SURGICAL THERAPY

IN OBSTRUCTIVE JAUNDICE

DR. ARNOLD SIMANJUNTAK SpB-KBD

SUB DIVISION DIGESTIVE SURGERY,
DEPARTMENT OF SURGERY, FAKULTY OF MEDICINE
UNIVERSITY OF INDONESIA/CIPTO MANGUNKUSUMO
HOSPITAL
JAKARTA
Cholestasis : failure of normal bile
to reach duodenum

Common Causes
Choledocholithiasis
Ca Pancreas and Ampulla
Benign bile duct stricture
Cholangiocarcinoma


CLASSIFICATION ( Benjamin 1983)

Type I Complete Obstruction

Type II Intermittent Obstruction
Type III Chronic Incomplete Obstruction
Type IV Segmental Obstruction
 Complete Obstruction

Tumor, especially of the pancreatic head

Ligation of the common bile duct
Cholangiocarcinoma
Parenchymal liver tumors, primary or secondary


 Intermittent Obstruction

Choledocholithiasis
Periampullary Tumors
Duodenal Diverticula
Papillomas of the bile duct
Choledochal cyst
Polycystic liver diseases
Intrabiliary parasites

 Chronic Incomplete Obstruction

Strictures of the common bile duct

Congenital
Traumatic (iatrogenic)
Sclerosing Cholangitis
Post Radiotherapy
Stenosed biliary-enteric anastomoses
Chronic pancreatitis
Cystic fibrosis
Stenosis of the sphincter of Oddi
? Dyskinesia ( Sphincter of Oddi dysfunction )
 Segmental Obstruction

Traumatic (including latrogenic )

Hepatodocholithiasis
Sclerosing cholangitis
Cholangiocarcinoma

 Effects

PHYSICAL EFFECTS
PATHOLOGICAL EFFECTS
BIOCHEMICAL EFFECTS
OTHER FUNCTIONAL EFFECTS
 PHYSICAL EFFECTS
INCREASED PRESSURE

Secretory Pressure : 120 - 250 mmH2o
Secretion ceases : 300 mmH2o
Biliary Pressures Bacterial reflux into lymphatic and
venous
Systems ( Cholangiovenous Reflux )

HEPATIC BLOOD FLOW
PAIN

"PAINLESS" Progressive Jaundice
Malignant billiary Tract obstruction
PAIN Distention of the gall bladder - bile duct - strecthing
of
the liver capsule
Severe Pain Calculous obstruction

PATHOLOGICAL EFFECTS

Bile Ducts and Canaliculi

Hydrostatic pressure
Intra hepatic inflammation
Accumulation of toxic bile compounds

Fibrotic changes
Mucosal atrophy
Squamous metaplasia
Inflammatory infiltration
Fibrosis sub-epithelial layers

Cholangitis
Atrophy
 Biochemical Effects

Bilirubbin
Complete obstruction : bilirubin
increase by
25-43 mol/L/my

Alkaline phosphatase
Protein synthesis
Lipids
Carbodhydrate metabolism
Bile Salt Circulation

Other Functional Effects

Hepatocyte function
Endotoxemia and Reticulo-endothelial function
Immunological Effect

Changes After Relief of

Obstruction

Bile secretion
Recovery of function
Structural changes


Biliary Drainage Before Surgery is
Controversial

The presence of bile in the intestine

Preventing endotoxemia
Improving nutritional status
Biliary decompression
Liver regeneration
Recovery of the reticuloendothelial function
Improved cardiac function

Preoperative Internal Biliary Drainage

Was Superior to external drainage

The Eight Factors to Evaluate Individual

Patient Risk

1. Malignant obstruction
2. Age greater than 60 years
3. Albumin less than 3.0gl/100ml
4. Haematocrit less than 30 percent
5. White blood cell count greater than 10.000/mm3
6. Total Bilirubin greater than 10mg/100ml
7. Alkaline Phosphatase greater than 100IU
8. Creatinine greater than 1.3 ml/100ml

 PALIATIVE TREATMENT

Endoscopic Stenting
Percutaneous Transhepatic Drainage
Surgical Decompression

Should be safe, effective and comfortable for the
patient

Surgical decompression can be used for bridging to

definitive therapy ( curative or palliative)

 Sub Bagian Bedah Digestif, Bagian
Ilmu Bedah RSCM/FKUI 1994
2000

117 Obstructive Jaundice

66 Periampullary tumor
27 Biliary stones
24 Other
 Therapy

Bilio-digestive by-pass 61
Exploration of Choledochus+T-tube
29
Pancreaticoduodenectomy
18
Other 9