Bile Duct Injury during cholecystectomy - ... £â€ misidentification of cystic...

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  • Bile Duct Injury during cholecystectomyBile Duct Injury during cholecystectomy

    Catherine HUBERTCatherine HUBERT JeanJean--FranFranççois GIGOTois GIGOT BenoBenoîît NAVEZt NAVEZ Division of HepatoDivision of Hepato--BiliaryBiliary--Pancreatic Pancreatic SurgerySurgery

    Department of Abdominal Surgery and Department of Abdominal Surgery and TransplantationTransplantation

    Strasbourg, IRCAD, October 2010

    TOPICSTOPICS

    Bile DuctBile Duct Injury during Lap CholeInjury during Lap Chole

    1.1. Prevalence, mechanisms, prevention and diagnosisPrevalence, mechanisms, prevention and diagnosis

    2. Treatment strategies:2. Treatment strategies: a.a. primary surgical repairprimary surgical repair b.b. postoperative biliary fistulapostoperative biliary fistula c.c. biliary peritonitisbiliary peritonitis d.d. biliary stricturebiliary stricture

  • Multicenter Belgian SurveysMulticenter Belgian Surveys

    VereeckenVereecken 1992 3244 LC all t1992 3244 LC all type 0.50 %ype 0.50 %

    GigotGigot < 1997 9959 LC < 1997 9959 LC all type 0.50 %all type 0.50 %

    VandesandeVandesande 1997 10.595 LC all ty1997 10.595 LC all typepe 0.37 %0.37 %

    11.628 11.628 all type all type 0.58 %all type all type 0.58 %

    VandesandeVandesande 2000 14.715 LC all t2000 14.715 LC all typeype 0.31 %0.31 %

    16.915 16.915 all type all type 0.54 %all type all type 0.54 %

    Navez Navez 2004 1089 LC 2004 1089 LC acute cholecystitis 1 %acute cholecystitis 1 %

    Authors Period Patients type of Authors Period Patients type of clinical BDI rateclinical BDI rate procedure presentationprocedure presentation

    X 2X 2

    Local risk factors of BDI

    THETHE RISK FACTORSRISK FACTORS for BDI during LAP. for BDI during LAP.  CHOLE are CHOLE are MULTIFACTORIALMULTIFACTORIAL

    1.1. factors inherent to the laparoscopic approachfactors inherent to the laparoscopic approach 2. inadequate training of the surgeon2. inadequate training of the surgeon 3. local risk factors3. local risk factors 4.4. Technical factorsTechnical factors

  • loss of depth perception loss of manual palpation surgeon's dependance to the equipment limited field easily obscured by bile or

    blood (loss of vision) blind manipulation of instruments.

    1.RISK FACTORS 1.RISK FACTORS INHERENTINHERENT TO THE TO THE LAPAROSCOPIC APPROACHLAPAROSCOPIC APPROACH

    0

    5

    10

    15

    20

    25

    50 100 150 200 250 300 350 400 450

    Nb ofNb of BDIBDI

    ! GIGOT, Surg Endosc 1997, 11 : 1171GIGOT, Surg Endosc 1997, 11 : 1171--11781178

    absentabsent presentpresent

    < 50 cases :< 50 cases : 55 %55 % 4545 %%

    > 50 cases :> 50 cases : 24 %24 % 76 %76 %

    SURGEON EXPERIENCE and LOCAL RISK FACTORS LOCAL RISK FACTORS **

    SurgeonSurgeon’’s experience (Nb of LC)s experience (Nb of LC)

    •• anonymous survey on 9959 LCanonymous survey on 9959 LC •• 65 patients with BDI (0.5 %)65 patients with BDI (0.5 %)

    p = 0.03p = 0.03

  • misidentification of cystic ductmisidentification of cystic duct : : the the «« classicalclassical »» injuryinjury

    ‐with   CBD   duct during IOC 6 % during dissection 35 %        43 %43 %

    ‐with cystic artery 1.5 %

    Laparoscopic belgian survey

    cystic duct avulsion cystic duct avulsion CBD tenting CBD tenting Clipping during urgent hClipping during urgent haaemostasis emostasis

    DIFFICULT 3. LOCAL RISK FACTORSAND BILE DUCT  INJURIES

    3 acute or severe chronic inflammation !!! (65 %)(65 %)

    33 large ilarge impacted stone in the Hartman mpacted stone in the Hartman ppouchouch (16 %)(16 %)

    33 MIRIZZI syndromeMIRIZZI syndrome +/+/-- biliobilio--biliary fistula (4%)biliary fistula (4%)

    33 Morbid obesityMorbid obesity

    33 Anatomical anomaliesAnatomical anomalies

    complete cholangiogram!complete cholangiogram!

  • You can perform a You can perform a Subtotal cholecystectomySubtotal cholecystectomy

    leave a piece of leave a piece of gallbladdergallbladder wallwall on on the the Calot triangle and at the level of Calot triangle and at the level of the Hartman Pouchthe Hartman Pouch

    In SEVERE CHOLECYSTITIS with anomalous RHD

    * lateral injury : 48%* lateral injury : 48%

    * complete* complete transsection : 32%transsection : 32%

    * resection : 10%* resection : 10% * thermal : * thermal : 11%11%

    SEVERITYSEVERITY SITE ( BISMUTH classif. )SITE ( BISMUTH classif. )

    * * type I : 51%type I : 51% * type II : 28%* type II : 28%

    * type III : 9%* type III : 9% * type IV : 3%* type IV : 3% * type V : 9%* type V : 9%

    52%52% 21%21%

    GIGOT, Surg Endosc 1997; 11: 1171GIGOT, Surg Endosc 1997; 11: 1171

    BDI during LC

  • CLINICAL PRESENTATIONCLINICAL PRESENTATION

    •• peroperative detection (29) :peroperative detection (29) :

    •• external biliary leak (8):external biliary leak (8): 12%12% •• biliary peritonitis :biliary peritonitis :

    -- localized (biloma) (3): 6%localized (biloma) (3): 6% -- diffuse (19) :diffuse (19) : 29 % !!!29 % !!!

    •• biliary stricture :biliary stricture : -- early (3):early (3): 4.5%4.5% -- late (3) :late (3) : 4.5%4.5%

    65 patients BDI during LC : the Belgian Registry

    51 %51 %

    44.544.5 %%

    * IMMEDIATE REPAIR :* IMMEDIATE REPAIR : * small caliber of non dilated ducts* small caliber of non dilated ducts (during the 1st op) * but absence of local inflammatio(during the 1st op) * but absence of local inflammation n

    * EARLY REPAIR : * non dilated ducts !!!* EARLY REPAIR : * non dilated ducts !!! (2 months) (>2 months) * presence of ductal dilatation with fibrotic tissues* presence of ductal dilatation with fibrotic tissues

    Bile Duct Injury during Lap.Chole.. TIMING of REPAIRTIMING of REPAIR

  • 1.Early1.Early REPAIR ofREPAIR of BDI BDI

    THERMAL INJURYTHERMAL INJURY In 1/3 of BDI VASCULAR INJURYVASCULAR INJURY

    risk factors for late stricture

    3030--50%50% type IV : 60 %type IV : 60 %

    Stewart et al. Ann Surg 2003; 237: 460Stewart et al. Ann Surg 2003; 237: 460

    Patients Patients Mortality Biliary Reinterv. FU (mo)Mortality Biliary Reinterv. FU (mo) RecurrentRecurrent complic.complic. median median StrictureStricture

    . Perop. detect. :. Perop. detect. : 7 %7 % 24 %24 % 14 %14 % 4646

    . Peritonitis :. Peritonitis : 50 %50 % 23 %23 % 5353 45 %45 %

    34 %34 % 20 %20 %

    29 %29 %

    47 %47 %

    Laparoscopic cholecystectomy Laparoscopic cholecystectomy  = = minimallyminimally invasiveinvasive procedureprocedure

    BDIBDI = = maximallymaximally invasiveinvasive situationsituation →→ change your philosophychange your philosophy →→ treat properly treat properly  →→ medicomedico‐‐legal consequencelegal consequencess

    PHILOSOPHY of TREATMENT

  • Bile Duct Injury during Lap.Chole.

    MANAGEMENT of BILE DUCT INJURY DIAGNOSED MANAGEMENT of BILE DUCT INJURY DIAGNOSED EARLY EARLY after LAPAROSCOPIC CHOLECYSTECTOMYafter LAPAROSCOPIC CHOLECYSTECTOMY

    •• external biliary fistulaexternal biliary fistula •• bile peritonitisbile peritonitis •• obstructive jaundice from biliary strictureobstructive jaundice from biliary stricture

    3 types of postoperative clinical presentations :3 types of postoperative clinical presentations :

    1. Postoperative Biliary Fistula RADIOLOGICAL EVALUATIONRADIOLOGICAL EVALUATION

    AVOID to REOPERATE AVOID to REOPERATE …… before complete evaluationbefore complete evaluationPURPOSEPURPOSE

    1. to define site and severity of BDI 2. to evaluate the intraabdominal bile leakage 3. to detect coexistent injury

    TYPE of IMAGING STUDIESTYPE of IMAGING STUDIES

    1. CT with contrast injection is superior to US 2. MRI is a “all-in” exam (cholangio + angio-MRI) to define lesions 3. ERCP is the most useful tool in partial injury

    (excepted if complete obstruction or transsection)

  • WAIT

    ERCP

    CT or (MRI)CT or (MRI)

    ddiffuse bileiffuse bile peritonitisperitonitis

    llocalizedocalized bilomabiloma

    * * nno collectiono collection * * ggood clinical conditionood clinical condition

    if if -- persistant > 1 week or worseningpersistant > 1 week or worsening -- LFTs elevated (obstruction ?)LFTs elevated (obstruction ?) -- total biliary diversiontotal biliary diversion

    SURGERYSURGERY Percut.Percut.RX drainageRX drainage

    -- amount of bile / 24 h.amount of bile / 24 h. -- evolution of biliary leakevolu