Download - BDI Slide Share
-
8/13/2019 BDI Slide Share
1/63
Pongsatorn Tangtawee, MD
HPB division, Department of Surgery
Ramathibodi Hospital
Bile Duct Injury
-
8/13/2019 BDI Slide Share
2/63
From GBB rama Photo club
-
8/13/2019 BDI Slide Share
3/63
Hit to the Point (General board exam)
Introduction
Classification and type
Investigation
Management
Immediately
Late presentation
Prevention
-
8/13/2019 BDI Slide Share
4/63
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
-
8/13/2019 BDI Slide Share
5/63
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
-
8/13/2019 BDI Slide Share
6/63
Introduction
Jaboska B, World J Gastroenterol 2009;15(33): 4097-4104
-
8/13/2019 BDI Slide Share
7/63
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
-
8/13/2019 BDI Slide Share
8/63
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
Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011
-
8/13/2019 BDI Slide Share
9/63
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
Jaboska B, World J Gastroenterol 2009;15(33): 4097-4104
-
8/13/2019 BDI Slide Share
10/63
Clinical Presentation and Diagnosis
Kourosh F., Tech Gastrointest Endosc,2006,VOL 8:81-91
-
8/13/2019 BDI Slide Share
11/63
Classification
-
8/13/2019 BDI Slide Share
12/63
Classification
Starberg, J Am Coll Surg.,1995VOL180:101-125
-
8/13/2019 BDI Slide Share
13/63
Investigation
Intraoperative
IOC
ERCP
Early or late postoperative
LFT
Ultrasound
CT : Unhelpful merely confirming the U/S
ERCP (can treatment in some type)
MRCP
-
8/13/2019 BDI Slide Share
14/63
Investigation
MRCPis a sensitive (85%-100%) and non-invasive
imaging modality
Currently, it is the gld standard in preoperative
diagnosis
Jaboska B, World J Gastroenterol 2009;15(33): 4097-4104
-
8/13/2019 BDI Slide Share
15/63
MRCPPTC
-
8/13/2019 BDI Slide Share
16/63
-
8/13/2019 BDI Slide Share
17/63
A. R. MOOSSA, Ann. Surg., Vol. 2 15, No. 3, March 1992
-
8/13/2019 BDI Slide Share
18/63
-
8/13/2019 BDI Slide Share
19/63
-
8/13/2019 BDI Slide Share
20/63
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
-
8/13/2019 BDI Slide Share
21/63
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.
-
8/13/2019 BDI Slide Share
22/63
Intraoperative management
Townsend: Sabiston Textbook of Surgery, 18th ed.
-
8/13/2019 BDI Slide Share
23/63
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.
-
8/13/2019 BDI Slide Share
24/63
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
-
8/13/2019 BDI Slide Share
25/63
Strategy for management
-
8/13/2019 BDI Slide Share
26/63
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
-
8/13/2019 BDI Slide Share
27/63
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
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
-
8/13/2019 BDI Slide Share
28/63
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
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
-
8/13/2019 BDI Slide Share
29/63
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
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
-
8/13/2019 BDI Slide Share
30/63
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
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
external drainage + mandatory endoscopic
sphincterotomy + stent should be performed
-
8/13/2019 BDI Slide Share
31/63
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
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
-
8/13/2019 BDI Slide Share
32/63
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
Eduardo de Santibanes,HPB, 2008; 10: 412
-
8/13/2019 BDI Slide Share
33/63
Algorithm for the management of postoperative diagnosed biliary stenosis
Eduardo de Santibanes,HPB, 2008; 10: 412
-
8/13/2019 BDI Slide Share
34/63
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.
-
8/13/2019 BDI Slide Share
35/63
Vasculobiliary injury
Steven M. Strasberg, HPB 2011, 13, 114
-
8/13/2019 BDI Slide Share
36/63
Vasculobiliary injury
Steven M. Strasberg, HPB 2011, 13, 114
-
8/13/2019 BDI Slide Share
37/63
vasculobiliary injury
Steven M. Strasberg, HPB 2011, 13, 114
-
8/13/2019 BDI Slide Share
38/63
Steven M. Strasberg, HPB 2011, 13, 114
-
8/13/2019 BDI Slide Share
39/63
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.
-
8/13/2019 BDI Slide Share
40/63
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
Steven M. Strasberg, HPB 2011, 13, 114
-
8/13/2019 BDI Slide Share
41/63
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
-
8/13/2019 BDI Slide Share
42/63
Critical view of safety(1995)
From Dr. Paramin, HPB division, Surgery department, Ramathibodi
-
8/13/2019 BDI Slide Share
43/63
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
Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011
-
8/13/2019 BDI Slide Share
44/63
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
-
8/13/2019 BDI Slide Share
45/63
-
8/13/2019 BDI Slide Share
46/63
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
-
8/13/2019 BDI Slide Share
47/63
Surgical technique
-
8/13/2019 BDI Slide Share
48/63
What is Starsberg type?
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
-
8/13/2019 BDI Slide Share
49/63
What is Starsberg type?
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
-
8/13/2019 BDI Slide Share
50/63
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
-
8/13/2019 BDI Slide Share
51/63
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
-
8/13/2019 BDI Slide Share
52/63
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
-
8/13/2019 BDI Slide Share
53/63
Hepp-Couinaud
-
8/13/2019 BDI Slide Share
54/63
Soupault -Couinaud WEDGE SEGMENT III
-
8/13/2019 BDI Slide Share
55/63
LONGMIRE PROCEDURE
-
8/13/2019 BDI Slide Share
56/63
Roux-en-Y hepaticojejunostomy with ablind subcutaneous jejunal loop
Quintero,World J. Surg. 16:1178, 1992
-
8/13/2019 BDI Slide Share
57/63
Summary
BDIpoor prognosis
Multiple risk factorMost importantBlind
surgical management in Caltstriangle
Clinical presentationLeak, stricture,
vasculobiliary injury
Investigation : immediatelyIOC D nt assumeLateMRCP is Gold standard
-
8/13/2019 BDI Slide Share
58/63
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
-
8/13/2019 BDI Slide Share
59/63
-
8/13/2019 BDI Slide Share
60/63
-
8/13/2019 BDI Slide Share
61/63
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
-
8/13/2019 BDI Slide Share
62/63
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
-
8/13/2019 BDI Slide Share
63/63
Thank You