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Pongsatorn Tangtawee, MDHPB division, Department of Surgery
Ramathibodi Hospital
Bile Duct Injury
From GBB rama Photo club
Hit to the Point (General board exam)
Introduction
Classification and type
Investigation
Management Immediately Late presentation
Prevention
Introduction
The first planned cholecystectomy in the world was performed by Langenbuch in 1882
The first Choledochotomy was performed by Couvoissier in 1890.
The first iatrogenic bile duct injury was described by Sprengel in 1891. He also reported the first choledochoduodenostomy (ChD) for calculi (1891)
The first surgical reconstruction (“end-to-side” ChD) of IBDI was performed by Mayo in 1905
Jabłońska B, World J Gastroenterol 2009;15(33): 4097-4104
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, 1–14Wan-Yee Lau, Hepatobiliary Pancreat Dis Int 2007; 6: 459-463
Adamsen S,J AM Coll Surg, VOL184:571-578
Introduction
Jabłońska B, World J Gastroenterol 2009;15(33): 4097-4104
Risk Factors for BDI
Severe local risk factors acute cholecystitis, acute biliary pancreatitis, bleeding in Calot’s triangle severely scarred or shrunken gall bladder large impacted gallstone in Hartmann’s pouch, short cystic duct, and Mirizzi’s syndrome abnormal biliary anatomy
Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011
Risk Factors for BDI
Male sex and prolonged surgery for more than 120minutes
more than half of all such injuries occurred during the so called “easy” LC performed by an inexperienced surgeon
Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011
Clinical presentation of BDI
Depends on the type of injury and bile leaks or stricture
Bile leaks subhepatic bile collection (biloma) or abscess developsfever, abdominal pain and other signs of sepsis
Biliary strictures jaundice caused by cholestasis is the commonest
Jabłońska B, World J Gastroenterol 2009;15(33): 4097-4104
Clinical Presentation and Diagnosis
Kourosh F., Tech Gastrointest Endosc,2006,VOL 8:81-91
Classification
Classification
Starberg, J Am Coll Surg.,1995VOL180:101-125
Investigation
Intraoperative IOC ERCP
Early or late postoperative LFT Ultrasound CT : Unhelpful merely confirming the U/S ERCP (can treatment in some type) MRCP
Investigation
MRCP is a sensitive (85%-100%) and non-invasive imaging modality
Currently, it is the “gold standard” in preoperative diagnosis
Jabłońska B, World J Gastroenterol 2009;15(33): 4097-4104
MRCPPTC
A. R. MOOSSA, Ann. Surg., Vol. 2 15, No. 3, March 1992
Management
Initial Management
Concept of initial management Control of sepsis peritoneal and biliary PCD
Once sepsis is controlled complete cholangiogram site (in relation to the ductal confluence) nature (partial or complete) extent (loss of segment) of the injury
Sicklick et al, Annals of Surgery • Volume 241, Number 5, May 2005
Intraoperative management
Only 15% to 30% of biliary injuries are diagnosed during the surgical procedure
The surgeon should carefully consider his experience and ability to repair any injury that is immediately
Eduardo de Santibanes,HPB, 2008; 10: 412
Repaired by an experienced HPB surgeon This will reduce morbidity, shorten the stay in hospital, and decrease hospital costs
Savader SJ, Lillemoe KD, Ann Surg 1997;225:26873.
Intraoperative management
Townsend: Sabiston Textbook of Surgery, 18th ed.
Postoperative BDI management
Early or Elective should 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;134:604–10.
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;234:750–7.
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) 14:476–479
Strategy for management
Strasberg A injury
injuries maintain continuity with the rest of the bile ducts
Easily treated through endoscopic intervention to decrease 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
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 cholangitis makes the drainage of the occluded liver segment necessary PTBD Hepatectomy (cholangitis cannot controlled)
HJ technically hard to perform Long term prognosis is poorMercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
Strasberg C injury
accessory right duct is sectioned but the proximal stump is not detected
Subhepatic collections are frequent in the postoperative setting must be drained
Bile leak is occluded spontaneously with no other intervention
If this does not happen, therapeutic options are the same that Strasberg B
Poor long term prognosisMercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
Strasberg D injury
Partial injury of the common bile duct in its medial side
If a small injury with no devascularization is present, 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
Strasberg D injury
In the setting of a devascularized duct bile 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
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
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
Algorithm for the management of postoperative diagnosed biliary stenosis
Eduardo de Santibanes,HPB, 2008; 10: 412
Key of successfully
Exposure of damaged area avoiding too much dissection
The end of injured bile duct has to be free from burns and 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.
Vasculobiliary injury
Steven M. Strasberg, HPB 2011, 13, 1–14
Vasculobiliary injury
Steven M. Strasberg, HPB 2011, 13, 1–14
vasculobiliary injury
Steven M. Strasberg, HPB 2011, 13, 1–14
Steven M. Strasberg, HPB 2011, 13, 1–14
Suggested algorithm for the management of bile duct injury combined with hepatic artery.
Carlo Pulitanò, The American Journal of Surgery (2011) 201, 238–244
An indication of the relative frequency of scenarios is given.
Right hepatic artery (RHA) vasculobiliary injury with collateral flow from left hepatic artery and atrophy of right liver. (A) Computed tomography scan 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 hilar plexus (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 arterial pattern 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, 1–14
How to Avoid a Bile Duct Injury
Correct Exposure and Identification of Structures in Calot’s Triangle cystic lymph node, gall bladder neck, and Rouviere’s
sulcus
Wauben, World journal of surgery, vol.3 issue4, 2008
Critical view of safety(1995)
From Dr. Paramin, HPB division, Surgery department, Ramathibodi
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
“Caterpillar turn” or “Moynihan hump”
Incidence of variation is variable, and may be as high as 50%
Adams DB.,Surg Clin N America,1993,Vol73;861-71
Surgeons Characteristics of Risk Taking
Tendency 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. 460–469, 2003
N. N. Massarweh, Journal of the American College of Surgeons, vol. 209, no. 1, pp. 17–24,2009
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Surgical technique
What is Starsberg type?
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
What is Starsberg type?
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
Hepp-Couinaud
Soupault -Couinaud WEDGE SEGMENT III
LONGMIRE PROCEDURE
Roux-en-Y hepaticojejunostomy with a blind subcutaneous jejunal loop
Quintero,World J. Surg. 16:1178, 1992
Summary
BDI poor prognosis
Multiple risk factor Most important Blind surgical management in Calot’s triangle
Clinical presentation Leak, stricture, vasculobiliary injury
Investigation : immediately IOC “Do not assume” Late MRCP is Gold standard
Summary
Concept treatment Control of sepsis peritoneal and biliary PCD,
PTBD Once sepsis is controlled complete cholangiogram
Mapping and classified type manage follow by type
“Repaired by an experienced HPB surgeon This will reduce morbidity, shorten the stay in hospital, and
decrease hospital costs”
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
Thank You