Palliation of Obstructive Jaundice

Laparoscopic CCJ is therefore reserved primarily for patients with malignancy, and its primary role is for palliation of obstructive jaundice in patients with unresectable PAC. It is accepted that patients with obstructive jaundice and unresectable PAC cancer due to either metastatic or locally advanced disease are best treated by endoscopic insertion of a biliary stent whenever possible; the percutaneous transhepatic route is being reserved for failures of the endoscopic approach. Laparoscopic biliary bypass is a last resort in the uncommon instances of failure of the endoscopic and radiologic percutaneous approaches to biliary stent insertion.

Occasionally, the surgeon is faced with the diagnosis of inoperable disease at the time of staging laparoscopy. Consideration may be given to laparoscopic CCJ if the patient’s biliary tree remains obstructed at the time of staging laparoscopy and the endoscopic approach to biliary drainage is not feasible because of gastric outlet obstruction (in which case, CCJ is combined with a gastrojejunostomy) or has failed.

Before Whipple Procedure

It is recognized that pre-resection biliary drainage using stents increases the risk for septic morbidity after resection and is therefore best avoided unless the patient is deeply jaundiced (e.g., bilirubin <11 to 14 mg/dL) or some delay is anticipated before resection with an inevitable further rise in bilirubin to above that threshold. An alternative to biliary stenting under those circumstances is to consider laparoscopic CCJ at the time of staging laparoscopy; this avoids the immediate and delayed risks for stent insertion and minimizes the number of interventions. Resection could be undertaken about 2 weeks later.

Prophylaxis

Patients with unresectable PAC who present with gastric outlet obstruction are usually managed by a palliative insertion of an expandable metal duodenal stent in the first instance. Failure of this endoscopic procedure is an indication to proceed to laparoscopic gastric bypass. If unresectability is due to a locally advanced rather than metastatic disease with its associated better prognosis, and if the patient has no distal biliary obstruction, then consideration should be given to a prophylactic CCJ. A typical example is in patients with uncinate process tumors that involve the superior mesenteric vessels as well as the distal duodenum, leading to duodenal obstruction. In the absence of metastases, future disease progression to involve the distal biliary tree is likely. A prophylactic CCJ at the time of gastrojejunostomy is a valid option and ensures a course of palliative chemotherapy uninterrupted by a delayed onset of obstructive jaundice.

Physical Conditions

Clearly, a patent cystic duct is a prerequisite for CCJ to function. In addition, the point of insertion of the cystic duct into the bile duct should preferably be 1 cm or greater above the distal biliary stricture to achieve a durable biliary drainage for the duration of the patient’s life expectancy, particularly in patients with locally advanced rather than metastatic disease who have a better survival outlook. To identify the biliary anatomy correctly, a magnetic resonance cholangiopancreatogram may be required. Alternatively, information could be obtained from staging computed tomography or from endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography that has failed to achieve stenting (Fig. 19-2). If preoperative imaging information is not available or when in doubt, one could consider intraoperative transcholecystic cholangiography or laparoscopic ultrasound to delineate the anatomy of the cystic duct insertion in relation to the stricture; however, we prefer to rely on preoperative imaging, thus avoiding extension of the duration of what is palliative surgery.

FIGURE 19-2 Preoperative percutaneous transhepatic cholangiogram in a patient with locally advanced pancreatic head cancer and a failed endoscopic retrograde pancreatography confirms a cystic duct insertion more than 1 cm above the stricture and, therefore, suitability for palliative laparoscopic cholecystojejunostomy if transcutaneous stenting fails.

In the context of palliation, it is essential that the intra-abdominal conditions not be hostile to the intended drainage procedure. The need to divide significant upper abdominal adhesions from previous major surgery, the presence of a bulky tumor that could preclude easy access to the gallbladder and hamper a tension-free anastomosis, the presence of ascites, or previous intestinal surgery with considerable adhesions render the option of CCJ unfavorable.

The presence of gallstones within the gallbladder is not a contraindication to CCJ because these can be evacuated at the time of surgery. However, the presence of gallstones in association with a diseased and contracted gallbladder is a contraindication to this procedure; this scenario is quite uncommon.

Safety Conditions

All the prerequisites for healing of an intestinal anastomosis should be respected. In particular, severely malnourished, edematous, and hypoalbuminemic patients have a higher risk for anastomotic leak and should not be offered surgical bypass under those circumstances.

Whether CCJ is carried out as a palliative procedure in patients with shortened life expectancy or as a pre-resection drainage procedure, it is essential that operative morbidity be kept to the very minimum. Although the laparoscopic approach has its advantages as a minimally invasive procedure, it is equally important that the surgeon has established expertise in intestinal anastomoses and intracorporeal suturing.