Prof John Windsor

Surgical Diseases of the Biliary System

There are several biliary diseases that may require surgery. There are benign and malignant diseases of the gallbladder and the bile duct outside the liver.

Gallstones in the gallbladder

Gallstones in the gallbladder can cause recurrent pain (biliary colic) and infection in the gallbladder (acute cholecystitis). Both of these situations are treated by removing the gallbladder by keyhole surgery (laparoscopic cholecystectomy). Sometimes when the recurrent pain has been going on for a long time the gallbladder becomes scarred and it is necessary to do an open operation.

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Cancer of the gallbladder

Surgery may be required to remove gallbladder polyps before they become malignant and sometime the gallbladder needs to be removed along with some surrounding liver and local lymph nodes if a cancer is present.

Gallstones in the bile duct

Gallstones can migrate from the gallbladder into the bile duct causing an obstruction to bile flow from the liver (jaundice and cholestasis). These stones are usually removed by endoscopy, but if the gallbladder needs to be removed and the surgeon has the skills they can also be removed at the same time by exploration of the bile duct. Sometimes the bile becomes infected in this setting (acute cholangitis) and this should be treated by urgent endoscopic drainage of the bile duct (ERCP/sphincterotomy and/or stenting) and antibiotics. The gallbladder should be removed at a later time point, once the infection has settled. Sometimes a narrowing of the bile duct occurs in association with stones and this may necessitate a surgical bypass of the bile duct.

Cancer in the bile duct

Cancer can develop in any part of the bile duct (cholangiocarcinoma). When this is outside the liver the treatment is excision of the duct along with local lymph nodes as an extension of the Whipple’s procedure. When this is where the bile duct exits the liver (Klatskin tumour) the surgery will involve a liver resection. When this is in the liver (peripheral cholangiocarcinoma) a liver resection is the treatment of choice. Postoperative chemotherapy is commonly used. When the cancer cannot be removed, bile drainage is re-established with the insertion of a stent through the narrowed bile duct and palliative chemotherapy may be offered.

Royal Australasian College of SurgeonsThe University of AucklankMercy Ascotacckuland sages isdeihbpaaasuniversity-society-of-surgeonsssatiap Royal Society Newzealand