Biliary Injuries/Choledochal Cysts

Historical perspective First planned cholecystectomy in the world was

performed by Carl Langenbuch in 1882. First choledochotomy was performed by Couvoisser

in 1890. First iatrogenic bile duct injury was described by

Sprengel in 1891. Prof. Dr. Med Erich Muhe of Boblingen, Germany,

performed the first laparoscopic cholecystectomy in 1985.

Biliary Anatomy

a. Right hepatic duct.b. Left hepatic duct.c. Common hepatic duct.d. Portal vein.e. Hepatic artery.f. Gastroduodenal artery.g. Right gastroepiploic artery.h. Common bile duct.i. Fundus of the gallbladder.j. Body of the gallbladder.k. Infundibulum.l. Cystic duct.m. Cystic artery.n. Superior pancreaticoduodenal artery.

Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

Stewart et al. Bile Duct Injuries During Laparoscopic Cholecystectomy

Classic anatomy of biliary tree is present in only 30% of individuals, so it may be said that anomalies are rule, not

the exception. ( Maingot’s abdominal operations)

Anatomy

Calot's triangle bounded by cystic duct, cystic

artery, and common hepatic duct.

Hepatocystic triangle bounded by gallbladder wall and cystic duct, liver edge, and common hepatic duct; the cystic artery (and hence Calot's triangle) lies within this space.

(Maingot’s abdominal operation)

Laparoscopic cholecystectomy Pros and cons

General advantages Shorter stay in hospital Faster recovery period Reduced post-op recovery time Less postoperative pain Improved cosmetic outcome Disadvantage Increase in serious bile duct complications and

injuries

Introduction Open cholecystectomy was standard practice for

treatment of symptomatic gall bladder disease until late 1980’s.

At present 90% of cholecystectomies performed by LC which is one of the commonest surgical procedure in world.

widespread application of LC led to concurrent rise in incidence of major bile duct injuries (BDI),which are more complicated than after open procedures.

Since its introduction and routine use in 1990s, the incidence of biliary injuries has doubled from 0.2% to 0.4%.

Classic Laparoscopic Injury Mistaking common bile duct for the cystic duct

Thermal Injuries

Inappropriate use of electrocautery near biliary ducts

May lead to stricture and/or bile leaks

Mechanical trauma can have similar effects

Lahey Clinic, Burlington, MA.1994

Bile duct injuries during cholecystectomy

In 1990s, high rate of biliary injury was due to learning curve effect.

Surgeon had 1.7% chance of a bile duct injury occuring in first case and 0.17% at the 50th case.

However most surgeons passed through learning curve, steady – state reached, but there has been no significant improvement in the incidence of biliary duct injuries.

Biliary Injuries during Cholecystectomy

Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative Biliary tract injuries.

On other hand LC has been associated with 2.5-fold to 4-fold increase in the incidence of postoperative BDI compared with OC.

These preventable injuries can be devastating, increasing morbidity, mortality, and medical cost, while decreasing the patient’s quality of life.

Biliary injuries will always exist, and we need to be aware of the best methods to avoid, evaluate, and treat them.

Incidence of IBDI following cholecystectomy (%)

Author IBDI incidence following OC

IBDI Incidence following LC

Mc Mohan et al,1995 0.2 0.81

Strassberg et al, 1995 0.07 0.5

Shea et al,1996 0.19-0.29 0.36-0.47

Targarona et al, 1998 0.6 0.95

Lillemoe et al, 2000 0.3 0.4-0.6

Gazzaniga et al, 2001 0.0-0.5 0.07-0.95

Savar et al,2004 0.18 0.21

Moore et al,2004 0.2 0.4

Misra et al,2004 0.1-0.3 0.4-0.6

Gentileschi et al,2004 0.0-0.7 0.1-1.1

Kaman et al,2006 0.3 0.6

Risk Factors for Biliary tract injury

Surgeon related factors Lack of experience (learning curve) Misidentification of biliary anatomy Intraoperative bleeding Lack of recognition of anatomical variations of biliary

tree Improper interpretation of IOC Improperly functioning equipment

Risk for biliary tract injury

Patient related Acute and chronic cholecystitis Empyema Long standing recurrent disease -> fibrosis Porcelain gallbladder Obesity Previous surgery Male sex Advanced age

The Effect of Acute Cholecystitis on Lap. cholecystectomy complications

Complication rate three times greater than for elective LC.

Early cholecystectomy (72 h) outcome better than delayed cholecystectomy.

Conversion rate to open cholecystectomy is higher than elective cholecystectomy 35% vs 9%.

Risk Factors for biliary tract injuries Anatomic Variations

Present in 18 – 39% cases Dangerous variations predisposing to BTI are present in only 3-6% of cases

Abnormal biliary anatomy Short cystic duct, cystic duct

entering in the right duct- Accessory right hepatic duct

Arterial anomalies Right hepatic artery running

parallel to the cystic duct Anomalous or accessory right

hepatic artery

(Sabiston text book of surgery 19thedtn.)

Summary of Causes of Bile Duct Injuries Misidentification of Common bile duct Common hepatic duct An aberrant duct (usually on the right side)

Technical failure such as Slippage of clips placed on the cystic duct Inadvertent thermal injury to CBD Tenting of CBD during clip placement Disruption of a bile duct entering directly into gallbladder fossa .

(Goal of dissection should be conclusive identification of cystic structure within Calot triangle)

(If the cystic duct and cystic artery are conclusively and correctly identified before dividing, more than 70% of bile duct injuries would be avoided )

Technique Four methods of identification of cystic structures

during cholecystectomy

1) Routine cholangiography2) Critical view technique3) Infundibular technique-> widely used4) Dissection of main bile duct with visualization of cystic

duct or common duct insertion-> ( increased chance of either thermal or retraction

injury to CBD, aberrant insertion of cystic duct can also complicate this approach)

Routine intra-op cholangiogram (IOC)Laparoscopic ultrasonography

Performed routinely or not ? Done via presumed cystic duct If this happens to be CBD, injury has already occurred!! IOC does not identify all aberrant ducts Arterial anatomy not identified IOC does not prevent BDI but may reduce its severity ( if

correctly performed & interpreted, IOC can prevent complete CBD transection)

IOC higher rate of intra-op identification of BDI decreased cost of treatment & shorter hospital stay

If critical view not obtained due to inflamation or hostile anatomy perform IOC prior to dividing cystic duct .Routine IOC reduces CBD injuries from 0.58% to 0.39% (American Medicare data base study)

Critical view of safety

Calot’s triangle dissected free of all tissue except cystic duct & artery

Base of liver bed exposed When this view is achieved,

the two structures entering GB can only be cystic duct & artery

Not necessary to see CBD

(A)Usual anatomy when infundibular technique applied. Cyst duct-gallbladder junction is characterized by a flaring tunnel shape(boldlines). Arrow represents circumferential dissection of CD-gallbladder junction during infundibular technique.

(B) Inflammation can pull CBD on the gallbladder creating similar flaring tunnel shape. As a result, CBD mistaken for cystic duct, resulting in classic injuries.

CD, cystic duct;CHD, common hepatic duct. (Strasberg S. Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg 2008;15(3):285;)

Cystic duct or CBD?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

--

Classical LC BDI

Strasburg Classification Type A Cystic duct leaks or leaks from

small ducts in liver bed Type B Occlusion of aberrant right

hepatic ducts Type C Transection of aberrant right

hepatic ducts Type D Partial (<50%) transection of

major bile duct Type E Transection involve >50% Subdivided as per Bismuth

classification into E1 to E5

Strasburg Classification, cont’d E: injury to main duct (Bismuth)

E1: Transection >2cm from confluence

E2: Transection <2cm from confluence

E3: Transection in hilum E4: Seperation of major ducts in

hilum E5: Type C plus injury in hilum

Class I CBD mistaken for cystic duct, but error recognized before CBD is divided.Class II Damage to CHD from clips or cautery placed on duct. Often occurs where visibility is limited due to inflammation or bleeding.Class III Most common (60%), CBD mistaken for cystic duct. Common duct is transected and variable portion that includes junction of cystic and common duct is excised .Class IV Damage to right hepatic duct , either because this structure is mistaken for cystic duct, or injured during dissection.

Bile duct injury

Prevention should be main point (much more important than treatment)

ALL laparoscopic cholecystectomies ARE difficult! None of them is easy!

If injury occurred, …who should treat it?when should it be treated?how should it be treated?

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 Intraoperative laparoscopic ultrasound (IOUS) .

Mastery of Surgery 6th ed.

Changing the Culture of Cholecystectomy: Stopping Rules

Safety and avoiding BDI should be paramount concern to surgeon performing LC.

LC can be converted to open procedure or even aborted if local conditions present unacceptable risks of danger.

As Strasberg points out, the negative effects of conversion or even aborting procedure and placing a cholecystostomy tube are minor compared with the negative effect of a BDI.

Failure of progression of dissection, inability to grasp and retract gallbladder, anatomic ambiguity, poor visualization of field due to hemorrhage, should trigger the surgeon to consider alternate approach.

Conversion rate < 5% can be expected in hands of a well trained laparoscopic surgeon.

Timing of Identification

• Intra-op

• Unexpected ductal structures seen• Bile leak into field from lacerated or transected

duct

• Post-op

• Depends on continuity of bile duct & • Presence or absence of bile leak

Presentation of Bile Duct Injuries

About 25% recognized intraoperatively. About 25% discovered within 24 hours post- operative About 50% present weeks to years post-operative. Most BDI are not recognized intraoperatively, and patients sent home after or

within 24 hours. Patients who fails to recover within first few days or develop progressive vague

abdominal symptoms. Abdominal fullness, distension, nausea, vomiting, abdominal pain, fever and chills. Symptoms can leads to bilomas, biliary fistula, cholangitis, sepsis, or multi organ

system failure. Clinical presentation- Biliary obstructions-> anorexia, jaundice, liver enzyme elevation Bile leaks Both can occur simultaneously Concomitant vascular injuries (complicate matter) Obstruction secondary to biliary stricture appear weeks to month later and may

present with recurrent colangitis, obstructive jaundice, or secondary biliary cirrosis.

Intraoperative Detection

If experienced, convert to Open Procedure and perform Cholangiography (determine extent of injury)

If not experienced, perform cholangiogram laparoscopically with intent of referring patient (placement of drains)

Consult an experienced hepatobiliary surgeon

Quicker the repair, better the outcome!!!

Acute Management Biliary catheter for decompression of biliary tract and

control of bile leaks Percutaneous drainage of intraperitoneal bile collection

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 drain• Diffuse abdominal pain & persistent ileus

several days post-op high index of suspicion possible unrecognized BDI

Post-Operative Detection Plan Controlling sepsis, establish biliary drainage, postulate

diagnosis, type and extent of bile duct injury. Broad-spectrum antibiotics No need for an urgent laparotomy. Biliary reconstruction in

presence of peritonitis results a statistically worse outcome. No need for urgent with reconstruction of biliary tree.

Inflammation, scar formation and development of fibrosis take several weeks to subside.

Reconstruction of biliary tract is best performed electively after interval of at least 6 to 8 weeks.

BDI Management

Investigation Ultrasonagraphy and CT -- Ductal dilatation intra-

abdominal collection and dilatation of biliary tree. Cholangiogram

ERCP—biliary anatomy and assess the injury PTC—define biliary anatomy proximal to

injury MRCP—noninvasive (can miss minor leaks)

HIDA scan -- If doubt exists, HIDA scan can confirm leak but not the specific leak site

MR angiography—vascular injuries

When realise that there is an injury, ASK for HELP!

If possible do not try to repair, even you are experienced

An experienced and FRESH surgeon should repair the injury.

If it is impossible AND it is a difficult injury that you can not treat, place catheters and refer the patient.There is no ‘Tissue Lost’, primary repair (end to end CBD repair) over T-tube???

stricture rate is high!!!

There is ‘Tissue Lost’, biliodigestive anastomosis:choledocoduodenostomy/ Roux-en-Y

hepaticojejunostomy

Primary repair high incidence of failure percutaneous or endoscopic balloon dilatation later

Preoperative Investigation and Preparation for the Procedure

■ Communication with previous surgeon ■ Previous surgical report ■ Laboratory tests: bilirubin, alkaline phosphatase, ALT, AST,

albumin, coagulation parameters, white blood cell count

Principles of Repair ■ Anastomosis should be tension free, with good blood supply,

mucosa to mucosa and of adequate caliber. ■ Hepaticojejunostomy should be used in preference to either

choledochocholedocotomy or choledochoduodenostomy. ■ Anterior longitudinal opening in the bile duct with a long side-to-

side anastomosis is preferred. ■ Dissection behind the ducts should be minimized in order to

minimize devascularization of the duct.

Timing of RepairFactors favoring immediate repair are: (1) Early referral (2) Lack of right upper quadrant bile collection (3) Simple injuries (4) No vascular injury and (5) Stable patient Factors favoring delayed repair are: (1) Late (less than 1week after injury) referral (2) Complex injuries (types E4, E5) (3) Thermal etiology (4) Concomitant ischemic injury

Strasburg classification

Type A

No reconstructionTreated endoscopicaly

Type B & CPotentialy serious injuriesMore common since introduction of LC

Type B

Silent

Asymptomatic atrophy of involved liverCompensated by hypertrophy of normally drained liver

Pain or cholangitis many yrs. after injury

Type C

Biliary fistula

Volume less

Converted to silent Type B

Persistence

Reconstruction

Type D

<25%

25% - 50% or Caused by diathermy orSmall bile duct

Type E (>50%)

Repaired primarily Over T-tube

Reconstruction by hepaticojejunostomy

B,C and E1 to E5 are major biliary injuries

ERCP – multiple stents

• Lateral 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

Simple injuries types A and D may be treated in community

setting when discovered intraoperatively by endoscopic or percutaneous

techniques when they present in postoperative period.

Complex injuries that require hepaticojejunostomy for repair (types B and C

injuries and most to type E injuries).

More complex injuries types E1 and E2 may also be treated by nonsurgical

techniques when they present as strictures.

Notations >2 cm and <2 cm in types E1 and E2 indicate length of common

hepatic duct remaining.

Bile leak

Immediate intra operative diagnosis

Delayed diagnosis

injurMinor y Major injury

Repair over T-tube

No experienced hepato-Biliary surgeon Clip open ductDrainIV antibioticsTransfer to tertiary centre

Experienced hepatobiliary surgeon available

Call second surgeonRoux-en-Y hepatico-jejunostomy

Drainage

Low -output High-output

Observe

Resolve < 5-7 daysContinued ERCP

Duct of Luschka

Cystic duct stump leak

Suspected CBD injury

SphinctrectomyStent± sphincterectomy

PTC to deliniate anatomyControl drainageRepair by experienced hepatobiliary surgeon

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

ERCP – clips across CBD

CBD transection normal-sized distal CBD upto site of transection

Percutaneous transhepatic cholangiography (PTC) necessary

Surgery

Intraoperative repair

Surgical repairCholedocho-choledochostomy

Surgical repair Choledocho-duodenostomy

Biliary enteric anastomosis Most laparoscopic BDI –

complete discontinuity of biliary tree

Surgical reconstruction, Roux-en-Y hepaticojejunostomy

Tension-free, mucosa-to-mucosa anastomosis with healthy, nonischemic bile duct

Surgical repair Hepatico-jejunostomy (Roux-en-Y)

Definitive management Goal

Reestablishment of bile flow into proximal GIT In a manner that prevents cholangitis, sludge

or stone formation, restricturing & progressive liver injury

Bile duct intact & simply narrowed percutaneous or endoscopic dilatation

Treatment summary Strasberg 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 over a 5-F pediatric feeding tube to serve as a biliary stent

Summary

• Multidisciplinary management of BDI expertise of surgeons, radiologists & gastroenterologists

• Mismanagement lifelong disability & chronic liver disease

• BDI with lap. Chole results of operative repair, excellent in Specialist Centres

Choledochal Cysts

• Choledochal cysts are focal or diffuse dilatations of

the biliary tree

• Most commonly present in childhood but

increasingly being recognized in adults.

• represent significant clinical challenges where

proper evaluation and management are paramount

to prevent serious clinical sequelae.

Epidemiology

• incidence of choledochal cysts varies significantly

throughout the world.

• In Asia, incidence is as high as 1 in 1000 population

with 50% cases representing from Japan

• In Western Countries, choledochal cysts occur less

frequently with reported cases ranging from 1:13,000

to 1:150,000 population.

• Occur more commonly in females with a M:F

ratio of 1:3-4

• Classically present in childhood, but recent series

report as many as 25% of cases presenting in

adults.

EPIDEMIOLOY

Classification

• Proper management of choledochal cysts requires consideration

of their classification.

• Original Classification by Alonso-Lej and associates exclusively

involved the extrahepatic duct

• The classification was revised by Dr. Todani and colleagues in

1977 to include intrahepatic cystic anomalies

Todani Classification

• Type I (50-85%): They are characterized by cystic or

fusiform dilation of the common bile duct.

• Type IA is defined by cystic dilation of the entire

extrahepatic biliary tree,

• Type IB is defined by focal, segmental (often distal)

dilation of the extrahepatic bile duct.

• Type IC is defined by smooth, fusiform (as opposed to

cystic) dilation of the entire extrahepatic bile duct.

Todani Classification

• Type II ( 2%): true diverticula of the extrahepatic bile duct

and communicate with the bile duct through a narrow stalk.

• Type III ( 5%) : Cystic dilatation of the intraduodenal portion

of the extra hepatic common bile duct; also known as a

choledochocele

• Type IV (30-40%): Involve multiple cysts of the intrahepatic

and extrahepatic biliary tree; IV A > IV B

• Type V: Caroli’s Disease

• Type 1 A

Type II

Type III

Type IV A

Type IV B

Type V

Pathogenesis

• Cause not currently known. Most cysts are congenital in

nature.

• It is unclear whether cases of choledochal cysts diagnosed in

adults are acquired or late manifestations of congenital cysts.

• There may be multiple mechanisms involved in the creation

of biliary cysts

• The high incidence of biliary cysts in Asia suggests a role for

either genetic or environmental factors.

• Congenital weakness in the bile duct wall

• Abnormal biliary epithelial proliferation before bile duct

cannulation is complete

• Bile duct obstruction or distension in the prenatal or

neonatal periods

• Fetal viral infection

• Pancreaticobiliary maljunction

PATHOGENESIS

APBJ – Babbit Theory• Pancreaticobiliary maljunction is defined as an

extramural junction of the pancreatic and biliary ducts in

the duodenum beyond the intramural sphincter function

• characterized by a long common channel (typically over 2

cm)

• Increased reflux of pancreatic juice into the biliary tree --

>

Associated Developmental Anomalies

• Biliary atresia , Duodenal atresia, Colonic atresia, Imperforate anus

• Pancreatic arteriovenous malformation, Heterotopic pancreatic tissue

• Multiseptate gallbladder• OMENS plus syndrome• Ventricular septal defect, Aortic hypoplasia, • Congenital absence of the portal vein• Familial adenomatous polyposis• Autosomal recessive and autosomal dominant

polycystic kidney disease

Presentation

• Classic triad : pain, jaundice, and abdominal mass. ( ~ 10%)

• Infants commonly present with elevated conjugated bilirubin

(80%), failure to thrive, or an abdominal mass (30%).

• In patients older than 2 years of age, abdominal pain is the

most common presenting symptom.

• Intermittent jaundice and recurrent cholangitis are also

common, especially in patients with a type III cyst.

Diagnosis• U/S abdomen : to detect the presence

• CT scan – more appropriate in adults.

• MRCP

• Cholangiography: gold standard , PTC or ERC in adults

and intraoperative cholangiography in small children

• Liver function tests

Operative Management

• Type I: excision of the cyst with its mucosa and

reconstruction by Roux-en-Y hepatico-jejunostomy

• Type II: excision of the diverticulum and suturing of the

CBD wall

• Type III: endoscopic sphincterotomy is done.

• Type IV: Extrahepatic biliary resection, cholecystectomy,

and biliary reconstruction

• Type V: Liver transplantation, hepatectomy