Bile duct injury during laparoscopic cholecystectomy

Dr. Law Sze HongTuen Mun Hospital

Joint Hospital Surgical Grand Joint Hospital Surgical Grand

RoundRound

September 2007September 2007

Introduction

Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation

Introduction

Numerous reports have demonstrated that the incidence of bile duct injuries has risen from 0.1-0.2% to 0.4-0.7% between the era of open cholecystectomy and the era of laparoscopic cholecystectomy (Strasberg SM. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101-125)

New type of injury

New type of injury

Prevention

One-third of biliary injuries happen after the surgeon has performed more than 200 cases

Therefore, it is more than inexperience that leads to bile duct injuries

Commonest cause is misidentification of biliary anatomy (70-80%)

Prevention

Hunter and Troidl proposed: 30 degree telescope Avoidance of diathermy close to CHD Dissection close to gallbladder-cystic

junction Conversion to open when uncertain

Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy Am J Surg 1991;162:71-76

Troidl H. Disasters of endoscopic surgery and how to avoid them: error analysis. World J Surg 1999;23:846-855

Main theme

Management of bile duct injuries detected intraoperatively

Bile leakage detected in the early postoperative period

Biliary strictures will not be discussed

Intraoperative management

In general, 75-90% of the injuries are not recognized intraoperatively

Intraoperative identification of injury may occur by recognition of bile in the field, indicating a cut bile duct; by cholangiography; or rarely by direct observation of a divided duct

Role of intraoperative cholangiography (IOC) There is good evidence to show

that intraoperative cholangiography is likely to identify the injury at the time of surgery (Archer SB. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001;234:549-559)

Early recognition of biliary injury and appropriate repair is associated with improved outcome (Savader SJ. Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster. Ann Surg 1997;225:268-273)

Intraoperative management

If injury to the biliary tree is recognized at the time of initial cholecystectomy, the surgeon should consider his or her experience and ability to repair it immediately

Intraoperative management

Substantial evidence suggests that immediate open conversion and repair by an experienced surgeon is associated with reduced morbidity, shorter duration of illness, and lower cost (Bile duct injuries during laparoscopic cholecystectomy: factors that influence the results of treatment. Stewart L, Way LW. Arch Surg 1995;130:1123-1129)

Intraoperative management Each failed repair is associated with some

loss of bile duct length and greatly exacerbates an already difficult situation

If the surgeon cannot effect a reasonable repair, and competent help is unavailable, drains should be placed to control any biliary leak, and the patient should be referred to a specialist centre

Intraoperative management

In cases of injuries of the biliary tract with minimal tissue loss, primary repair can be performed

Hepaticojejunostomy is required for major duct transection with tissue loss

Intraoperative management

Early recognition of bile duct injury is important as primary repair can be performed at the same operation and in expert hands, the long term outcome is favorable

Management of bile leak in early postoperative period

Patients with bile leaks generally present within the first week after operation, but some may not become apparent for several weeks

These patients usually present with abdominal pain coupled with fever or other signs of sepsis

Management of bile leak in early postoperative period

Elevated alkaline phosphatase levels are characteristic, as is hyperbilirubinemia, but jaundice is very uncommon

A few patients present only with vague symptoms such as distension, malaise, anorexia, complaints of discomfort, or requirements for more than the usual amount of analgesia

Management of bile leak in early postoperative period

Such complaints are all too easy to dismiss, but they might be the only manifestations of a serious biliary injury

Successful management of bile duct injuries recognized in the postoperative period requires thorough investigation and optimal patient preparation

Investigations Ultrasonography (USG)

An excellent, noninvasive means of showing intrahepatic ductal dilatation and intraperitoneal fluid collection

If a bile collection is suspected, percutaneous aspiration or drain placement can confirm that the fluid is bile and serve as a step to control the effects of the bile leak

Investigations

Computed tomography (CT) Able to show a dilated biliary tree,

identify fluid collections and help localize the level of ductal obstruction in patients with strictures

More sensitive than USG (96% Vs 70%)

Probably the best initial study in biliary injuries

Investigations

Endoscopic retrograde cholangiopancreatography (ERCP) Has a role in the diagnosis and

treatment of patients with bile leakage from the cystic duct stump or from a laceration of the common duct

Helpful for incomplete strictures

Investigations Little value in cases of complete

proximal bile duct strictures because there is often discontinuity of the common bile duct preventing visualization of the intrahepatic ductal system

Investigations Percutaneous transhepatic

cholangiography (PTC) Defines the anatomy of the proximal

biliary tree to be used in the surgical reconstruction

Can be followed by placement of percutaneous transhepatic catheters, which can be useful in decompressing the biliary system

Investigations These catheters also will be of

assistance in the surgical reconstruction

Technically difficult in patients with nondilated biliary tree

Optimal patient preparation

Sepsis must be controlled with board-spectrum antibiotics

Intraperitoneal bile collection should be drained

Optimization of nutritional status of the patients ensured

Management of bile leak in early postoperative period

After thorough investigations and optimal patient preparation, treatment of the biliary injuries can be started

The treatment options will depend on the type of biliary injuries

Management of bile leak in early postoperative period

For biliary leakage from the cystic duct stump, liver bed, or minor lacerations of major bile ducts, reducing intrabiliary pressure by endoscopic sphincterotomy with placement of a stent is usually adequate

The value of ERCP in patients with bile leak

24 consecutive patients were studied over a 4-year period (2003 – 2006) in Tuen Mun Hospital

A total of 981 laparoscopic cholecystectomies were performed

Incidence: 2%

The value of ERCP in patients with bile leak

The median age of the patients is 55 years (31-77) with no gender difference

ERCP was performed after a median of 4 days postoperatively (3-8 days)

Presenting symptoms

2015

4

Fever Abdominal Pain Cholestasis

Distribution of leakage site

10

33

3

3

2

Cystic Duct Stump leak CHD leak CBD leak

Rt IHD leak Gall bladder bed leak No leak identified

Treatment

All patients (except the two without any leakage site identified with ERCP) were treated successfully with endoscopic sphincterotomy and subsequent stent placement

Follow-up ERCP at 6 weeks showed no more bile leak in all patients

Conclusion

ERCP is a safe and valuable method to detect bile leak and provide treatment

Summary Bile duct injury is a very serious

complication of laparoscopic cholecystectomy

High index of suspicion when patients do not recover uneventfully after laparoscopic cholecystectomy

If biliary injuries occur, seek specialist help