Biliary system

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Biliary system
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Anatomy
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Plain x ray
GB stone in 10
Gas in biliary tree
Gall stone ileus
Gas in GB wall
Porcilin GB
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Radiological investigationsOral Cholecystography

• We comment on
• Site
• Size
• Shape
• Filling Defect
• Function
• Concentration of dye
• contractility

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Investigations

• Imaging techniques
• Ultrasound this is most useful
• Most important to show intrahepatic bile ducts
  dilatation
• Measure the diameter of CBD (normal up to 7 mm)
• Comment on the status of the GB and its stones
• Visualize CBD diameter, stones or areas of
  narrowing
• Tumors in the region of the pancreas is seen
• CT (conventional or helical) competes with the
  U/S especially as regards the pancreatic tumors.

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Radiological investigationsUltrasound
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cholangiogram

• Preoperative cholangiogram
• IV cholangiogram
• PTC
• ERCP
• Intra operative
• T tube ( post operative )

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Investigations for a case of obstructive jaundice

• ERCP
• ERCP is an outpatient procedure that combines
  endoscopic and radiologic modalities to visualize
  both the biliary and pancreatic duct systems.
• Endoscopically, the ampulla of Vater is
  identified and cannulated.
• A contrast agent is injected into these ducts,
  and
• x-ray images are taken to evaluate their caliber,
  length, and course.
• ERCP is used to
• get a final diagnosis and
• do biopsy of ampullary tumors, or brush cytology.
  

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Investigations for a case of obstructive jaundice

• ERCP
• It can be also therapeutic for
• stone extraction by Dormia basket or
• insertion of a stent, both are preceded by
  sphincterotomy.
• It has its risks
• ascending infections,
• perforations,
• pancreatitis, an
• bleeding due to sphincterotomy done routinely
  before CBD cannulation

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ERCP
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Klatskin tumor
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mid duct stricture
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pancratitis
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Congenitalcarolis syndrome
congenital intrahepatic dilated bile ducts
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Chledochal cyst (type I)
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Investigations for a case of obstructive jaundice

• MRCP
• a sensitive noninvasive method of detecting
  biliary and pancreatic duct stones, strictures,
  or dilatations within the biliary system.
• It is also sensitive for helping detect cancer.

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Investigations for a case of obstructive jaundice

• MRCP (contraindications)
• Absolute include
• the presence of a cardiac pacemaker,
• cerebral aneurysm clips,
• ocular or cochlear implants
• ocular foreign bodies.
• Relative contraindications include
• the presence of cardiac prosthetic valves,
• neurostimulators,
• metal prostheses,
• penile implants

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Investigations for a case of obstructive jaundice

• PTC
• performed by a radiologist using fluoroscopic
  guidance.
• The liver is punctured to enter the peripheral
  intrahepatic bile duct system.
• An iodine-based contrast medium is injected into
  the biliary system and flows through the ducts.
• Obstruction can be identified on the fluoroscopic
  monitor.

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Investigations for a case of obstructive jaundice

• PTC
• It is especially useful for lesions proximal to
  the common hepatic duct.
• Still, ERCP is generally preferred.
• PTC is reserved for use if ERCP fails or when
  altered anatomy precludes accessing the ampulla.

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Investigations for a case of obstructive jaundice

• PTC
• Complications of this procedure include
• the possibility of allergic reaction to the
  contrast medium.
• peritonitis.
• intraperitoneal hemorrhage, sepsis
• cholangitis.
• subphrenic abscess.
• lung collapse.
• Severe complications occur in 3 of cases

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PTC
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stone
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cancer
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cancer
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impacted stone at lower end
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Investigations for a case of obstructive jaundice

• Endoscopic ultrasound (EUS) combines endoscopy
  and US to provide remarkably detailed images of
  the pancreas and biliary tree.
• It uses higher-frequency ultrasonic waves
  compared to traditional US (3.5 MHz vs 20 MHz)
• allows diagnostic tissue sampling via EUS-guided
  fine-needle aspiration (EUS-FNA).

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Acute Cholecystitis

• Acute obstructive (Calcular)
• Acute Acalcaus
• Acute emphysematous

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Acute obstructive (Calcular)(Pathology)

• Calcular obstruction
• GB become hyperemic, oedematous distended
• Chemical inflammation
• Release of Phosphlipases
• Act on lecithin which is a mucosal protector
  transforming it into
• Lysolecithin (mucosal toxin
• Arachidonic acid (PG precursor) (inflammation)
• Sepsis
• Ecoli, klebsilla strept which occur later on

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Acute obstructive (Calcular)(Pathology)

• Following acute inflammation the condition end by
  one of the following
• Resolution
• Mucocele
• Empyema
• Gangrene And perforation
• Bilo-enteric fistula

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Acute Acalcular Cholecystitis

• It form 8
• Risk factors are
• Sepsis
• Starvation
• Prolonged TPN
• Ileus
• Morphine use gt 6 days

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Acute Acalcular Cholecystitis

• Pathology is not knowen
• Prolonged distention of GB , Bile stasis
  inspissations lead to mucosal injury and vessel
  thrombosis
• Hypersensitivity to concomitant antibiotics
• Gangrene occur in 25 of cases

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Acute emphysematous GB

• Caused by mixed poly-microbial infection
  including gas forming bacteria
• 70 male , diabetics
• Thrombosis of cystic artery is the cause
• It lead tom
• Gangrene in 75
• Perforation in 15

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Clinical picture

• Patient 5 F
• General
• High fever with shivering
• Nausea, vomiting biliary dyspepsia
• Local
• Biliary colic
• Tenderness
• Murphys sign
• Boas sign
• Complication

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Clinical picture

• The attack of biliary colic is the start with
  visceral type of pain (diffuse, colicky,
  radiating, and associated with vomiting)
• Later on after 6 to 8 hours, the pain localizes
  to the right hypochondrium, and become associated
  with tenderness, rebound T, and rigidity and mild
  fever (somatic pain)
• The presence of distended gall bladder is the
  hallmark of the disease, either discovered
  clinically or by U/S
• In 25 of cases the bilirubin rises, due to
  compression of the CBD (Mirrizi syndrome) or less
  commonly due to an associated stone CBD
• Serum amylase should be a routine as well as
  plain X ray abdomen (pancreatitis, and
  perforation or gas in biliary system

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Acute calculous cholecystitis

• Obstruction of GB outlet leads to chemical
  inflammation, which persists for 72 h then a fate
  of the following, will occur
• Resolution (most common), with relief of
  obstruction gtscarring and non-function of GB
• Resolution of the inflammatory process with
  persistence of the obstruction (mucocele of the
  GB)
• Persistence of infection (empyema of the gall
  bladder) with obstruction persistence
• Gangrene and acute perforation leading to
  localized pericholecystic abscess or generalized
  frank biliary peritonitis
• Chronic perforation with development of biliary
  eneteric fistula

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Investigation

• Laboratory
• Leucocytosis
• Liver function
• S. amylase
• Radiological
• Plain xray
• US
• Doppler US
• HIDDA scan
• CT scan MRI

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Investigations the best is ultrasound

• An ultrasound is the most common screening test.
• It is 90-95 sensitive for cholecystitis
• It is 78-80 specific.
• For simple cholelithiasis, it is 98 sensitive
  and specific.

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Investigations the best is ultrasound

• Findings include gallstones or sludge and one or
  more of the following conditions
• Gallbladder wall thickening (gt2-4 mm)
• Gallbladder distention (diameter gt4 cm, length
  gt10 cm)
• Pericholecystic fluid from perforation or exudate
  
• Air in the gallbladder wall (indicating
  gangrenous cholecystitis)
• Sonographic Murphy sign (86-92 sensitive, 35
  specific), pain when the probe is pushed directly
  on the gallbladder (not related to breathing)

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Treatment (conservative)

• NPO, nasogastric IV fluids
• Analgesic, antipyretic spasmolytic
• Antibilotic
• Broad spectrum ( cephalosporins )
• Metronidazole aminoglycoside
• Follow up and surgery
• In the same admission
• Interval cholecystectomy

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Treatment (surgical)

• Urgent if
• Doubt in diagnosis
• Failure to improve
• Complication
• We perform
• Chole-cyst-ectomy
• retrograde Chole-cyst-ectomy
• Chole-cyst-ostomy
• Subtotal Chole-cyst-ectomy
• Mini Chole-cyst-ectomy
• Laparscopic Chole-cyst-ectomy

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Treatment (surgical)

• Established Non-progressive disease
• Interval Chole-cyst-ectomy
• Early chole-cyst-ectomy

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Gall stones
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Increase bile pigments
Metabolic
Decrease phosphlipid bile salts
Increase cholesterol
Gall stones
Infection
Stasis
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Cholesterol stone

• 75 of stones formed in sterile GB (10
  infection)
• Protein matrix
• cholesterol (70)
• bile pigment
• Ca carbonate
• Ca palmitate (Ca salts deposited at periphery,
  their amount determine the radiolucency)

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Cholesterol stone

• Two types
• Pure cholesterol
• Oval or rounded
• mamillated or mullbery-surfaced
• pale yellow in color
• solitary big size (100 cholesterol rounded)
• 60 cholesterol (mixed)
• Multiple mediums sized (60 cholesterol,
  faceted)
• brownish polished surface

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cholesterol
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Gall stones
cholesterol
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Formation involves 7 processes

• Super saturation with cholesterol
• Incomplete transfer of cholesterol from vesicles
  to micelles
• Formation of vesicles with high cholesterol
• Aggregation and fusion of unstable vesicles
• Cholesterol crystallization (mucin is a
  nucleating agent)
• Biliary sludge formation (mucin cholesterol
  Capigment precursor of stones)
• Stone growth

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Black Pigment Stone

• 25 of stones.
• It is common in cirrhotics, after terminal ileum
  resection and in hemolytic diseases. Formed in a
  sterile GB (20 infection rate)
• Composed of bilirubin polymer without Ca
  palmitate and cholesterol (25)matrix of
  organic material
• Usually multiple, small, irregular, dark green or
  black in color
• Hard in consistency and cut surface is layered
• Formation
• Elevated concentration of mono-conjugated
  bilirubin
• lower bile salt concentration is the usual
  constitution in forming patients
• yet the exact pathogenesis is not known

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pigmented
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Brown Pigment Stone

• Rare ductal stones caused by infection by gram
  -ve bacteria releasing B glucuronidase releasing
  free bilirubin
• Composed mainly of
• Ca bilirubinate,
• Ca palmitate small amounts of cholesterol
• matrix of organic material
• Amorphous soft stones

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Gall stone disease

• Symptom less
• no interference
• interference in
• Diabetics
• Acromegalic
• Calcified
• Patient under go surgical intervention
• Symptomatic
• Chronic cholecystitis
• Acute biliary colic, acute cholecystitis
• Jaundice

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Clinical presentations

• Acute cholecystitis
• Empyema of the gallbladder
• Mucocele of the gallbladder
• Biliary colic
• 'Flatulent dyspepsia'
• Mirrizi's syndrome
• Obstructive jaundice
• Pancreatitis
• Acute cholangitis

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Chronic calcular cholecystitis

• Clinical picture
• Recurrent attacks of epigastric or right
  hypochondrial pain (persistent pain)
• May be attacks of severe biliary colic
• Nausea vomiting
• Flatulent dyspepsia with intolerance to fatty
  meals
• Tenderness in right hypochondrium (Murphys

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Treatment

• Cholecystectomy either conventional or
  laparoscopic is the ideal treatment for
  symptomatic patients.
• Patients with asymptomatic gall stones can be
  left without surgery specially if cirrhotics.
• However patients with a calcified or porcelain
  gallbladder should consider elective
  cholecystectomy due to the increased risk of
  carcinoma (25).

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Laparoscopic cholecystectomy (LC)

• Shown to be equally as effective as open
  cholecystectomy in controlled trials
• Pre-operative ERCP is indicated if
• Recent jaundice
• Abnormal liver function tests
• Significantly dilated common bile duct
• Ultrasonic suspicion of bile duct stones

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cholecystectomy

• Indication
• Trauma
• Inflammation
• Acute chronic
• Mucocele
• empyema
• Tumor
• Torsion
• As a part of other operations

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cholecystectomy

• Incisions
• Subcostal (Kochers)
• Upper right paramedian
• Right upper transverse
• Upper midline

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cholecystectomy
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Technique

• Preliminary exploration
• Signs of cholecystitis
• Associated pathology
• Saints triade
• Welkies triade
• Pancrease
• Stone in CBD

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Saints triade
Welkies triade
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Technique

• Packing of the field retractors

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GB is grasped
Separation of GB Artery Duct
Identification of Calots
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Operative complications

• Injury to important structure
• Common bile duct injury
• observed more frequently in the laparoscopic
  approach.
• Iatrogenic common bile duct injury often results
  from a combination of inexperience of the
  surgeon, the presence of anomalous biliary
  anatomy, and acute inflammation.
• Duodenum injury
• Pancreatic and liver injury
• Ligation of Rt hepatic artery
• Primary hge
• Injury of cystic artery
• Injury of Rt hepatic
• Injury portal vein
• GB bed

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Post operative complications

• General
• Chest abdomen
• DVT
• Infection
• Spillage of stones into the peritoneal cavity
  during cholecystectomy increases the risk of
  infection and abscess formation.
• Wound infections also are possible but are less
  common in the laparoscopic approach..

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Post operative complications

• Local
• Bleeding
• Reactionary slipped ligature
• 2 ry hge if infection which may lead to
  collection above IVC ( Waltman- Walter syndrome)
• Ligation of
• CBD or CHD
• Hepatic artery
• Biliary peritonitis
• Biliary fistula
• Subphrenic collection
• Postcholecystectomy syndrome

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Post cholecystectomy syndrome

• Organic causes
• Long stump of cystic duct
• Missed stone
• Stricture
• Stenos is of sphincter of Oddi
• Non organic causes
• Psycho-somatic
• Biliary dyskinesia

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Long stump of cystic duct

• If stone is formed
• Stump must be excised with
• Stone extraction
• If no stones
• symptomatic treatment

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Missed stone after cholecystectomy

• Confirm diagnosis by US ERCP
• Minimal invasive
• ERCP sphincterectomy stone extraction by Dormia
  Basket
• PTC then choledochoscpic extrction
• Surgical
• Supradoudenal choledochotomy
• Transdoudenal sphincteroplasty

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Stricture

• Minimal invasive by stent insertion
• Surgical
• Roux en Y choledocho jujunostomy
• Roux en Y hepatico jujunostomy

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Post cholecystectomy syndrome

• Organic causes
• Long stump of cystic duct
• Missed stone
• Stricture
• Stenos is of sphincter of Oddi
• Non organic causes
• Psycho-somatic
• Biliary dyskinesia

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Post cholecystectomy syndrome

• Stenos is of sphincter of Oddi
• Endoscopic papillotomy and sphincterotomy
• Sphincteroplasty
• Choledocho doudenotomy
• Biliary dyskinesia
• Endoscopic papillotomy and sphincterotomy

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Stone in CBD
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Aetiology

• GB stone (commonest)
• Primary stones of CBD usually (Brown)
• Parasites
• Stasis
• FB
• cholangitis

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Clinical picture

• Symptom less 20
• Symptoms
• Charcots triade
• Jaundice
• Pain
• Fever
• Raynauds pentale
• Charcots triade
• Hypotension
• Altered mental status

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Investigations

• Laboratory
• CBC
• Liver function
• urine
• Radiological
• US
• ERCP
• MRCP
• PTC

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Management of stone CBD

• Support liver by correction of the general
  condition by I.V. fluids for hydration
• Support kidney by Mannitol (hypotension and
  hyperbilirubinemia together causes renal shut
  down)
• Prevent infection by antibiotics,
• Prevent bleeding by correction of the
  avitaminosis K by parentral vitamin administration

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Concurrent common bile duct and gallbladder stones

• Preoperative ERCP, with clearance of the common
  bile duct, followed by LC
• Open cholecystectomy and common bile duct
  exploration
• Combined laparoscopic-endoscopic management
• Endoscopic sphincterotomy and stone extraction
  are performed on the operation table
• after the surgeon has passed a guidewire through
  the cystic duct into the duodenum
• to help the endoscopist because the procedure is
  performed with the patient in the supine
  position.
• LC, with postoperative ERCP

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Management of a case of stone CBD

• Minimal invasive
• Endoscopic extraction of calculi followed by
  cholecystectomy whether surgical or most commonly
  laparoscopic
• PTC which provide drainage and subsequent
  choledochoscopy stone extraction

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Management of a case of stone CBD

• Conventional choledochtomy
• Chole cystectomy and supra doudenal choledochtomy
  choledocholithotomy (exploration of the common
  bile duct)
• Trans doudenal sphincterotomy
• Choledocho douden ostomy

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Indications of common bile duct exploration
(supra doudenal choledochtomy)

• Preoperative
• confirmation of the presence of CBD stones (U/S,
  ERCP, or operative cholangiography)
• Jaundice or history of jaundice
• History of pancreatitis (although it is usually
  due to a passing stone)
• Operative
• Stone palpable in CBD
• Dilated CBD with thick lusterless fibrous wall,
  with mud inside
• Dilated cystic duct specially if there is
  multiple small stones in the gall bladde
• Postoperative
• Surgical Jaundice

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Management of a case of stone CBD

• T tube insertion which should be
• Widest possible diameter
• Latex or red rubber (never plastic)
• Exist from one side of the choledochotomy wound
• Horizontal limb is cut to lie below the carina
  and above the common channel
• Vertical limb comes out straight from the abdomen
• T tube cholangiography is done on the 4 th days
  and tube is extracted at the 10-12 days after
  24-hour occlusion without problems (fever,
  leakage, or pain)

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Management of stone CBD

• Sphincterotomy or sphincteroplasty done In the
  presence of
• stenosed termination of CBD or
• an impacted stone in its lower end that cannot be
  extracted from the choledochotomy wound
• the ampulla is attacked through a duodenal
  incision and the ampulla should undergo either
  sphincterotomy or sphincteroplasty at 10 or
  11-oclock positions to avoid pancreatic duct
  injury

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Management of a stone CBD

• Chole docho duodenostomy is done (in the
  following situations)
• In dilated CBD (more than one cm)
• In case there is multiple stones (gt 4 stones in
  CBD) because of the high possibility of missing a
  stone inside
• Presence of intrahepatic biliary stones
• Stricture of the lower end of CBD

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Missed stone after CBD exploration

• Confirm diagnosis bt US ERCP
• Wait for 6 weeks
• Hydrostatic pressure
• Minimal invasive
• ERCP sphincterectomy stone extraction by Dormia
  Basket
• PTC then choledochoscpic extrction
• Surgical
• Supradoudenal choledochotomy
• Transdoudenal sphincteroplasty

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Jaundice
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Jaundice

• Pre-hepatic (Hemolytic)
• Hepatic
• Post hepatic (Obstructive)

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Pre-hepatic (Hemolytic)

• Congenital abnormal
• Shape
• spherocytosis,
• eleptocytosis
• Hb
• thalssemia,
• sickle cell
• Enzymes
• G6 PD,
• pyruvate kinase

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Pre-hepatic (Hemolytic)

• Acquired
• Immune hemolytic
• Collagenic SLE, Rheumatoid
• Tumor lekemia, lymphoma
• Infections malaria, syphilis
• Drugs penicillin tetracycline, quinidine, aSPIRIN
• Non immune
• Septicemia
• Burn
• Metal poisoning
• Mismatch blood transfusion
• Haematoma
• Snake venum

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Hepatic

• Acute
• Viral
• Amoebic or bacterial
• Alcoholic
• Liver cell necrosiis
• Drugs
• Direct hepatotoxic
• A antibiotics (Tetracycline),
• Analgesic (salycilate, paracetamol)
• Antihelminthic carbon tetra chloride
• Anaesthestics fluthane
• Arsenic

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Hepatic

• Drugs
• Direct hepatotoxic
• B benzidine dervative TNT
• C cytotoxic 5FU
• Intra hepatic cholestasis
• Non sensitivity methyl testosterone
• Sensitivity neomercazole, thiuracil,
  chloropromazine
• Hypersensitivity PASA
• Chronic
• Chronic active
• Cirrhosis
• Primary hepatic cirrhosis
• Space occuping lesions

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Obstructive jaundice (Etiology)

• Common
• Common bile duct stones
• Carcinoma of the head of pancreas
• Malignant porta hepatis lymph nodes
• Infrequent
• Ampullary carcinoma
• Pancreatitis
• Liver secondaries

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Obstructive jaundice (Etiology)

• Rare
• Benign strictures - iatrogenic, trauma
• Recurrent cholangitis
• Mirrizi's syndrome
• Sclerosing cholangitis
• Cholangiocarcinoma
• Biliary atresia
• Choledochal cysts

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Calcular obstruction

• Intermittent (can be progressive if stone is
  impacted)
• Usually no reaching high levels
• Pain is colicky in nature, and typical for
  biliary colic
• G.B not palpable except very rarely if its neck
  is obstructed too (double stone)

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Malignant obstruction

• Progressive except very rarely in ampullary
  tumors where sloughing can give temporary
  decrease
• Usually reaching high levels
• Pain is constant and referred to the back in
  pancreatic tumor, while it is absent in CBD
  tumors
• G.B is palpable except in Klatskin tumors

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Obstructive jaundice
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Calcular
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Complications of obstructive jaundice

• Ascending cholangitis
• Charcot's triad is classical clinical picture
  which is formed of intermittent pain, jaundice
  and fever
• Cholangitis can lead to hepatic abscesses
• Need parenteral antibiotics and biliary
  decompression
• Operative mortality in elderly of up to 20

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Complications of obstructive jaundice

• Clotting disorders
• Vitamin K required for gamma-carboxylation of
  Factors II, VII, IX, XI
• Vitamin K is fat-soluble. No absorbed. So it
  needs to be given parenterally
• Urgent correction will need Fresh Frozen Plasma
• Also endotoxin activation of complement system

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Complications of obstructive jaundice

• Hepato-renal syndrome
• Poorly understood
• Renal failure post intervention
• Most probably due to gram negative endotoxinaemia
  from gut
• Preoperative lactulose may improve outcome by
  improving altered systemic and renal
  haemodynamics
• Drug Metabolism
• Half-life of some drugs prolonged. (E.g.
  morphine)
• Impaired wound healing.

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Investigations for a case of obstructive jaundice

• Laboratory
• Raised
• Direct bilirubin (in most of the cases the
  indirect bilirubin also rises due to hepatic
  cellular malfunction).
• Alkaline phosphatase
• Gamma glutamyl transferase
• 5 nucleotidase

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Investigations for a case of obstructive jaundice

• Laboratory
• Mild elevation or normal
• SGOT SGPT (these are shooting in viral
  hepatitis)
• Slightly depressed or normal
• Prothrombin time (due to avitaminosis K)
• Urine urobilinogen

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Investigations for a case of obstructive jaundice

• Imaging techniques
• Ultrasound this is most useful
• CT (conventional or helical) competes with the
  U/S especially as regards the pancreatic tumors.
• ERCP
• MRCP
• PTC
• EUS

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malignant
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Treatment for cholangiocarcinoma of CBD

• Palliative
• Plastic stent insertion through ERCP
• Stent insertion through percutanous transhepatic
  route
• Self-expanding stainless steel wire biliary
  endoprosthesis is new modality with high patency
  rate, and less infection rate

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Treatment for cholangiocarcinoma of CBD

• Palliative
• Bypass surgery
• Round ligament approach for Klatiskin tumors (on
  condition that the carina is permitting right to
  left communication)
• Hepatico jujenostomy for middle and low tumors
• Cholecystojujenostomy for low tumors.
• usually we add gastrojujenostomy and
  enteroanastomosis (triple anastomosis) for
  pancreatic head tumors

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Treatment for cholangiocarcinoma of CBD

• For operable cancers
• For Klastiskin tumor,
• segment IV excision provides good access to the
  confluence
• allows good proximal clearance and facilitates
  hepaticojujenostomy
• For middle tumors excision of the tumor from just
  below the carina to the duodenum is done with
  hepaticojujenostomy
• For distal tumors. Whipple operation is done

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Biliary strictureEtiology

• Congenital (biliary atresia)
• Traumatic (most important, and usually follow
  cholecystectomy)
• Complete ligation of CBD
• Narrowing of the duct by partial inclusion in a
  ligature
• Ischemia of the duct, or diathermy injury
• Inflammatory Sclerosing cholangitis (multiple
  strictures separated by normal or dilated
  segments).
• Cholangiocarcinoma

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Sclerosing cholangitis

• PSC (primary sclerosing choangitis ) is a chronic
  cholestatic biliary disease characterized by non
  suppurative inflammation and fibrosis of the
  biliary ductal system.
• The cause is unknown but is associated with
  autoimmune inflammatory diseases such as chronic
  ulcerative colitis.

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Sclerosing cholangitis

• Most patients present with fatigue and pruritus
  and, occasionally, jaundice.
• The natural history is variable but involves
  progressive destruction of the bile ducts,
  leading to cirrhosis and liver failure.

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Biliary stricture

• Investigations used are similar to those used in
  any case of obstructive jaundice (U/S then CT,
  ERCP, MRCP or PTC
• Treatment is centered on creating a biliary
  enteric anastomosis with mucosa-to-mucosa sutures
  without compromising the blood supply of any of
  the ends.