الفهرس 
ANATOMY OF BILIARY TRACTOnly 14 pages are availabe for public view
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Abstract
The management of biliary strictures presents a significant challenge to surgeons. If not recognized promptly or if managed improperly, severe complications may result; including cholangitis, portal hypertension, and biliary cirrhosis. With the introduction and widespread use of laparoscopic cholecystectomy in the 1990s, the incidence of biliary injuries and associated bile duct strictures has increased. This increase has led to substantial patient morbidity and impressive financial implications to our health care system, 2 necessitating close scrutiny and review of current management principles of biliary strictures
Unfortunately, most benign biliary strictures are iatrogenic resulting from surgical trauma. However not all biliary strictures are benign, pancreatic cancer is the most malignant cause of biliary stricture. Most of these patient die of complication of tumor invasion and metastasis.
Benign strictures most commonly occur after surgical procedures related to the gall bladder or biliary tree are performed. With the introduction of laparoscopic cholecystectomy, bile duct injuries have occurred with increased frequency and currently account for over 80% of postoperative biliary strictures.
A number of factors are associated with bile duct injury during either open or laparoscopic cholecystectomy, including inflammation related to acute or chronic cholecystitis, inadequate exposure, and failure to correctly and completely identify the anatomy before clipping, ligating, and dividing structures.
The classical error made with regard to laparoscopic cholecystectomy is a misidentification of the common bile duct for the cystic duct, often caused by excessive cephalad retraction of the fundus of the gall bladder in which the cystic and common ducts become closely aligned. Preservation of the blood supply to the common bile duct is important for the prevention of subsequent stricture formation
The majority of patients with postoperative bile duct strictures will present early after their initial operation with 70% of strictures diagnosed within the first 6 months and 80% diagnosed within the first year.
Cholangiocarcinomas (CCCs) are malignancies of the biliary duct system that may originate in the liver and extrahepatic bile ducts, which terminate at the ampulla of Vater. CCCs are encountered in 3 geographic regions: intrahepatic, extrahepatic (i.e., perihilar), and distal extrahepatic. Perihilar tumors are the most common, and intrahepatic tumors are the least common. Perihilar tumors, also called Klatskin tumors (after Klatskin’s description of them in 1965), occur at the bifurcation of right and left hepatic ducts. Distal extrahepatic tumors are located from the upper border of the pancreas to the ampulla. More than 95% of these tumors are ductal adenocarcinomas; many patients present with unresectable or metastatic disease. Cholangiocarcinoma is a tumor that arises from the intrahepatic or extrahepatic biliary epithelium. More than 90% are adenocarcinomas, and the remainders are squamous cell tumors. The etiology of most bile duct cancers remains undetermined. Long-standing inflammation, as with primary sclerosing cholangitis (PSC) or chronic parasitic infection, has been suggested to play a role by inducing hyperplasia, cellular proliferation, and, ultimately, malignant transformation.
The etiology of most bile duct cancers remains undetermined. Currently, gallstones are not believed to increase the risk of cholangiocarcinoma but there are some risk factors can be accused to cause cholangio-carcinoma as infections, inflammatory bowel diseases, exposure to some chemicals and some congenital anomalies of the biliary tree.
Symptoms may include jaundice, clay-colored stools, bilirubinuria (dark urine), pruritus, weight loss, and abdominal pain. Jaundice is the most common manifestation of bile duct cancer and, in general, is best detected in direct sunlight. The obstruction and subsequent cholestasis tends to occur early if the tumor is located in the common bile duct or common hepatic duct. Jaundice often occurs later in perihilar or intrahepatic tumors and is often a marker of advanced disease. Pruritus usually is preceded by jaundice, but itching may be the initial symptom of cholangiocarcinoma, Weight loss is a variable finding and may be present in one third of patients at the time of diagnosis also abdominal pain is relatively common in advanced diseases.
Hepatocellular function should initially be assessed in cases of suspected or diagnosed biliary stricture.
Initial imaging techniques employed regarding the evaluation of patients with postoperative biliary stricture include abdominal ultrasound and CT scan.
The gold standard for the evaluation of patients with benign bile duct strictures is cholangiography. Recently, magnetic resonance cholangiography
(MRC) has increasingly become the method of choice for the diagnosis and delineation of bile duct injuries because of its high sensitivity and low complication rates.
The ultimate goal regarding the management of patients with benign biliary strictures is to correct the increased resistance to biliary flow caused by a reduction in lumen diameter. Three options for the management of benign biliary strictures are currently available: percutaneous dilation and stenting, endoscopic dilation and stenting, and surgical biliary drainage, most commonly by a RouxenY hepaticojejunostomy.
Resectable intrahepatic cholangiocarcinomas are treated using standard liver resections, and distal cholangiocarci¬nomas are treated by pancreatico-duodenectomy. The following focuses on our surgical approach to resectable perihilar cholangiocarcinomas.
The primary aim of palliation in a patient with unresectable cholangiocarcinoma is to relieve the obstructive cholestasis and its associated morbidities like pruritus, cholangitis and pain. Therefore, the essence of an ideal palliation includes improved quality of life via minimal invasiveness, low-procedural related complications, few hospital days or clinic visits, and low cost.