What is the role of surgery in the treatment of biliary obstruction?

Updated: Oct 16, 2019
  • Author: Jennifer Lynn Bonheur, MD; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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Answer

As with medical care, the need for surgical intervention depends on the cause of biliary obstruction.

Cholecystectomy is the recommended treatment in cases of symptomatic cholelithiasis because these patients have an increased risk of developing complications. Open cholecystectomy is relatively safe, with a mortality rate of 0.1-0.5 %.

Laparoscopic cholecystectomy remains the treatment of choice for symptomatic gallstones, partially because of the shorter recovery period (return to work in an average of 7 d), decreased postoperative discomfort, and improved cosmetic result. Approximately 5% of laparoscopic cases are converted to an open procedure secondary to difficulty in visualizing the anatomy or a complication. Risk of bile duct injury during laparoscopic cholecystectomy is around 0.4-0.6%.

Choledochal cyst requires excision and hepaticojejunosotmy. Biliary obstruction in chronic pancreatitis may need a biliary-enteric anastomosis at the time of the drainage of the pancreatic duct.

Resectability of neoplastic causes of biliary obstruction varies with respect to the location and extent of the disease. Photodynamic therapy (PDT) has been shown to have good results in the palliative treatment of advanced biliary tract malignancies, particularly when used in conjunction with a biliary stenting procedure. [16, 17] PDT produces localized tissue necrosis by applying a photosensitizing agent, which preferentially accumulates in the tumor tissue, and then exposing the area to laser light, which activates the medication and results in destruction of tumor cells.

Endoscopic biliary stenting is considered first-line treatment for unresectable malignant hilar biliary obstruction and for distal biliary obstruction, with self-expandable metal stents (SEMSs) preferred over plastic stents in patients expected to live longer than 3 months. [18] Bilateral or unilateral stent insertion appear to be equally effective with similar long-term outcomes for patients with malignant hilar biliary obstruction. [19] Percutaneous transhepatic endobiliary radiofrequency ablation in combination with biliary stenting may hold potential for safely and effectively restoring biliary drainage in patients with malignant biliary obstruction based on the findings of a Turkish study in 21 patients. [20]

Findings from the WATCH-2 study appear to show comparable rates of recurrent biliary obstruction, time to recurrent biliary obstruction, and survival between patients with unresectable distal malignant biliary obstruction undergoing fully covered (n = 151) or partially covered (n = 141) SEMSs. [21] In addition, there was also no significant difference in the rate of stent migration between the two groups.

In a separate international multicenter study of endoscopic management of combined distal malignant biliary obstruction and duodenal obstruction in 110 patients, transpapillary or transmural endoscopic biliary drainage with a duodenal stent was effective in 95% of the patients, regardless of the timing or location of the duodenal obstruction. [22] Time to recurrent biliary obstruction was longer for metal versus plastic stents, and a higher rate of adverse events was associated with endoscopic ultrasonographic-guided biliary drainage relative to endoscopic retrograde cholangiopancreatography (ERCP).

In a single-center retrospective study (2013-2015) of 520 therapeutic ERCP, of which 45 cases failed ERCP, Nakai et al found similar technical success and ERCP-related adverse events among patients who underwent ERCP, rescue percutaneous transhepatic biliary drainage (PTBD), primary EUS-BD, and endoscopic ultrasonography-guided biliary drainage (EUS-BD). [23] Based on their findings, the investigators suggested that primary EUS-BD without failed ERCP may be a treatment option if it provides advantages over ERCP.

Liver transplantation may be considered in appropriate patients (eg,end-stage liver disease [ESLD], primary sclerosing cholangitis [PSC], hepatocellular carcinoma [HCC]).


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