9 Section of Surgery
REFERENCES
Cattell RB (1947) J. Anter. nmed. Ass. 134,235
Cattell R B & Braasch J W
(1959) New Engl. J. Med. 261,929
Smith R
(1964a) In: Surgery of the Gallbladder and Bile Ducts.
Ed. R Smith & S Sherlock. London; p 305
(1964b) Brit.J. Surg. 51, 183
Miss Phyllis George
(Royal Free Hospital, London)
Cholangiography
The biliary tree is not normally visible on plain
X-ray of the abdomen but may be seen after
biliary surgery - a sphincterotomy, a spbinctero-
plasty or an anastomosis, particularly if partially
or recurrently obstructed - air is trapped in the
ducts and will show on plain X-ray; where no air
is visible, it is sometimes feasible to give the
patient a gassy drink, when gas will enter the tree.
Gas in the biliary tree may be due to a spon-
taneous or post-operative biliary fistula and may
be regurgitated through an incompetent sphincter
of Oddi - usually when there is a coexistent
disease of the biliary tract such as cholecystitis or
gall-stones.
Oral Cholecystogram
Provided the gall-bladder concentrates the
opaque medium adequately in oral cholecysto-
graphy, the administration of a fatty meal or of
cholecystokinin will cause it to empty and show
the bile duct in part but this is seldom a satis-
factory method; it may show that the common
bile duct is normal or possibly or probably
abnormal - rarely do the right and left hepatic
ducts show well.
Intravenous Clholangiography
If liver function is normal, then the ducts may be
shown after approximately 15 minutes or up to 2
hours. This method is especially useful in the
nonjaundiced 'post-cholecystectomy syndrome'
patient; it is contraindicated if the serum bilirubin
is greater than 2-3 mg/100 ml, unless the level is
falling; if the bilirubin is morethan [ Smg/100ml,
oral cholecystography will usually be useless; if
more than 2 5-3 mg/100 ml, intravenous cholan-
giography will most probably be ineffective; the
continuous infusion method with iopanoic acid
(Telepaque) may show the ducts with a bilirubin
up to 4-5 mg/100 ml.
Percutaneous Cholangiography
Percutaneous transhepatic cholangiography (PTC)
is of use in the obscure case of jaundice of at least
10
137
six weeks' standing, where a definite diagnosis has
not been made between 'medical' and 'surgical'
jaundice or where the patient is known to have
obstructive jaundice but exact delineation of the
site and probable cause will be an advantage to
the surgeon and thereby also to the patient. Thus
it can differentiate between jaundice caused by
drugs, hepatitis, biliary cirrhosis or cholangitis. If
no duct is entered after four or five attempts by an
experienced person, then the duct system is
assumed to be undilated and the patient is spared
an unnecessary or possibly hazardous operation.
Occasionally an undilated duct system is entered
and here, too, it will be seen that operation is not
indicated.
Surgically, percutaneous cholangiography is
most helpful in the case of stricture of the ducts,
when multiple previous operations may have been
carried out and the patient is still jaundiced: in
these cases there are likely to be many and dense
adhesions, when dissection in the area without
the benefit of percutaneous cholangiography
may be both time consuming and hazardous
of damage to otherwise normal structures.
If the site of the obstruction is demonstrated,
then the surgeon can plan the operation
and will know precisely where to dissect
to find dilated duct suitable for anastomosis.
In other cases there may be a history of a
previous 'negative' laparotomy (without an
operative cholangiogram) with a still-jaundiced
patient. The patient may naturally be loath to
undergo another operation but will usually agree
when told that an X-ray will show whether his
jaundice should be relieved by surgery or whether
he is better treated medically. The diagnosis
usually proves to be carcinoma high in the ducts.
Whenever a 'positive' percutaneous cholangio-
gram is obtained (that is, when the duct system is
entered) then it is essential to operate within four
hours; we usually take the patient straight from
the X-ray department to the theatre because there
is a risk of biliary peritonitis or hiemorrhage if a
distended duct system is punctured and the
peritoneal cavity is not drained; the polythene
tube is left in place to prevent leakage while the
patient is being transported to the theatre.
Sometimes the procedure is 'negative' because
the ducts are infiltrated by growth or are full of
stones or the liver itself is fibrotic and the needle
will not readily penetrate its substance. In these
patients operation is required because the patient
is known to have an obstructive lesion; operative
cholangiography is then indicated.
Cholangiography
at Operation
Sometimes a transhepatic cholangiogram may
be done at operation after the abdomen is opened,
138 Proc. roy. Soc. Med. Volume 62 February 1969
when a PTC has proved impossible. Operative
cholangiography should be done routinely at the
operation of cholecystectomy wherever portable
X-rays are feasible and where the X-ray depart-
ment is willing to co-operate. Once this is an
established procedure, it adds no more than five
minutes to the operation, the gall-bladder being
removed while the radiographer is developing
the films. There is some controversy as to the
ideal amount of contrast material which should
be used. Some surgeons use 1 ml in the first film,
others 5 ml. It seems to be a matter of which
amount is thought to produce the most useful
films in each individual case. Serial exposures
may be indicated. The less contrast that is used,
the more likely that calculi in the ducts will show.
Too much contrast may obscure small stones.
Whenever cholangiography is anticipated, a
sterile transparent adhesive polythene rectangle
is applied, obviating the need to sew on skin
towels; towel clips must not be used as they may
obliterate a vital part of the duct system on the
X-ray.
Operative cholangiography in routine explora-
tion will show some lesions indicating exploration
of the common bile duct where there is no other
indication for this. On the other hand, if the
cholangiogram shows a normal, undilated tree
in patients clinically thought to require explora-
tion, the common bile duct need not be opened.
Cholangiography may also show abnormal
anatomy such as the low union of the right and
left hepatic ducts, with the cystic duct entering
the right hepatic duct: the right hepatic duct has
been tied off in error for the cystic duct; this
could also occur if the gall-bladder is sessile and
there is no cystic duct.
Furthermore, an operative cholangiogram
shows the length and site of entrance of the
cystic duct. This is important in the prevention
of the cystic duct remnant syndrome as the duct
should be tied off flush with the common duct
and it often travels for a distance parallel to the
duct before it enters. Unless the duct does not
enter until it is within the pancreatic substance, it
should be dissected out to its termination. (If the
dye does not satisfactorily enter the duodenum a
sphincterotomy and usually sphincteroplasty is
indicated.)
An operative cholangiogram may give addi-
tional information in cases where a PTC has
already been done, if the lower tract is needed for
anastomosis as with a carcinoma of the hepatic
duct. If the common duct or the gall-bladder is
being used, it is vital to know there is nothing
to impede the flow of bile to the duodenum.
J0
In cases of carcinoma of the pancreas it is
equally important to know the site of entrance
of the cystic duct as cases have been seen where
the gall-bladder has been anastomosed to the
duodenum and the patient remains jaundiced.
If the operative cholangiogram shows the cystic
duct to have a low entrance, then there will be no
drainage of the bile as the cystic duct is already
involved by growth or soon will be. If there is not
at least 5 cm between the entrance of the cystic
duct and the upper limit of the pancreatic
carcinoma then I do not use the gall-bladder. In
all cases it is anyway preferable to transect the
common duct if the patient's condition warrants
this and do a choledochojejunostomy as jaundice
cannot then recur from direct extension of the
growth.
In oneinstance of suspected carcinoma of the
pancreas, an operative cholangiogram showed
that dye did in fact enter the duodenum in spite
of the mass in the pancreas. A biopsy confirmed
the existence of chronic pancreatitis. We have
never seen a case of carcinoma of the head of the
pancreas which did not produce complete
obstruction to the flow of dye by the time it had
produced clinical jaundice. Operative cholangio-
grams will also help to differentiate between
calculous obstruction and carcinoma of the
pancreas a stone impacted in the ampulla may
-
feel very much like a carcinoma. Furthermore,
the intrahepatic ducts are usually markedly
dilated in carcinoma of the pancreas but the
dilatation is usually limited to the common and
hepatic ducts outside the liver in calculus disease.
Sclerosing cholangitis is a rare condition; an
operative cholangiogram will show the typical
thickened spidery irregular ducts which are not
amenable to surgery and such an X-ray will
prevent any further surgery at a later date. A
liver biopsy is of course also indicated at the
same time.
Operative cholangiography may be carried out
through the gall-bladder wall but the cystic duct
is the most usual route, using a small polythene
catheter, if the gall-bladder has not already been
removed. Next in frequency is directly into the
common or hepatic duct via a small needle. If
serial pictures are required it is preferable to
reinsert the needle rather than to leave it in situ
between pictures.
Post-procedure Cholangiography
Once the common duct has been opened a balloon
catheter with the tip cut off can be used to get an
X-ray picture: the end is introduced into the duct
11
and the balloon inflated until the lumen of the
duct is gently occluded and dye cannot then
escape.
A T-tube cholangiogram should be taken
routinely before closure of the abdomen in cases
where T-tube drainage is indicated. Then if, for
example, a stone is seen still to be present, it can
be removed. It is pointless to wait for this X-ray
until the patient is back in the ward. It is helpful
to obliterate digitally first the upper limb of the
tube and then the lower when injecting the dye,
to make sure that there is filling of both upper
and lower parts of the biliary tree. If there is any
doubt about the normal functioning of the biliary
tree after operation, then an intravenous cholan-
giogram will again be useful, provided that the
patient is not heavily jaundiced. In cases where a
tube has been left in situ to drain either a hydatid
cyst cavity or a large liver abscess, contrast X-ray
via the tube will reveal the state of the cavity and
sometimes also show the biliary tree.
Finally, after operation for stricture of the
bile ducts, it is seldom easy to get good pictures
of the anastomotic site and the higher reaches of
the biliary tree. A triple tute has been made for
this purpose by Eschmann Ltd: it is placed in
position at the point of the anastomosis at the
time of operation and an X-ray is taken of it
before finally closing the abdomen to ensure that
it is exactly sited; one lumen is the drainage
lumen for the bile and has a side outlet about
4 in (10 cm) from the tip to allow the main bile
flow to enter the jejunum; the second lumen
allows the balloon to be inflated and is placed at
the exact point of the stricture and can be
inflated twice a week post-operatively to try to
prevent recurrence of the stricture; the third
lumen is an irrigation or X-ray lumen and can
be used for introduction of antibiotics, irrigation
of the bile ducts and anastomotic areas or the
introduction of radio-opaque material.
Professor L P Le Quesne (Middlesex Hospital,
London) emphasized the importance of operative
cholangiography in the diagnosis of stone in the
common duct and said that the available evidence
indicated that this was the single most accurate
method of determining whether or not the duct
contained stones and hence did or did not require
Section of Surgery 139
operative exploration. He stressed that to give
accurate information this examination required
scrupulous attention to detail in technique and
to the criteria of normality in interpretation of
the films.
Mr Rodney Maingot (London) said that the causes
of injuries to the bile ducts during operation and
of post-operative strictures were worth a much
closer scrutiny than had been afforded them so
far. In over 130 cases of post-operative stricture
referred to him he-estimated that about 95 % had
followed cholecystectomy for calcufous chole-
cystitis, 2% injudicious exploration of the
choledochus, 1 % partial gastrectomy for duo-
denal ulcer and 1% excision of a duodenal
diverticulum; 1 % had other causes.
The main causes of post-operative stricture of
the bile ducts might be listed as follows:
(1) Hemorrhage from the cystic artery, an
anomalous cystic artery, an accessory cystic
artery, the right hepatic artery or an accessory
right hepatic artery. Brisk bleeding from one of
these arteries, a pool of blood and a blind plunge
with a hemostat for the spurting point would
frequently lead to a number of tragic events.
(2) Poor exposure, poor illumination, poor
anxesthesia and poor assistance.
(3) A lack of anatomical knowledge and of the
appreciation of anomalies, e.g. accessory bile
ducts.
(4) The easy cholecystectomy: The easy chole-
cystectomy and the over-confident surgeon lack-
ing in technical skill constituted a sinister
combination.
(5) The difficult cholecystectomy; the shrivelled
gall-bladder; anatomy obscuration, as obtained
in some cases of acute cholecystitis.
(6) Mutilation or perforation of the duct during
exploration for stone.
(7) Suturing the free margin of the hepato-
duodenal ligament too tightly over the bile ducts
at the completion of cholecystectomy.
(8) The pooling of infected bile in the subhepatic
space caused by the 'slipped ligature'.
(9) Injury to the lower end of the duct during
partial gastrectomy and excessive inturning of the
duodenal stump.
(10) Injury to the duct during excision of a
diverticulum of the second part of the duodenum.