Complications
– bile
bile--peritonitis
– suture insuffitiency
– obturation
Bile duct ”stenting”

Surgery of the Biliary System
 Bile duct
„stenting”
Bile duct ”stenting”
EHBO
Indication
– Reversible obstruction of common bile duct
– EHBO=extrahepatic biliary obstruction
– In cat: „5”: pancreatitis, cholangiohepatitis,
duodenitis, cholelithiasis, EHBO

Surgery
– retrograde duct catheterisation (major duod.
Papilla through duodenotomy)
– „stenting” (polyethilene, silicone, red rubber)
Bile duct ”stenting”
Bile duct ”stenting”
EHBO
EHBO
Subacute pancreatitis caused EHBO
Retrográd duct. choled. katéterezés (major duodenalis papilla)
Bile duct ”stenting”
Bile duct ”stenting”
EHBO

Complications
–
–
–
–
–
mostly in cats*
death (2/7)
recurrent obstruction
ascending cholangitis
vomiting

5/7
* Mayhew et al, JSAP, March, 2008
duct. choled. stenting (polyethylene)
Surgery of PSS
Types of PSS

–
–
–
–
Surgical aspects of portosystemic
shunts (PSS)
Dr. T. Németh, DVM, PhD

Intrahepatic
– Left, right or
central
PSS
(ref. Internal Medicine)
(ref. Internal Medicine)
Incidence
Signs
– Neurological (hepatocerebral syndrome)
– Alimentary (vomiting, diarrhoea)
– Urinary (PU/PD, pollakiuria)


portocaval
gastrocaval
splenocaval
portoazygos
PSS
– EPSS (small breeds and cats)
– IPSS (large breeds: Irish wolfhound, retrievers, Ausztralian
shepherd)

Extrahepatic
Diagnostics
– Physical signs
– Blood work (microcytosis, leukocytosis, hypoprot.,  karbamid,
AP, NH3, bile acids, plasma prot. C,  hyaluronic acid)
– Urinalysis (spec. grav., ammonium urate crystalluria)
– DI (portography, US/Doppler, scintigraphy, MRI)

Conservative treatment
–
–
–
–
–
Enema
Low protein diet
Lactulose
Antibiotics
Hepatic support
Surgery of PSS
Surgery of EPSS
Types of PSS

The simple complete ligation of PSS without
lethal portal hypertension has been reported
successful in 1717-55% in EPSS and 13% in IPSS
cases!!!

„Attenuation”:: partial narrowing
„Attenuation”

„Occlusion”:: gradual closure
„Occlusion”
Extrahepatic
–
–
–
–


portocaval
gastrocaval
splenocaval
portoazygos
Intrahepatic
– Left, right or
central

Surgery of EPSS
Surgery of EPSS
Main methods of EPSS attenuation
Main methods of EPSS attenuation
Ligature-attenuation under portal pressure measuring
Ligature(„classic”)

„Gauged attenuation” without pressure measuring

„Ameroid ring constrictor”

„Cellophane banding”
Ligature-attenuation under portal
Ligaturepressure measuring („classic”)
• Martin RA, Freeman LE:
Identification and surgical
management of portosystemic
shunts in the dog and cat.
Semin Vet Med Surg Small
Anim 2:302–306, 1987
• Swalec KM, Smeak DD: Partial
versus complete attenuation of
single portosystemic shunts.
Vet Surg 19:406–411, 1990
Surgery of EPSS
Surgery of EPSS
Main methods of EPSS attenuation
Main methods of EPSS attenuation
„Gauged attenuation” without pressure measuring
„Gauged attenuation” without pressure measuring
• Smith KR, Bauer M, Monet E:
Portosystemic communications:
follow-up of 32 cases. J Small
Anim Pract 36:435–440, 1995
• Smith KR, Bauer M, Monet E:
Portosystemic communications:
follow-up of 32 cases. J Small
Anim Pract 36:435–440, 1995
portal v
hepatic a.
EPSS
caud. vena cava.
cava.
Surgery of EPSS
Surgery of EPSS
Main methods of EPSS attenuation
Main methods of EPSS attenuation
Surgery of EPSS
Surgery of EPSS
Main methods of EPSS attenuation
Main methods of EPSS attenuation
„Gauged attenuation” without pressure measuring
• Smith KR, Bauer M, Monet E:
Portosystemic communications:
follow-up of 32 cases. J Small
Anim Pract 36:435–440, 1995
„Ameroid ring
constrictor”
- inner caseincasein-ring
(hygroscopic)
- biphasic occlusion
portal v
EPSS hepatic a.
caud. vena cava.
cava.
• Vogt JC, Krahwinkel DJ, Bright RM, et al:
Gradual occlusion of extrahepatic portosystemic
shunts in dogs and cats using the ameroid
constrictor. Vet Surg 25:495–502, 1996
Surgery of EPSS
Surgery of PSS
Main methods of EPSS attenuation
Types of PSS
„Cellophane--band
„Cellophane
band””

–
–
–
–
• Youmans KR, Hunt GB: Experimental
evaluation of four methods of progressive
venous attenuation in dogs.
Vet Surg 28:38–47, 1999
- 50%initial attenuation
- „total” closure in 5 weeks
- < 3 mm inner diameter
Extrahepatic

portocaval
gastrocaval
splenocaval
portoazygos
Intrahepatic
– Large breeds
– Left
Left,, right or
central
Surgical anatomy
Surgery of IPSS
- Diagnostics (imaging!)
Doppler US
Surgery of IPSS
- Diagnostics (imaging!)
Surgery of IPSS
- Diagnostics (imaging!)
Porto--caval
Porto
Trans--splenic scintigraphy
Trans
Porto--azygos
Porto
Multiplex acquired extrahep.
extrahep.
MR angiogram
CT angiogram
Surgery of IPSS
Surgery of IPSS
Ultrasonography of IPSS , before attenuation
- Complete closure ( left shunt – left hepatic vein ligature)
- Ultrasound
Ultrasound--assisted ((-guided) ligatureligature-attenuation
Surgery of IPSS
Surgery of IPSS
Ultrasonography of IPSS , during attenuation
Surgery of IPSS
Surgery of IPSS
- Teljes lekötés (lobectomia)
- Részleges lekötés (ultrahang(ultrahang-vezérelt)
Surgery of IPSS
Surgery of IPSS
Ultrasonography of IPSS , after attenuation
- Complete closure ( left shunt – left hepatic vein ligature)
- Ultrasound
Ultrasound--assisted ((-guided) ligatureligature-attenuation
- Intrahepatic attenuation (Bellenger et al)
Surgery of IPSS
- Complete closure ( left shunt – left hepatic vein ligature)
- Ultrasound
Ultrasound--assisted ((-guided) ligatureligature-attenuation
- Intrahepatic attenuation (Bellenger et al)
- Modified „Eck fistula” (White et al, 1996)
Surgery of IPSS
- Complete closure ( left shunt – left hepatic vein ligature)
- Ultrasound
Ultrasound--assisted (-guided
guided)) ligature
ligature--attenuation
- Intrahepatic attenuation (Bellenger et al
al))
- Modified „Eck fistula
fistula”
” (White et al
al,, 1996)
- Ameroid ring constrictor (Kyles et al, 2001)
- Cellophan
Cellophan--band (Connery et al
al,, 2002)
Surgery of IPSS
- Complete closure ( left shunt – left hepatic vein ligature)
- Ultrasound
Ultrasound--assisted ((-guided) ligatureligature-attenuation
- Intrahepatic attenuation (Bellenger et al)
- Modified „Eck fistula” (White et al, 1996)
- Ameroid ring constrictor (Kyles et al, 2001)
Surgery of IPSS
- Complete closure ( left shunt – left hepatic vein ligature)
- Ultrasound
Ultrasound--assisted (-guided
guided)) ligature
ligature--attenuation
- Intrahepatic attenuation (Bellenger et al
al))
- Modified „Eck fistula
fistula”” (White et al
al,, 1996)
- Ameroid ring constrictor (Kyles et al, 2001)
- Cellophan
Cellophan--band (Connery et al
al,, 2002)
- Transcatheter coil embolisation
coil
stent