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Bile Duct
Bile duct obstruction

Bile duct obstruction is a blockage in the tubes that carry bile from the liver to the gallbladder and small intestine.

Causes

Bile is a liquid released by the liver. It contains cholesterol, bile salts, and waste products such as bilirubin. Bile salts help your body break down (digest) fats. Bile passes out of the liver through the bile ducts and is stored in the gallbladder. After a meal, it is released into the small intestine.


When the bile ducts become blocked, bile builds up in the liver, and jaundice (yellow color of the skin) develops due to the increasing levels of bilirubin in the blood.

The possible causes of a blocked bile duct include:
  • Cysts of the common bile duct
  • Enlarged lymph nodes in the porta hepatis
  • Gallstones
  • Inflammation of the bile ducts
  • Narrowing of the bile ducts from scarring
  • Injury from gallbladder surgery
  • Tumors of the bile ducts or pancreas
  • Tumors that have spread to the biliary system
  • Liver and bile duct worms (flukes)
The risk factors include:
  • History of gallstones, chronic pancreatitis, or pancreatic cancer
  • Injury to the abdominal area
  • Recent biliary surgery
  • Recent biliary cancer (such as bile duct cancer)

The blockage can also be caused by infections. This is more common in persons with weakened immune systems.

Laparoscopic Common Bile Duct Exploration:

Choledocholithiasis (stones in the bile duct) can be treated by either open, laparoscopic, or endoscopic means (Endoscopic Retrograde Cholangiopancreatography [ERCP]). In experienced hands, the laparoscopic common bile duct exploration is a potential option for managing stones within the biliary tree at the same time as laparoscopic cholecystectomy.

Preoperative preparation:

Patients should be given a prevention for deep venous thrombosis as well as sequential compression devices, prophylactic antibiotics. The procedure is performed with the patient in the supine position, with the surgeon on the patient’s right and the assistant on the left. Normally, the laparoscopic monitors are placed at the patient’s head to the left and right. All equipment, including equipment necessary for common bile duct exploration and an open surgical tray on stand-by, should be confirmed prior to the patient being brought into the room.

Port placement:

Port placement (key holes) can be identical to that for laparoscopic cholecystectomy, whether or not cholecystectomy is being performed at the same time. Cholangiogram (Bile duct dye test) and common bile duct exploration: There are two different approaches to performing laparoscopic common bile duct exploration: transcystic (through the gall bladder duct) and through a choledochotomy (through the main bile duct).

Trancystic approach:

The cystic duct is exposed for 2-3 cm and scissors used to incise it. A cholangiogram catheter is then introduced. If it has a balloon tip, this can be inflated, and 50% contrast injected under fluoroscopy to confirm position and anatomy. The common bile duct can be flushed with 30 cc of saline via the catheter. Small stones may be flushed this way, especially with administration of 1 mg of glucagon. Through the choledochoscope a retrieval basket can be inserted under direct visualization.

Choledochotomy:

Alternatively, the above methods can be performed through a choledochotomy. The common bile duct is exposed and a vertical ductomy performed for about 5 mm on the anterior surface of the duct, distal to the cystic-common bile duct junction. The techniques for stone clearance are identical to the trans-cystic approach.

Postoperative care:

When the transcystic approach is used, no special care is required other than routine postoperative care. However, if the access was through the main bile duct, a little tube (drain) might be left for few days to treat any possible bile leak.