STEP 7Managing and avoiding injury to the common bile duct CBD avoiding injury

About 50% of patients with chronic pancreatitis have radiographic evidence of anatomic tortuosity, kinking, and narrowing of CBD; with significant stricturing, 10% of patients undergoing head resection have preoperative findings of CBD obstruction -biochemical or clinical jaundice.

During the coring out process, it is important to identify and free the intrapancreatic portion of the CBD from the inflamed, fibrotic periductal tissue.

The position of the CBD in the posterior pancreas is variable and either may be posterior to the pancreas, indenting the pancreas (on palpation a "groove" may be discerned), or traversing the pancreatic parenchyma; the latter site is most commonly associated with stricturing.

In patients with anatomic obstruction, a 3-mm Bakes dilator or biliary Fogarty® catheter is passed into the CBD to guide and protect the CBD during pancreatic resection.

If the CBD is injured or strictured or the obstruction is unable to be relieved, a choledochojejunostomy is an option.

An alternative method for coring out the head of the pancreas is excavation of the head with total resection of the main and secondary ducts. The ductal system is followed to the level of the ampulla or to where the pancreatic duct meets the intrapancreatic CBD; the pancreatic duct is divided; the proximal duct margin is sewn closed with a 4-0 nylon suture. Use of the Cavitron R Ultrasonic Aspirator (CUSA), System 200 (Valleylab, Norwalk, CT), facilitates conical removal of parenchyma in conjunction with electrocautery; the high-energy hand-piece at a setting of 70-80% power permits clear visualization of tissue, ducts, and vessels in the head of pancreas. The proximal pancreatic duct is removed in total by transecting the dorsal duct at the pancreatic neck.

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