Biliary Bypass Procedures: Detour Ahead

What Are Biliary Bypass Procedures?

Biliary bypass procedures are done to relieve symptoms caused due to blockage in the biliary tract. During this procedure, the gall bladder or a segment of the bile duct before the blockage is connected with the part that is present beyond the blockage. It is done to allow the flow of the bile around the blockage. This procedure is performed in patients suffering from bile duct tumors that cannot be removed entirely by surgery.

What Are the Indications for This Procedure?

• Choledocholithiasis: It is a condition characterized by the presence of at least one gallstone in the common bile duct. The stones are made up of calcium and cholesterol salts.

• Biliary Strictures: It is also known as bile duct stricture, which occurs when the bile duct gets smaller or narrower. The tube carries bile produced in the liver to the small intestine. Bile helps in the digestion of fatty foods and excretes harmful substances.

• Sclerosing Cholangitis: It is a disease of bile ducts that carries the digestive liquid called bile from the liver to the small intestine.

• Periampullary Growth: Cancer that forms near the ampulla of Vater (a small reservoir where the bile and pancreatic duct meet).

• Head of the Pancreas Carcinoma: Cancer that begins in the organ lying behind the lower part of the stomach, which is the pancreas. It helps in secreting enzymes that aid in digestion and helps in regulating the metabolism of sugars.

• Common Hepatic Duct Injury: The tube carries bile from the liver. Injury to this duct is called the common hepatic duct injury.

• Cholangiocarcinoma: It is a group of cancers that originate in the bile duct. Bile ducts are branched tubes that connect the liver and the gallbladder to the small intestine. This tube carries bile which helps in the digestion of fats in the food that is consumed.

What Will Happen During the Procedure?

A laparoscopic or robotic surgery will be performed. General anesthesia would help the patient sleep through the surgery and relieve pain. The surgeon will make an incision past the blockage in the intestine. Next, the surgeon will connect the first part of the bile duct to the other part of the duct or the intestine, which would create a new pathway for the bile to flow through. Absorbable sutures are then used to close the incision. Biliary duct disorders affect a significant amount of the population globally.

Most of these cases are cholelithiasis and cholestasis due to the obstruction of the bile ducts. These disorders can be managed by one of the biliary bypass procedures depending on the type of pathology to relieve the obstruction or communicate the pathway when other alternatives are not feasible. These procedures can be done using conventional surgical methods or laparoscopy, depending on the available facilities. Again, the decision to choose this surgical procedure is based on the pathology, and most of these patients have had at least one of those conditions that needed this procedure.

What Are the Types of Biliary Bypass Procedures?

• Cholecystectomy: It is a surgical procedure to remove the gallbladder. A pear-shaped organ that is located below the liver on the upper right side of the abdomen. This organ collects and stores bile (a digestive fluid produced in the liver). It is a joint surgery and carries only a small risk of complications. It is commonly performed by inserting a tiny camera and surgical tools through four small incisions to see inside the abdomen and remove the gallbladder. It is otherwise called laparoscopic cholecystectomy. Sometimes, one large incision can be made to remove the gallbladder. This is called an open cystectomy.

• Choledochoduodenostomy: This is a procedure to create a surgical connection between the common bile duct and an alternative portion of the duodenum. In healthy individuals, the common bile duct meets the pancreatic duct at the ampulla of the Vater (a small reservoir where the common bile duct and pancreatic duct meet). It is a recommended procedure for biliary strictures and cholelithiasis.

• Choledocho-Jejunostomy: It is a surgical procedure used for creating anastomosis (surgical connection) of the common bile duct to the jejunum to relieve any symptoms of biliary obstruction and restore continuity to the biliary tract. It is most commonly used for pancreatic malignancies.

• Cholecystojejunostomy: It is a surgical connection (anastomosis) between the gallbladder and the jejunum. This procedure is used in the event of advanced pancreatic cancers.

• Hepaticojejunostomy: It is a surgical connection between the hepatic duct and the jejunum. It is used mostly for injuries in the biliary system and fibrosis of the common bile duct.

What Are the Risks of Biliary Bypass?

• The patient may start bleeding more than expected or could develop an infection.

• The area where the bile gets drained can leak.

• The patient may develop problems digesting food.

• The patient may have postoperative symptoms like nausea and vomiting.

• The new surgical connection can become blocked over time.

What Are the Postoperative Instructions to Be Followed?

The postoperative instructions include the following:

• The doctor will prescribe a clear diet consisting of broth, gelatin, and clear juice.

• The patient will then start eating slowly.

• Soft drinks can be given first to prevent nausea and vomiting.

• The healing usually takes about a few months.

Laparoscopic Roux en Y Cholangiojejunostomy:

Cholangiojejunostomy is a standard surgical procedure for treating biliary tract diseases. Among all cholangiojejunostomy procedures, Roux-en-Y cholangiojejunostomy (RCJS) is considered to have a lower incidence of postoperative cholangitis and recurrent stones. With the development of laparoscopy, laparoscopic roux en Y cholangiojejunostomy (LRCJS) has become the treatment option for biliary tract diseases. Biliary bypass operation has better survival rates than metallic stents in treating inoperable distal malignant biliary obstruction.

Indications:

• Bile Duct Injury: An injury caused by the bile duct. It is most commonly caused while performing a surgical procedure. It can also be caused due to trauma to the biliary tract.

• Congenital Choledochal Cyst Resection: An abnormality of the duct that transports bile from the liver to the gallbladder and small intestine.

• Obstructive Jaundice: It is caused by advanced pancreatic head carcinoma: Yellowing of the skin and white of the eyes, light-colored stools, and dark urine are some of the signs of obstructive jaundice, where normal drainage of bile from the liver to the small intestine is blocked.

• Biliary Tract Reconstruction: It is a procedure that is used to replace portions of the child’s biliary system that are damaged due to some illness or missing at birth.

What Could Be the Possible Complications of This Procedure?

Biliary Leakage:

It is one of the main complications of cholangiojejunostomy, which could lead to peritoneal inflammation (redness and swelling of the stomach lining or the abdomen). In addition, if it occurs in the small bile duct, it could lead to failure in surgery.

Postoperative Stress Ulcer and Peritoneal Bleeding:

Inflammation and bleeding near the operation site are common complications post-surgery.

What Are the Steps to Prevent Bile Leakage?

The surgeon should check for bile leakage after suturing. The posterior wall of the common bile duct was the most common position for bile leakage because of its deep anatomical position, as it also increased the difficulty of operating.

Conclusion

Thus, Roux en Y biliary bypass is considered a safe procedure for major bile duct injuries showing better outcomes in rerouting the bile flow. However, surgeons must have the required instruments and technology to perform these procedures. Thus, these surgeries help to relieve symptoms caused by cancer infections or the formation of gallstones. With recent advancements in medicine, these procedures are now being carried out more efficiently.