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CHOLECYSTOGASTROSTOMY

INDICATIONS

This procedure may be utilized in poor-risk patients having a limited life expectancy because

of inoperable malignant disease obstructing the common duct that cannot be decompressed

with endoscopic retrograde cholangiopancreatography (ERCP) or transhepatic

cholangiopancreatography (THCP) passage of a stent. The cystic duct must be opened and

the common-duct malignancy should be quite low, with an expectation that the process will

not reach the cystic duct region for several months. In making this short-circuiting

anastomosis, it is preferable to utilize the nearest portion of the upper gastrointestinal tract

that can be approximated easily to the gallbladder without tension. This is usually the

mobilized duodenum rather than the stomach. A direct anastomosis to the upper jejunum may

be done. If a long-term survival is anticipated, the gallbladder or common duct is

anastomosed to a Roux-en-Y arm of mobilized jejunum. A cholecystogastrostomy is done

rarely. However, the technique shown is more frequently used to anastomose the gallbladder

to the duodenum. The gallbladder should not be utilized in an attempt to relieve obstructive

jaundice if the cystic duct is obstructed or if the lower end of the common duct is to be

removed in a radical resection. Visualization of the gallbladder and ducts by contrast media

may be worthwhile to prove beyond any doubt the site of obstruction.

PREOPERATIVE PREPARATION Although the operation is a simple one, the patients are such poor risks that they require

careful preparation to avoid fatality. Nutritional needs may require total parenteral nutrition


(TPN) support. As a rule, the patient is deeply jaundiced and there is already serious liver

damage. Blood products and large doses of vitamin K are indicated until the prothrombin level

returns to a normal range.

ANESTHESIA

See Cholecystectomy, Retrograde Method.

POSITION

The position of the patient is adjusted as described for cholecystectomy (see

Cholecystectomy, Retrograde Method, Figure 1); if local anesthesia is used, this position may

be modified for the patient's comfort.

OPERATIVE PREPARATION

The skin is prepared in the usual manner.

INCISION AND EXPOSURE

Usually, a midline incision reaching from the xiphocostal junction almost to the umbilicus is

made. However, either a transverse or a Kocher oblique incision is satisfactory for those

familiar with these approaches to the gallbladder. Bleeding and oozing points in the wound or

within the peritoneal cavity are meticulously ligated. Exploration is carried out to determine

the nature of the disease causing the obstruction, i.e., whether there is a tumor located in or

about the common duct or in the head of the pancreas, whether the tumor is primary or

metastatic, or whether there is a common duct stone. In the presence of malignant disease

obstructing the common duct without distant metastasis, the duodenum should be mobilized

and the operability of the lesion determined. Involvement about the portal vein contraindicates

surgery. If extensive involvement or dislocation of the duodenum by tumor is apparent, a

gastroenterostomy may be planned to avoid possible late obstruction. A determined attempt

should be made to prove the suspicion of tumor, even though extra effort may be required to

obtain the biopsy. For biopsy purposes, mobilization of the duodenum may be indicated to

expose the posterior side of the head of the pancreas, if the tumor seems more superficial

there.

DETAILS OF PROCEDURE

If the lesion is inoperable and the life expectancy short, the surgeon must determine whether

it is easier to anastomose the distended gallbladder to the stomach, the duodenum, or the

jejunum as a palliative measure. The same type of anastomosis is used whichever viscus is

chosen. The more complicated but efficient types of anastomosis, such as a Roux-en-Y

anastomosis is not necessary unless there is a reasonable chance of prolonged life

expectancy.


As a rule, it is easy to perform the anastomosis to the stomach, preferably 2 to 4 cm above

the pylorus and near the greater curvature. Should such an anastomosis be likely to leave the

gallbladder under tension when the patient is erect, the anastomosis should be made to the

duodenum or upper jejunum.

A portion of the bowel is held up to the gallbladder on its medial side about 2 to 3 cm below

the fundus (Figure A1). If the gallbladder is greatly distended, it may be emptied through a

trocar before the anastomosis is started; if not, a posterior row of interrupted fine

nonabsorbable sutures is placed to bring the two viscera in apposition without opening either

of them (Figure A2). These sutures should not enter the lumen. The interrupted sutures (S1)

on the either end of the posterior serosal layer are left long, and the others are cut to expose

the field where the incisions into the gallbladder and stomach are to be made (Figure A3).

The incision are then made with electrocautery paralleling the suture line, with suction used to

control the spread of any contents from either viscus (Figure A3). The incisions are then

lengthened to give a stoma of 1 to 2 cm (Figure A4). To avoid contamination some surgeons

prefer to carry out this procedure with enterostomy clamps applied to the gallbladder and

stomach. The bleeding from the mucosa of the stomach, which is the only bothersome

element, can be controlled easily by placing a mosquito snap on each of the major vessels.

The clamps should be loosened and all bleeding points ligated before closure of the anterior

layer.

When the field is dry, the operator places a series of interrupted 0000 fine sutures in the

mucosal layers (Figure A5). The anterior mucosal layer is closed with interrupted sutures with

the knots on the inside (Figure A6). After the mucosal sutures are laid, an anterior row of

interrupted sutures is placed between the serosal coats to complete the anastomosis (Figures

A7 and A8). The patency of the stoma is tested by palpation between the thumb and index

finger, and as a precaution several sutures may be inserted at either angle. The field must be

free of oozing points.

CLOSURE

After the table is leveled, the omentum is brought up about the anastomosis. A nasogastric

tube is placed since gastric emptying will be delayed. The incision is closed without drainage

in a routine fashion.

POSTOPERATIVE CARE The administration of fluids and food by mouth is restricted for a few days, as in other

intestinal anastomoses. The appearance of bile in the stools and a decreasing icteric index

indicate that the anastomosis is functioning. A high-vitamin, high-protein, and high-

carbohydrate diet is resumed as soon as tolerated. In elderly, poor-risk patients who refuse to

eat, a gastrostomy tube placed during surgery can be used for the refeeding of bile mixed

with milk and other liquids in order to hasten their recovery.


BIOPSY OF LIVER

INDICATIONS

It is not uncommon during an exploratory laparotomy to remove a small fragment of the liver

for histologic study. Biopsy of the liver is indicated in most patients who have a history of

splenic or liver disease, or in the presence of a metastatic nodule. The specimen should not

be taken from an area near the gallbladder, since the vascular and lymphatic connections

between the liver and gallbladder are such that a pathologic process involving the gallbladder

may have spread to the neighboring liver, and as a result the biopsy would not give a true

picture of the liver as a whole.

DETAILS OF PROCEDURE Two deep 00 sutures, a and b, are placed about 2 cm apart at the liver border (Figure B1)

using atraumatic type of needle. The suture is passed through the edge of the liver and back

through again to include about one-half the original distance (Figure B1A). This prevents the

suture from slipping off the biopsy margin with resultant bleeding. These sutures are tied with

a surgeon's knot, which will not slip between the tying of the first and second parts (Figure

B1A). The suture should be tied as snugly as possible without cutting into the liver, for the

tension under which these knots are tied is the important factor in the procedure. Such

sutures control the blood supply to the intervening liver substance. The two sutures are

placed not more than 2 cm apart, deep in the liver substance; yet as they are tied, at least 2

cm of liver are included at the free margin to increase the size of the biopsy by making it

triangular in shape. An additional mattress suture, c, may be taken at the tip of the triangular

wound (Figure B2). After the biopsy is removed with a scalpel (Figure B3), the wound is

closed by tying together the sutures, a and b, or by placing an additional mattress suture, d,

beyond the limits of the original sutures (Figures B4 and B5). The area of biopsy is covered

with some type of anticoagulant matrix and omentum.

colecistogastrostomia-biopsia de higado

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