A male patient presents with injury to the duodenum, head of pancreas and common bile duct. There is a stricture in distal bile duct. What is the most appropriate line of management?
|C||Lateral tube duodenostomy|
a. Benign bile duct strictures can have numerous causes-laparoscopic cholecystectomy, fibrosis due to chronic pancreatitis, common bile duct stones, acute cholangitis, biliary obstruction due to cholecystolithiasis (Mirizzi's syndrome), sclerosing cholangitis, cholangiohepatitis, and strictures of a biliary-enteric anastomosis.
b. Bile duct strictures that go unrecognized or are improperly managed may lead to recurrent cholangitis, secondary biliary cirrhosis, and portal hypertension.
c. Patients with bile duct strictures most commonly present with episodes of cholangitis. Less commonly, they may present with jaundice without evidence of infection. Liver function tests usually show evidence of cholestasis.
d. An ultrasound or a CT scan will show dilated bile ducts proximal to the stricture, as well as provide some information about the level of the stenosis. MRC will also provide good anatomic information about the location and the degree of dilatation.
e. In patients with intrahepatic ductal dilatation, a percutaneous transhepatic cholangiogram will outline the proximal biliary tree, define the stricture and its location, and allow decompression of the biliary tree with transhepatic catheters or stents. Treatment depends on the location and the cause of the stricture.
f. Percutaneous or endoscopic dilatation and/or stent placement give good results in more than one half of patients. Surgery with Roux-en-Y choledochojejunostomy or hepaticojejunostomy is the standard of care with good or excellent results in 80 to 90% of patients. Choledochoduodenostomy may be a choice for strictures in the distal-most part of the common bile duct.