Biliary Tract
The biliary system, or bile ducts, consists of tubes that carry bile produced in the liver into the small intestine. Initially, these tubes are very small, but they enlarge as they approach the surface of the liver. There are two larger bile ducts: the right and left ducts. These two ducts join to form a single tube known as the common hepatic duct, located near the exit of the liver.
A few centimeters below this confluence is a small, mushroom- or balloon-like out-pouching on the right side called the gallbladder. The gallbladder concentrates bile stored within it, functioning primarily as a storage organ with a capacity of around 50 ml, and has a minimal role in digestion.
The main bile duct, below the level of the gallbladder, is referred to as the common bile duct. This duct joins the pancreatic duct within the duodenum, emptying into it. The opening of these ducts into the small intestine is called the ampulla.
Although the biliary tract is primarily a conduit for bile and digestive juices, it is susceptible to various diseases. Commonly encountered conditions include gallbladder stones, strictures (narrowing), and cancers that may affect the intrahepatic ducts (within the liver tissue) and/or extrahepatic ducts (outside the liver tissue).
1. Gallbladder Stones and Cholecystectomy
The gallbladder, a small balloon-like structure, functions primarily as a storage facility with minimal role in our digestive system. It is susceptible to forming stones and can become infected. Stones are formed due to various reasons and are most frequently seen in females in their fourth decade. The majority of these stones are asymptomatic or silent, with size and number varying significantly.
Symptoms:
- Abdominal pain in the right upper region, which can be mild or severe and may radiate to the back or right shoulder.
- Bloating.
- Fullness after meals.
- Difficulty in taking deep breaths.
- Jaundice.
- Fever.
- Nausea.
- Vomiting.
Diagnosis:
- Ultrasound abdomen and pelvis.
- CT abdomen and pelvis with contrast.
- MRCP.
- Blood investigations – Liver function tests, complete blood counts, coagulation profile.
Treatment:
- Laparoscopic / Open Cholecystectomy.
Laparoscopic / Open Cholecystectomy:
Using multiple (three to four) small keyholes, the gallbladder is removed along with the stones. The laparoscopic approach is preferred and rarely requires the open technique. Being a laparoscopic procedure, it results in less pain, faster recovery, and quicker resumption of routine activities.
2. CBD Explorations for Stones in the Bile Duct
Stones in the bile ducts are frequently encountered, with the majority slipping from the gallbladder and causing blockage of the biliary system, resulting in various symptoms. Both smaller stones or sludge and larger stones can slip into the bile duct, necessitating intervention. Conditions such as narrowing in the bile ducts (strictures) or wide dilatation (choledochal cysts) can also contribute to stone formation within the biliary system.
Symptoms:
- Abdominal pain in the right upper and mid regions below the ribs.
- Nausea.
- Vomiting.
- Jaundice.
- Fever.
- Altered sensorium.
Diagnosis:
- Liver function tests.
- Ultrasound abdomen and pelvis.
- MRI - MRCP.
- Endoscopic ultrasound.
Treatment:
- ERCP – Through endoscope.
- Laparoscopic / Open CBD exploration.
Laparoscopic / Open CBD Exploration:
Surgical removal of bile duct stones is performed when ERCP is not accessible or when ERCP has failed to retrieve the stones. This procedure can be executed through small keyholes or via an open approach. During the surgery, the bile duct is opened along its length, and the stones are extracted under direct vision. Once the stones are removed, a balloon or scope may be used to ensure complete clearance. The opened bile duct is then closed directly or over a tube, which is removed subsequently.
3. Choledochal Cyst Excision
A choledochal cyst is a condition where the bile ducts, both inside and outside the liver, become wider than normal. This widening can occur in a single location or at multiple sites. Based on the location, they are classified into types (I to V), with Type I being the most common. This condition carries a potential risk of harboring cancer, making treatment advisable. Additionally, it can lead to bile stasis and precipitate stone formation.
Symptoms:
- Abdominal pain.
- Fever.
- Nausea.
- Vomiting.
- Jaundice.
- Mass in the abdomen.
- Loss of weight and appetite.
Diagnosis:
- Ultrasound abdomen and pelvis.
- CT abdomen and pelvis with contrast.
- MRI - MRCP.
Treatment:
- Surgical excision – Laparoscopic / Open choledochal cyst excision with hepatico-jejunostomy.
Laparoscopic / Open Choledochal Cyst Excision with Hepatico-jejunostomy:
In this procedure, the cyst is completely removed from its formation to its end. Once excised, the small intestine is divided, and its distal end is brought up and joined to the normal bile duct to ensure smooth bile flow into the intestine, followed by restoration of intestinal continuity. This procedure can be performed using either the traditional open method or the advanced laparoscopic technique with multiple small keyholes.
4. Radical Cholecystectomy for Cancers
Gallbladder cancers are increasingly diagnosed today. The majority of these cancers are identified at presentation, while a smaller percentage are discovered after surgical removal of the gallbladder for stone disease or infection. Surgery remains the mainstay of treatment, and administering chemotherapy prior to surgery has shown benefits in selected cases.
Symptoms:
- Abdominal pain.
- Upper back pain.
- Nausea.
- Vomiting.
- Loss of weight.
- Loss of appetite.
- Jaundice.
Diagnosis:
- CA 19-9.
- CT abdomen and pelvis.
- Endoscopic ultrasound and biopsy.
Treatment:
- Surgery – Laparoscopic / Open radical cholecystectomy.
Laparoscopic / Open Radical Cholecystectomy:
This procedure involves the complete removal of the gallbladder, along with a portion of the liver to which it is attached, through small keyholes or a standard open technique. The lymph nodes surrounding this area are also excised. Occasionally, a portion of the bile duct may also require removal, and reconstruction is performed to restore bile flow.
5. Bile Duct Excision for Tumours and Cancers
Tumours and cancers of the bile tubes are not uncommon. Based on their location, these tumours can present with a variety of symptoms. Tumours may be located within the bile tubes or may compress them from outside.
Symptoms:
- Abdominal pain.
- Fever.
- Jaundice.
- Back ache.
- Loss of weight.
- Loss of appetite.
Diagnosis:
- Ultrasound abdomen and pelvis.
- Endoscopic ultrasound.
- CT abdomen and pelvis with intravenous contrast.
- MRI-MRCP.
Treatment:
- Surgery – Laparoscopic / Open excision +/- liver resection with Hepatico-jejunostomy.
Laparoscopic / Open Excision +/- Liver Resection with Hepatico-jejunostomy:
While laparoscopy can be performed in select cases, open surgery is the standard approach. In this procedure, the affected bile tubes are excised in their entirety along with the surrounding lymph nodes. If the tumour extends into the smaller bile tubes within the liver, a segment of the adjacent liver may also be removed. The gallbladder is also excised as part of the procedure. Once the tumour is removed, bile flow to the intestines is reconstructed and restored.
6. Hepatico-jejunostomy for Strictures
Strictures, or narrowing of the bile tubes, can occur following any previous intervention or surgery on the biliary system. These narrowings are mostly benign or non-cancerous but require a complete evaluation to rule out cancer.
Symptoms:
- Abdominal pain.
- Recurrent fevers.
- Jaundice.
- Chills.
Diagnosis:
- CT abdomen and pelvis with intravenous contrast.
- MRI-MRCP.
- CA 19-9.
Treatment:
- Laparoscopic / Open Hepatico-jejunostomy.
Laparoscopic / Open Hepatico-jejunostomy:
In this procedure, the bile tube with narrowing is completely removed. Once excised, the small intestine is divided, and its distal end is attached to the normal bile tube to ensure smooth bile flow into the intestine. The continuity of the intestine is then restored. This procedure can be performed either through the traditional open technique or using advanced laparoscopic methods with multiple small keyholes.
7. Biliary Bypass for Cancers
Biliary bypass surgeries are performed in cases where complete removal of the disease is not possible due to its advanced nature, as seen in biliary or pancreatic malignancies. This procedure is performed as a palliative measure for selected patients.
Symptoms:
- Abdominal pain.
- Recurrent fevers.
- Jaundice.
- Chills.
Diagnosis:
- CT abdomen and pelvis with intravenous contrast.
- MRI-MRCP.
- CA 19-9.
Treatment:
- Percutaneous biliary bypasses - PTBD.
- Laparoscopic / Open biliary bypass.
Laparoscopic / Open Biliary Bypass:
In this procedure, an obstructed biliary system is provided with an alternate route to empty itself. An accessible portion of the biliary system is connected to the intestine to facilitate this process.
