bile duct injuries.slideshare
TRANSCRIPT
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Dr. Sreenath KDept of surgery, RIMS Imphal
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Introduction
Bile duct injury (BDI) Rare but potentially devastating condition Biliary peritonitis & sepsis, cholangitis, portal
hypertension & secondary biliary cirrhosis Significant morbidity & mortality
Iatrogenic BDI Increased financial burden (patient or hospital)
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Anatomy
Calot’s triangle – between inferior surface of liver, Cystic duct & CHD
Contents – Cystic artery, RHA, Cystic lymph node
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Bile Duct Injuries (BDI)Iatrogenic injury
Cholecystectomy Gastrectomy Pancreatectomy ERCP
TraumaDuodenal ulcer
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Risk factorsInflammation in the porta,Variable biiary anatomy,Inappropriate exposure,Aggressive attempts at hemostasis,Surgeon inexperience. 97% due to visual misperception, only 3% accounts for
technical skills and knowledge.
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Misperception ..
With sufficient cephalad retraction of the gall bladder fundus ,the cystic duct overlies the common hepatc duct running in a parrellel path. without inferolateral traction of the gallbladder infundibulum to dossociate this structures, the dissection of apparent cystic duct may actually include CBD…
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Classical LC BDI
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Laparoscopic cholecystectomy (LC) Gold standard for management of benign gallbladder diseaseCompared with laparotomy
Less post-op pain Shorter hospital stay Earlier return to normal activity Better cosmesis Iatrogenic bile duct injury rate
0.1% to 0.2% (open) vs 0.4% to 0.6% (lap)‘’Learning curve phenomenon’’
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LC & Bile duct injury (BDI)LC most common cause of BDI
More severe than those seen with Open chole
’Learning curve phenomenon’’
BDI after LC stable around 0.6 to 0.7%, 4 times that of open chole – high for a benign condition
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Classificationlocation of injury mechanism & type of injuryeffect on biliary continuitytiming of identification
Each plays significant role in determining appropriate management & operative repair
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Classification of BDIBismuth classification (1982)Era of Open CholeBased upon level of biliary strictures with respect to hepatic
bifurcationType 1-5.Helps surgeon choose appropriate site for repairDegree of injury correlates with surgical outcomes
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Strasberg classification(1995)Type Criteria
A Leak from Cystic duct or small ducts in liver bed
B Injury to sectoral duct(aberrant RHD) with obstruction
C Injury to sectoral duct with consequent bile leak
D Lateral injury to extrahepatic ductE1 Transection >2 cm from the confluenceE2 Transection <2 cm from the confluenceE3 Transection at the confluenceE4 Separation of major ducts in the confluenceE5 Complete occlusion of all bile ducts.
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Strasberg classification
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Clinical Presentation (post-op)Obstruction
Clip ligation or resection of CBD obstructive jaundice, cholangitis
Bile Leak Bile from intra-op drain or More commonly, localized biloma or free bile ascites /
peritonitis, if no drainFever,abd pain , jaundice, or bile leakage from incision. Diffuse abdominal pain & persistent ileus several days
post-op high index of suspicion possible unrecognized BDI
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Classical LC BDI
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ReasonsMisidentification
CBD or aberrant RHD mistaken for cystic duct Risk factors inexperience, inflammation or aberrant
anatomy Infundibular technique – flaring of cystic duct as it
becomes infundibulum misleading in inflammation
Technical errors Cautery induced injury
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Prevention 30° laparoscope, high quality imaging equipment Firm cephalic traction on fundus & lateral traction on
infundibulum, so cystic duct perpendicular to CBD Dissect infundibulo-cystic junction Expose “Critical view of safety” before dividing cystic duct Convert to open, if unable to mobilise infundibulum or
bleeding or inflammation in Calot’s triangle Routine intra-op cholangiogram “Fundus-first” dissection
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Critical view of safetyCalot’s triangle dissected free
of all tissue except cystic duct & artery
Base of liver bed exposedWhen this view is achieved,
the two structures entering GB can only be cystic duct & artery
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Cystic duct or CBD?
Cystic duct CBD Caution
2 – 3mm wide 5mm wide CD > 5mm – Is it CBD?Even with low cystic duct insertion, CD rarely goes behind duodenum
CBD goes behind duodenum
Duct behind duodenum must be CBD
Double cystic duct very rare
-- 2 ducts seem to go towards inflammed Gallbladder – one must be CBD
No vessels on surface
Vessels on surface
--
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Management
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Recognized at the Time of CholecystectomyConversion to an open operation and use of
cholangiography.
Goals .. Maintenance of ductal length, elimination of any bile
leakage that would affect subsequent management, and creation of a tension-free repair.
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Ducts smaller than 3 mm drain only a single segment or subsegment of liver..simple ligation.
Ducts larger than 3 mm usually drain more than a single segment of liver,if transected.. should be reimplanted into the biliary tree.
Injury occurs to a larger duct, but is not caused by electrocautery and involves less than 50% of the circumference of the wall, a T tube placed through the injury
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Low injuries to the bile duct can be reimplanted into the duodenum.
Most injuries to the bile duct occur higher in the biliary tree, close to the hilum, thus not allowing for tension-free anastomosis to the duodenum. Therefore, in almost all cases of bile duct injury, a resection of the injured segment with mucosa to mucosa anastomosis using a Roux-en-Y jejunal limb (end-to-side choledochojejunostomy ) is preferred.
Transanastomotic stenting has been shown to improve anastomotic patency.
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Identified After CholecystectomyGoals of Therapy in Iatrogenic Bile Duct Injury 1.Control of infection limiting inflammation Parenteral antibiotics
Percutaneous drainage 2.Clear and thorough delineation of entire biliary anatomy. MRCP/PTC , ERCP3.Re-establishment of biliary enteric continuity Tension-free, mucosa-to-mucosa anastomosis
Roux-en-Y hepaticojejunostomy Long-term transanastomotic stents if involving
bifurcation or higher
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Approach..Should undergo imaging to assess for a fluid collection and
evaluate the biliary tree. Ultrasonography can achieve both these goals.
Cross-sectional imaging via CT will generally provide more useful data.
Radionucleotide scanning to confirm bile leakage, but with any documentation of a leak, CT will be necessary to plan management.
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CT or U/S guided (or surgical) drainage
Sepsis control Broad-spectrum antibiotics & percutaneous biliary drainage to control any bile leak most fistulas will be controlled or even close.
1.5% mortality rate due to uncontrolled sepsis
No rush to proceed with definitive management of BDI.
Delay of several weeks allows local inflammation to resolve & almost certainly improves final outcome.
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Definitive management is to reestablish durable biliary enteric drainage.
Combination of percutaneous and endoscopic biliary dilations and stenting may establish continuity.
Surgical reconstruction has the highest patency rates.
performed between a minimally inflamed bile duct to intestines in a tension-free, mucosa to mucosa fashion.
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If the anastomosis is within 2 cm of the hepatic duct bifurcation, or involves intrahepatic ducts, long-term stenting appears to improve patency
If the bifurcation is involved, stenting of both right and left ducts should be performed
When the reconstruction involves the common bile duct or common hepatic duct more than 2 cm from the bifurcation, stenting is not necessary.
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Interventional Radiologic and Endoscopic Techniques
Using balloon dilation techniques, the stricture is dilated and a catheter is left in place to decompress the system, allow healing, document resolution and, if necessary guide repeat dilations.
This approach is successful in up to 70% of patients.
Endoscopic balloon dilation of bile duct strictures is generally reserved for those with primary bile duct strictures or patients who have undergone choledochoduodenostomy for reconstruction, because the Roux limb does not usually allow for endoscopic strategies.
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Two large retrospective reviews have been performed and both have shown higher success rates from surgical therapy, with lower morbidity and lower mortality following operative management compared with those for nonoperative strategies
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ERCP – multiple stentsLateral duct wall injury or
cystic duct leak transampullary stent controls leak & provides definitive treatment
Distal CBD must be intact to augment internal
drainage with endoscopic stent
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ERC – clips across CBD CBD transection
normal-sized distal CBD upto site of transection
Percutaneous transhepatic cholangiography (PTC) necessary
Surgery
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Cholangiography (ERCP + PTC)Percutaneous transhepatic cholangiography (PTC)
Defines proximal anatomy Allows placement of percutaneous transhepatic biliary
catheters to decompress biliary tree treats or prevents cholangitis & controls bile leak
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MRCP / CT cholangiographyNoninvasive
May avoid invasive procedures like ERCP or PTC
Do not allow intervention
Interpretatation in presence of bile collection difficult
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Biliary enteric anastomosisMost laparoscopic BDI –
complete discontinuity of biliary tree
Surgical reconstruction, Roux-en-Y hepaticojejunostomy
tension-free, mucosa-to-mucosa anastomosis with healthy, nonischemic bile duct
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Treatment summaryStrasberg Type A – ERCP + sphincterotomy + stent
Type B & C – traditional surgical hepaticojejunostomy
Type D – primary repair over an adjacently placed T-tube (if no evidence of significant ischemia or cautery damage at site of injury)
More extensive type D & E injuries – Roux an-Y
hepaticojejunostomy with biliary stent
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Risk Factors for BDI
Acute inflammation at Calot’s triangleAtypical anatomy
aberrant RHD (most common) complex cystic duct insertion
Conditons that impair “Critical view of safety” Obesity & periportal fat Complex biliary disease – choledocholithiasis ,
gallstone pancreatitis, cholangitis Intra-op bleeding
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ReasonsMisidentification
CBD or aberrant RHD mistaken for cystic duct Risk factors inexperience, inflammation or aberrant
anatomy Infundibular technique – flaring of cystic duct as it
becomes infundibulum misleading in inflammation
Technical errors Cautery induced injury
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Anatomic illusion?Misperception (97%) rather than technical error (3%)
Everyone is susceptible – experience, knowledge & technical skill alone may not be adequate
All BDI may not represent “substandard practice”
Improvements may have to depend on technology
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Summary
Multidisciplinary management of BDI expertise of surgeons, radiologists & gastroenterologists
Mismanagement lifelong disability & chronic liver disease
BDI with lap. Chole results of operative repair is excellent in Specialist Centres
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Thank
you…