NON SURGICAL OPTIONS IN “SURGICAL” JAUNDICE

The term “Surgical Jaundice” is used in literature to describe extra hepatic biliary obstruction, for which the only treatment available till few years back, was surgical drainage [1]. Recent introduction of endoscopic techniques to establish biliary drainage, and their continuing refinement is redefining the management of such cases.

The common causes of extrahepatic biliary obstruction are, stones in the common bile duct (CBD), benign strictures of CBD, tumours of the bile ducts and periampullary region. When obstructive jaundice is associated with cholangitis, antibiotic therapy may not be effective unless drainage of biliary tract is established and patient may die of ensuing septicaemia. The possibility of complicating renal failure, endotoxaemia, bleeding and delayed wound healing places these patients at significant surgical risk [2]. Operative mortality varies from 2% in patients with gall stone obstruction to over 20% in patients with malignant obstruction. A low haematocrit, and initial plasma bilirubin of > 12 mg/dl and the presence of malignant cause of obstruction is associated with much higher risk of dying post operatively.

Biliary drainage can be achieved without surgery by percutaneous or endoscopic routes. Percutaneous drainage has not shown any significant advantage over surgical drainage in prospective controlled trials [3]. Meanwhile endoscopic sphincterotomy followed by extraction of CBD stones has now become established as an effective non surgical approach in patients with ductal stones [4]. It has distinct survival advantage over surgery in high risk patients. Sphincterotomy with endoscopic stone extraction has a mortality of 1% and a 1% chance of perforation, bleeding, or pancreatitis [5]. The risk is less in experienced hands and more when CBD size is normal. Laparoscopic cholecystectomy cannot as yet tackle bile-duct stones; therefore pre-operative endoscopic CBD stone extraction has gained importance. The sphincterotomy may have to be combined with mechanical lithotripsy if the stone size is more than 2 cm. Short of removing bile duct stones, obstructed bile ducts can be drained in emergency situations by placing nasobiliary catheters by the endoscopic route. Such drainage is associated with significantly less morbidity and mortality then emergency surgery in patients with obstructing CBD stones and cholangitis [6]. In a patient at poor risk for surgery, a more permanent ductal drainage can be established by endoscopic placement of a stent, in the CBD. Stent clogging is a problem sometimes but a clogged stent can always be replaced [7]. Lithotripsy by ultrasonic shock waves, or lasers delivered through a cholangioscope [8] is another non surgical treatment modality now available for clearing obstructing CBD stones.

Retained CBD stones after surgery can be approached through a mature T tube track 4–6 weeks after surgery. Endoscopic sphincterotomy is now a better and more firmly established alternative for retained CBD stones. Open surgery for retained CBD stones carries higher mortality and is now reserved for patients who do not have access to the above modalities of treatment [9].

Benign post operative strictures of the CBD can be managed by percutaneous or endoscopic stent placement and balloon dilatation. This compares well with the 76% patency rate achieved by surgical reconstruction and/or by-pass [10].

Malignant obstructive jaundice due to ductal, periampullary and pancreatic tumours still presents a very dismal picture. Most of the patients (85–90%) with pancreatic growths are beyond curative surgery at presentation and only need palliation to relieve jaundice and itching. Endoscopy as a diagnostic modality can view the ampulla and obtain cells or tissue bits for histopathological examination. Endoscopic ultrasound can help localise and assess tumours and lymph node involvement. It is possible today to visualise directly the pancreatic duct by a miniature endoscope which can carry an ultrasonic probe. Therapeutic endoscopy now offers a viable alternative to surgery in the palliative management of jaundice. It helps to reduce hospital stay and hasten recovery [11]. The survival however is not improved. The problem of stent occlusion has been overcome by the introduction of self expanding metal stents. In patients with malignant biliary obstruction particularly those with slow growing tumours these large diameter stents may offer improved stent survival and thus avoid the need for readmission for shunt blockage [12]. Surgery was being preferred by some because it also allows the addition of a gastric drainage procedure. It now appears that the addition of a ‘prophylactic’ gastroenterostomy doubles mortality without any survival advantage [13] and hence should only be done if clearly indicated.

Therapeutic endoscopy along with better imaging techniques capable of accurately determining resectablility in malignant disease, will reduce the number of patients needing conventional surgery. With further refinement of endoscopic techniques, improved results can be expected. The best results will come from specialised centres dedicated to the management of these conditions.

Till expertise develops and such centres are freely accessible to our patients with obstructive jaundice, operative treatment can not be discarded as it may well be the simplest, cheapest and most readily available treatment alternative for our patients.