Biliary Tree, Liver pathology, liver pathology

Choledocolithiasis (symptoms)

1. obstructive jaundice 2. cholangitis 3. acute pancreatitis *Charcot-Villard* classic triad triad: *pain, fever and jaundice* is characteristic for forms associated with angiocolitis.

Choledocolithiasis (size)

<2 mm, which can cross the papilla 3-5 mm stones that can pass through the papilla giving rise to episodes of jaundice or pancreatic reactions. >5 mm stones that can become impacted into the papilla.

MRC (magnetic resonance cholangiography)

Delineates fluid column within biliary tree and is sensitive technique for detection of CBD stones in presence of dilated duct The technique may be less accurate in absence of duct dilatation

Symptoms (cholecystolithiasis)

Digestive discomfort Bloating Nausea Abnormal intestinal transit Migraines *Pain* - in RUQ or epigastrium *AFTER MEALS* - with radiation to right inter-scapulo-vertebral space or shoulder) - disappear after antispastic medication. - If not relieved by medication => means there are complications (infection or migration) - freq assoc w vomiting and nausea

Cholecisto-digestive fistula

Fistula with duodenum, stomach or colon wall of choleductus eroded - Due to compression on common bile bile duct and associated inflammatory processes migration of large stones => biliary ileum (intestinal obstruction) Abdominal radiography: air shown in the gallbladder ( pneumobilia pneumobilia) Barium swallow: barium passes into the gallbladder.

Brown (bilirubin) pigment stones

Formed within the intrahepatic and extrahepatic bile ducts + gallbladder Form due to stasis and infection (E. Coli and Klebsiella spp) Happens in people with hemolytic diseases

Gallbladder - fundus

Free edge in contact w abdominal wall

Positive diagnosis (cholecystolithiasis)

History Ultrasound *ERCP and MRCP*: *magnetic resonance cholagiopanreatgraphy*!!! VERY IMPORTANT — used especially when common bile duct lithiasis is suspected Less on physical examination

Gallbladder - body

In Contact with liver and inferior - w transverse colon and D2 duodenum

late postoperative complication (cholecystectomy)

Incisional hernia Remnant gallstones in the common bile duct - stones can be removed by ERCP Stenosis of the common bile duct Postcholecystectomy syndrome

Renal colic pain vs cholecystolithiasic pain

Located in lumbar region irradiating toward inguinal region and external genitalia Giordano sign positive Urinanalysis - modified US: reveal urinary stones or dilated urinary tract

complications of cholecystolithiasis

Mechanic complication Inflammation Degenerative (Cancer of the gallbladder, Cholesterolosis, Calcium impregnation of the gallbladder)

primary Choledocolithiasis

Stones are composed: calcium bilirubinate favorable condition: biliary stasis, infection, foreign bodies in common bile duct In Asian the stone are frequently -associated with parasitic infections Gallstones may come from intrahepatic ducts where are formed as a result of congenital or acquired stenosis of the main biliary pathway.

Migration of stones into CBD

Stones smaller than 3 mm can pass through papilla major into duodenum If larger - remain in common bile duct Asymptomatic or periodically produce intenseprolonged colicky pain + jaundice + fever May induce acute panreatitis (as result of bile reflux into wirsung duct)

Gallbladder - Cervix (neck)

Terminal part that continue with cystic duct Here is *Mascagni´s lymph node - that may be hypertrophic in acute inflammation of gallbladder

Bismuth´s classification

Type 1: low CHD stricture , common hepatic duct stump >2 cm Type 2: proximal CHD stricture, hepatic duct stump <2 cm Type 3: hilar stricture, no residual, hepatic ductal confluence is preserved Type 4: hilar structure , with involv of confluence and loss of communication between right and left hepatic duct Type 5: involv of aberrant right sectorial hepatic duct alone or with concomitant stricture of CHD

Pre-hepatic jaundice laboratory analysis

Urine: no bilirubin present, urobilinogen > 2 units Serum: increased UCB

Cholesterol stones (cholecystolithiasis)

Varable color: light-yellow —dark-green or Brown Tiny dark central spot Must have 80% ..... in composition

Symptoms (Malignant tumor of gallbladder)

abd pain (diffuse and persistent nature), jaundice, anorexia, wight loss

Reynolds' pentad

collection of sign and symptoms for acute cholangitis - Charcot's triad (RUQ pain, jaundice, and fever) - shock (ow blood pressure, tachycardia!!!) - altered mental status

secondary Choledocolithiasis

due to stones migration from the gallbladder migration need: small stones, less than 0.5 mm or a large cystic duct Rarely migration can be produced through a cholecysto-choledocus fistula. Gallstones are usually of cholesterol with structure and macroscopic properties like gallbladder stones

Acute pancreatitis

due to the obstruction of Wirsung duct and bilio-pancreatic reflux in cases when stones are impacted or pass the papilla.

Treatment (Malignant tumor of gallbladder)

en bloc surgical resection of gallbladdder and surrounding liver tissue (Mirizzis operation), adjuvant therapy of chemotherapeutic and radiotherapy

Benign stenosis of biliary ducts (etiology)

iatrogenic (classical or laporascopic procedure), abdominal trauma, stones w repeated episodes of cholangitis, Repeated episodes of acute pancreatitis, chronic pancreatitis, sclerosing cholangitis, cholangiopathy during HIV infection

Benign stenosis of biliary ducts

iatrogenic, due to surgical trauma of bile ducts

histopatology (tumours of bile duct)

infiltratice form nodular intramural polypoid proximal medium distal: retroduodeno-pancretic choledocus

Morpho of Malignant tumor of gallbladder

infiltrative, high aggressive - Local invasion -> Live, and later bile ducts, hepato-duodenal Ligament - Spread through lymphatic (to Mirizzi lymph node, around choleductus, pancreaticoduodenal lymph node) - Venous spread - Peritoneal spread

what do you do If there is a suspicion of migrated stones into the common bile duct (enlarged CBD, associated jaundice)

intraoperative cholangiography through the cystic duct may be performed. If migration is confirmed, gallstones can be removed in the same operative time, endoscopicaly through the papilla major with a duodenoscope (ERCP). The procedure may be performed in a later session, but in this case a transcystic drainage will be installed for CBD decompression.

what is ERCP

is performed through an endoscope with side view. The papilla is found and a catheter is inserted through it and the radiopaque dye will highlight the stones. It has also the possibility to perform papilosphincterotomy and extract stones from CBD and pancreatic duct. ERCP is encumbered by some complications of which the most important are acute pancreatitis and reflux cholangitis with liver abscesses.

Signs (Malignant tumor of gallbladder)

jaundice, palpable mass in RUQ (Courvoisier sign), left supraclavicular adenopathy (Virchow´s node), periumbilical lymphadenopathy (sister Mary Joseph nodes), Pelvic seeding (masses palpable on digital rectal examination (Biumer´s shelf)

Cholecystectomy

laparoscopic or classical (laparotomy) approach.

Acute cholangitis (cholecystolithiasis)

life life-threatening. *jaundice* *fever* *chills* *abdominal pain* in severe cases - *low blood pressure and confusion confusion*.

Acute cholangitis (complications)

liver abscess metastatic abscess kidney - Prerenal: hypotension and renal impairment by the action of endotoxins causing tubular necrosis - manifested by renal failure with oligo-anuria. - the hepato-renal syndrome or so called *cholangitis icterus uremigene of Caroli* - Bacteria involved: E. Coli, Klebsiella, Enterobacter and Enterococci

Peptic ulcer pain vs cholecystolithiasic pain

located in epigastric region, has the lesser periodicity (pain - food ingestion - relief - pain), not calmed by antispastics and gastro gastro- duoduodenoscopy shows the ulcer.

Mirizzi syndrome

obstructive jaundice due to a bulky stone in Hartmann pouch compresses CBD

etiology (tumours of bile duct)

parasitic disease: clonorchis sinensis (lives in Asians people´s Liver, bile duct and gallbladder), Congenital anomalies of biliary tract and congenital cysts of choledocus benign tumour ulceratice colitis sclerosing cholangitis

(Common bile duct (choledocus)) supradoudenal portion

posteriorly - portal vein left - by own hepatic artery

Choledocolithiasis (desc the jaundice)

ppears at 24 hours after the onset of pain and is of mechanical type associated with *acholic stools* (discolored stools), *dark urine and pruritus* (because of the deposition of bile salts).

Endoscopic decompression (Benign stenosis of biliary ducts)

preferable, perform papilosphincterotomy and then inserts prosthesis (stent) in bile duct, and should be replaced

Surgery (Benign stenosis of biliary ducts)

preformed when endoscopic treatment fail or in young patient) - bilio-digestive anastomoses between suprastenotic segment of bile duct and jejunum

Chronic cholecystitis

repeated infect of gallbladder w good passage of bile through the cystic duct Hypertrophic: - enlarged w thick and hard walls of whitish color (sclerosis) - may accompanied by calcium deposits in the wall - porcelain gallbladder (calcified bladder) Atrophic type: - small molded on biliary stones

Acute cholangitis (2 forms) (Choledocolithiasis)

*Catarrhal* cholangitis : - characterized by common Charcot-Villard classic triad. *Suppurated acute* cholangitis - extremely serious requiring antibiotics and emergency biliary drainage.

Risk factors for gallstones

*Female* - due to excess estrogen from pregnancy, hormone replacement therapy, contraceptive medications => increase cholesterol levels in bile and decrease gallbladder movement *Fourty* - body tends to secrete more cholesterol into bile *Fatty* - obesity - reduction of amount of bile salt in bile => more cholesterol *Fertile* Rapid weight loss - decrease lipids can create imbalance in bile composition that increases the chances of calcium-bilirubin precipitation and gallstone formation Diet - high fat and cholesterol and low fiber => increases the chance due to increase cholesterol in bile and gallbladder emptying Family - genetic Cholesterol-lowering drugs - drugs that lower cholesterol in blood actually increases the amount of cholesterol secreted onto bile Diabetes - high levels if fatty acids may increase the risk

Mechanic complication of cholecystolithiasis

*Hydrops* of the gallbladder *migration of stones* -> common bile duct w jaundice and possible pancreatitits *Biliary-digestive fistulas* (cholecisto-duodenal, cholecisto-gastric, cholecisto-colic) - biliary ileus *Bilio-Biliary fistulas* (cholecisto-choledocian)

Paraclinical investigations (Choledocolithiasis)

- Abdominal ultrasound ultrasound: (CBD dilated over 9 mm) - Computed tomography tomography: for obese pat, in DD of mechanical jaundice - Nuclear magnetic resonance *(NMR)* and especially cholangiopancreatography MRI *(MRCP)*: exploration which has the possibility to highlight the slow flows in the abdomen such as bile and pancreatic juice. It may reveal stones in up to 95% of cases. It is *indicated especially in cases when CBD dilatation is not confirmed by ultrasonography* - (ERCP): exploration of choice for diagnosis of CBD lithiasis and can be also a treatment option - Endoscopic ultrasound examination with transducers of high resolution, which are inserted in the duodenum allows the exploration of the CBD with an index of diagnosis approximately equal to ERCP but without its possible complications.

Hepatocellular jaundice

- Acute inflammation of the liver (viral hepatitis, toxic hepatitis, leptospirosis, etc) - Chronic inflammation of the liver (cirrhosis - viral, alcoholic, autoimmune, etc) - Infiltrative diseases of the liver (liver cancer or metastases, Wilson's disease, etc) - Inflammation of the bile ducts (primary biliary cirrhosis or sclerosing cholangitis cholangitis) - Drugs (many drugs can cause jaundice and/or cholestasis cholestasis) Laboratory: CB present, urobilirubin > 2 units but variable, high levels of aminotransferases

Laboratory (Malignant tumor of gallbladder)

- Tumour marker: CA 19-9 (increased in cholangiocarcinoma and gallbladder cancer) - Increase alkaline phosphatase and bilirubin - Urea, creatinine, urinanalysis - CBC: anemia (indicator of advanced disease)

Imaging studies (Malignant tumor of gallbladder)

- Ultrasonography: mass detectible - CT: tumour invasion, identify metastatic disease - MRI : MRA and MRCP - Cholangiography: via percutaneous route or endoscopic retrograde cholangiography (ERCOP), - Endoscopic ultrasonography = useful for regional lymphadenopathy and depth of tumour invasion - Angiography

Choledocolithiasis (desc the pain)

- intense - continous - in right hypochondrium - appear after meal and may last several hours - poor response to treatment w antispastic

Laparoscopic cholecystectomy

- most used now days - minimal invasive procedure - allows rapid healing and recovery of the patient - laparoscopic tower (CO2 insufflator insufflator, video camera, light source, electrocautery and monitor)

Internal drainage (diversion into the digestive tract) (Choledocolithiasis)

1. Choledoco-duodenostomy - in most cases a latero-lateral anastomosis is performed (Florken, Finsterer or other type). This procedure is used in larger CBD (between 1.5 and 2.5 cm diameter). This situation is encountered in CBD stones evolving for a longer period of time with repeated inflammatory processes and primary etiology of the stones. The communication between CBD and duodenum ensures further intra duodenal passage of the eventually newly formed stones. It predisposes to reflux cholangitis (duodenal content may enter into the CBD). It is performed in *elderly*. 2. Choledoco-jejunostomy - is performed in complex forms when the CBD is very large (>2.5 cm diameter) with multiple primary stones (steinstrasse) with ) intrahepatic lithiasis, with chronic sclerosing papillitis papillitis. The best montage is the Roux. type with a long intestinal loop which prevents the intestinaltype intestinal- biliary reflux.

Choledocolithiasis (treatment)

1. Laparotomy - preferably through a right subcostal incision because it offers a better access to the hepatic pedicle. 2. Cholecystectomy (preferably retrograde) 3. Assessing the common bile duct 4. Choledocotomy - usually longitudinal 5. Lithotomy - removing the stones from CBD using the Dejardin forceps or Fogarty catheter or Dormia basket. 6. Drainage of the CBD 7. Laparoscopic - Choledocotomy and removal of stones followed by T tube drainage is possible by laparoscopic approach. The vacuity of the CBD must be checked through choledocoscopy or fluoroscopy.

Cholesterol gallstone (metabolic cause)

1. Occur by disbalance between Lecithin and bile salt (both being the ones that keep cholesterol in soluble form) 2. Cholesterol - supersaturation 3. Presence of nucleus of precipitation - Nidus - represented by much-glycoproteins in gallbladder wall or crystals of bilirubin

Extrahepatic bild ducts are formed by?

1. Right and left hepatic ducts 2. Common hepatic duct 3. Gallbladder 4. Cystic duct 5. Common bile duct -CBD- (choleducus) which join pancreatic duct => form ampulla of Vater => enter duodenum via papilla major

obstructive jaundice (Post-hepatic)

1. Tumors of the head of the pancreas 2. Ductal carcinoma 3. Vater's ampulloma 4. Biliary ducts stenosis 5. Pancreatitis and pancreatic pseudocysts 6. Parasites

Laboratory (Choledocolithiasis)

1. increased Total bilirubin > 1 mg%, > 3 mg% jaundice becomes clinically evident. 2. increase AP (alkaline phosphatase) > 80 ui ui. 3. increase Amylasemia in case of associated acute pancreatitis. 4. Leukocytosis especially over 15000/cm3. 5. Aminotransferases may increase but not at such levels as in acute viral hepatitis

Contraindications for laparoscopic approach (cholecystectomy)

Absolute: 1. major coagulation disorders 2. contraindications for general anesthesia with tracheal intubation Relative: 1. Previous supramesocolic surgery (due to adhesions). Hasson Hasson's technique is used for introduction of the first trocar (a small incision at umbilicus is performed and under direct visual control and finger palpation the trocar is introduced into the peritoneal cavity avoiding intestinal lesions). 2. Stones in the CBD is a contraindication just for those centers which are not endowed with special instruments and surgeons do not have enough experience in this field. 3. Some patients with pacemaker. Position: supine, left rotated and in anti anti-Trendelemburg position (for a better access to the gallbladder). The CO2 is introduced through Veres needle - The intra-abdominal pressure: 12 mm Hg. There are used 4 ports. 1. The first trocar (10 mm) - at umbilicus (supra or sub) for laparoscope 2. The second trocar (10 mm) - in the epigastrium for working instruments (hook, scissors, suction, etc) 3. The third trocar (5 mm) mm)- under the right costal margins for handling the gallbladder or elevate the liver 4. The fourth trocar (5 mm) in the lower part of the right hypocondriumhypocondrium for gallbladder manipulation and drainage Triangulation is very important ! In laparoscopy tension and contra contra-tension is very important for exposing tissues which have to be divided cystic duct and artery are sealed by titanium clips applied with a clip applicator. The gallbladder is extracted through one of the 10 mm trocar trocar.

Common bile duct (choledocus)) retrodoudenal portion

Anterior - duodenum Crossed by - gastroduodenal artery Posterior - portal vein Left - by own hepatic artery

Common bile duct (choledocus)) retropancreatic portion

Anterior: pancreas Posterior: vena cava and right renal vein

intraoperative complication (cholecystectomy)

Break of the gallbladder Hemorrhage from cystic artery Lesion of the right hepatic duct or common hepatic duct Lesions of the hepatic artery Lesions of the liver Lesions of the duodenum or colon

Mixed stones (cholecystolithiasis)

Calcium carbonate Phosphate Bilirubin Radiographically visible (due to calcium content)

Hepatic artery is located ..... side of the common bile duct

Left

Etiology (cholecystolithiasis)

Cholesterol stones Pigment stones Mixed stones

Cystic duct

Connect gallbladder to common Variable length Coiled fibers of duct => form Lutkens sphincter and inside lining mucosa disposition forms Heisters spiral valve

Common bile duct (choledocus)) intrapartietal (transduodenal)

Crosses duodenal wall thickness together w pancreatic duct => forming vaters ampulla

What can be found in Calot triangle

Cystic artery (in 80% of cases)

Gallbladder blood supply

Cystic artery + small vessels from liver

Cholesterol gallstone (mechanical cause)

Failure of gallbladder to adequately evacuate its contents Obstacles: - sclero-inflammatory stenosis of cystic duct - dystrophic modifications (cholesterolosis) - biliary dyskinesia caused by lack of synergy between gallbladder contraction and cystic phincter relaxation - congenital malformation of gallbladder (Heister valves hyperplasia)

degenerative complications (cholecystolithiasis)

Gallbladder cancer Cholesterolosis (strawberry gallbladder)

Common bile duct supplied by

Gastroduodenal artery Hepatic artery Cystic artery

Vesicular hydrops (cholecystolithiasis)

Happens when Stone blocks the cystic duct

Character (Vesicular hydrops (cholecystolithiasis))

Intense prolonged colicky pain Palpable gallbladder Bile stasis => superinfection => possible acute cholecystis with *perforation* Discolored bile in gallbladder

early postoperative complication (cholecystectomy)

Intraperitoneal bleeding Bile leakage on drain tubes (aberrant bile ducts (Luska Luska), ), cystic duct clip slippage slippage, lesions of the common or right bile duct duct) General peritonitis Acute pancreatitis Jaundice wound suppuration

Length and thickness of common bile duct (CBD)

L: 10-12 cm T: 6 mm

Bilio-vascular triangle of Calot

Laterally - cystic duct medically - common hepatic duct Superiorly: inferior edge of Liver

cholecystolithiasis (treatment)

Multimodal treatment - SUREGRY: cholecystectomy

Physical examination (cholecystolithiasis)

Murphy Maneuver (pat inspires deeply - palpating RUQ => pain) Asymptomatic form: disease discovered by US or CT when examination is for another illness Painful form - w biliary colic Dyspeptic form: nausea, vomiting, bloating Tumoral like form: pain assoc w intestinal transit disorders, tumoral mass palpable in right hypocondrium

Clinical pic (Benign stenosis of biliary ducts)

RUQ pain, jaundice, may begin directly with signs of suppurated acute cholangiti, Xantelasma around the eyes and dorsal thoracic region, wight loss

Differential diagnosis (cholecystolithiasis)

Renal colic Peptic ulcer pain Acute pancreatitis Transverse colon tumor

Cholecysto-choledocus fistula

Result of large biliary stone which develops the Hartmann´s pouch wall of choleductus eroded - Due to compression on common bile bile duct and associated inflammatory processes Clinical manifestation: jaundice (due to compression)

Pigment stones (cholecystolithiasis)

Small stones Dark Made of bilirubin and calcium salts in bile Contain less than 20& chelsterol

cholecystolithiasis (absolut, definite, relative indication for cholecystectomy)

absolut: all acute complications of gallstones: - perforation with peritonitis, - biliary ileus - abscesses definite: - frequent colicky pain - biliary fistulas - acute pancreatitis - jaundice - cholangitis - cancer relative: - asymptomatic gallbladder stones (few and not small stones).

complication (Choledocolithiasis)

acute cholangitis and acute pancreatitis pancreatitis.

Pneumobilia

after choledoco-duodenostomy (presence of gas in the biliary system generally after biliary-enteric anastomosis)

Treatmet (Benign stenosis of biliary ducts)

against cholangitis and restore imbalance caused by prolonged cholestasis Antibiotics (broad spectrum against gram neg, Gram Pos and anaerobic + biliary excretion K vitamin (coagulation disorders) If not responsive to conservative treatment => biliary decompression (by percutaneous transhepatic or endoscopic

classical clinical triad of Charcot (Choledocolithiasis)

assoc w *hemodynamic instability*(hypotension leading to shock), *impaired consciousness* from dizziness to coma. This association is called *Reynolds' pentad*.

Benign tumour of gallbladder

asymptomatic - discovered accidentally by US. Surgery indicated if symtopms occurs Cholecystectomy - indicated if tumor > 1 cm, assoc w. Calculi, pat > 50 y

Etiology of Malignant tumor of gallbladder

gallstones, porcelain gallbladder, benign tumors, genetic abnormalities - mutation in p53 suppressor gene on CH 17, assoc w gallbladder cancer malformation - bilio-pancreatic tree carcinogenic agents - nitrosamines, metilcolantren

Prognosis (Benign stenosis of biliary ducts)

good if treated before chronic complications. Poor outcome in HIV pat

acute cholecystitis

result of stasis and infection of bile inside gallbladder - often due to obstruction of cystic duct. can be w/o biliary stones - biliary colic - right hypocondrium - frequently assoc w fever, nausea, vomiting - chills: signs of cholangitis or abscess formation PE: - intense pain on right hypocondrium (painful Murphy maneuver - muscular defense and even contraction - palpable gallbladder (sometimes) - pericholecystic abscess. - general signs of infection are present - edematous, flegnomous ad gangrenous gangrenous - Emhysematous acute cholecystitis is a rare but serious condition caused by anaerobes, which is highlighted at ultrasound and radiologically examination by the presence of air in the gallbladder wall E. Colli, Klebsiella, enterococcus, staphylococcus and anaerobes Laboratory: leucocytosis, high ESR and high bilirubin US: presence of stones and enlarged gallbladder w thickened (>3 mm) walls CT and MRI in difficult diagnosis

Pre-hepatic jaundice

results from excessive breakdown of red blood cells (malaria, sickle cell anemia, spherocytosis, thalassemia, glucose 6-phosphate dehydrogenase deficiency)

Choledocolithiasis (desc the fever)

septic type being accompanied by chills and has sudden exacerbations and higher values then in acute cholecystitis.

Choledocolithiasis

stones in the common bile duct

classic approach of cholecystectomy

subcostal Kocher's incision or median laparotomy. sectioning the abdominal wall structures, the peritoneal cavity is exposed and isolated. A general, regional and local inspection is performed. starting from the fundus - so called *anterograde* cholecystectomy, from cystic duct - the *retrograde* from both sides - the *bipolar* retrograde - preferred because: 1. Ligation and resection of the cystic duct as a first step prevents further migration of stones into the common bile duct during gallbladder manipulation 2. Ligation of cystic artery prevents further bleeding during cholecistectomy The cystic duct is discovered, ligated and sectioned. Then the cystic artery is found in the Callot Callot's triangle - sectioned and ligated ligated. From this point the operation may . go on in retrograde way or bipolar. The gallbladder is divided from its hepatic bed and careful hemostasis is performed. Lavage and drainage of the subhepatic space and then suturing the abdominal wall finishes the operation

biliary obstruction is associated with

systemic infection when pressure in the biliary tree exceeds a critical point and bilio-venous reflux becomes possible => bacteremia and septicemia.

Transverse colon tumor vs cholecystolithiasic pain

the pain is associated with digestive transit modification, anemia, palpable tumor. *Colonoscopy will highlight the tumor.

Acute pancreatitis vs cholecystolithiasic pain

the pain is in the *epigastrium with transverse irradiation*, assoc. with vomiting and altered general condition. High levels of amylases. CT!

obstructive jaundice laboratory

urine: no urobilibogen presence of bilirubin (conjugated) in urine wo urine-urobilinogen suggest obstructive jaundice

Percutaneous treatment (Benign stenosis of biliary ducts)

useful in proximal malignant stenosis or when endoscopic procedure fails

External drainage (Choledocolithiasis)

using a Kehr (T) tube - the choledocus is sutured on a Kehr tube which serves for calibration and also for securing the suture by lowering the pressure into the CBD. This option is used when the CBD is not very enlarged (<1.5 cm diameter) and the Oddi sphincter is fully functional, in *young* patients. The tube is removed after 3-6 weeks.