This procedure may be utilized in poor-risk patients having a limited life expectancy because of inoperable malignant disease obstructing the common duct that cannot be decompressed with endoscopic retrograde cholangiopancreatography (ERCP) or transhepatic cholangiopancreatography (THCP) passage of a stent. The cystic duct must be opened and the common-duct malignancy should be quite low, with an expectation that the process will not reach the cystic duct region for several months. In making this short-circuiting anastomosis, it is preferable to utilize the nearest portion of the upper gastrointestinal tract that can be approximated easily to the gallbladder without tension. This is usually the mobilized duodenum or a direct anastomosis to the upper jejunum may be done. If long-term survival is anticipated, the gallbladder or common duct is anastomosed to a Roux-en-Y arm of mobilized jejunum. A cholecystogastrostomy is done rarely. However, the technique shown is more frequently used to anastomose the gallbladder to the duodenum. The gallbladder should not be utilized in an attempt to relieve obstructive jaundice if the cystic duct is obstructed or if the lower end of the common duct is to be removed in a radical resection. Visualization of the gallbladder and ducts by contrast media may be worthwhile to prove beyond any doubt the site of obstruction.
Although the operation is a simple one, the patients are such poor risks that they require careful preparation to avoid fatality. Nutritional needs may require total parenteral nutrition (TPN) support. As a rule, the patient is deeply jaundiced and there is already serious liver damage. Blood products and large doses of vitamin K are indicated until the prothrombin level returns to a normal range.
The position of the patient is adjusted as described for cholecystectomy (Plate 95); if local anesthesia is used, this position may be modified for the patient's comfort.
The skin is prepared in the usual manner.
Usually, a midline incision reaching from the xiphocostal junction almost to the umbilicus is made. However, either a transverse or a Kocher oblique incision is satisfactory for those familiar with these approaches to the gallbladder. Bleeding and oozing points in the wound or within the peritoneal cavity are meticulously ligated. Exploration is carried out to determine the nature of the disease causing the obstruction, i.e., whether there is a tumor located in or about the common duct or in the head of the pancreas, whether the tumor is primary or metastatic, or whether there is a common duct stone. In the presence of malignant disease obstructing the common duct without distant metastasis, the duodenum should be mobilized and the operability of the lesion determined. Involvement about the portal vein contraindicates surgery. If extensive involvement or dislocation of the duodenum by tumor is apparent, a gastroenterostomy may be planned to avoid possible late obstruction. A determined attempt should be made to prove the suspicion of tumor, even though extra effort may be required to obtain the biopsy. For biopsy purposes, mobilization of the duodenum may be indicated to expose the posterior side of the head of the pancreas, if the tumor seems more superficial there.
If the lesion is inoperable and the life expectancy short, the surgeon must determine whether it is easier to anastomose the distended gallbladder to the stomach, the duodenum, or the jejunum as a palliative measure. The same type of anastomosis is used whichever viscus is chosen. The more complicated but efficient types of anastomosis, such as a Roux-en-Y anastomosis is not necessary unless there is a reasonable chance of prolonged life expectancy.
As a rule, it is easy to perform the anastomosis to the stomach, preferably 2 to 4 cm above the pylorus and near the greater curvature. Should such an anastomosis be likely to leave the gallbladder under tension when the patient is erect, the anastomosis should be made to the duodenum or upper jejunum. A portion of the bowel is held up to the gallbladder on its medial side about 2 to 3 cm below the fundus (Figure 1). If the gallbladder is greatly distended, it may be emptied through a trocar before the anastomosis is started; if not, a posterior row of interrupted fine nonabsorbable sutures is placed to bring the two viscera in apposition without opening either of them (Figure 2). These sutures should not enter the lumen. The interrupted sutures (S1) on the either end of the posterior serosal layer are left long, and the others are cut to expose the field where the incisions into the gallbladder and stomach are to be made (Figure 3). The incision are then made with electrocautery paralleling the suture line, with suction used to control the spread of any contents from either viscus (Figure 3). The incisions are then lengthened to give a stoma of 1 to 2 cm (Figure 4). To avoid contamination some surgeons prefer to carry out this procedure with enterostomy clamps applied to the gallbladder and stomach. The bleeding from the mucosa of the stomach, which is the only bothersome element, can be controlled easily by placing a mosquito snap on each of the major vessels. The clamps should be loosened and all bleeding points ligated before closure of the anterior layer. When the field is dry, the operator places a series of interrupted 0000 fine sutures in the mucosal layers (Figure 5). The anterior mucosal layer is closed with interrupted sutures with the knots on the inside (Figure 6). After the mucosal sutures are laid, an anterior row of interrupted sutures is placed between the serosal coats to complete the anastomosis (Figures 7 and 8). The patency of the stoma is tested by palpation between the thumb and index finger, and as a precaution several sutures may be inserted at either angle. The field must be free of oozing points.
After the table is leveled, the omentum is brought up about the anastomosis. A nasogastric tube is placed since gastric emptying will be delayed. The incision is closed without drainage in a routine fashion.
The administration of fluids and food by mouth is restricted for a few days, as in other intestinal anastomoses. The appearance of bile in the stools and a decreasing icteric index indicate that the anastomosis is functioning. A high-vitamin, high-protein, and high-carbohydrate diet is resumed as soon as tolerated. In elderly, poor-risk patients who refuse to eat, a gastrostomy tube placed during surgery can be used for the refeeding of bile mixed with milk and other liquids in order to hasten their recovery.
It is not uncommon during an exploratory laparotomy to remove a small fragment of the liver for histologic study. Biopsy of the liver is indicated in most patients who have a history of splenic or liver disease, or in the presence of a metastatic nodule. The specimen should not be taken from an area near the gallbladder, since the vascular and lymphatic connections between the liver and gallbladder are such that a pathologic process involving the gallbladder may have spread to the neighboring liver, and as a result the biopsy would not give a true picture of the liver as a whole.
Two deep 00 sutures, a and b, are placed about 2 cm apart at the liver border (Figure 1) using atraumatic type of needle. The suture is passed through the edge of the liver and back through again to include about one-half the original distance (Figure 1A). This prevents the suture from slipping off the biopsy margin with resultant bleeding. These sutures are tied with a surgeon's knot, which will not slip between the tying of the first and second parts (Figure 1A). The suture should be tied as snugly as possible without cutting into the liver, for the tension under which these knots are tied is the important factor in the procedure. Such sutures control the blood supply to the intervening liver substance. The two sutures are placed not more than 2 cm apart, deep in the liver substance; yet as they are tied, at least 2 cm of liver are included at the free margin to increase the size of the biopsy by making it triangular in shape. An additional mattress suture, c, may be taken at the tip of the triangular wound (Figure 2). After the biopsy is removed with a scalpel (Figure 3), the wound is closed by tying together the sutures, a and b, or by placing an additional mattress suture, d, beyond the limits of the original sutures (Figures 4 and 5). The area of biopsy is covered with some type of anticoagulant matrix and omentum.