Bile Duct and Gallbladder in Margate, FL
- Diseases of the bile ducts and gallbladder
Diseases of the bile ducts and gallbladder
The biliary system, also called the biliary tree, is a system of bile vessels, called bile ducts, which drain bile. The bile is produced in the liver and is drained into the duodenum. The whole system looks like a tree – the trunk of the tree is formed by the common bile duct. Higher up the trunk of the tree is called common hepatic duct. The common hepatic duct divides into two main branches, right hepatic duct and left hepatic duct. The point where the two ducts divide, is called biliary bifurcation. Each of these two ducts has smaller branches inside the liver. Each branch drains one segment of the liver. Please refer to the liver section of this website for details on the liver segments. The gallbladder is a major branch of the trunk of the biliary tree, which is a storage compartment for bile. The point where the gallbladder joins the main bile duct marks the transition between the common hepatic duct (towards the liver) and the common bile duct (towards the duodenum).
Malignant tumors of the bile duct
Perihilar cholangiocarcinoma (PHC)
Perihilar cholangiocarcinoma (PHC) is also called Klatskin tumor. This is a bile duct cancer that forms at the bifurcation between the left and the right bile ducts. This is the most critical anatomical point in the entire system of liver, pancreas and bile ducts. This is so, because the bifurcation of the bile ducts is very close to the liver inflow vessels, both hepatic artery and portal vein. Please refer to the liver section of this website for details on the liver inflow vessels, hepatic artery and portal vein. Because the bifurcation is so close to the inflow vessels, when there is a tumor there, it frequently grows into the inflow vessels and that causes compromise of the liver blood supply and may make surgery impossible. Klatskin tumor also causes profound jaundice and secondary changes of the liver which are called secondary biliary cirrhosis. That severely compromises the liver function which may preclude surgery. Bile duct cancer tends to grow along the bile ducts and also tends to spread inside the liver (liver metastases) and also along the lymph nodes around the liver inflow vessels (lymph node metastases). Surgery for perihilar cholangiocarcinoma is one of the most difficult ones in the field of liver and bile duct surgery and is associated with one of the highest risks.
Distal cholangiocarcinoma
Distal cholangiocarcinoma originates from the common bile duct. The common bile duct has two parts. The upper part is above the duodenum-pancreas complex. When bile duct cancer involves that part, removal of that part alone may be possible. It requires a complex reconstruction after that. The lower part of the common bile duct travels through the head of the pancreas. When bile duct cancer involves that part, the surgical treatment is the same as for pancreatic head cancer. This is the Whipple procedure. For details on the Whipple procedure, please see the pancreas section of this website.
Benign tumors of the bile duct
Choledochocele
Choledochocele, also called bile duct cyst, is a group of diseases, characterized by transformation of certain part of the bile duct into a cyst. Depending on which part of the bile duct is involved, there are 5 different types of choledochocele. Even though not malignant per se, bile duct cysts have a potential to transform into cancer and need to be removed. That usually consists of removal of the part of the bile duct that contains them, which requires complex reconstruction after that.
Bile duct stones
Bile duct stones usually have formed in the gallbladder and have secondarily fallen into the bile duct, where they may cause blockage of the bile duct, resulting in jaundice and sometimes severe infection. They are usually treated by a gastroenterologist using an endoscopic procedure, called ERCP. Rarely, ERCP is not successful and in this case a surgical procedure is needed to remove the stones from the bile duct. That requires a small incision on the bile duct to be made through which the bile stones are removed from the bile duct. At the end a special drain is placed inside the bile duct through the incision. This drain is called a T-tube. The T-tube stays for at least 6 weeks and prior to its removal a contrast X-ray study is done, which is called cholangiogram.
Benign bile duct strictures
Benign bile duct strictures are areas of narrowing of the bile ducts. They usually occur as a long-term complications of gallbladder surgery (cholecystectomy). They may cause blockage of the bile ducts, resulting in jaundice and infection. In these cases, the number one priority is to make sure that there is no cancer. Sometimes, it is not possibly to ensure that there is no cancer and a cancer-type of operation is necessary in order to definitively confirm that there is no cancer at the level of the blockage. Depending on where the strictures form, a different type of operation may be required. When the stricture is high up at the bifurcation, it may require liver resection and resection of the bile duct. When the stricture is lower, along extrahepatic the bile duct, only removal of the bile duct with a complex reconstruction may be required. When the stricture is further down, where the bile duct travels through the head of the pancreas, a Whipple procedure may be needed.
Bile duct injuries
Bile duct injuries occur as immediate complications of gallbladder surgery (cholecystectomy). Bile duct injuries may be recognized at the time of cholecystectomy and then, if there is immediately available HPB surgeon, an intraoperative consultation is obtained in order to fix the injury right away. If the bile duct injury has been recognized at the time of surgery, but there is no HPB surgeon available at the facility, then the best option is to place a drain and to transfer the patient to a facility with HPB surgeon on site for emergent repair. Dr. Donchev is accepting patients with bile duct injuries for repair. Sometimes bile duct injury may not be recognized until several days after surgery. At this point it presents as bile leak. The patient usually comes with pain, nausea, vomiting, fever, jaundice and is found on CT to have a large collection around the liver. Usually that collection is drained by an interventional radiologist, who places a drain through the skin into a bag. Cultures are obtained and the patient is placed on antibiotics. Then additional images are obtained using a HIDA scan and MRI. Then a gastroenterologist is involved to perform an endoscopic procedure, ERCP, where a stent in the bile duct may be placed. Sometimes endoscopic stenting may be enough to allow the bile leak to stop and seal on its own. In other situations, surgery will be needed. At this point, based on the individual circumstances of each patient, a decision is made by Dr. Donchev of when it would be the best time to perform surgery. When bile leak is identified several days after surgery, there may be severe inflammation in the area where surgery is to be performed and if the patient is stable a decision may be made to wait for several weeks until the inflammation improves. If the patient is sick, then a decision to perform surgery even in view of severe inflammation may be made. Sometimes the patients are so sick, that they need to be stabilized in ICU before surgery is possible.
Resection of extrahepatic bile duct with hepatico-jejunostomy reconstruction
Resection of the extrahepatic bile duct is a procedure that removes the common hepatic duct and common bile duct and the gallbladder and a new connection (anastomosis) is made between the upper bile duct, close to the bifurcation, and the small bowel. This connection is called hepatico-jejunostomy. The procedure is associated with a risk of bile leak in the short term and narrowing of the anastomosis in the long term, which may require repeat operations. If the procedure is performed for a benign condition, i.e. bile duct cyst (choledochocele), then removal of the bile duct is all that is needed. If the operation is performed for cancer, then all the lymph nodes of the area, which are along the large inflow vessels of the liver, need to be removed. This is required for proper staging of the tumor and to prevent recurrence. That additional procedure is called portal or regional lymphadenectomy. Because the operation is done working around large vessels, there is significant risk of bleeding. The anastomosis is also associated with a risk of bile leak.
Liver resection with resection of the extrahepatic bile duct and hepatico-jejunostomy reconstruction and portal lymphadenectomy
Liver resection in addition to resection of the extrahepatic bile duct is required for perihilar cholangiocarcinoma (Klatskin) tumor. Usually, the bile duct cancer grows into the right or the left bile duct and in that case the respective right or left half of the liver needs to be removed along with the bile duct. Please see the liver section of this website for details on liver resections. All the lymph nodes along the liver inflow vessels need to be removed as well, which is called portal lymphadenectomy or regional lymphadenectomy. With this operation, there is not only a risk of injury to the large inflow liver vessels with bleeding, but also risk of bleeding from the resection of the liver. Once the extrahepatic bile duct and half of the liver with all the lymph nodes are removed, then a new connection (anastomosis) between the remaining right or left bile duct is made (hepatico-jejunostomy). In addition to other risks, this operation, since it is removing half of the liver and sometimes even 3/4 of it, poses a risk of postoperative liver failure. That risk is even higher because usually the liver function is already compromised by the biliary obstruction and possibly secondary biliary cirrhosis. Sometimes it is not possible to obtain a negative margin and there is residual tumor at the anastomosis.
Whipple procedure
When the bile duct cancer involves the lower part of the bile duct, that travels through the head of the pancreas, then a Whipple procedure needs to be performed. This is done in the same way as it is done for pancreatic head cancer. Please refer to the pancreas section of this website for details on the Whipple procedure.
Hepatico-jejunostomy
Hepatico-jejunostomy is the procedure, where the upper end of the bile duct is connected to the small bowel (anastomosis) to provide flow of bile into the intestine. Hepatico-jejunostomy is a complex biliary reconstruction procedure. It has a risk of bile leak in the short term and risk of biliary strictures in the long term, which may require repeat operations. It may be a stand-alone procedure when it is performed for repair of bile duct injury from cholecystectomy. It may also be a part of other more complex procedures like resection of Klatskin tumor or Whipple procedure.
Gallbladder disease
As described above, the gallbladder is a major branch of the biliary tree and it serves as a storage compartment for bile. It is attached to the undersurface of the liver, which is called gallbladder fossa. The gallbladder has the shape of a water balloon. Its neck connects to the bile duct through a narrow passage which is called cystic duct. When there is a disease of the gallbladder, the gallbladder is removed. People can have a pretty normal life without the gallbladder without any long-term consequences.
Gall Bladder Cancer
Gallbladder cancer may be found incidentally on pathology specimen following a cholecystectomy or it may be diagnosed on images as a mass in the gallbladder raising suspicion for malignancy. When it is found incidentally, it may be in a very early stage, for which the removal of the gallbladder itself, which has already been done, may be all that is necessary. Sometimes the pathology report from the gallbladder shows that the tumor is in a more advanced stage and then an additional surgery to remove the liver bed of the gallbladder (gallbladder fossa) and the lymph nodes around the bile duct and the liver inflow vessels (portal lymphadenectomy) is needed. In another group of patients, the tumor is even more advanced and it has already grown into the cystic duct and then the extrahepatic bile duct needs to be removed in addition to the removal of the gallbladder bed and the lymph nodes. In that case, at the end, a reconstruction of the bile flow needs to be performed by a hepatico-jejunostomy (see above). When it is even more advanced, the tumor may have grown even more into the liver and the right sided bile duct and liver inflow vessels. Then, the entire right half of the liver needs to be removed along with the extrahepatic bile duct and all the lymph nodes. Then, a reconstruction is done between the left bile duct from the remaining left half of the liver and the small bowel – again hepatico-jejunostomy. In addition to surgery, chemotherapy and radiation therapy are used for treatment of gallbladder cancer. They may be done in addition to surgery, sometimes before and sometimes after surgery. In the most unfortunate patients, the gallbladder cancer may be too advanced at the time of diagnosis and surgery may not be possible. When that is the case, chemotherapy and radiation therapy alone are uses. Sometimes in these cases the tumor may be blocking the bile ducts and causing jaundice. In these cases, bile duct stents are placed which can be done endoscopically by a gastroenterologist or through the skin by an interventional radiologist.
Gallstones
Benign diseases of the gallbladder are a group of various diseases which are not cancerous. Some of them may be pre-cancerous. Others are functional disorders of the gallbladder without any structural abnormality. The treatment for all of them is removal of the gallbladder which as a standard is done through four little holes using conventional laparoscopy or a surgical robot.
Gallstones form in the gallbladder and may cause pain, nausea and vomiting. When the stones are only causing these symptoms but there is no other complication, the stones are considered symptomatic and then removal of the gallbladder is recommended. In these cases, usually the patient is seen in the office and outpatient elective surgery is scheduled and the patient goes home on the same day. When the stones are causing complications, then the patient is usually admitted to the hospital and the treatment varies but it eventually always includes removal of the gallbladder (cholecystectomy).
When the stone is blocking the neck of the gallbladder or the cystic duct, the condition is called acute cholecystitis. Acute cholecystitis is inflammation and infection of the gallbladder. Cholecystectomy is standard treatment. The best time to perform the cholecystectomy is within 24 to 72 hours since the onset of symptoms. After cholecystectomy is performed, the patient’s condition rapidly improves and the patient is discharged usually on the next day.
Sometimes the patient’s symptoms have been present for too long or the patient may be too sick for surgery, or may have been on blood thinners, or may have a heart disease or other medical condition. Any of these situations may be a reason not to perform the surgery as we would otherwise normally do. In these cases, in addition to antibiotics, another procedure is done to relieve the inflammation of the gallbladder. A drainage tube is placed through the skin into the gallbladder. It drains the contents of the gallbladder and relieves the infection. This drainage tube is called a cholecystostomy tube. The names sound similar but it is not to be confused with the removal of the gallbladder itself, which is called a cholecystectomy. Cholecyst-OSTOMY versus Cholecyst-ECTOMY. When a cholecystostomy tube is placed in the gallbladder, the gallbladder is not removed. It is left in place for removal later. The removal of the gallbladder, after a cholecystostomy tube is placed, is done no sooner than 6 weeks after placement. Once the patient’s condition improves, the patient is discharged from the hospital with the tube and is seen in Dr. Donchev’s office and is planned for elective outpatient cholecystectomy at the appropriate interval. The time that the patient waits prior to surgery is used to obtain medical clearance, stop the blood thinners, etc. When the gallbladder is finally removed, the tube is removed with it.
In some patients a stone is not blocking the cystic duct but it has passed into the common bile duct. Once there, it can cause two different types of problems. It may lodge at the end of the bile duct and cause blockage of the bile flow in which case the patient may develop jaundice. In that case an endoscopic procedure, ERCP, is done by the gastroenterologist, which sweeps the bile duct and clears the stone. Following that, removal of the gallbladder is done on the same admission to prevent future events like that. The stone in the bile duct, either sitting there or passing spontaneously into the duodenum, may cause inflammation of the pancreas, called acute biliary pancreatitis. In that case a test is done, MRCP, to find out if the stone is still in the bile duct or if it has passed. If it is still in the bile duct, an ERCP is performed to remove it. If the stone has passed, no ERCP is needed. When the inflammation of the pancreas is resolved, then the gallbladder is removed on the same admission to prevent future episodes like this. The data shows that if the gallbladder is not removed on the same admission, there is 1 in 3 chance of having another episode of pancreatitis within 30 days. This risk is too high to allow the patient not to have the gallbladder removed on the same admission.
Gallbladder Polyps
Gallbladder polyps are areas of growth of the inside lining of the gallbladder similar to polyps that people may have in the colon. When they are really small, less than 6 mm, they may safely be observed with ultrasound. However, when they are larger than 1 cm in size, cholecystectomy is recommended. The decision-making is more complex for polyps 6-9 mm in size and depends on many individual factors, which Dr. Donchev will discuss with the patient at the time of office visit.
Adenomyomatosis
Adenomyomatosis is a benign condition of the gallbladder in which the inner lining of the gallbladder resembles the lining of the uterus. In the past it has been considered pre-cancerous, but current evidence suggests that it has no risk of transforming into cancer. However, sometimes it may be difficult to distinguish adenomyomatosis from gallbladder cancer and in these cases removal of the gallbladder is recommended. When the diagnosis of adenomyomatosis is clear and there is no concern for cancer, but the patient has symptoms, removal of the gallbladder is still the recommended treatment. When the diagnosis of adenomyomatosis is clear but the patient does not have symptoms, then the decision to observe or to remove the gallbladder will be based on the individual factors of each patient.
Biliary dyskinesia
Biliary dyskinesia is a functional disorder of the gallbladder without anatomical abnormality. The function of the gallbladder is measured by its ejection fraction, which is how much of its contents, the gallbladder is able to squeeze when stimulated by a medication called CCK. The gallbladder ejection fraction is measured by a test called HIDA with CCK stimulation. Normal gallbladder ejection fraction is 35-65%.
Biliary dyskinesia presents in two forms.
In one of them, the gallbladder ejection fraction is lower than normal and the gallbladder fails to squeeze and empty properly. This causes nausea, vomiting and abdominal pain. Sometimes the dysfunction is so severe, that inflammation and infection of the gallbladder may develop due to its inability to empty. This is called acalculous cholecystitis. Acalculous means without stones. The name is used to distinguish this type of inflammation of the gallbladder from the other, more common type of inflammation of the gallbladder, which is caused by stones, called calculous cholecystitis. (“Calculus” means “stone”, calculous cholecystitis is cholecystitis due to stones, acalculous cholecystitis is cholecystitis without stones). When there is low gallbladder ejection fraction and the patient has symptoms, the recommended treatment is removal of the gallbladder.
In the other form of biliary dyskinesia, the gallbladder ejection fraction is higher than normal. In this case the gallbladder is hyperactive and squeezes too violently which causes essentially the same symptoms as when it does not sqeeze at all – abdominal pain, nausea and vomiting, sometimes diarrhea. There is no consensus regarding treatment of hyperactive gallbladder. Some doctors do not recommend removal of the gallbladder and do not believe that hyperactive gallbladder is a disease. Others recommend removal of the gallbladder for hyperactive gallbladder and their studies show significant success with that approach. Dr. Donchev subscribes to the group that recommends gallbladder removal for hyperactive gallbladder.
Porcelain gallbladder
Porcelain gallbladder is a condition where calcium deposits in the wall of the gallbladder. In the past it has been strongly implicated as a pre-cancerous condition. More contemporary studies have found less that the risk is lower. However, within the surgical community, the standard recommendation is still to remove the gallbladder out of concern for the possibility of malignant transformation. If after removal of the gallbladder, on final pathology it is found indeed that it contains cancer, then the treatment will follow the same pathway as described in the section on gallbladder cancer above.
Cholecystectomy (open, robotic, laparoscopic)
The standard treatment for most gallbladder disease is removal of the gallbladder, which is called cholecystectomy. Traditionally it has been done open. In the 1990s the minimally invasive approach of laparoscopic cholecystectomy was introduced and soon after, laparoscopic cholecystectomy has completely replaced open surgery and was recognized as the standard of care for more than 20 years. Most recently, with the further development of new technologies, the surgical robot was introduced and has become more available. Currently robotic cholecystectomy is becoming more and more common and will likely replace conventional laparoscopic cholecystectomy in the near future. Dr. Donchev performs cholecystectomy robotically unless there is a specific reason to do it otherwise. Robotic cholecystectomy is done using four little incisions, three of them are 8 mm and one is 12 mm. The abdomen is blown up with air and a camera is introduces. Three additional robotic instruments are introduced and the gallbladder is grabbed and pulled up. The key part of the operation includes peeling off the fat around the cystic duct to expose the cystic duct (the junction between the gallbladder and the bile duct) and the small vessel that feeds the gallbladder (cystic artery). Once these two structures are seen, they are clipped and divided. Then the gallbladder is peeled off from the undersurface of the liver. Then the gallbladder is placed in a plastic bag and is removed through the 12 mm incision. The specific risk of the operation is inadvertent injury to the bile duct. Please refer to the above section on bile duct injuries for further detail. While not impossible, the risk of bile duct injury in Dr. Donchev’s hands is very low. In addition, his expertise as an HPB surgeon, allows him to perform a repair, should bile duct injury happen. So far, Dr. Donchev has not had a case of bile duct injury.
Radical cholecystectomy
Radical cholecystectomy is an operation which is done when there is a proof or strong suspicion for gallbladder cancer. It includes in addition to removal of the gallbladder, resection of the liver bed of the gallbladder and removal of the lymph nodes along the bile duct and the liver inflow vessels. It is a much more complex operation than the routine cholecystectomy. Traditionally it is done open, but recently with the availability of the surgical robot, it can be done robotically, when the patient’s factors allow that. Dr. Donchev does perform radical cholecystectomy robotically when possible.
Liver resection with resection of the extrahepatic bile duct and hepatico-jejunostomy reconstruction and portal lymphadenectomy
Liver resection in addition to resection of the extrahepatic bile duct is required for larger gallbladder cancer. Usually, the gallbladder cancer grows into the liver bed and the right bile duct and in that case the right half of the liver needs to be removed along with the right and common hepatic and common bile duct. Please see the liver section of this website for details on liver resections. All the lymph nodes along the liver inflow vessels need to be removed as well, which is called portal lymphadenectomy or regional lymphadenectomy. With this operation, there is not only a risk of injury to the large inflow liver vessels with bleeding, but also risk of bleeding from the resection of the liver. Once the extrahepatic bile duct and the right half of the liver with all the lymph nodes are removed, then a new connection (anastomosis) between the remaining left bile duct is made (hepatico-jejunostomy). In addition to other risks, this operation, since it is removing half of the liver and sometimes even 3/4 of it, poses a risk of postoperative liver failure. That risk is even higher if the liver function is already compromised by the biliary obstruction and possibly secondary biliary cirrhosis. Sometimes it is not possible to obtain a negative margin and there is residual tumor at the anastomosis.