Palliative Cholecysto-Jejunostomy for Extra-Hepatic Billiary Obstruction under Local Anaesthesia: A Rewarding Experience

Abstract

Extra-hepatic billiary obstruction is a common disorder seen in surgical practice, and it greatly affects the quality of life of patients afflicted with such disorder. In its severe form, it may be life threatening due to complications such as, hepatic encephalopathy, Hepato-renal syndrome, fulminant cholangitis and jaundice related coagulopathy. Obstructive Jaundice is the most common presentation following extra-hepatic billiary obstruction and carcinoma of the head of the pancreas and choledocholithiasis are the most common malignant and benign causes. Most patients present with advanced disease where palliation is the only viable option. However, such patients may not be suitable for surgery under General Anaesthesia due to advanced age, poor nutritional state with hypolbuminaemia, extra-abdominal metastasis producing respiratory compromise or a high risk for hepatic encephalopathy. Objectives: We aim to assess the safety and effectiveness of a palliative Cholecysto-Jejunostomy done under local Anaesthesia. Methods: This is a prospective cross-sectional study of total of 54 patients, both males and females, aged 16 years and above, who presented at the General Surgery units of State Specialist Hospital Damaturu and General Hospital Potiskum, both in Yobe State Nigeria; with Obstructive Jaundice. All had clinical and Radiological evidence of extra-hepatic Billiary obstruction and were managed surgically with a palliative Cholecysto-Jejunostomy under local Anaesthesia involving infiltrative cutaneous field block and USS guided Oblique Subcostal Transversus Abdominis Plain Block (OSTAPB). It is a 6-year study done from January 2015-December 2020. Informed consent was obtained from all patients according to Helsinki guidelines and Ethical clearance was granted by the leadership of both hospitals. All data were analysed with SPSS 20.0 software for correlation of outcomes. Results: The study population were 54 patients, 59.3% males and 40.7% females. The mean age is 50.5 years and an age range of 16-75 years. Malignant lesion is the most common cause of extra-hepatic billiary obstruction, with exocrine pancreatic cancer responsible for 48.1% of all causes. Chronic pancreatitis (16.7%) and impacted common bile duct (CBD) stones at 14.8%, are the two most common benign causes. All the patients had an abdominal USS for diagnosis or non-contrast enhanced abdominal CT Scan if there is ambiguity. A total of 77.8% had palliative Cholecysto-Jejunostomy done under local Anaesthesia involving cutaneous field block with Lignocaine with Adrenaline at a standardised dose of 4mg/kg body weight and USS guided Subcostal TAP Block. The remaining had a palliative Cholecystostomy or no surgery done. All abandoned cases were because of an involved or fibrosed Gallbladder. The most common post-operative complications are Surgical Site Infection (SSI) at 24.1%, excessive Primary Haemorrhage and reactionary haemorrhage, at 9.3% each. The total fatality rate was 7.4%. Conclusion: Palliative Cholecysto-Jejunostomy is safe, operative mortality rate is 7.4% and is effective in providing billiary drainage with limited postoperative morbidity.