Perioperative management - Standard bilioenteric anastomosis

• Reinsertion of the bile ducts after resection of the pancreatic head.
• Bilioenteric bypass in unresectable neoplastic obstructions of the bile ducts and papilla.
• Iatrogenic injury to the CBD
• Congenital and acquired bile duct stenosis

• Significant comorbidity with unfitness for anesthesia and/or surgery

Following iatrogenic bile duct injury, e.g., during laparoscopic cholecystectomy, the preoperative diagnostic work-up requires vascular imaging (CT-/MRI-angiography) as well as bile duct imaging (ERCP/MRCP).

None

General risks of surgery

• Bleeding
• Thrombosis
• Embolism
• Infections
• Vascular/nerve injury
• Secondary bleeding
• Injury to adjacent organs

Special aspects of informed consent

• Dehiscent suture with biliary leaks
• Late sequela of stenosis with intermittent cholangitis
• Peritonitis

• General anesthesia
• Epidural nerve block

• Supine
• Left arm adducted
• Right arm abducted

Surgeon on right side of patient with first and second assistants facing him/her; scrub nurse left of first assistant.

Retractor systems for access to upper quadrants, e.g. abdominal frame (Zenker) and cable winch retractor systems (ulrich medical®).

Postoperative care:

Early postoperative extubation and adequate analgesia (epidural nerve block!) are of vital importance.

Follow this link to PROSPECT  (Procedures Specific Postoperative Pain Management).

This link will take you to the International Guideline Library.

• Perioperative antibiotics:48-72 hours postoperatively
• Perioperative antibiotics started with initiation of anesthesia, e.g., an i.v. combination of cefotaxime 3x2 g and metronidazole 3 x 0.5 g; in case of penicillin allergy substitute ciprofloxazin 200 mg 1-0-1 for cefotaxime
• Frequent lab studies
• Measuring bilirubin in drain secretions
• Drains removed depending on secretion volume and level of above mentioned parameters
• Epidural catheter removed by anesthesiologist on postoperative day 3-6
• Prophylactic PPI administration, initially i.v. and then p.o.

T-drain

In small CHDs and/or difficult anastomoses insertion of a T-tube (caliber 2.5-3.5 mm) is recommended. For 7 days following surgery the drain is left open; then contrast-enhanced fluoroscopy is performed. After ruling out anastomotic failure the tube is clamped and then the EasyFlow drain at the anastomosis removed. The T-tube is left in place for 6-8 weeks (with the patient discharged in the meantime) and then undergoes another contrast-enhanced imaging study. If the anastomosis is unremarkable the drain is removed under antibiotics (either per the sensitivity test of the intraoperative culture swab of the bile duct or levofloxacin 500 mg 1-0-1 p.o.). Lab studies and ultrasound follow-up on next day are recommended; when infection is suspected, e.g., lab study, fever, etc., some cases may require inpatient management for a few days.

Deep venous thrombosis prophylaxis:

With low-molecular-weight heparin. This link will take you to the International Guideline Library.

Ambulation:

Early – starting on day of surgery

Physical therapy:

Physical therapist helps the patient in ambulation and performs intensive respiratory therapy.

Diet:

Remove gastric tube on postoperative day 1 the latest, then continue with return to regular diet.

Bowel movement:

Usually, there will be bowel movement after 3-4 days. This may be helped with a mild laxative.

Work disability

Depending on patient recovery and any other treatment measures, e.g., chemotherapy.