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Pongsatorn Tangtawee, MD

HPB division, Department of Surgery

Ramathibodi Hospital

Bile Duct Injury


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From GBB rama Photo club


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Hit to the Point (General board exam)

Introduction

Classification and type

Investigation

Management

Immediately

Late presentation

Prevention


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Introduction

The first planned cholecystectomy in the world wasperformed by Langenbuch in 1882

The first Choledochotomy was performed by Couvoissier in

1890.

The first iatrogenic bile duct injury was described by Sprengelin 1891. He also reported the first choledochoduodenostomy(ChD) for calculi (1891)

The first surgical reconstruction (end-to-side ChD) of IBDIwas performed by Mayoin 1905

Jaboska B, World J Gastroenterol 2009;15(33): 4097-4104


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Introduction

Biliary injury is the most common severe complication

of cholecystectomy.

incidence of bile duct injuries has risen from 0.1%-0.2%

to 0.4%-0.7% from the era OC to the era LC

BDI continue to appear by experience surgeons

Steven M. Strasberg, HPB 2011, 13, 114

Wan-Yee Lau,Hepatobiliary Pancreat Dis Int 2007; 6: 459-463

Adamsen S,J AM Coll Surg, VOL184:571-578


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Introduction



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Risk Factors for BDI

Severe local risk factors

acute cholecystitis,

acute biliary pancreatitis, bleeding in Caltstriangle

severely scarred or shrunkengall bladder large impacted gallstne in Hartmanns puch,

short cystic duct, and Mirizzissyndrome abnormal biliary anatomy

Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011


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Risk Factors for BDI

Male sex and prolonged surgery for morethan120minutes

more than half of all such injuriesoccurred duringthe s called easy LC perfrmed by aninexperienced surgeon



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Clinical presentation of BDI

Depends on the type of injury and bile leaks or

stricture

Bile leakssubhepatic bile collection (biloma) or

abscess developsfever, abdominal pain and other

signs of sepsis

Biliary strictures

jaundice caused by cholestasis isthe commonest



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Clinical Presentation and Diagnosis

Kourosh F., Tech Gastrointest Endosc,2006,VOL 8:81-91


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Classification


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Classification

Starberg, J Am Coll Surg.,1995VOL180:101-125


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Investigation

Intraoperative

IOC

ERCP

Early or late postoperative

LFT

Ultrasound

CT : Unhelpful merely confirming the U/S

ERCP (can treatment in some type)

MRCP


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Investigation

MRCPis a sensitive (85%-100%) and non-invasive

imaging modality

Currently, it is the gld standard in preoperative

diagnosis



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MRCPPTC


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A. R. MOOSSA, Ann. Surg., Vol. 2 15, No. 3, March 1992


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Initial Management

Concept of initial management

Control of sepsisperitoneal and biliary PCD

Once sepsis is controlled

completecholangiogram

site (in relation to the ductal confluence)

nature (partial or complete)

extent (loss of segment) of the injury

Sicklick et al, Annals of Surgery Vlume 241, Number 5, May 2005


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Intraoperative management

Only 15% to 30% of biliary injuries are diagnosedduring the surgical procedure

The surgeon should carefully consider hisexperience and ability to repair any injury that isimmediately

Eduardo de Santibanes,HPB, 2008; 10: 412

Repaired by an experienced HPB surgeon This willreduce morbidity, shorten the stay in hospital, and

decrease hospital costs

Savader SJ, Lillemoe KD, Ann Surg 1997;225:26873.


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Intraoperative management

Townsend: Sabiston Textbook of Surgery, 18th ed.


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Postoperative BDI management

Early or Electiveshould be consider

Controversial in HPB surgeon

-The Mayo clinic , early repair may be done in a

patient with a ligated/ clipped duct after LC when

there is no bile leak, no cholangitis, and good

proximal dilatation

Murr MM,Arch Surg 1995;134:60410.


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Postoperative BDI management

3 out of 4 failures in 25 HJs occurred in patients who

had undergone early reconstruction (within 6 weeks

of cholecystectomy)

Boerma D, Ann Surg 2001;234:7507.

We do not recommend early repair and have

performed early (within 4 weeks) repair in only 11

out of 362 patients in whom we have performed HJ

for BDI between 1989 and 2005

Vinay K, J Hepatobiliary Pancreat Surg (2007) 14:476479


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Strategy for management


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Strasberg A injury

injuries maintain continuity with the rest of the bile

ducts

Easily treated through endoscopic intervention todecrease intraductal pressure distal to the bile duct leak

If endoscopy is not available, a T tube could be useful

The last resource is to control the bile leak through

subhepatic drains and refer

Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48


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Strasberg B injury

Segmentary bile duct occlusion

If mild pain and elevation of LFT are present with no

clinical impairmentconservative management

The presence of moderate and severe cholangitismakes the drainage of the occluded liver segmentnecessaryPTBDHepatectomy (cholangitis

cannot controlled)

HJ technically hard to performLong termprognosis is poor



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Strasberg C injury

accessory right duct is sectioned but the proximal stumpis not detected

Subhepatic collections are frequent in the postoperativesettingmust be drained

Bile leak is occluded spontaneously with no otherintervention

If this does not happen, therapeutic options are thesame that Strasberg B

Poor long term prognosis



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Strasberg D injury

Partial injury of the common bile duct in its medial

side

If a small injury with no devascularization ispresent, a 5-0 absorbable monofilament suture to

close the defect is adequate

external drainage + mandatory endoscopic

sphincterotomy + stent should be performed in rare

case



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Strasberg D injury

In the setting of a devascularized ductbile leak

will develop during the first postoperative week

with concomitant bile collections

Surgery is the last resource


external drainage + mandatory endoscopic

sphincterotomy + stent should be performed


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Strasberg E injury

Complete loss of common and/or hepatic bile duct

continuity

Devascularization and loss of bile duct tissue

More complex and hard to surgical treatment



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Consideration

Injuries that involve the hepatic duct confluence,

i.e. Bismuth class III, IV, V (combined or not with

common bile injury); or in Strasberg classification

Type E3, E4, E5.

High stenosis with previous repair attempts

Any biliary injury associated with a vascular injury.

Biliary injuries associated with portal hypertension

or secondary biliary cirrhosis



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Algorithm for the management of postoperative diagnosed biliary stenosis



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Key of successfully

Exposure of damaged area avoiding too much dissection

The end of injured bile duct has to be free from burnsand attritions

Intraoperative cholangiography in every bile leakage

Vascular integrity should be confirmed

Hepaticojejunostomy with an isolated Roux-en-Y

Opposition of both mucosas with reabsorbable suture

Use of magnification

Blumgart LH, Arch Surg, 1999;134:76975.


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Vasculobiliary injury



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Vasculobiliary injury



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vasculobiliary injury



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Suggested algorithm for the management of bileduct injury combined with hepatic artery.

Carlo Pulitan, The American Journal of Surgery (2011) 201, 238244

An indication of the relative frequency of scenarios is given.


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Right hepatic artery (RHA) vasculobiliary injury

with collateral flow from left hepatic artery and

atrophy of right liver. (A) Computed tomographyscan of liver shortly after injury. The arterial

phase shows no filling of right liver.

(B) Arteriogram performed 2 years later.

Abundant arterial collaterals extend from the

left hepatic artery to the RHA along the hilarplexus (white arrowhead). The clip which

occluded the RHA is also seen (black

arrowhead). The arterial pattern of the right

liver shows crowding (black arrows) indicative of

atrophy of the right liver, whereas the arterialpattern of the left liver shows elongation and

spreading characteristic of hypertrophy of the

left liver. (Reproduction of original photographs

from Mathisen et al. by permission



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How to Avoid a Bile Duct Injury

Correct Exposure and Identification of Structures in

CaltsTriangle

cystic lymph node, gall bladder neck, and Ruvieressulcus

Wauben, World journal of surgery, vol.3 issue4, 2008


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Critical view of safety(1995)

From Dr. Paramin, HPB division, Surgery department, Ramathibodi


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How to Avoid a Bile Duct Injury

To Avoid Thermal Injury

To Avoid Blind Haemostasis

Awareness of Anatomic Variation

Conversion to Open Approach When Necessary



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Caterpillar turn r Mynihan hump

Incidence of variation is variable, and may be as

high as 50%

Adams DB.,Surg Clin N America,1993,Vol73;861-71


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Surgeons Characteristics of Risk TakingTendency and BDI

Casual approach, overconfidence, and ignorance of

difficult situations

better training and standard use of safety measures

with Surgical simulation to be helpful

L. W. Way, L. Stewart,Annals of Surgery, vol. 237, no. 4, pp. 460469, 2003

N. N. Massarweh,Journal of the American College of Surgeons, vol. 209, no. 1, pp. 1724,2009


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Surgical technique


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What is Starsberg type?

From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi


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What is Starsberg type?



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Hepp-Couinaud


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Soupault -Couinaud WEDGE SEGMENT III


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LONGMIRE PROCEDURE


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Roux-en-Y hepaticojejunostomy with ablind subcutaneous jejunal loop

Quintero,World J. Surg. 16:1178, 1992


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Summary

BDIpoor prognosis

Multiple risk factorMost importantBlind

surgical management in Caltstriangle

Clinical presentationLeak, stricture,

vasculobiliary injury

Investigation : immediatelyIOC D nt assumeLateMRCP is Gold standard


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Summary

Concept treatment

Control of sepsisperitoneal and biliary

PCD, PTBD

Once sepsis is controlled

complete cholangiogram

Mapping and classified typemanage follow by

type

Repaired by an experienced HPB surgen This will

reduce morbidity, shorten the stay in hospital, and

decrease hspital csts


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Thank You

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