Considerations Regarding Biliary-digestive Bypasses in Benign and Malignant Diseases of the Biliary- Pancreatic Confluence

Abstract

Introduction. The usual indication for a biliary-digestive bypass is the obstruction by a benign or a malignant stricture which can occur at the biliary- pancreatic confluence. Benign strictures mostly occur in the distal bile duct as a result of stones or chronic pancreatitis. Malignant obstructions involve mostly the distal end as a result of a ductal adenocarcinoma of the head of the pancreas, the ampulla of Vater and cholangiocarcinoma and can be virtually impossible to distinguish from each other preoperatively.

Material and method. We studied 331 patients with benign and malignant diseases of the biliary-pancreatic confluence, that were comitted in the 3 rd Surgical Clinic Cluj in 2009-2010 and underwent radical or palliative surgery. A high number of parameters were observed and analysed, a special interest being represented by the types and frequency rate of the complications in relationship with the type of operation.

Results. Forty-four (22.35%) hepaticojejunostomies, 49 (14.8%) choledocho- duodenostomies were performed, as a palliative resort, or as part of a radical therapy. Pancreatico-duodenectomy was performed in 40 (12.08%) cases as a complete procedure and in 25 (7.55%) cases after a BDB. In 47 (14.20%) cases only an exploratory laparotomy could be performed. Ninety (27.19%) cases were associated with postoperative complications, the most common of them being wound suppuration - 38 (11.48%), pancreatic fistula - 24 (7.25%), gastric stasis - 16 (4.83%). Most patients underwent surgery with a diagnosis of adenocarcinoma and an advanced tumoral stage: T3 - 72 (43.37%). Lymph nodules were involved in 75 (45.18%) - N1, metastasis in 43 (25.9%) - M0. The most common pathological diagnose was adenocarcinoma (32,02%). Reinterventions were necessary in 29 (9%) of the cases.

Conclusions. The postoperative complications occurred mostly related to the biliary-digestive bypasses associated with a radical procedure than the biliary- digestive bypasses performed as a palliative resource. The complications also ocurred related to an advanced tumoral stage.