Bile duct injuries

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BILE DUCT INJURIES Dr. Joe M Das

Junior ResidentS3 Unit

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• Bile duct injuries represent a complex clinical scenario seen with increased frequency owing to – aberrant anatomy and – more lap cholecystectomies being performed

• Incidence : –0.1-0.2 % in open cholecystectomy–0.4-0.6 % in lap cholecystectomy

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HISTORY

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• Earliest known gall stones - Priestess of Arnan (1085-945 BC) - Egyptian

• Recognition of gallstones was first recorded by a Greek physician Alexander Trallianus (525-605 BC)

• The first clinical description of gallstone disease - Gordon Taylor, in his description of the symptoms manifested by Alexander the Great in 323 BC

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• Observations of human gallstones were first demonstrated during autopsy by Gentile da Foligno (1341) in Padua

• In 1667, Michael Entmuller said, “There are no medicine which will cure gallstones”.

• Jean Lovis Petit (1674-1750) – – identifying the biliary colic and other signs

of this disease – removing the gallstones after puncturing

the gall bladder with trocar and cannula in 1743.

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• John Stough Bobbs - first elective cholecystostomy in Indianapolis for hydrops of the gallbladder

• In 1878 Kocher drained an empyema of gallbladder.

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• Ludwig Georg Courvoisier (1843-1918).– Law (Statistical

article on the pathology and surgery of the biliary system)

– First choledocholithotomy

– Butterflies

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First open cholecystectomy•Dr Carl Johann August Langenbuch (German surgeon) •July 15, 1882, at Lazarus

Krankenhaus in Berlin

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• Bernard Naunyn (1839-1925) - pathophysiological basis of gall stone formation

• Hans Kehr - inventing a T tube

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First laparoscopic cholecystectomy

• Erich Mühe in Germany in 1985

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• The first laparoscopic cholecystectomy in India was done in 1990 at the J.J. Hospital, Mumbai

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"The pleasure of a physician is little, the gratitude of patients is rare and even rarer is material reward, but, these things never deter the student who feels the call within him”–BILLROTH

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REVIEW ON SURGICAL ANATOMY

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Extra hepatic biliary tract

• Left hepatic duct – segment 2,3,4.• Right hepatic duct Right anterior: 5,8 Right posterior:6,7• Hilar plate : seperates biliary confluence from

posterior aspect of caudate lobe.• Common hepatic duct lies anterolateral to

hepatic artery and vein in the hepatoduodenal ligament.

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• Common bile duct : – Length : 5 to 9cm– Diameter : 6 to 8 mm– Supraduodenal , retroduodenal &

intrapancreatic .• Gall bladder :

– 7 to 10 cm length.– 30 to 60 ml capacity.– Fundus ,body infundibulum and neck

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• Cystic duct : – Length : 1 to 5 cm – Diameter : 3 to 7 mm

• Blood supply :– Distal : Gastroduodenal,retroduodenal,

pancreatoduodenal arteries– Proximal : Right hepatic and cystic arteries.

Arteries run parallel to each other at 3 & 9 o’clock position.

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Common bile duct

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Calot’s triangle(Hepatobiliary / Cystohepatic triangle)

• Common hepatic duct ,liver and cystic duct.• Cystic artery, RHA & lymph node.

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Duct of Luschka (Accessory hepatic / cholecystohepatic duct)

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Variations of Accessory duct at Porta Hepatis

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Anatomical variations of Gall bladder

• Agenesis of GB : 0.02%.

• Cholangiography

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Multiple Gall Bladder

• 1 in 3800.• Should be removed

even when normal.• Magnetic or CT

cholangiography

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Ectopic Gall Bladder

• Normally formed gall bladder in an abnormal site.

• Intrahepatic , left sided , transverse or retrodisplaced.

• Floating gall bladder : suspended via a mesenteriole.

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Intrahepatic & floating

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Cystic duct Anomalies

• Only 33% have classical anatomic position and course.

• Most important : junction of cystic duct with CHD

• Length varies : 20% < 2cm ,majority 2-4cm.• Careful dissection of the Calot’s triangle.

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(a)Low & parallel course (15%)(b)Adherent to CHD (6%)

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(c)Normal course of the cystic duct(60)(d)Short & absent cystic duct(3.5&0.5)

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(e)Anterior spiral course to left of CHD(2)(f)Posterior spiral course to left of CHD(13)

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Variations of CBD & Extra hepatic confluence.

• Convergence of hepatic ducts vary greatly.

• Sectoral ducts: nonconfluence of the ducts with independent ending for each duct in duodenum.

• Length of CBD varies from person to person.

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(a) 1.4% (b) 2.6%

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(c) 0.16% (d)0.08%

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(e) 10.7% (f) 85%

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Cystic dilatations of biliary treeTodani Classification

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• Ty 1- Solitary fusiform extrahepatic cyst.• Ty 2 – Extrahepatic supraduodenal diverticulum.• Ty 3 – Choledochocele - intraduodenal

diverticulum• Ty 4a – Fusiform intra & extrahepatic cysts.• Ty 4b – Multiple extrahepatic cysts.• Ty 5 – Caroli’s disease (multiple intrahepatic

cysts)

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Cystic artery variations

• 20% cases arise from middle & left hepatic artery.

• Replacements : gastroduodenal ,celiac axis or independently from aorta.

• Abberant RHA from SMA .• Double cystic artery.

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Diagram shows cystic artery classification based on the relationship of the cystic artery to the Calot triangle.

Sugita R et al. Radiology 2008;248:124-131

©2008 by Radiological Society of North America

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Causes of bile duct injury

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CYSTIC DUCT INJURIES AND BILE LEAK

• Cystic duct : 50%

• Subvesical or Gallbladder bed : 25%

• Major bile duct :25%

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• Cystic duct leak – failure to safely ligate the cystic duct – failed application of endoscopic clips.

• Acute cholecystitis : wide and friable cystic duct.

• Intraoperative cholangiogram • Endo-loop application is better.

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Clinical features and investigation

• Excessive right upper quadrant pain and elevated bilirubin.

• Ultrasound or CT • HIDA (hepatobiliary iminodiacetic acid) • ERCP : procedure of choice

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Extra hepatic bile duct injuries

• Common hepatic duct most commonly injured.

• During dissection of Calot’s triangle & inadequate identification of the structures.

• Either partial lacerations or complete transections.

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Intrahepatic bile duct injuries

• During dissection of gallbladder off the liver bed.

• Right hepatic duct more commonly injured than left.

• Inadequate / incomplete cholangiogram : convert to open.

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Cause of biliary strictures

• Direct injury• Clipping of duct• Thermal injury• Ischaemia• Inflammation and scarring secondary to

bile leakage.

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Mechanisms of injury and risk factors

• Anatomic variations.

• Complicated pathology.

• Technical error.

• Thermal and laser injuries.

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Complicated pathology

• Acute inflammation and scarring of the triangle of calot.

• Acute cholecystitis.• Acute pancreatitis.• Chronic cholecystitis.• Mirizzi syndrome • Perforated duodenal ulcer.

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Technical errors

• Cephalad and lateral retraction of gall bladder is necessary to expose the structures.

• Cautious retraction in case of acute inflammation or gangrenous gall bladder.

• Avoid application of clips too close to the cystic duct CBD junction.

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• Avoid strenous dissection too close to the CBD.

• Blind application of clips to achieve hemostasis.

• Willingness to convert to open technique.

• Early in the surgeons learning curve.

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Thermal and laser injuries

• Use of electrocautery• Avoided near the CBD• Bipolar cautery is better.• Laser : severe injuries with tissue loss.• Avoid usage near metallic clips• Low intensity for short duration

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CLASSIFICATION

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Bergmann classification of bile duct injuries

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Stewart Way classification of Laparoscopic bile duct injuries

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A drawback of the Bismuth classification is that patients with limited strictures, isolated right hepatic duct strictures, or cystic duct leaks cannot be classified

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Strasberg classification is able to classify all types of injury and is used extensively in describing bile duct injuries associated with laparoscopic cholecystectomy

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• McMahon

• Amsterdam Academic Medical Center's classification (1996)

• Neuhaus' classification (2000)

• Csendes' classification (2001)

• CUHK (Chinese University of Hong Kong), 2007

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What are the clinical features and how to detect these injuries?

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• Most class I injuries are recognized intraoperatively (about 60–70%).

• Those unrecognised present with mild abdominal pain, abdominal distention, ileus, with mild elevations in ALP (average 250 U/l) and bilirubin (average 2.3 mg/dl)

• Ultrasound and CT scans demonstrate an abdominal fluid collection without dilated bile ducts

• ERCP reveals an intact biliary tree with a fistula

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• The majority of class II injuries (60–70%) present

with– Obstructive jaundice, pruritus, cholangitis, ↑

bilirubin and alkaline phosphatase levels.• The remainder of the patients, who have

associated biliary fistulas, present similar to class I injuries.

• Some patients may have a prolonged bile leak from surgically placed drain that then closes, with the subsequent development of a biliary stricture and jaundice

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• CT and USS – – dilated bile ducts in patients without biliary

fistulas– non-dilated ducts and abdominal fluid

collections in patients with associated biliary fistulas.

• ERCP shows the lesion, invariably with multiple clips overlying it with or without a fistula.

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• Patients with class III injuries present like class I injuries, only they can have a more toxic illness.

• About 25% of these injuries are recognized during the index operation when bile is seen to drain from the common (or hepatic) duct.

• The remainder of patients present later with abdominal pain, abdominal distention, ileus, and cholangitis

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• Laboratory abnormalities are highly variable

• Total bilirubin can be normal or elevated (average of 4–5 mg/dl)

• Alkaline phosphatase can be normal to elevated (average of 225 U/l)

• White blood cell count similarly can be normal to mildly elevated (average 13 000/cm2)

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• CT and ultrasound scans - an abdominal fluid collection and nondilated bile ducts.

• ERCP distinguishes class III from other bile duct injuries involving a biliary fistula.

• The findings in class III injuries consist of a truncated common bile duct that is occluded with a clip, and non-filling of the biliary radicles .

• PTC demonstrates the proximal extent of these injuries.

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• Class IV injury patients present with abdominal pain, abdominal distention, ileus, cholangitis, hepatic abscess (20–25%)

• Unlike the other injuries, many (45%) of these patients can have associated severe hemorrhage requiring blood transfusions.

• CT and USS – non-dilated ducts and fluid collections

• ERCP - injury to or occlusion of the right hepatic duct (or a right sectoral duct) by a clip

• PTC - a fistula from the right hepatic ductal system

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Routine intraoperative cholangiography

• Fletcher et al. in 1999 found that intraoperative cholangiography had a protective effect for complications of cholecystectomy in a retrospective study of 19,000 cholecystectomies.

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Is it possible to detect these injuries intra operatively?

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Intraoperative clues to a bile duct injury

• Cholangiogram abnormalities:– Failure to opacify the proximal hepatic ducts– Narrowing of the CBD at the site of cholangiogram

catheter insertion• Bile drainage:

– Drainage of bile from any location other than a lacerated gallbladder

– Bile draining from a tubular structure

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• Atypical features of cystic duct:– A ‘cystic duct’ that is not completely

encompassed by the standard M/L. clip, which measures 9mm in the closed position, the structure may be the common duct

– A ‘cystic duct’ that can be traced without interruption behind the duodenum, that will prove to be the common duct, not the cystic duct

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• Anomalous anatomy:– Second cystic duct, aberrant duct, accessory duct, or

suspected duct of Lushka, these are generally the common duct or a hepatic duct

– Second cystic artery, this may be the right hepatic artery

– Lymphatics surrounding the ‘cystic duct’ or more tissue around the cystic duct than is usually encountered, this indicates that the dissection is in the porta

– Fibrous tissue in the gallbladder bed, indicates transection of the proximal hepatic ducts

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How to prevent?

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• Proper selection of cases• In obese patients place the optical port little higher

up from the umbilicus to avoid the tangential view of the Calot’s triangle.

• Posterior peritoneal fold should be opened before approaching the Calot’s triangle anteriorly. This provides an extra mobility to GB and helps the CHD to fall away from the CD thereby avoiding proximal BDI during the dissection of Calot’s triangle.

• Always dissect to the right of the line joining the right free margin of lesser omentum to cystic node.

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• While dissecting the Calot’s triangle stay close to the GB.

• It is advised that Calot’s triangle is dissected in such a way that the retro-infundibular window is opened first and then the window between the cystic artery and duct is opened. Visualisation of the double window is called “Critical view of Strasberg”.

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• The technique of “critical view of safety” of Strasberg

• Calot’s triangle is completely unfolded by mobilizing the gallbladder neck from the gallbladder bed of the liver before transecting the cystic artery and duct

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• Always dissect to the right of the line joining the right free margin of lesser omentum to cystic node.

• Vessels pulsating before clipping should be considered as hepatic artery until proved otherwise.

• While dissecting GB from the liver bed stay close to the GB and avoid any injury to superficial portal radical or abnormally superficial right anterior sectoral duct.

• Intra-operative cholangiogram may be used routinely in order to better identify the anatomy after dissection of Calot’s triangle.

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• Once the Calot’s triangle is fully dissected and cystic artery has been clipped and cut, GB is left attached medially to only one structure, CD.

• If the plane between the liver and GB is absent, it might be better to leave a part of posterior GB wall adhered to the liver bed and cauterise its mucosa than to cause an inadvertent injury to hepatic parenchyma resulting in bleeds and postoperative biliary fistula.

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• The cystic duct and the GB neck and infundibulum together looks like Lord Ganesha’s trunk and head (or elephant’s trunk and head) respectively and so also called as Lord Ganesha’s sign.

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• Use the suction-irrigation cannula to aid in dissection. The oozing surface absorbs light with a resultant darker picture.

• In case of impacted stone in the neck, it may be safer to transect the Hartman’s pouch and remove the stone. The left out mucosa can be cauterised and stump is sutured.

• In case of a dilated CD where clip cannot adequately close its lumen, it is advised to use endoloop or intracorporeal suturing for safe closure of the stump.

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In case of excessive bleeding during the surgery:

• Have a low threshold for conversion.• If there is continuous ooze from the inflammed

surface, liberal irrigation and aspiration should be used.

• If there is sudden arterial spurt, compress the area temporary with small gauge or atraumatic grasper. Irrigate / aspirate and clean the operative field. Effectively control the bleeding vessel with left hand grasper, identify the vessel and arrest bleeding with clips or bipolar electrocautery.

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“I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work”-Letter to Dr Henry Christian Nov 20, 1911

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MANAGEMENT

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HOW ESSENTIAL IS TO TREAT BILE DUCT INJURIES?

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• Most bile duct injuries or strictures occur as a result of cholecystectomy for symptomatic gallstone disease.

• The majority of these patients are young (40–50 years), female, have a long life expectancy, and are in the most productive years of their life.

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• Biliary strictures may result in significant morbidity and mortality secondary to complications such as biliary cirrhosis , cholangitis,portal hypertension.

• Because of this, it is essential that these patients have prompt recognition of their problem and a reliable treatment with a long-term success rate.

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WHAT ARE THE FACTORS ONE SHOULD CONSIDER BEFORE TREATING BILE DUCT

INJURIES?

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1.Timing of diagnosis - Intra-operative - Early post-op

- Late post-op

2.Extent and level of injury

3.Patient presentation

4.Hospital setup

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WHAT ARE THE TREATMENT OPTIONS AVAILABLE ?

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• A multidisciplinary approach• The team consisting of experienced

interventional radiologists, endoscopists, and surgeons, coordinated by an experienced hepatobiliary surgeon

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1) Surgical Management 2) Interventional Radiologic Techniques 3) Endoscopic Techniques • Most of these injuries and strictures are best

repaired surgically. SURGERY - GOLD STANDARD

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"Surgery is the first and the highest division of the healing art, pure in itself, perpetual in its applicability, a working product of heaven and sure of fame on earth" - Sushruta (400 B.C.)

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PRE-OPERATIVE MANAGEMENT

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• Early post-op period Sepsis /SIRS Treat with –Broad spectrum antibiotics -Percutaneous biliary drainage - Percutaneous/operative drainage of bilomas

No hurry for surgical repair - friable tissue -retraction of small ducts

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• Next step- Pre-op cholangiography (to define anatomy)

Control bile leak with percutaneous stents

Delayed surgical repair

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• Late post-op periodStricturesCholangitisTreat with- Broad spectrum antibiotics

Urgent cholangiography

Biliary decompression -Transhepatic biliary drainage -Endoscopic drainage + stent

Surgical repair

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• If patient presents only with jaundice & no cholangitis

ERC / PTC - to define anatomy

In these cases biliary decompression has not been demonstrated to improve outcome

Surgical repair

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INTRA OPERATIVE MANAGEMENT

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• Intra-operatively, any suspicious biliary injury

1) Intra-op cholangiography +/- Careful dissection 2) Lap to open conversion is often necessary

• Isolated, small, non–cautery-based partial lateral bile duct injury Placement of a T tube

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• Injury involves <50% of the circumference of the bile duct wall

Primary closure over a T-tube

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• More extensive biliary injury• Significant thermal damage owing to cautery-

based trauma• Injury involving >50% of the circumference of

the bile duct wall

End-to-side choledochojejunostomy with a Roux-en-Y loop of jejunum should be performed

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MANAGEMENT OF HEPATIC DUCT INJURIES

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• Major bile duct injuries, including transections of the common common hepatic duct, can be repaired.

• Isolated hepatic ducts smaller than 3 mm or those draining a single hepatic segment can be safely ligated.

• Ducts larger than 3 mm are more likely to drain several segments or an entire lobe and need to be reimplanted.

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TECHNICAL ASPECTS OF SURGICAL REPAIR

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SURGICAL REPAIR• The blood supply of the common duct is axial

running at 3:00 and 9:00 on the duct. • These vessels are small and easily damaged during

extensive mobilization of the duct.• In addition, the majority of the blood supply (60%)

comes from below, while only 38% comes from above, further contributing to ischemia in the proximal portion of the duct

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• The choice and technique of repair correlates with the success rate.

• End-to-end anastomosis- The common duct (or common hepatic

duct) has been divided and there is sufficient length to perform an end-to-end anastomosis without tension

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Unsuccessful :1.When repaired at the initial open cholecystectomy

2. Class III injuries, especially laparoscopic.• The reasons for the high failure rate of end-to-

end biliary anastomoses relate to ischemia and tension.

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Roux-en-Y hepaticojejunostomy • Has the best success rate for the repair of a transection injury of CBD/CHD

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Certain technical factors for a successful hepaticojejunostomy are

• Preoperative eradication of intra-abdominal infection

• Viable ductal tissue (excise damaged ductal tissue)

• Single-layer mucosa-to-mucosa anastomosis• Fine, monofilament, absorbable suture• Alleviate tension on the anastomoses

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Stenting

• Stenting is useful, however, when very small ducts are repaired (class IV injuries or class III injuries where the resection has been carried high into the porta).

• For other injuries stenting may not be required.

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WHEN DETECTED POST-OP….?

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• The management of postoperative biliary strictures following ductal injury depends on the degree of injury, the presence of stricture-induced complications, and the operative risk of the patient.

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• After recognition of a bile duct injury or stricture, a multidisciplinary team consisting of experienced interventional radiologists, endoscopists, and surgeons, coordinated by an experienced hepatobiliary surgeon, should plan the following specific goals:

1. Control the infection (abscess or cholangitis)

2. Drain the biloma 3. Complete the cholangiography 4. Provide definitive therapy with controlled

reconstruction or stenting

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OVERVIEW

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Suspected CBD injury during lap-cholecystectomy

Intra-op cholangiogram

Partial injury(<30%) Primary repair over T-tubeExtensive injury(>30%) Roux en Y

choledochojejunostomyComplete transection Roux en Y.Injury to isolated hepatic duct >3mm Reimplantation or reconstruction by Roux en Y hepaticojejunostomy <3mm Ligate

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Role of Interventional Radiology

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• Interventional radiologic techniques are useful in patients with bile duct injuries, leaks, or postoperative strictures.

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• These techniques allow 1)Percutaneous drainage of abdominal fluid

collections 2)Preoperative identification of the ductal anatomy

through percutaneous transhepatic cholangiography

3)Stricture dilation with or without placement of palliative stents for bile drainage in the patient whose overall physiologic status precludes a major operation.

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• Percutaneous transhepatic biliary dilatation: – Intrahepatic ductal disease – ERCP is not possible– Adjunct to operative repair in order to assist

with identification of the proximal biliary tree for reconstruction and for the dilation of anastomotic strictures

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ROLE OF ENDOSCOPIC DILATATION IN BILIARY STRICTURES

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• Adjunctive option in patents with a dominant extrahepatic stricture causing clinical symptoms.

• Requires multiple sessions of dilations• Nonischemic strictures (anastomotic

strictures) respond best.

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• Metalic stents are more durable than plastic stents

• Endoscopic dilation also has a low mortality rate, but it has a significant morbidity rate.

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• Complications following endoscopic biliary interventions:– Hemobilia– Bile leak– Pancreatitis– Cholangitis – Re-stricture

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POST-REPAIR COMPLICATIONS

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1. Cholangitis2. Pancreatitis3. Stent occlusion4. Stent migration5. Ductal perforation6. Restricturing7. Biliary fistula8. Hemobilia

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MANAGEMENT OF BILIARY FISTULA

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• To define biliary fistula – ‘ a bilirubin rich drainage lasting for more

than 5 days’

• Most of them resolve spontaneously with conservative management.

• 3 R’S

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3 Rs

• Resuscitation• Restitution• Rehabilitation

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Resuscitation

The first stage in the management is the restoration of volume using crystalloid and colloid products as appropriate to restore oxygen carrying capacity and plasma oncotic pressure.

Blood PCV 30% Albumin -3

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• Control of sepsis• Per cutaneous drainage• Antibiotcs should only be given for defined

infections and for a set duration of therapy• Nutritional support• Cholangiography

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Non-operative management

• Usually for low output fistula

• Percutaneous drainage• Trans-hepatic stenting

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Surgical intervention

• For early high output fistula• Persistent sepsis

Reoperation

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References

• Surg Clin N Am 90 (2010) 787-802• Surg Clin N Am 88 (2008) 1329-1343• Schwartz's Principles of Surgery, 9e• Sabiston Textbook of Surgery, 17e

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THANK YOU