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OBSTRUCTIVEJAUNDICEAreviewarticle

1.Introduction/Definition
2.SurgicalAnatomyoftheHepatobiliarysystem
3.Physiology/BiochemistryofBilirubinproductionandtransport
4.Pathophysiology
5.Etiology
6.ClinicalFeatures
7.Investigations
8.ApproachtotheJaundicedpatient
9.Treatment
9.1.GeneralConsiderations
9.2.Specifictreatmentbasedoncauses
9.2.1.Choledocholithiasis
9.2.2.Cholangiocarcinoma
9.2.3.Ampullarytumours
9.2.4.PancreaticCancer
9.2.5.BiliaryStrictures
10.Complications
11.Conclusion
12.Recommendations
ReferenceList

1.Introduction/Definition
Jaundice(derivedfromFrenchwordjauneforyellow)oricterus(Latinwordforjaundice)isayellowishstainingoftheskin,sclera
andmucousmembranesbydepositionofbilirubin(ayelloworangebilepigment)inthesetissues.(1)Jaundicewasoncecalledthe
"morbusregius"(theregaldisease)inthebeliefthatonlythetouchofakingcouldcureit.

Jaundiceindicatesexcessivelevelsofconjugatedorunconjugatedbilirubininthebloodandisclinicallyapparentwhenthebilirubin
levelexceeds2mg/dl(34.2molperL).Itismostapparentinnaturalsunlight.Infact,itmaybeundetectableinartificialorpoorlight.
Infairskinnedpatients,jaundiceismostnoticeableontheface,trunk,andscleraeindarkskinnedpatients,itsnoticeableonthehard
palate,sclerae,andconjunctivae.Pseudojaundicemaybefoundinblackpatientswithpigmentedsclera,fromcarotinemia,uremia(a
sallowyellowishpallor),andquinacrine(ayellowgreencolor).

Causesofjaundicecanbeclassifiedintoprehepatic,hepaticorposthepatic.Inthisreview,ourfocusisonposthepaticcausesof
jaundice(obstructiveorsurgicalcholestasis)asthisismorerelevanttosurgeons.Obstructivejaundiceisnotadefinitivediagnosisand
earlyevaluationtoestablishtheetiologyofthecholestasisiscrucialtoavoidsecondarypathologicalchanges(e.g.secondarybiliary
cirrhosis)ifobstructionisnotrelieved.(2)

2.SurgicalAnatomyoftheHepatobiliarysystem
Anaccurateknowledgeoftheanatomyoftheliverandbiliarytract,andtheirrelationshiptoassociatedbloodvesselsisessentialfor
theperformanceofhepatobiliarysurgerybecausewideanatomicvariationsarecommon.Theclassicanatomicdescriptionofthe
biliarytractisonlypresentin58%ofthepopulation.(3)

Theliver,gallbladder,andbiliarytreeariseasaventralbud(hepaticdiverticulum)fromthemostcaudalpartoftheforegutearlyinthe
fourthweek.Thisdividesintotwopartsasitgrowsbetweenthelayersoftheventralmesentery:thelargercranialpart(parshepatica)
istheprimordiumoftheliver,andthesmallercaudalpart(parscystica)expandstoformthegallbladder,itsstalkbecomingthecystic
duct.Theinitialconnectionbetweenthehepaticdiverticulumandtheforegutnarrows,thusformingthebileduct.Asaresultofthe
positionalchangesoftheduodenum,theentranceofthebileductiscarriedaroundtothedorsalaspectoftheduodenum.(4)

Thebiliarysystemcanbebroadlydividedintotwocomponents,theintrahepaticandtheextrahepatictracts.Thesecretoryunitsof
theliver(hepatocytesandbiliaryepithelialcells,includingtheperibiliaryglands),thebilecanaliculi,bileductules(canalsofHering),
andtheintrahepaticbileductsmakeuptheintrahepatictractwhiletheextrahepaticbileducts(rightandleft),thecommonhepatic
duct,thecysticduct,thegallbladder,andthecommonbileductconstitutetheextrahepaticcomponentofthebiliarytree.(56)

Thecysticandcommonhepaticductsjointoformthecommonbileduct.Thecommonbileductisapproximately8to10cminlength
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and0.4to0.8cmindiameter.Thecommonbileductcanbedividedintothreeanatomicsegments:supraduodenal,retroduodenal,and
intrapancreatic.Thecommonbileductthenentersthemedialwalloftheduodenum,coursestangentiallythroughthesubmucosallayer
for1to2cm,andterminatesinthemajorpapillainthesecondportionoftheduodenum.Thedistalportionoftheductisencircledby
smoothmusclethatformsthesphincterofOddi.Thecommonbileductmayentertheduodenumdirectly(25%)orjointhepancreatic
duct(75%)toformacommonchannel,termedtheampullaofVater.
Thebiliarytractissuppliedbyacomplexvasculaturecalledtheperibiliaryvascularplexus.Afferentvesselsofthisplexusderivefrom
hepaticarterialbranches,andthisplexusdrainsintotheportalvenoussystemordirectlyintohepaticsinusoids.

3.Physiology/BiochemistryofBilirubinproductionandtransport
Bileisasubstanceproducedintheliverandcontainsbilesalts,water,cholesterol,electrolytes,andbilirubin,whichisabreakdown
productofhemoglobin.

Theformationofbilirubinfromhemeisessentialformammalianlife,becauseitprovidesthebodywiththemainmeansofelimination
ofheme.Eightypercentofthecirculatingbilirubinisderivedfromhemeofhemoglobinfromsenescentredbloodcellsdestroyedin
thereticuloendotheliumofthebonemarrow,spleen,andliver.Tentotwentypercentofthebilirubincomesfromothersourcessuchas
myoglobin,cytochromes,andotherhemecontainingproteinsprocessedintheliver.Initially,hemeisoxidizedatthealphapositionto
thegreenpigmentbiliverdin,whichisthenreducedatthegammapositiontobilirubin.
Bilirubinisvirtuallyinsolubleinaqueoussolutions.Inblooditisreversiblybuttightlyboundtoplasmaalbuminata1:1ratio.Newly
formedbilirubinisremovedfromthecirculationveryrapidlybytheliver.

Theprocessingoftheserumbilirubinloadbythehepatocytesoccursinfoursteps.Theseare:uptake,cytosolicbinding,conjugation,
andsecretion.Hepaticuptakeofbilirubinoccurswiththedissociationofthealbuminbilirubincomplexfacilitatedbyplasma
membraneproteinswithsubsequenttranslocationofbilirubinintothehepatocytethroughasaturableproteincarrier,whichalsobinds
otherorganicanions,butnotbilesalts.

Inthehepatocytes,bilirubinbindstotwocytosolicproteins:ligandinandZprotein.Thebindinglimitstherefluxofbilirubinbackto
theplasmaanddeliversittotheendoplasmicreticulumforconjugation.Conjugationofbilirubininvolvesitsesterificationwith
glucuronicacidtoform,first,amonoglucuronide,thenadiglucuronide.Theprincipalenzymeinvolvedisuridinediphosphate(UDP)
glucuronyltransferase.Conjugationrendersbilirubinwatersolubleandisessentialforitseliminationfromthebodyinbileandurine.
Mostoftheconjugatedbilirubinexcretedintobileinhumansisdiglucuronidewithalesseramountofmonoglucuronide.Secretionof
conjugatedbilirubinfromthehepatocytetothebilecanaliculiinvolvesaspecificcarrierandoccursagainstaconcentrationgradient.

Conjugatedbilirubinisexcretedinbile,asamicellarcomplexwithcholesterol,phospholipids,andbilesalts,throughthebiliaryand
cysticductstoenterthegallbladder,whereitisstoredoritpassesthroughVatersampullatoentertheduodenum.Insidethe
intestines,somebilirubinisexcretedinthestool,whiletherestismetabolizedbythegutfloraintourobilinogensandthenreabsorbed.
Themajorityoftheurobilinogensarefilteredfromthebloodbythekidneyandexcretedintheurine.Asmallpercentageofthe
urobilinogensarereabsorbedintheintestinesandreexcretedintothebilethroughtheenterohepaticcirculation(78)

Recentfindingsinthefieldofmolecularbiologyandthehumangenomeprojecthavehighlightedvariousproteinsandgenes
responsibleforthemetabolismofbilirubinandsomeofthesearebeingexploitedinthetreatmentofcholestasis.(911)

4.Pathophysiologyofobstructivejaundice
Bileisamultipurposesecretionwithanarrayoffunctions,includingintestinaldigestionandabsorptionoflipids,eliminationof
environmentaltoxins,carcinogens,drugs,andtheirmetabolites(xenobiotics),andservingastheprimaryrouteofexcretionfora
varietyofendogenouscompoundsandmetabolicproducts,suchascholesterol,bilirubin,andmanyhormones.(12)

Inobstructivejaundice,thepathophysiologiceffectsreflecttheabsenceofbileconstituents(mostimportantly,bilirubin,bilesalts,and
lipids)intheintestines,andtheirbackup,whichcausesspillageintothesystemiccirculation.Stoolsareoftenpalebecauseless
bilirubinreachestheintestine.Absenceofbilesaltscanproducemalabsorption,leadingtosteatorrheaanddeficienciesoffatsoluble
vitamins(particularlyA,K,andD)vitaminKdeficiencycanreduceprothrombinlevels.Inlongstandingcholestasis,concomitant
vitaminDandCamalabsorptioncancauseosteoporosisorosteomalacia.

Bilirubinretentionproducesmixedhyperbilirubinemia.Someconjugatedbilirubinreachesanddarkenstheurine.Highlevelsof
circulatingbilesaltsareassociatedwith,butmaynotcause,pruritus.Cholesterolandphospholipidretentionproduceshyperlipidemia
despitefatmalabsorption(althoughincreasedliversynthesisanddecreasedplasmaesterificationofcholesterolalsocontribute)
triglyceridelevelsarelargelyunaffected.Thelipidscirculateasaunique,abnormal,lowdensitylipoproteincalledlipoproteinX.

Cholestaticliverdiseasesarecharacterizedbyaccumulationofhepatotoxicsubstances,mitochondrialdysfunctionandimpairmentof
liverantioxidantdefense.Thestorageofhydrophobicbileacidshasbeenindicatedasthemaincauseofhepatotoxicitywithalteration
ofsomeimportantcellfunctions,suchasthemitochondrialenergyproduction.Bothmitochondrialmetabolismimpairmentand
hydrophobicbileacidsaccumulationareassociatedwithincreasedproductionofoxygenfreeradicalspeciesanddevelopmentof
oxidativedamage.(13)

5.Etiology
Myriadofdiseasescanleadtoextrahepaticbiliaryobstruction(Table1)
Thecommononesinclude:

Choledocholithiasis
Cholangiocarcinoma,
Ampullarycancers,
CancerofthePancreas

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Biliarystrictures.

6.ClinicalFeatures
Agoodhistory,physicalexaminationanddiagnostictestsaretherequisitesfortheevaluationofthejaundicedpatient.Jaundice,dark
urine,palestoolsandgeneralizedpruritusarethehallmarkofobstructivejaundice.Historyoffever,biliarycolicandintermittent
jaundicemaybesuggestiveofcholangitis/choledocholithiasis.Weightloss,abdominalmass,painradiatingtothebackand
progressivelydeepeningjaundicemaybesuggestiveofpancreaticcancer.Deepjaundice(withagreenishhue)thatappearstofluctuate
inintensitymaybeduetoaperiampullarycancer.Apalpablyenlargedgallbladderinajaundicedpatientisalsosuggestiveofan
extrahepaticmalignancy(Couvoissiersstatement).

7.Investigations
a)Biochemistry/Hematology
Elevatedserumbilirubinlevelwithapreponderanceoftheconjugatedfractionistherule.Theserumgammaglutamyltranspeptidase
(GGT)levelisalsoraisedincholestasis.

Ingeneral,patientswithgallstonediseasehavelesshyperbilirubinemiathanthosewithextrahepaticmalignantobstruction.Theserum
bilirubinisusuallylessthan20mg/dL.Thealkalinephosphatasemaybeelevateduptotentimesnormal.Thetransaminasesmay
abruptlyriseabouttentimesnormalanddecreaserapidlyoncetheobstructionisrelieved.

ElevatedWBCmaybepresentincholangitis.Inpancreaticcancerandotherobstructivecancers,theserumbilirubinmayriseto35to
40mg/dL,thealkalinephosphatasemayriseuptotentimesnormal,butthetransaminasesmayremainnormal.
TumormarkerslikeCA199,CEAandCA125areusuallyelevatedinpancreaticcancers,cholangiocarcinomaandperiampullary
cancers,buttheyarenonspecificandmaybeelevatedinotherbenigndiseasesofthehepatobiliarytree.(14)

b)Imaging
Thegoalsofimagingare:
(1)toconfirmthepresenceofanextrahepaticobstruction(i.e.,toverifythatthejaundiceisindeedposthepaticratherthanhepatic),
(2)todeterminetheleveloftheobstruction,(3)toidentifythespecificcauseoftheobstruction,and(4)toprovidecomplementary
informationrelatingtotheunderlyingdiagnosis(e.g.,staginginformationincasesofmalignancy).(15)Aplainabdominalxraymay
showcalcifiedgallstones,porcelaingallbladder,airinthebiliarytractorairinthegallbladderwall.
Ultrasonographyshowsthesizeofthebileducts,maydefinetheleveloftheobstruction,mayidentifythecauseandgivesother
informationrelatedtothedisease(e.g.hepaticmetastases,gallstones,hepaticparenchymalchange).(2)

Itidentifiesbileductobstructionwith95%accuracythoughresultsarelargelyoperatordependent.Itwillalsoshowstonesinthe
gallbladderanddilatedbileduct,butitisunreliableforsmallstonesorstricturesinthebileducts.Itmayalsodemonstratetumors,
cysts,orabscessesinthepancreas,liver,andsurroundingstructures.InAfrica,thisisavailableinmostcentersandprobably
constitutesthemainimagingmodalityavailableapartfromXray.

Computedtomography(CT)oftheabdomenprovidesexcellentvisualizationoftheliver,gallbladder,pancreas,kidneys,and
retroperitoneum.Itcandifferentiatebetweenintraandextrahepaticobstructionwith95%accuracy.However,CTmaynotdefine
incompleteobstructioncausedbysmallgallstones,tumors,orstrictures.ContrastenhancedmultisliceCTisveryusefulfor
assessmentofbiliarymalignancies.Contrastagentsgivenorallyorintravenouslyareusedandimagingdoneinunenhanced,arterial
andvenousphases.

ERCPandPTC(Percutaneoustranshepaticcholangiography)providedirectvisualizationofthelevelofobstruction.Howevertheyare
invasiveandassociatedwithcomplicationslikecholangitis,biliaryleakage,pancreatitisandbleeding.Thesefacilitiesaregenerallynot
availableinmostcentersinAfrica.

Endoscopicultrasound:Endoscopicultrasonographyhasvariousapplications,suchasstagingofgastrointestinalmalignancy,
evaluationofsubmucosaltumors,andhasgrowntobeanimportantmodalityinevaluatingthepancreaticobiliarysystem.Withregard
tothebiliarysystem,EUSisusefulforthedetectionandstagingofampullarytumors,detectionofmicrolithiasis,choledocholithiasis
andevaluationofbenignandmalignantbileductstrictures.Itcanfurtherevaluaterelationshipstovascularstructures.Itmayhelp
definebenignlesionsmimickingcancer(e.g.sclerosingpancreatitis)ifthereisdiagnosticdoubt.Endoscopicultrasoundenablesthe
aspirationofcystsandbiopsyofsolidlesions,butisoperatordependent.(16)Unfortunately,thisisnotreadilyavailableinmost
centersinAfrica.

Magneticresonancecholangiopancreatography(MRCP)isanewer,noninvasivetechniqueforvisualizationofthebiliaryand
pancreaticductalsystem.Itisespeciallyusefulinpatientswhohavecontraindicationsforendoscopicretrograde
cholangiopancreatography(ERCP).ExcellentvisualizationofbiliaryanatomyispossiblewithouttheinvasivenessofERCP.Unlike
ERCP,itispurelydiagnostic.

OtherimagingtestsincludeCholescintigraphy,radionuclidescanning(Tc99)angiographyandstaginglaparoscopy.
TheseimagingfacilitiesarehardtofindinAfricaandultrasonographyremainstheonlydiagnostictestavailableinmostcenters.

8.ApproachtotheJaundicedPatient
Barkunetalhavewrittenanexcellentreviewonanapproachtothejaundicedpatient.(15)Ihavesummarizedtheapproachwiththe
followingquestions:
Question1:IsJaundicepresent?Askindiscolorationsuggestiveofjaundicecanbemimickedbyavarietyofconditionswhich
include:
a)consumptionoflargequantitiesoffoodcontaininglycopeneorcarotene
b)useofdrugslikerifampicinorquinacrine

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Itisthereforenecessarytoinspectnotonlytheskin,butthemucousmembranesofthemouth,palm,solesandthesclera.

Q2:IsitDirectorIndirectHyperbilirubinemia?Darkurine,palestoolsandotherfeaturesofcholestasis,likepruritus,aresuggestiveof
directhyperbilirubinemia,whilenormalcoloredurineandstoolreflectunconjugatedhyperbilirubinemia.Inmajorityofcases,clinical
findingsalonewillbesufficienttodifferentiateconjugatedfromunconjugatedhyperbilirubinemia.

Q3:IsitHepaticorPosthepatic?Oncedirecthyperbilirubinemiahasbeenconfirmed,thenextquestiontoansweriswhetherthe
jaundiceisfromhepaticorposthepaticlesions.Clinicalfeaturesofhepaticjaundiceincludehistoryofalcoholabuse,acutehepatitis,
andstigmataofchronicliverdiseaselikepalmarerythema,caputmedusae,ascitesandDupuytrenscontracture.
Posthepaticjaundiceusuallypresentwithabdominalpain,rigors,itchingandpalpablelivermorethan2cmbelowthecostalmargin.
Usingclinicalapproachandsimplebiochemicaltests(totalserumbilirubin,alkalinephosphataseandgammaglutamyltransferrase
levels)willusuallygiveagoodjudgmentonwhetherthejaundiceishepaticorposthepatic.However,thisapproachwillnotbeableto
identifytheleveloftheobstruction.

Q4:Whatistheleveloftheobstruction?Imagingisthekeytoidentifyingthelevelofobstruction.Ultrasonographywillbeableto
identifythelevelofobstructioninabout90%ofcases.OtherimagingfacilitieslikeMRCP,ERCP,PTC,andCTscanmaybeused
whereUltrasonographycannotdeterminetheleveloftheobstruction.

Q5:Whatisthecauseoftheobstruction?ThecommonestcauseofobstructionintheWestisusuallycholedocholithiasis.However,if
choledocholithiasisisexcluded,pancreaticandperiampullarycancersarethenextcommoncauses.

Q6.Whatistheextentofthedisease(staging)/complications(cholangitis)?Whileobviousmetastasesmaybepresentbyapalpationof
anodularenlargedliverorotherevidenceofwidespreaddisease,sophisticatedimagingisrequiredformoreprecisestaging.Feverand
elevatedWBCareindicativeofcholangitis.

Q7.Ifitismalignant,isitrespectable?Assessmentoftheresectabilityofatumorusuallyhingesonwhetherthesuperiormesenteric
vein,theportalvein,thesuperiormesentericartery,andtheportahepatisarefreeoftumorandonwhetherthereisevidenceof
significantlocaladenopathyorextrapancreaticextensionoftumor.MultislicespiralCTistheimagingofchoiceforassessmentof
respectabilityofpancreaticcancers.Optimalevaluationisachievedwithafinecutdualphase(arterialphaseandportalvenousphase).

MRCP,EUS,CTangiographyorduplexDopplerUltrasonographyareotherimagingfacilitiesthatcanbeusedinassessmentof
hepatobiliarymalignanciesincenterswheretheyareavailable.Forunresectablemalignancies,thechoiceisbetweensurgical
palliation/bypassandERCP/PTCwithdrainage.Insomecases,neitheroptionmaybefeasiblebecauseofadvanceddiseaseinsucha
casesupportivecarealonewillsuffice.

Forlesionsthatarerespectableoramenabletosurgicalpalliation,thechoiceoftreatmentwilldependonthelevelofobstructionand
thepreciseetiology.

Forthispurpose,thelesionscanbeclassifiedintothree:(Table2)
a)Upperthirdobstruction:Surgicalpalliationisbestachievedwithaleft(segment3)hepaticojejunostomy(Thelongextrahepatic
courseofthelefthepaticductmakesitmoreaccessible).Forrespectablelesions,thetumorisresectedwithapossiblehepatectomyor
segmentectomyandreconstructionachievedbyhepaticojejunostomyorcholangiojejunostomy.
b)Middlethirdobstruction:Surgicalpalliationiseasierandhepaticojejunostomyafterthebifurcationisdone.Iftumorisresectable,
reconstructionisachievedwithhepaticojejunostomy.
c)Lowerthirdobstruction:SurgicalpalliationdoneusingaRouxenYcholedochojejunostomy.Cholecystojejunostomycarriesahigh
riskofcomplicationsandsubsequentjaundice.Iftumorisrespectable,apancreatiduodenectomy(Whipplesprocedure)orlocal
ampullaryresectionshouldbedone.

9.Treatment
Extrahepaticbiliaryobstructionrequiresmechanicaldecompression.Othergoalsincludetreatmentoftheunderlyingcause,symptoms,
andcomplications(e.g.,vitaminmalabsorption).Decompressionofextrahepaticbiliaryobstructioncanbeachievedbyanyofthese
threemethods:surgicalbypass,resectionofobstructinglesions,percutaneousinsertionofstents,andendoscopicinsertionofstents.
(17)

9.1.GeneralConsiderations
Pruritususuallysubsideswithcorrectionoftheunderlyingdisorderorwith2to8gm.orallyofcholestyraminebid,whichbindsbile
saltsintheintestine.However,thisisineffectiveincompletebiliaryobstruction.Unlessseverehepatocellulardamageispresent,
hypoprothrombinemiausuallysubsidesafteruseof(vitaminK1)5to10mgsconce/dayfor2to3days.CaandvitaminD
supplements,withorwithoutabisphosphonate,slowtheprogressionofosteoporosisonlyslightlyinlongstandingirreversible
cholestasis.VitaminAsupplementspreventdeficiencyandseveresteatorrheacanbeminimizedbyreplacingsomedietaryfatwith
mediumchaintriglycerides.
Jaundicedpatientsundergoingsurgeryforlargebileductobstruction(fromanycause)aresubjecttospecificrisksthatrequire
prophylacticmeasures.Theseinclude:

infections(cholangitis,septicaemia,woundinfections)
bleeding(noncoagulantacarboxylderivativesofvitaminKdependentfactors)
renalfailure
liverfailure
fluidandelectrolyteabnormalities

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Preparationforsurgeryisimportantbecauseoftheassociatedperioperativemorbiditypreviouslydiscussed.Thespecificmeasures
requiredinallpatientsare:

parenteraladministrationofvitaminKanaloguestonormaliseprothrombintime
intravenoushydrationandcatheterizationoftheurinarybladder
forcednatriuresisbymannitolwithinductionofanaesthesia
antibioticprophylaxisagainstgramnegativeaerobesusingathreedoseregimen
frozensectionshouldbebookedforallpatientsundergoingresectionforcancer

9.2.SpecificTreatmentbasedoncauses
9.2.1.Choledocholithiasis(bileductstones)
Therearevariousoptionsavailable.Thebestoptionshouldbeindividualizedandbasedonthefollowingfactors:

Physicalconditionofthepatientincludingcomorbidityandmedicalhistory
Previousattemptsatinterventionorpreviouscholecystectomy
Availabilityofequipment/theatre/anesthetist/expertiseofInterventionist
Patientpreference.

Openexplorationofthecommonbileduct:involves:

Cholecystectomy,ifpresent.
supraduodenallongitudinalcholedochotomy
ExtractionofcalculibyFogartyballoontrawl,DesjardinsforcepsorDormiabasketandirrigationwithsaline.
Confirmationofductclearancesuperiorlyandinferiorlybycholedochoscopyand/orcholangiography.

Wherefacilitiesforcholedochoscopyandintraoperativecholangiogramarenotavailable,toavoidtheriskofleavingretainedduct
stones,aTtubeisusuallyinsertedtoconfirmclearanceoftheductbyapostoperativecholangiogramafteratleastfivedays.TheT
tubeisremovedaftertwoweeks,whenanepithelialzedtracthasformedtoavoidbileleakintotheperitonealcavity.
SeveraltrialshoweverhaveshownthatprimaryclosureofthebileductwithoutTtubeisassafeasusingTtubeandisassociatedwith
lesscomplicationslikesepsis,tubemigrationsandbileperitonitis.(1819).InAfricaandotherdevelopingcountrieswheretheremay
benofacilitiesforintraoperativecholangiogramorintraoperativeUltrasonography,Ttubeplacementwillbeapragmaticapproach.
Unfortunately,inmostcenters,Ttubesarehardtofind.

Otherproceduresindifficultcases:
Removalofcommonbileductcalculimayprovedifficultbyanyoftheabovemethods,forexample:

impactedstonewhenalleffortstoremoveithavefailed
multiplelargestones
inaccessibleduct(e.g.previoussurgery,unfitpatient).

Surgicalorpercutaneousdrainageproceduresmaybeuseful.Choledochoduodenostomymaybedonebyanastomosisofadilated
commonbileducttotheduodenum.Alternatively,particularlyinanondilatedduct,atransduodenalsphincteroplasty
isundertakenbyfirstcarryingoutanopensphincterotomyandstoneextraction,thensuturingthemucosaoftheductandduodenum
togethertokeepthelowerendpatenttheseproceduresarerarelyundertaken.Percutaneousstentingornasobiliarydrainagemaybe
doneinanunfitpatientwithcommonbileductstonesthatcannotberemovedbyERCP
ERCPsphincterotomy:AcholangiogramisdoneaftertheampullaofVaterhasbeenidentifiedandcannulatedtoconfirmanatomy
andthepresenceofstones.AnadequatesphincterotomyisundertakenandtheductclearedusingaballooncatheterorDormiabasket.
Confirmationofductclearanceshouldbeestablishedwitharadiograph.

Ifthestonesaretoolarge,theycanbecrushedinsituusingamechanicallithotripterhowevercareshouldbeexercisedtoavoid
damagetotheductlining.Othertechniquesdescribedintheliteratureincludeextracorporealshockwavelithotripsy,contactlithotripsy,
laserunderdirectvision.Thesearehowevertimeconsuming,resourceintensiveandarelimitedtofewspecializedcenters.

Endoscopicplacementofastent,ortemporarynasobiliarydrainagecanbeagoodoptionifthestonesaremultipleortoolargefor
extraction.ThisrelievesobstructionandpreventsimpactionofstonesattheampullaofVater.SuccessrateafterERCPsphincterotomy
isabout90%withlowcomplicationsinexperiencedhands.Complicationsincludeperforation,acutepancreatitis,andbleedingfrom
damagetoabranchofthesuperiorpancreaticoduodenalartery.Difficultiesmayariseasaresultoftechnicalproblemsincannulating
theampullaofVateroranatomicalanomalieslikeduodenaldiverticulumERCPmaybeconsideredthedefinitivetreatmentforsome
unfitpatients,butmostwillproceedtocholecystectomytoremoveremaininggallstonesandpreventfurthercomplications.(22021)

Endoscopicballoondilationwasintroducedaboutthreedecadesagoforelderlyandfrailpatientsasanalternativetosphincterotomy,
becauseoftheadvantagesofpreservingthesphincterofOddi.ThishasbeenabandonedinNorthAmericabecauseoftheriskof
pancreatitis.ItisstillpracticedinpartsofAsiaandEurope.

ArecentCochranereviewconcludedthatitisslightlylesssuccessfulthanendoscopicsphincterotomyinstoneextractionandmore
riskyregardingpancreatitisandprobablyhasaclinicalroleinpatientswhohavecoagulopathy,whoareatriskforinfection,and
possiblyinthosewhoareolder.(22)

Laparoscopicexplorationofthecommonbileductmaybedonethroughthecysticduct(ifthegallbladderhasnotbeenpreviously
removed)orcommonductviaacholedochotomy.StonesareextractedunderfluoroscopicguidanceusingballooncathetersorDormia
basket.Choledochoscopyandlithotripsycanalsobedoneforlargerstones.Thistechniquerequiresconsiderablelaparoscopic
expertiseandistimeconsuming,soitisrarelythefirstlinetreatmentforcommonbileductstonestheseareusuallyremovedatERCP
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preoperativelyandalaparoscopiccholecystectomydoneelectively.Singlestagelaparoscopiccholecystectomyandductalstone
clearancehasbeenshowninseveralstudiestohavethesameefficacyandmorbiditywiththestagedapproachwiththeaddedbenefit
ofreducedcosts.(152324)

Nevertheless,mostcentersstillfavorpreoperativeendoscopicductalclearancebecauseLECBDistechnicallydemandingand
sophisticatedlaparoscopicequipmentmaynotbeavailableineverysurgicalunit.

Medicaldissolutionofcommonbileductstones:
Flushingwithnormalsalineinfusionofbilesalts,monooctanoin,methyltertbutylether,orothersolventsintotheCBDthrougha
Ttubearemedicalremediesforcholedocholithiasisthathavebeendescribedintheliterature.

Theefficacyofthesurgical/endoscopicapproachestobileductstoneshavemademedicalapproachesunattractive.Theprincipal
disadvantagesofbileacidinfusionaretheprolongedperiodofhospitalizationrequiredtocarryoutthetreatment,theunsatisfactory
handlingofdistaloccludingstonesandthoseonthehepaticsideoftheTtube,thehighincidenceofsideeffects,andtherather
unpredictableoutcome.(2529)

9.2.2.Cholangiocarcinoma
Cholangiocarcinomasareepithelialcancersofthecholangiocytesandtheycanoccuratanylevelofthebiliarytree.Theyarebroadly
classifiedintointrahepatictumours,(extrahepatic)hilartumoursand(extrahepatic)distalbileducttumours.
Majorityariseintheabsenceofriskfactors,howeveridentifiedriskfactorsincludeage,primarysclerosingcholangitis,chronic
choledocholithiasis,bileductadenoma,biliarypapillomatosis,Carolisdisease,choledochalcyst,thorotrast,smoking,parasiticbiliary
infestationandchronictyphoidcarrierstate.(30)Hilarcholangiocarcinomaaccountsfortwothirdsofallcasesofextrahepatic
cholangiocarcinoma.

Intrahepaticanddistalextrahepaticcholangiocarcinomasarelesscommon,butsurgicalresectionremainstheonlychanceofcure
consistingofliverresectionandpancreaticoduodenectomy,respectively.Unfortunately,themajorityofthesetumorsareunresectable,
Surgeryistheonlycurativeoptionforcholangiocarcinoma.Theextentofspread,availablesurgicalexpertiseandassociatedco
morbiditiesareimportantfactorsthatwilldeterminethetreatmentapproach.Althoughseveralsurgicalserieshavebeenreported,
recenttrendsaretoadvocateaccuratepreoperativestagingwithanaggressiveoncosurgicalapproachinvolvingenblochilaror
hepaticresections.

Currently,cholecystectomy,lobarorextendedlobarhepaticandbileductresection,regionallymphadenectomy,andRouxenY
hepaticojejunostomyarethetreatmentsofchoiceforhilarcholangiocarcinoma.Encouragingreportswiththeuseofphotofrinbased
photodynamictherapyhavebeenreportedintheliterature.(3134)

Systemictherapy/Palliativetherapy:Themajorityofpatientswithcholangiocarcinomapresentatanadvancedstageorhaveassociated
comorbiditythatprecludesurgery.Forthesepatients,thegoaloftreatmentistoobtainadequatepalliation.Biliaryendoprosthesis
(stent)placementisausefuloptionforpalliationofjaundice.TheapproachisusuallybyERCPbutforproximallesionsthe
transhepaticroutemaybeused.

Photodynamictherapy,radiationandchemotherapyareallavailableaspalliativeoptions.Severalchemotherapeuticagentshavebeen
evaluatedwithlimitedresults.Gemcitabineor5Fluorouracilarethetwocommonagentsusedasasingleagentorincombinationwith
otherdrugs.(3536)

9.2.3.Ampullarytumours
Periampullarycancerscanbebroadlyconsideredastumorsarisingwithin1cmoftheampullaofVaterandincludeampullary,distal
bileduct,pancreatic,andduodenalcancers.However,withoutcarefulhistologicalanalysis,itisdifficultifnotimpossibleto
differentiatethetumortype.

Surgicalexcisionisthemainstayoftreatmentforperiampullarycancers.Carefulpreoperativestagingandassessmentofrespectability
iscrucial.Ifthetumorisresectable,theprocedureofchoiceisapancreaticoduodenectomy.Theclassicalapproach(Whipples
procedureorcWhipple)describedbyKauschandWhippleremainsthemostpopulartechniqueinNorthAmericaandEurope.The
moreconservativeapproach(pyloruspreservingWhippleresectionorppWhipple)describedbyWatsonin1943andlaterpopularized
byTraversoandLongmireisanothertechniquethatisgraduallygainingmoreconverts.Pyloruspreservingpancreaticoduodenectomy
isreportedtobeaneasierandlesstimeconsumingoperationwithlessbloodloss,ashorterhospitalstay,andbetterweightgainduring
followupcare.Also,nodifferencesintherecurrencerateandpatientsurvivalexistbetweenpyloruspreserving
pancreaticoduodenectomyandthestandardWhippleprocedure.(3738)

Forunresectabletumors,palliativetreatmentwilldependoncomorbidityfactors,andavailabilityofresourcesandexpertisefor
endoscopictreatment.Biliarybypassprocedurescanbedoneoperatively,laparoscopically,endoscopicstentingorbypercutaneous
transhepaticapproaches.(39)

Gastricbypassproceduresmayalsobeindicatedinpatientswithgastricoutletobstruction.Theroleofprophylacticgastricbypass
proceduresiscontroversial,howeveraprospectiverandomizedclinicaltrialconcludedthataprophylacticgastrojejunostomy
significantlydecreasestheincidenceoflategastricoutletobstructionanddidnotincreasetheincidenceofpostoperativecomplications
orextendthelengthofstay.(40)

9.2.4.PancreaticCancer
PancreaticductaladenocarcinomaisonethemostlethalGImalignancywithanoverall5yearsurvivalrateoflessthan4%.Factors
influencingthisgrimprognosisare1)clinicalsymptomsintheearlystageareusuallyabsentornonspecificresultinginlatediagnosis,
withonly1520%oftumorsbeingrespectableatpresentation.2)Clinically,aggressivegrowth,withretroperitonealandperineural

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3/31/2017 OBSTRUCTIVEJAUNDICE
infiltration,angioinvasion,highratesoflocalrelapse,formationofmetastases,and3)resistancetomostoftheavailabletreatment
regimens,makespatientmanagementacomplexandchallengingtask.(41)
Theonlyhopeforcureissurgery,butunfortunatelylessthan20%arerespectable.

Thereisnowanacceptableoperativemortalityrateoflessthanorequalto5%forresectedpatientswhenperformedatexperiencedor
dedicatedcenterswithhighvolumeofpatientsinthewesternworld.Thetreatmentoptionsaresimilartoperiampullarycancers.The
roleofadjuvanttherapyinadvancedpancreaticcanceriscontroversialasmostofthetrialsshowlimitedbenefits.Gemcitabine,5FU
areagentsthatshowsomepromise.

PainPalliation:Patientswhopresentwithseverepainmustreceiveopioids.Morphineisgenerallythedrugofchoice.Usually,theoral
routeispreferredinroutinepractice.Parenteralroutesofadministrationshouldbeconsideredforpatientswhohave
impairedswallowingorgastrointestinalobstruction.Percutaneousceliacplexusblockadecanbeconsidered,especiallyforpatients
whoexperiencepoortoleranceofopiate
analgesics.(42)

9.2.5.BiliaryStrictures
Biliarystricturescanbebenignormalignant.Inthissectionofthereview,ourfocuswillbeonbenignbiliarystricturesasthecommon
causesofmalignantstrictureshavebeentreatedearlier.

Themajorityofbenignstricturesareiatrogenicasaresultofoperationsonthegallbladderandthebiliarytree.Theintroductionof
laparoscopiccholecystectomyinitiallyledtoanincreaseinoperativetraumatothebileductsfrom0.10.2%to2%.Thiswasnot
surprisingconsideringthesteeplearningcurveoflaparoscopicprocedures.However,afterwidespreadadoptionoflap
cholecystectomy,theincidenceofoperativetraumastillremainshigherthanwhatobtainedintheeraofopencholecystectomyat0.2
0.7%.(43)

Noniatrogeniccausesofbenignstricturesincludeinflammatoryconditionsandsubsequentfibrosisrelatedtochronicpancreatitis,
cholelithiasis,choledocholithiasis,sclerosingcholangitis,stenosisofthesphincterofOddi,orinfectionsofthebiliarytract.
Threeoptionsforthemanagementofbenignbiliarystricturesarecurrentlyavailable:percutaneousdilationandstenting,endoscopic
dilationandstenting,andsurgicalbiliarydrainage,mostcommonlybyaRouxenYhepaticojejunostomy.
Alltheoptionshavecomparableresults,withstricturerelapseratesreportedbetween15%45%andmeanfollowuptimesof49
years.(43)

Thechoiceoftreatmentmodalitymustbeindividualizedandshouldbebasedonthefollowingconsiderations:thelocationand
severityofthestricture,thepresenceofbiliaryentericcontinuity,thedegreeofinfection,overallhealthoftheindividualpatient,the
lengthoftimeanticipatedforstenting,andtheneedforrepeateddilationandstentexchange.Itcallsforaclosecollaborationbetween
thesurgeonandtheinterventionalradiologist.

10.Complications
Complicationsofobstructivejaundiceincludesepsisespeciallycholangitis,biliarycirrhosis,pancreatitis,coagulopathy,renalandliver
failure.Othercomplicationsarerelatedtotheunderlyingdiseaseandtheproceduresemployedinthediagnosisandmanagementof
individualdiseases.Cholangitisespeciallythesuppurativetype(CharcotstriadorRaynaudspentad)isusuallysecondaryto
choledocholithiasis.ItmayalsocomplicateprocedureslikeERCP.Treatmentshouldincludecorrectionofcoagulopathy,
fluid/electrolyteanomaly,antibioticsandbiliarydrainagewithERCPwhereavailableortranshepaticdrainageorsurgery.

11.Conclusion
Obstructivejaundiceisaclinicaldiagnosisthatrequiresbothclinicalanddiagnosticworkuptoelucidatethepreciseetiology.Amulti
disciplinaryapproachthatrequirestheclinician,radiologist,endoscopistandinterventionalradiologistwillleadtoabetteroutcome.

12.Recommendations

1.Treatmentshouldbeindividualizedbasedonpatientfactorsandavailabilityofresourcesandpersonnel.
2.Tooptimizetreatmentforpancreaticcancers,dedicatedcentersshouldbeestablished.
3.PyloruspreservingresectionisrecommendedinsteadoftheClassicalWhipplesresection.
4.Extensivepalliativeprocedurescarryasignificantdegreeofmorbidityandmortalityinadvancedhepatobiliarymalignanciesand
shouldbediscouraged.
5.NeedfortraininginendoscopicproceduresforAfricansurgeons.
6.ERCPispreferredtotranshepaticdrainageforbiliarydecompressionexceptforobstructionsnearthehepaticbifurcation.
7.PrimaryclosureofthecommonbileductafterexplorationforstonesisassafeasleavingaTtubeinsituandassociatedwith
fewercomplicationsifconfirmationofbiliaryclearancecanbeobtained.

AdisaAdeyinkaCharlesMD,FWACS,FICS
AssociateProfessorofSurgery
AbiaStateUniversityTeachingHospital
Aba,Nigeria

ReferenceList

(1)RocheSP,KobosR.Jaundiceintheadultpatient.[seecomment].[Review][20refs].AmericanFamilyPhysician69(2):299304,
2004.http://simplelink.library.utoronto.ca/url.cfm/27868

http://www.ptolemy.ca/members/archives/2007/Jaundice/ 7/9
3/31/2017 OBSTRUCTIVEJAUNDICE
(2)CDBriggsMPeterson.Investigationandmanagementofobstructivejaundice.Surgery25[2],7480.2007.

(3)KoenraadJ.MortelandPabloR.Ros.AnatomicVariantsoftheBiliaryTreeMRCholangiographicFindingsandClinical
Applications.AJRAm.J.Roentgenol.177,389394.2001.

(4)M.LAMAH1NDKAGHD.AnatomicalVariationsoftheExtrahepaticBiliaryTree:ReviewoftheWorldLiterature.Clinical
Anatomy14,167172.2001.http://simplelink.library.utoronto.ca/url.cfm/27873

(5)JACQUESGILLOTEAUX.IntroductiontoTheBiliaryTract,TheGallbladderandGallstones.MICROSCOPYRESEARCH
ANDTECHNIQUE38,547551.1997.http://simplelink.library.utoronto.ca/url.cfm/27875

(6)YASUNINAKANUMA,MASAHIROHOSO,TAKAHIROSANZEN,MOTOKOSASAKI.MicrostructureandDevelopmentof
theNormalandPathologicBiliaryTractinHumans,IncludingBloodSupply.MICROSCOPYRESEARCHANDTECHNIQUE38,
552570.1997.http://simplelink.library.utoronto.ca/url.cfm/27876

(7)RocheSP,KobosR.Jaundiceintheadultpatient.[seecomment].[Review][20refs].AmericanFamilyPhysician69(2):299304,
2004.http://simplelink.library.utoronto.ca/url.cfm/27868

(8)ToshinoriKamisakoYKKTTIKHYTECGAYA.Recentadvancesinbilirubinmetabolismresearch:themolecularmechanismof
hepatocytebilirubintransportanditsclinicalrelevance.JournalofGastroenterology35,659664.2000.
http://simplelink.library.utoronto.ca/url.cfm/27877

(9)HardikarW,HardikarW.Genesforjaundice.[Review][24refs].JournalofPaediatrics&ChildHealth199935(6):522524.

(10)BoyerJL.Newperspectivesforthetreatmentofcholestasis:lessonsfrombasicscienceappliedclinically.[Review][79refs].
JournalofHepatology46(3):36571,2007.http://simplelink.library.utoronto.ca/url.cfm/27878

(11)MichaelTraunerandJamesL.Boyer.Cholestaticsyndromes.Curr.Opin.Gastroenterol.20,220230.2004.
http://simplelink.library.utoronto.ca/url.cfm/27879

(12)GrantF.HutchinsMJLG.Recentdevelopmentsinthepathophysiology
ofcholestasis.Clin.LiverDis.8,126.2004.

(13)VendemialeG,GrattaglianoI,LupoL,MemeoV,AltomareE.Hepaticoxidativealterationsinpatientswithextrahepatic
cholestasis.Effectofsurgicaldrainage.JHepatol200237(5):601605.http://simplelink.library.utoronto.ca/url.cfm/27880

(14)MalhiH,GoresGJ,MalhiH,GoresGJ.Reviewarticle:themoderndiagnosisandtherapyofcholangiocarcinoma.[Review][78
refs].AlimentaryPharmacology&Therapeutics200623(9):12871296.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/28202

(15)JEFFREYS.BARKUN,PROSANTOCHAUDHURY,ALANN.BARKUN.ApproachtotheJaundicedPatient.ACSSurgery:
Principlesandpractice.2006.

(16)YusufTE,BhutaniMS,YusufTE,BhutaniMS.Roleofendoscopicultrasonographyindiseasesoftheextrahepaticbiliarysystem.
[Review][45refs].JournalofGastroenterology&Hepatology200419(3):243250.
http://simplelink.library.utoronto.ca/url.cfm/27882

(17)BaronTH.Palliationofmalignantobstructivejaundice.GastroenterolClinNorthAm200635(1):101112.

(18)GurusamyKS,SamrajK,GurusamyKS,SamrajK.PrimaryclosureversusTtubedrainageafterlaparoscopiccommonbileduct
stoneexploration.[Review][48refs].CochraneDatabaseofSystematicReviews2007(1):CD005641.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/27840

(19)GurusamyKS,SamrajK,GurusamyKS,SamrajK.PrimaryclosureversusTtubedrainageafteropencommonbileduct
exploration.[Review][45refs].CochraneDatabaseofSystematicReviews2007(1):CD005640.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/27841

(20)TaiCK,TangCN,HaJP,ChauCH,SiuWT,LiMK.Laparoscopicexplorationofcommonbileductindifficult
choledocholithiasis.SurgEndosc200418(6):910914.http://simplelink.library.utoronto.ca/url.cfm/27884

(21)WamstekerEJ,WamstekerEJ.Updatesinbiliaryendoscopy2006.[Review][45refs].CurrentOpinioninGastroenterology2007
23(3):324328.http://simplelink.library.utoronto.ca/url.cfm/27885

(22)WeinbergBMSWLS.Endoscopicballoonsphincterdilation(sphincteroplasty)versussphincterotomyforcommonbileduct
stones(Review).CochraneDatabaseofSystematicReviews[3],146.2007.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/27883

(23)TaiCK,TangCN,HaJP,ChauCH,SiuWT,LiMK.Laparoscopicexplorationofcommonbileductindifficult
choledocholithiasis.SurgEndosc200418(6):910914.http://simplelink.library.utoronto.ca/url.cfm/27884

(24)MehtaSN,BarkunA.Theroleofendoscopicultrasonographyinbiliarytractdisease,obstructivejaundice.GastrointestEndosc
199643(5):534535.

http://www.ptolemy.ca/members/archives/2007/Jaundice/ 8/9
3/31/2017 OBSTRUCTIVEJAUNDICE

(25)GonzalezKochA,NerviF,GonzalezKochA,NerviF.Medicalmanagementofcommonbileductstones.[Review][48refs].
WorldJournalofSurgery199822(11):11451150.http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/28200

(26)TakacsT,LonovicsJ,CaroliBoscFX,MontetAM,MontetJC.[Contactlitholysisofcommonbileductcalculi.Studyof44
patients].GastroenterolClinBiol199721(10):655659.

(27)StrasbergSM,ClavienPA.Overviewoftherapeuticmodalitiesforthetreatmentofgallstonediseases.AmJSurg1993
165(4):420426.http://simplelink.library.utoronto.ca/url.cfm/27888

(28)MunchR.[Nonsurgicaltherapyofgallstones].SchweizRundschMedPrax199180(20):548555.

(29)CaddyGR,ThamTC.Gallstonedisease:Symptoms,diagnosisandendoscopicmanagementofcommonbileductstones.
[Review][104refs].BestPractice&ResearchinClinicalGastroenterology1920(6):10851101.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/27889

(30)MalhiH,GoresGJ,MalhiH,GoresGJ.Reviewarticle:themoderndiagnosisandtherapyofcholangiocarcinoma.[Review][78
refs].AlimentaryPharmacology&Therapeutics200623(9):12871296.http://simplelink.library.utoronto.ca/url.cfm/27890

(31)OrtnerM.Photodynamictherapyforcholangiocarcinoma.JHepatobiliaryPancreatSurg20018(2):137139.

(32)OrtnerM.Photodynamictherapyinthebiliarytract.CurrGastroenterolRep20013(2):154159.

(33)OrtnerMA,DortaG.Technologyinsight:Photodynamictherapyforcholangiocarcinoma.NatClinPractGastroenterolHepatol
20063(8):459467.

(34)OrtnerMA,OrtnerMA.Photodynamictherapyincholangiocarcinomas.[Review][53refs].BestPractice&ResearchinClinical
Gastroenterology200418(1):147154.http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/27852

(35)AlbertsSR,GoresGJ,KimGP,RobertsLR,KendrickML,RosenCBetal.Treatmentoptionsforhepatobiliaryandpancreatic
cancer.[Review][92refs].MayoClinicProceedings200782(5):628637.http://simplelink.library.utoronto.ca/url.cfm/27891

(36)SinghP,PatelT,SinghP,PatelT.Advancesinthediagnosis,evaluationandmanagementofcholangiocarcinoma.[Review][41
refs].CurrentOpinioninGastroenterology200622(3):294299.http://simplelink.library.utoronto.ca/url.cfm/27892

(37)SeilerCA,WagnerM,BachmannT,RedaelliCA,SchmiedB,UhlWetal.Randomizedclinicaltrialofpyloruspreserving
duodenopancreatectomyversusclassicalWhippleresectionlongtermresults.BritishJournalofSurgery200592(5):547556.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/27857

(38)SeilerCA,WagnerM,SadowskiC,KulliC,BuchlerMW,SeilerCAetal.Randomizedprospectivetrialofpyloruspreservingvs.
Classicduodenopancreatectomy(Whippleprocedure):initialclinicalresults.JournalofGastrointestinalSurgery20004(5):443452.

(39)HamadeAM,AlBahraniAZ,OweraAM,HamoodiAA,AbidGH,BaniHaniOIetal.Therapeutic,prophylactic,and
preresectionapplicationsoflaparoscopicgastricandbiliarybypassforpatientswithperiampullarymalignancy.SurgEndosc2005
19(10):13331340.http://simplelink.library.utoronto.ca/url.cfm/27894

(40)LillemoeKD,CameronJL,HardacreJM,SohnTA,SauterPK,ColemanJetal.Isprophylacticgastrojejunostomyindicatedfor
unresectableperiampullarycancer?Aprospectiverandomizedtrial.AnnalsofSurgery1999230(3):322328.
http://simplelink.library.utoronto.ca/url.cfm/27895

(41)JorgKleeffCMHFaMWBc.PancreaticCancerFromBenchto5YearSurvival.Pancreas33,111118.2006.
http://simplelink.library.utoronto.ca/url.cfm/27896

(42)deBF,CascinuS,GattaG.Cancerofpancreas.[Review][95refs].CriticalReviewsinOncologyHematology50(2):14755,
2004.

(43)HallJG,PappasTN,HallJG,PappasTN.Currentmanagementofbiliarystrictures.[Review][103refs].Journalof
GastrointestinalSurgery20048(8):10981110,http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/28199

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