Bile duct

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Transcript of Bile duct

  • 1. Dr. Sreenath KDept of surgery, RIMS Imphal

2. IntroductionBile duct injury (BDI) Rare but potentially devastating condition Biliary peritonitis & sepsis, cholangitis, portalhypertension & secondary biliary cirrhosis Significant morbidity & mortalityIatrogenic BDI Increased financial burden (patient or hospital) 3. AnatomyCalots triangle betweeninferior surface of liver, Cysticduct & CHDContents Cystic artery,RHA, Cystic lymph node 4. Bile Duct Injuries (BDI)Iatrogenic injury Cholecystectomy Gastrectomy Pancreatectomy ERCPTraumaDuodenal ulcer 5. Risk factorsInflammation in the porta,Variable biiary anatomy,Inappropriate exposure,Aggressive attempts at hemostasis,Surgeon inexperience.97% due to visual misperception, only 3% accounts fortechnical skills and knowledge. 6. Misperception ..With sufficient cephalad retraction of the gall bladder fundus ,the cysticduct overlies the common hepatc duct running in a parrellel path.without inferolateral traction of the gallbladder infundibulum todossociate this structures, the dissection of apparent cystic duct mayactually include CBD 7. Classical LC BDI 8. Laparoscopic cholecystectomy (LC)Gold standard for management of benign gallbladder diseaseCompared with laparotomy Less post-op pain Shorter hospital stay Earlier return to normal activity Better cosmesis Iatrogenic bile duct injury rate 0.1% to 0.2% (open) vs 0.4% to 0.6% (lap)Learning curve phenomenon 9. LC & Bile duct injury (BDI)LC most common cause of BDIMore severe than those seen with Open choleLearning curve phenomenonBDI after LC stable around 0.6 to 0.7%, 4 times that of openchole high for a benign condition 10. Classificationlocation of injurymechanism & type of injuryeffect on biliary continuitytiming of identificationEach plays significant role in determining appropriatemanagement & operative repair 11. Classification of BDIBismuth classification (1982)Era of Open CholeBased upon level of biliary strictures with respect to hepaticbifurcationType 1-5.Helps surgeon choose appropriate site for repairDegree of injury correlates with surgical outcomes 12. Strasberg classification(1995)Type CriteriaA Leak from Cystic duct or small ducts in liver bedB Injury to sectoral duct(aberrant RHD) with obstructionC Injury to sectoral duct with consequent bile leakD Lateral injury to extrahepatic ductE1 Transection >2 cm from the confluenceE2 Transection 5mm Is it CBD?Even with low cysticduct insertion, CDrarely goes behindduodenumCBD goes behindduodenumDuct behind duodenummust be CBDDouble cystic ductvery rare-- 2 ducts seem to go towardsinflammed Gallbladder one must be CBDNo vessels onsurfaceVessels onsurface-- 20. Management 21. Recognized at the Time of CholecystectomyConversion to an open operation and use ofcholangiography.Goals ..Maintenance of ductal length, elimination of any bileleakage that would affect subsequent management, andcreation of a tension-free repair. 22. Ducts smaller than 3 mm drain only a single segment orsubsegment of liver..simple ligation. Ducts larger than 3 mm usually drain more than a singlesegment of liver,if transected.. should be reimplanted intothe biliary tree.Injury occurs to a larger duct, but is not caused byelectrocautery and involves less than 50% of thecircumference of the wall, a T tube placed through theinjury 23. Low injuries to the bile duct can be reimplanted into theduodenum.Most injuries to the bile duct occur higher in the biliary tree,close to the hilum, thus not allowing for tension-free anastomosisto the duodenum. Therefore, in almost all cases of bile ductinjury, a resection of the injured segment with mucosa tomucosa anastomosis using a Roux-en-Y jejunal limb (end-to-side choledochojejunostomy ) is preferred.Transanastomotic stenting has been shown to improveanastomotic patency. 24. Identified After CholecystectomyGoals of Therapy in Iatrogenic Bile Duct Injury1.Control of infection limiting inflammationParenteral antibioticsPercutaneous drainage2.Clear and thorough delineation of entire biliary anatomy.MRCP/PTC , ERCP3.Re-establishment of biliary enteric continuityTension-free, mucosa-to-mucosa anastomosisRoux-en-Y hepaticojejunostomyLong-term transanastomotic stents if involvingbifurcation or higher 25. Approach..Should undergo imaging to assess for a fluid collection andevaluate the biliary tree.Ultrasonography can achieve both these goals. Cross-sectional imaging via CT will generally provide moreuseful data.Radionucleotide scanning to confirm bile leakage, but withany documentation of a leak, CT will be necessary to planmanagement. 26. CT or U/S guided (or surgical) drainageSepsis control Broad-spectrum antibiotics &percutaneous biliary drainage to control any bile leak most fistulas will be controlled or even close.1.5% mortality rate due to uncontrolled sepsisNo rush to proceed with definitive management of BDI.Delay of several weeks allows local inflammation to resolve& almost certainly improves final outcome. 27. Definitive management is to reestablish durable biliaryenteric drainage.Combination of percutaneous and endoscopic biliarydilations and stenting may establish continuity.Surgical reconstruction has the highest patency rates.performed between a minimally inflamed bile duct tointestines in a tension-free, mucosa to mucosa fashion. 28. If the anastomosis is within 2 cm of the hepatic ductbifurcation, or involves intrahepatic ducts, long-term stentingappears to improve patencyIf the bifurcation is involved, stenting of both right and leftducts should be performedWhen the reconstruction involves the common bile duct orcommon hepatic duct more than 2 cm from the bifurcation,stenting is not necessary. 29. Interventional Radiologic and Endoscopic TechniquesUsing balloon dilation techniques, the stricture is dilated anda catheter is left in place to decompress the system, allowhealing, document resolution and, if necessary guide repeatdilations.This approach is successful in up to 70% of patients.Endoscopic balloon dilation of bile duct strictures is generallyreserved for those with primary bile duct strictures or patientswho have undergone choledochoduodenostomy forreconstruction, because the Roux limb does not usually allowfor endoscopic strategies. 30. Twolargeretrospectivereviewshavebeenperformedandbothhaveshownhighersuccessratesfromsurgicaltherapy,withlowermorbidityandlowermortalityfollowingoperativemanagementcomparedwiththosefornonoperativestrategies 31. ERCP multiple stentsLateral duct wall injury orcystic duct leak transampullary stent controlsleak & provides definitivetreatmentDistal CBD must be intact toaugment internaldrainage with endoscopicstent 32. ERC clips across CBDCBD transection normal-sized distal CBDupto site of transectionPercutaneous transhepaticcholangiography (PTC)necessarySurgery 33. Cholangiography (ERCP + PTC)Percutaneous transhepatic cholangiography (PTC) Defines proximal anatomy Allows placement of percutaneous transhepatic biliarycatheters to decompress biliary tree treats orprevents cholangitis & controls bile leak 34. MRCP / CT cholangiographyNoninvasiveMay avoid invasive procedures like ERCP or PTCDo not allow interventionInterpretatation in presence of bile collection difficult 35. Biliary enteric anastomosisMost laparoscopic BDI complete discontinuity ofbiliary treeSurgical reconstruction,Roux-en-Yhepaticojejunostomytension-free, mucosa-to-mucosa anastomosis withhealthy, nonischemic bile duct 36. Treatment summaryStrasberg Type A ERCP + sphincterotomy + stentType B & C traditional surgical hepaticojejunostomyType D primary repair over an adjacently placed T-tube (ifno evidence of significant ischemia or cautery damage at siteof injury)More extensive type D & E injuries Roux an-Yhepaticojejunostomy with biliary stent 37. Risk Factors for BDIAcute inflammation at Calots triangleAtypical anatomy aberrant RHD (most common) complex cystic duct insertionConditons that impair Critical view of safety Obesity & periportal fat Complex biliary disease choledocholithiasis ,gallstone pancreatitis, cholangitis Intra-op bleeding 38. ReasonsMisidentification CBD or aberrant RHD mistaken for cystic duct Risk factors inexperience, inflammation or aberrantanatomy Infundibular technique flaring of cystic duct as itbecomes infundibulum misleading in inflammationTechnical errors Cautery induced injury 39. Anatomic illusion?Misperception (97%) rather than technical error (3%)Everyone is susceptible experience, knowledge & technicalskill alone may not be adequateAll BDI may not represent substandard practiceImprovements may have to depend on technology 40. SummaryMultidisciplinary management of BDI expertise ofsurgeons, radiologists & gastroenterologistsMismanagement lifelong disability & chronic liverdiseaseBDI with lap. Chole results of operative repair isexcellent in Specialist Centres 41. Thank you