Postcholecystectomy Syndrome

Kathy LeeJune 23 2006

Introduction

bull First described in 1947bull Presence of symptoms after

cholecystectomybull May be either

ndash Development of new Sx ORndash Continuation of Sx

bull 10-15 of patients

bull Pain may persist recur mos or yrsbull Preliminary Dx should be renamed

relevant to the disease identified by an adequate workupndash Cause for PCS identified in 95 of patients

Preop Risk stratification

bull Higher risk patientsndash Younger femalendash Urgent operationndash No stones documentedndash Longer duration of symptoms prior to surgeryndash Choledochotomy performed

bull No differencendash Typicality of preop symptomsndash Prior surgery bile spill stone spill

Symptoms

bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24

Etiology

SO dyskinesia spasm or hypertrophy

SO stricturePapilloma Cancer

PeriampullaryResidual GBStump cholelithiasisNeuroma

GB remnant and cystic duct

Liver

Anatomy

Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst

Etiology

CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or

nonspecific dilationDyskinesiaFistula

Biliary tract

EtiologyAnatomy

Intestinal anginaCoronary angina

VascularArthritisBone

AdhesionsIncisional herniaIrritable bowel disease

Small bowel

AdhesionsDiverticulaIrritable bowel disease

Duodenum

EtiologyAnatomyEtiologyAnatomy

ConstipationDiarrheaIncisional herniaIBS

ColonPancreatitisStoneCancer

Pancreas

Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx

Other

NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety

Nerve

Bile gastritisPUDGastric cancer

StomachDiaphragmatic herniaHiatal herniaAchalasia

Esophagus

Workup

bull Hx Pxbull Labs

ndash Incl LFT INRPTT amylase bili

bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction

bull Therapeutic as well stone extraction stricture dilation sphincterotomy

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Introduction

bull First described in 1947bull Presence of symptoms after

cholecystectomybull May be either

ndash Development of new Sx ORndash Continuation of Sx

bull 10-15 of patients

bull Pain may persist recur mos or yrsbull Preliminary Dx should be renamed

relevant to the disease identified by an adequate workupndash Cause for PCS identified in 95 of patients

Preop Risk stratification

bull Higher risk patientsndash Younger femalendash Urgent operationndash No stones documentedndash Longer duration of symptoms prior to surgeryndash Choledochotomy performed

bull No differencendash Typicality of preop symptomsndash Prior surgery bile spill stone spill

Symptoms

bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24

Etiology

SO dyskinesia spasm or hypertrophy

SO stricturePapilloma Cancer

PeriampullaryResidual GBStump cholelithiasisNeuroma

GB remnant and cystic duct

Liver

Anatomy

Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst

Etiology

CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or

nonspecific dilationDyskinesiaFistula

Biliary tract

EtiologyAnatomy

Intestinal anginaCoronary angina

VascularArthritisBone

AdhesionsIncisional herniaIrritable bowel disease

Small bowel

AdhesionsDiverticulaIrritable bowel disease

Duodenum

EtiologyAnatomyEtiologyAnatomy

ConstipationDiarrheaIncisional herniaIBS

ColonPancreatitisStoneCancer

Pancreas

Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx

Other

NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety

Nerve

Bile gastritisPUDGastric cancer

StomachDiaphragmatic herniaHiatal herniaAchalasia

Esophagus

Workup

bull Hx Pxbull Labs

ndash Incl LFT INRPTT amylase bili

bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction

bull Therapeutic as well stone extraction stricture dilation sphincterotomy

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

bull Pain may persist recur mos or yrsbull Preliminary Dx should be renamed

relevant to the disease identified by an adequate workupndash Cause for PCS identified in 95 of patients

Preop Risk stratification

bull Higher risk patientsndash Younger femalendash Urgent operationndash No stones documentedndash Longer duration of symptoms prior to surgeryndash Choledochotomy performed

bull No differencendash Typicality of preop symptomsndash Prior surgery bile spill stone spill

Symptoms

bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24

Etiology

SO dyskinesia spasm or hypertrophy

SO stricturePapilloma Cancer

PeriampullaryResidual GBStump cholelithiasisNeuroma

GB remnant and cystic duct

Liver

Anatomy

Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst

Etiology

CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or

nonspecific dilationDyskinesiaFistula

Biliary tract

EtiologyAnatomy

Intestinal anginaCoronary angina

VascularArthritisBone

AdhesionsIncisional herniaIrritable bowel disease

Small bowel

AdhesionsDiverticulaIrritable bowel disease

Duodenum

EtiologyAnatomyEtiologyAnatomy

ConstipationDiarrheaIncisional herniaIBS

ColonPancreatitisStoneCancer

Pancreas

Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx

Other

NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety

Nerve

Bile gastritisPUDGastric cancer

StomachDiaphragmatic herniaHiatal herniaAchalasia

Esophagus

Workup

bull Hx Pxbull Labs

ndash Incl LFT INRPTT amylase bili

bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction

bull Therapeutic as well stone extraction stricture dilation sphincterotomy

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Preop Risk stratification

bull Higher risk patientsndash Younger femalendash Urgent operationndash No stones documentedndash Longer duration of symptoms prior to surgeryndash Choledochotomy performed

bull No differencendash Typicality of preop symptomsndash Prior surgery bile spill stone spill

Symptoms

bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24

Etiology

SO dyskinesia spasm or hypertrophy

SO stricturePapilloma Cancer

PeriampullaryResidual GBStump cholelithiasisNeuroma

GB remnant and cystic duct

Liver

Anatomy

Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst

Etiology

CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or

nonspecific dilationDyskinesiaFistula

Biliary tract

EtiologyAnatomy

Intestinal anginaCoronary angina

VascularArthritisBone

AdhesionsIncisional herniaIrritable bowel disease

Small bowel

AdhesionsDiverticulaIrritable bowel disease

Duodenum

EtiologyAnatomyEtiologyAnatomy

ConstipationDiarrheaIncisional herniaIBS

ColonPancreatitisStoneCancer

Pancreas

Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx

Other

NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety

Nerve

Bile gastritisPUDGastric cancer

StomachDiaphragmatic herniaHiatal herniaAchalasia

Esophagus

Workup

bull Hx Pxbull Labs

ndash Incl LFT INRPTT amylase bili

bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction

bull Therapeutic as well stone extraction stricture dilation sphincterotomy

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Symptoms

bull Colic 93bull Pain 76bull Fever 38bull Jaundice 24

Etiology

SO dyskinesia spasm or hypertrophy

SO stricturePapilloma Cancer

PeriampullaryResidual GBStump cholelithiasisNeuroma

GB remnant and cystic duct

Liver

Anatomy

Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst

Etiology

CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or

nonspecific dilationDyskinesiaFistula

Biliary tract

EtiologyAnatomy

Intestinal anginaCoronary angina

VascularArthritisBone

AdhesionsIncisional herniaIrritable bowel disease

Small bowel

AdhesionsDiverticulaIrritable bowel disease

Duodenum

EtiologyAnatomyEtiologyAnatomy

ConstipationDiarrheaIncisional herniaIBS

ColonPancreatitisStoneCancer

Pancreas

Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx

Other

NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety

Nerve

Bile gastritisPUDGastric cancer

StomachDiaphragmatic herniaHiatal herniaAchalasia

Esophagus

Workup

bull Hx Pxbull Labs

ndash Incl LFT INRPTT amylase bili

bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction

bull Therapeutic as well stone extraction stricture dilation sphincterotomy

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Etiology

SO dyskinesia spasm or hypertrophy

SO stricturePapilloma Cancer

PeriampullaryResidual GBStump cholelithiasisNeuroma

GB remnant and cystic duct

Liver

Anatomy

Fatty infiltration of liver HepatitisHydrohepatosisCirrhosisGilbert diseaseDubin-Johnson SxHepatolithiasisSclerosing cholangitisCyst

Etiology

CholangitisAdhesionsStricturesTraumaCystMalignancycholangioCAObstructionCholedocholithiasisDilation wout obstructionHypertension or

nonspecific dilationDyskinesiaFistula

Biliary tract

EtiologyAnatomy

Intestinal anginaCoronary angina

VascularArthritisBone

AdhesionsIncisional herniaIrritable bowel disease

Small bowel

AdhesionsDiverticulaIrritable bowel disease

Duodenum

EtiologyAnatomyEtiologyAnatomy

ConstipationDiarrheaIncisional herniaIBS

ColonPancreatitisStoneCancer

Pancreas

Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx

Other

NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety

Nerve

Bile gastritisPUDGastric cancer

StomachDiaphragmatic herniaHiatal herniaAchalasia

Esophagus

Workup

bull Hx Pxbull Labs

ndash Incl LFT INRPTT amylase bili

bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction

bull Therapeutic as well stone extraction stricture dilation sphincterotomy

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Intestinal anginaCoronary angina

VascularArthritisBone

AdhesionsIncisional herniaIrritable bowel disease

Small bowel

AdhesionsDiverticulaIrritable bowel disease

Duodenum

EtiologyAnatomyEtiologyAnatomy

ConstipationDiarrheaIncisional herniaIBS

ColonPancreatitisStoneCancer

Pancreas

Adrenal cancerThyrotoxicosis20 organ other than hepatobiliary or pancreaticUnknownErroneous preop Dx

Other

NeuromaIntercostal neuralgiaSpinal nerve lesionsSympathetic imbalanceNeurosisPsychic anxiety

Nerve

Bile gastritisPUDGastric cancer

StomachDiaphragmatic herniaHiatal herniaAchalasia

Esophagus

Workup

bull Hx Pxbull Labs

ndash Incl LFT INRPTT amylase bili

bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction

bull Therapeutic as well stone extraction stricture dilation sphincterotomy

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Workup

bull Hx Pxbull Labs

ndash Incl LFT INRPTT amylase bili

bull Imagingndash US CBD lt=12mm increased with agendash CT pancreatitis pseudocystndash HIDA scan postop bile leakndash MRCP to delineate biliary tree anatomyndash ERCP to detect spincter of Oddi dysfunction

bull Therapeutic as well stone extraction stricture dilation sphincterotomy

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

More common causes

bull Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone bile duct injury bile leak

bull Acute epigastric pain not associated with jaundice due to PUDGERD wound neroma IBS pancreatitis

bull Stump neuroma long cystic duct stumpndash But cystic duct left long by design in lap to minimize

BD injuries no increased biliary symptom

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Outline

Sphincter of Oddi dysfunction

Retained Stone

Bile Duct Injury

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Sphincter of Oddi Dysfunction

bull Complex muscular structure bull Surrounds distal CBD pancreatic duct ampulla

of Vaterbull Caused by structural or functional abNbull Fibrosis of sphincter from gallstone migration

operative or endoscopic trauma pancreatitis or nonspecific inflammatory processes

bull Sphincter dyskinesia or spasmbull ~1 of patient undergoing cholecystectomy

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

bull Labs uarr amylase LFTbull ERCP delayed emptying of contrast medium

from CBDndash uarr basal sphincter pressure gt40mmHg

bull US dilated (gt12mm) CBDbull Med high-dose Ca channel blockers or nitrates

but evidence not convincingbull Tx sphincterotomy (endoscopic or

transduodenal)ndash Mucosa-mucosa apposition in surgical approach can

minimize scarring and restenosisndash Results of both treatment similar more dependent on

presence of objective signs of sphincter dysfunctionndash 60-80 successful if have documented objective

evidence

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Retained stones

bull More likely to occur with lap chole esp if no IOC done

bull Can present late (20yrs)bull Sx = intermittent pain in upper ab and back n+v

pancreatitisbull Dx = ERCP (therapeutic and diagnostic) MRCPbull Tx = ERCP+endoscopic US repeat lap chole

(for GB remnant) open excision of retained cystic duct impacted stone holmium laserESWL+ERCP

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Bile duct injury

bull Most feared complication bull Most recognized intraoperatively or during early

postop periodbull Long-term results acceptable with appropriate

managementndash Otherwise recurrent cholangitis secondary biliary

cirrhosis portal hypertension

bull Lap chole greater risk than open chole for bile duct injury

bull 1 in 120 lap chole major BDI 055 minor 03

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Proportion of BDI by IOC type of surgery and case complexity

1310583317862Not complex

22446169295Complex

107632274017Open

213397434140Laparoscopic

Injuries per 1000

Total cases

Injuries per 1000

Total cases

IOC YesIOC No

Fletcher DR et al Complications of cholecystectomy risks of the laparoscopic approachand protective effects of operative cholangiography a population-based studyAnn Surg 1999 April 229(4) 449ndash457

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Risk Factors

bull Surgeon factorsndash training and experiencendash Beyond 20 cases BDI rate decreasesndash Tenting CBD

bull Patient factorsndash uarr patient age male genderndash obesityndash long period of prior symptom uarr number of attacks

bull Pathology factorsndash Acute chole pancreatitis cholangitis obstructive jaundicendash Chronic inflammation fat in the periportal area poor exposure

bleeding obscuring operative fieldndash Aberrant biliary anatomy

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Strasbergrsquos view of safety

Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Cephalad traction on GB to tent the CBD out of normal location leading to clip placement at the cystic duct-CBD junction

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Prevention

bull Routine operative cholangiography reduce 50 of BDI or bile leak

bull Define anatomy and limit the extent of biliary injury

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Presentation

bull 25 of ductal injuries recognized intraopbull Presentation within 1wk

ndash bile leak from cystic duct stump transected aberrant R hepatic duct lateral injury to main bile duct

ndash Pain fever mild uarr-bilirubinemiandash Biloma bile peritonitisndash Persistent bloating or anorexia

bull Presentation laterndash Occlusion of CHDCBD with no intraperitoneal bile leakndash Jaundice abdo painndash May present months to years with cholangitis or cirrhosis

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Diagnosis

bull CT identifies peritoneal fluid abscess bilomandash perihepaticintraabdominal fluid perc drainedndash If cont bile leak thru perc drain Tc-IDA scanndash Sinogram thru drain after fibrous tract formed to

delineate biliary anatomyndash ERC if no external bile leak for biliary anatomy

bull If jaundiced CT or UIS can demonstrate ductal dilationndash level of injury ndash one segment vs entire lobe vs entire

liver

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Management

bull Appropriate management depends on time of Dx type extent and level of injury

bull Perc drain and biliary endoprosthesis if just cystic duct bile leakbull Partial transection T-tube

ndash At site of injuryndash If more extensive injury repaired primarily and stented

bull Complete transectionndash If recognized intraop repaired tension-free mucosa-to-mucosa duct

enteric anastomosisbull Only if no ductal length lostbull High rate of postop stricture formationbull Most require end-to-side Roux-en-Y choledochojejunsotomy or

hepaticojejunostomybull Pre-op transhepatic stents may help identify hepatic ducts

ndash After early postop period PTC for biliary decompression operative exploration and repair in 6-8 wks when acute inflammation resolved

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Results

bull Operative mort lt1bull Complication incl cholangitis subhepatic or

subphrenic abscess bile leak hemobiliabull 23 restenosis within 2yrsbull 91 without jaundice and cholangitis

ndash Less success if more proximal stricture (at or prox to hepatic duct birfurcation)

ndash Perc balloon dilation with stenting lower success rate (64)

bull Lower quality of life surveys esp in psychological domain even years after successful repair

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

References

bull httpwwwemedicinecomMedtopic2740htm Post Cholecystectomy Syndrome Accessed June 15 2006

bull Vetrhus M Berhane T Soreide O Sondenaa K Pain persists in many patients five years after removal of the gallbladder observations from two randomized controlled trials of symptomatic noncomplicated gallstone disease and acute cholecystitis Journal of Gastrointestinal Surgery 9(6)826-31 2005 Jul-Aug

bull Walsh RM Ponsky JL Dumot J Retained gallbladdercystic duct remnant calculi as a cause of postcholecystectomy pain Surgical Endoscopy 16(6)981-4 2002 Jun

bull Toouli JTitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain is it time to disregard the scan Current Gastroenterology Reports 7(2)154-9 2005 May

bull Piccinni G Angrisano A Testini M Bonomo GM Diagnosing and treating Sphincter of Oddi dysfunction a critical literature review and reevaluation Journal of Clinical Gastroenterology 38(4)350-9 2004 Apr

bull Corazziari ETitleSphincter of Oddi dysfunction Digestive amp Liver Disease 35 Suppl 3S26-9 2003 Jul

bull Shamiyeh A Wayand W Laparosopic cholecystectomy early and latre complciations and their treatment Langenbecks Arch Surg 389164-171 2004

Disc

Kayvan

Samaad clapping

Ray praying

Kayvan checking out ldquothe viewrdquo

• Postcholecystectomy Syndrome
• Introduction
• Slide 3
• Preop Risk stratification
• Symptoms
• Etiology
• Slide 7
• Workup
• More common causes
• Outline
• Sphincter of Oddi Dysfunction
• Slide 12
• Retained stones
• Bile duct injury
• Proportion of BDI by IOC type of surgery and case complexity
• Risk Factors
• Strasbergrsquos view of safety
• Classic lap chole BDI
• Slide 19
• Prevention
• Presentation
• Diagnosis
• Management
• Results
• References
• Slide 26
• Slide 27

Samaad clapping

Ray praying

Kayvan checking out ldquothe viewrdquo

• Postcholecystectomy Syndrome
• Introduction
• Slide 3
• Preop Risk stratification
• Symptoms
• Etiology
• Slide 7
• Workup
• More common causes
• Outline
• Sphincter of Oddi Dysfunction
• Slide 12
• Retained stones
• Bile duct injury
• Proportion of BDI by IOC type of surgery and case complexity
• Risk Factors
• Strasbergrsquos view of safety
• Classic lap chole BDI
• Slide 19
• Prevention
• Presentation
• Diagnosis
• Management
• Results
• References
• Slide 26
• Slide 27