[Obstruction icterus--our experience].

Abstract

INTRODUCTION: The most common causes of extrahepatic obstruction are choledocholithiasis, malignant and benign stenosis of biliary ducts, pancreatic head carcinoma, and chronic cephalic pancreatitis. Differentiation between hepatocellular icterus with intrahepatic obstruction and extrahepatic mechanical obstruction is of utmost importance. Differential diagnosis usually includes a combination of clinical examination, biochemical testing, ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), transhepatic cholangiography, computed tomography (CT), nuclear magnetic resonance (NMR) and endoscopic ultrasonography (EUS). Choledocholithiasis mostly develops due to concrement migration from the gallbladder. The treatment of choice is operative therapy by either conventional method with laparotomy or endoscopic concrement extraction, the latter being preferred in case of residual concrements. Malignant stenoses of extrahepatic ducts can involve any segment of the biliary ducts or the gallbladder. The main symptom is so-called painless icterus. The condition is treated surgically by radical (various types of resection) or palliative (biliodigestive anastomoses) methods. Intraoperative lesion occurring on biliary duct procedures is generally involved in the etiology of benign stenoses of extrahepatic biliary ducts. The treatment is surgical and consists of the creation of hepaticojejunal anastomosis. PATIENTS AND METHODS: The study included 151 patients admitted during a 5-year period (1999-2003) to Department of Surgery, Zabok General Hospital. Icterus was caused by choledocholithiasis in 112, carcinoma of extrahepatic biliary ducts in seven, carcinoma of the gallbladder in five, and carcinoma of the head of pancreas in 18 patients. Cephalic pancreatitis, malposition of a clamp placed during laparoscopic procedure, postoperative choledochus stricture, stricture of choledochoduodenal anastomosis and multiple cystic liver disease caused icterus in nine patients. In 106 choledocholithiasis patients, the concrement was removed by choledocholithotomy; duodenotomy and papillotomy in addition to choledochotomy were required in four patients; and creation of biliodigestive anastomosis was needed in two patients due to impossible concrement removal. Biliodigestive anastomosis was created in another 20 patients with the findings of inoperable tumor of the head of pancreas, inoperable tumor of the papilla of Vater, postoperative choledochus stenosis, stenosis of choledochoduodenal anastomosis, and chronic cephalic pancreatitis. Cephalic duodenopancreatectomy was performed in two patients, whereas other methods consistent with the etiologic substrate were employed in 17 patients. The following complications were observed in 151 patients operated on: T drain fall off (n = 2), lesion of retroduodenal choledochus (n = 1), and loosening of the cholecystojejunal anastomosis suture line (n = 1). The hospital mortality rate was 3.31% (n = 5). DISCUSSION: Impairment in the biliary duodenal drainage is an etiologic factor in the development of obstructive icterus. It is of utmost importance to differentiate hepatocellular icterus with intrahepatic obstruction from extrahepatic mechanical obstruction. The treatment depends on the etiologic factor involved. Operative treatment can be fully successful in cases caused by lithiasis or benign stenosis, whereas in cases due to malignant disease a variety of radical and operative procedures associated with a variable level of success are available. CONCLUSION: Mechanical obstructive icterus of extrahepatic biliary ducts ranks high in the morbidity and mortality in the Krapina--Zagorje County. Timely diagnosis, well planned and properly performed operative procedures could considerably improve the results achieved by the operative treatment of the disease.