pancreatitis must be differentiated from underlying periampullary malignancy.

Figure 62-14. Actuarial survival rates among 31 noncirrhotic patients with primary sclerosing cholangitis who underwent resection

of the hepatic bifurcation and long-term transhepatic stenting. (Reproduced with permission from Lillemoe KD, Pitt HA, Cameron

JL. Primary sclerosing cholangitis. Surg Clin North Am 1990;70:1381–1402.)

The definitive evaluation of patients with a bile duct stricture caused by chronic pancreatitis is

cholangiography. Either MRCP or ERCP is the preferred diagnostic procedure as they both can

demonstrate both biliary and pancreatic ductal anatomy, which is essential in optimal surgical

management of chronic pancreatitis. ERCP with stenting allows decompression of the obstructed biliary

tree if necessary for cholangitis or severe jaundice. A long (usually 2- to 4-cm), smooth, gradual

tapering of the common bile duct is most compatible with a benign stricture due to chronic pancreatitis

(Fig. 62-15).

The indications for surgical management of common bile duct strictures due to chronic pancreatitis

are clear in patients with significant pain, jaundice, or cholangitis. Controversy exists, however,

concerning the necessity of biliary decompression in patients with an asymptomatic elevation of serum

alkaline phosphatase. In general, biliary bypass is indicated because changes from obstructive biliary

cirrhosis have been observed in liver biopsy specimens obtained from patients with long-standing,

functionally significant biliary obstruction due to chronic pancreatitis.41,42 Some clinicians may also

consider biliary dilatation and temporary intraluminal stenting in this setting using either endoscopic

(preferred) or percutaneous approaches.

Choledochoduodenostomy and Roux-en-Y choledochojejunostomy are acceptable methods of biliary

bypass in patients with bile duct strictures caused by chronic pancreatitis. Choledochoduodenostomy is

preferred by many surgeons because it does not divert bile from the duodenum, is technically easier to

perform, and leaves the jejunum intact for any associated procedures required for decompression of an

obstructed gastrointestinal tract or pancreatic duct. Finally, in patients in whom periampullary

malignancy cannot be completely ruled out by the clinical course or imaging studies, or in patients with

significant chronic pain thought secondary to proximal pancreatic duct disease,

pancreaticoduodenectomy offers an excellent treatment option. The results of surgical management of

distal bile duct structures due to chronic pancreatitis are usually excellent, with a low rate of

perioperative complications and excellent long-term results.

1625

Figure 62-15. Cholangiogram of a patient with a long distal common bile duct stricture (arrow) caused by chronic pancreatitis.

Transduodenal sphincteroplasty is not recommended for the management of common bile duct

strictures caused by chronic pancreatitis because the stricture is too long to be managed adequately by

this technique. Similarly, endoscopic sphincterotomy has no role in the management of biliary

obstruction due to chronic pancreatitis. Limited experience has been reported with balloon dilation of

distal bile duct strictures secondary to pancreatitis, with little long-term follow-up.

Over the last decade another variant of chronic pancreatitis has been recognized as a cause of distal

bile duct stricture – autoimmune pancreatitis.43 This process is characterized by a lymphoplasmacytic

infiltrate and is associated with secretion of large amounts of immunoglobulin (Ig) 4. The condition can

mimic pancreatic cancer and is diagnosed by characteristic imaging studies and elevation of serum Ig4

levels. Treatment is with corticosteroids with surgical resection or bypass reserved for unresponsive

cases or when a diagnostic dilemma remains. Although Ig4 serology is highly sensitive (90%), cases

where equipoise remains can also undergo an initial empiric test of corticosteroids to assist in achieving

the diagnosis and potentially provide concurrent therapy.

MISCELLANEOUS CAUSES OF BILE DUCT STRICTURES

Benign strictures of the bile duct can result from the chronic inflammation associated with gallstones in

either the gallbladder or common bile duct. This cause of bile duct strictures is uncommon and is a rare

complication of gallstone disease. Bile duct strictures caused by cholelithiasis are usually associated with

a narrowing at the level of the common hepatic duct caused by a stone impacted in the infundibulum of

the gallbladder. The narrowing can be caused by two means. First, simple compression can occur from a

large stone lying adjacent to the common hepatic duct (Mirizzi type A). Second, chronic or acute

inflammation arising from the gallbladder or cystic duct can extend to the contiguous bile duct,

resulting in stricture formation (Mirizzi type B, C, or D). The biliary obstruction associated with either

of these conditions is known as Mirizzi syndrome and culminates in Mirizzi type E disease which occurs

in any case of bilioenteric fistula.44

The clinical presentation of a bile duct stricture caused by cholelithiasis is often associated with acute

cholecystitis and hyperbilirubinemia. In some long-standing cases, these findings exist in the face of

chronic gallbladder symptoms. If hyperbilirubinemia is present and urgent cholecystectomy is not

indicated, ERCP or PTC can help to delineate the preoperative biliary anatomy. Most cases that are

associated with acute cholecystitis, however, are recognized at the time of cholecystectomy and

operative cholangiography. When the duct compression is associated with acute inflammation, the

common hepatic duct almost always returns to normal after the offending stone has been removed by

cholecystectomy and the inflammatory process has resolved. Care must be taken during the dissection

1626

to avoid creation of a defect in the common hepatic duct. Rarely, after the acute episode has resolved, a

well-established stricture presents months to years after the acute episode. In such cases, management

by Roux-en-Y hepaticojejunostomy is appropriate.

Strictures due to choledocholithiasis are also rare. The presumed mechanism is erosion of the

epithelium of the distal duct, creating inflammation with subsequent fibrosis and stricture. Because of

the anatomic tapering of the common bile duct, nearly all stones are entrapped in the intrapancreatic

portion of the duct and are often difficult to remove by the supraduodenal route.

Excessive intraoperative manipulation at the time of bile duct exploration with forceps, scoops, and

catheters can often create additional trauma to an already friable distal duct. After the stone has been

removed, the distal bile duct should be gently sized with a soft rubber catheter to be sure that no

stricture exists. If a stricture persists after stone removal, it may not be recognized until the time of

postoperative T-tube cholangiography. If recognized in the postoperative period, time should be

allowed for resolution of inflammation before considering stricture repair. If a distal bile duct stricture

does persist, a biliary-enteric anastomosis with either Roux-en-Y choledochojejunostomy or a

choledochoduodenostomy is indicated. If the proximal duct is adequately dilated (>2 cm in diameter)

to allow a large choledochoduodenal anastomosis, this procedure is usually preferable because of its

technical ease and excellent results.

Stenosis of the sphincter of Oddi, or papillitis, is a benign intrinsic obstruction of the outlet of the

common bile duct, usually associated with inflammation, fibrosis, or muscular hypertrophy. Sphincter

stenosis can result in any of three clinical conditions: (a) common bile duct obstruction due to fibrotic

stenosis of the papilla, (b) recurrent pancreatitis, or (c) recurrent right upper quadrant pain without

jaundice or pancreatitis. The pathogenesis of the inflammation of sphincter stenosis is unclear. In many

cases, it is thought to result from the trauma of the passage of multiple small stones from the common

duct through the ampulla. This trauma results in inflammation, scarring, and stricture formation. Many

patients with papillary stenosis have no gallstones. Other potential mechanisms include primary

sphincter motility disorders and congenital anomalies. The clinical presentation is usually either

jaundice or cholangitis. In some cases, an impacted common bile duct stone may be present. The

diagnosis can be supported with either PTC or ERC. This condition can be managed by sphincterotomy

performed either endoscopically or operatively. If a cholecystectomy was performed previously,

endoscopic papillotomy is the initial procedure of choice.

Cholangiohepatitis is an unusual infection of the biliary tree frequently associated with Clonorchis

sinensis and other parasites. These infections are most commonly seen in natives of Asia. Most patients

present with recurrent episodes of cholangitis. Cholangiography can demonstrate multiple strictures of

both the intrahepatic and extrahepatic biliary tree, with the bile ducts filled with sludge and stones (Fig.

62-16). Surgical management consists of cholecystectomy and improved biliary drainage with either

Roux-en-Y choledochojejunostomy or choledochoduodenostomy. Access to the biliary tree for

postoperative management of intrahepatic stones or sludge should be maintained with either

transhepatic biliary stents or a choledochojejunocutaneous or subcutaneous fistula. No specific medical

management is available for this condition.

Finally, rare causes of benign intrahepatic and extrahepatic bile duct strictures have been reported

secondary to intrahepatic arterial infusion of 5-fluorouracil used in the treatment of hepatic metastases

of colorectal carcinoma. The clinical picture closely resembles primary sclerosing cholangitis but usually

can be managed by simple discontinuation of infusion and, in some cases, percutaneous transhepatic

drainage. Surgery should be reserved for patients with persistent evidence of biliary obstruction. A

similar cholangiographic appearance has been reported in patients with acquired immunodeficiency

syndrome. The pathogenesis of this injury is believed to be viral and related to cytomegalovirus

infection. No experience in the surgical management of this condition has been reported.

1627