Biliary Injury

Nir Hus, M.D., Ph.D. Division of Trauma Services

Memorial Regional Hospital

3/3/2008

History

Pt is a 46 y.o male who presented to the ER with severe RUQ pain, nausea and vomiting with meals.

PMHx: HTN, Depression PSHx: Denies Medications: Atenolol, Lexapro, Lipitor,

Wellbutrin Allergy: NKDA

Physical Exam

ABD: Distended and tender to palpation in RUQ. + Murphy's sign. No rebound or guarding.

Labs- within normal limits Except – alk phos- 139

CT Scan

IMPRESSION- 1. NO CT EVIDENCE OF A HEPATIC MASS. 2. FINDINGS SUSPICIOUS FOR CHOLECYSTITIS.

CORRELATION WITHULTRASOUND EXAMINATION PERFORMED THE SAME DAY IS RECOMMENDED. IFTHERE IS NO CLINICAL SUSPICION FOR CHOLECYSTITIS, NEOPLASM OF THEGALLBLADDER CAN HAVE THIS APPEARANCE.

3. NONOBSTRUCTING LEFT RENAL CALCULUS. 4. MULTIPLE LEFT PARAPELVIC CYSTS.

Ultrasound

IMPRESSION- GALLSTONES.

Operating Room

Laparoscopic Cholecystectomy with intraoperative cholangiogram

Findings- Acutely inflamed gallbladder with evidence of acute as well as chronic inflammation, necrosis, and marked inflammatory changes

Cholangiogram revealed no filling defects

Intraoperative cholangiogram

Intraoperative cholangiogram

confirming the presence of common bile duct stones. Calculi are indicated with arrows

Post Operative Course

Patient was doing well post op Advance to a regular diet and discharged

home on POD 2 All labs were within normal limits upon

discharge

POD 6 Pt returns to the ER with complaints of

abdominal pain and distension AF VSS WBC- 11.99 Admit CT Scan GI consult for ERCP

CT SCAN 6 days post op

CT Scan IMPRESSION-

THE PATIENT IS STATUS POST CHOLECYSTECTOMY WITH DEVELOPMENT OF FLUID IN THE GALLBLADDER FOSSA AND SMALL AMOUNT OF SCATTERED ASCITES. NO RIM ENHANCING COLLECTION TO SUGGEST ABSCESS. THE POSSIBILITY OF BILE LEAK WITH BILE PERITONITIS IS CONSIDERED AND HEPATOBILIARY SCINTIGRAPHY MAY BE HELPFUL FOR FURTHER EVALUATION.

Plan

Special Procedures for percutaneous drainage of abscess and placement of drain

ID consult - Tigecycline started.

GI for ERCP

Common Bacterium Species Found in Biliary Tract Infections[*]

Enterobacteriaceae (68% incidence)

Escherichia coli

Klebsiella species

Enterobacter species

Enterococcus species (14% incidence)

Anaerobes (10% incidence)

Bacteroides species

Clostridium species (7% incidence)

Streptococcus species (rare)

Pseudomonas species (rare)

Candida species (rare) From Thompson JE Jr, Pitt HA, Doty JE, et al: Broad spectrum penicillin as an adequate therapy for acute cholangitis. Surg Gynecol 1990;171:275-282.

* Cholecystitis, cholangitis, biliary sepsis, or common duct obstruction.

ERCP INJECTION WAS PERFORMED INTO THE COMMON DUCT, WHICH

DEMONSTRATE A COLLECTION OF CONTRAST IN THE PRE-AMPULLARY SEGMENT OF THE COMMON DUCT AND CONTRAST IN THE GALLBLADDER FOSSA, WHICH COULD BE SECONDARY TO LEAKAGE FROM THE CYSTIC DUCT STUMP.

A STENT WAS PLACED WITH ONE END ABOVE THE SURGICAL CLIPS IN THE GALLBLADDER FOSSA AND THE OTHER END IN THE DUODENUM.

THERE IS NO INTRA OR EXTRAHEPATIC BILE DUCT DILATATION.

THERE IS NO SIGNIFICANT FILLING DEFECT IN THE COMMON DUCT.

IMPRESSION- EXTRAVASATION OF THE CONTRAST AS DESCRIBED ABOVE AND PLACEMENT OF STENT TO FACILITATE CLOSURE OF THE LEAK.

Hospital Stay

The patient had an uncomplicated hospital stay.

Afebrile with labs within normal limits Diet was advanced as tolerated A follow-up CT scan was ordered to assess

the size of the collection

Follow up CT Scan

Discharge

Follow up CT scan revealed a decrease in size of collection

ID changed abx to po Augmentin for 2 weeks. GI to follow up for ERCP and stent removal in

1 week.

Bile Leaks After Laparoscopic

Cholecystectomy

Biliary Injuries during Cholecystectomy In the 1990s, high rate of biliary injury was due

in part to learning curve effect. In reviews by Strasberg et al. and Roslyn et al.,

the incidence of biliary injury during open cholecystectomy was found to be 0.2-0.3%.

The review by Strasberg et al. in 1995 of more than 124,000 laparoscopic cholecystecomies reported in the literature found the incidence of major bile duct injury to be 0.5%.

Ann Surg. 1993 Aug;218(2):129-37. Am Surg. 1993 Apr;59(4):243-7. J Am Coll Surg. 1995 Jan;180(1):101-25. Review.

Incidence Incidence of biliary injury when laparoscopic

cholecystectomy is performed for acute cholecystitis is 3X greater than that for elective laparoscopic cholecystectomy and 2X as high as open cholecystectomy for acute cholecystitis.

The aberrant right hepatic duct anomaly is the most common problem.

The most dangerous variant is when the cystic duct joins a low-lying aberrant right sectional duct.

These injuries are underreported since occlusion of an aberrant duct may be asymptomatic and even unrecognized.

Variations in the confluence of the left and right hepatic ducts. A, Typical anatomy of the

confluence. B, Trifurcation of left, right

anterior, and right posterior hepatic ducts.

C, Aberrant drainage of a right anterior (C1) or posterior (C2) sectoral hepatic duct into the common hepatic duct.

D-F, Less common variations in hepatic ductal anatomy.  

(From Smadja C, Blumgart L: The biliary tract and the anatomy of biliary exposure. In Blumgart L [ed]: Surgery of the Liver and

Biliary Tract. New York, Churchill Livingstone, 1994, pp 11-24.)

Causes of Bile Leaks Secondary to dissection into hepatic

parenchyma Division of accessory bile ducts Dislodgement of clips Tears of cystic duct Injury to hepatic or common bile duct

Causes of Laparoscopic Biliary Injury Failure to properly occlude cystic duct. Injury to ducts in the liver bed - caused by

entering a plane deep to the fascial plate on which the gallbladder rests.

Misuse of cautery may cause serious bile duct injuries with loss of ductal tissue due to thermal necrosis.

Pulling forcefully up on the gallbladder when clipping the cystic duct causing a tenting injury in which the junction of the common bile duct and hepatic duct is occluded.

In 1995, Strasberg and Soper modified theBismuth classification of bile duct injuries:

Type A- leak from a minor duct still in continuity with the common bile duct. These leaks occur at the cystic duct or from the

liver bed. Type B- occlusion of part of the biliary tree.

Usually the result of an injury to an aberrant right hepatic duct.In 2% of patients, the cystic duct enters a right hepatic duct rather than the common bile duct-common hepatic duct junction.

Type C- bile leak from duct not in communication with common bile duct. Usually diagnosed in early postoperative period

as an intraperitoneal bile collection. Type D- lateral injury to extrahepatic bile ducts.

May involve the common bile duct, common hepatic duct, or the right or left bile duct.

Type E- circumferential injury of major bile ducts. This type causes separation of hepatic

parenchyma from the lower ducts and duodenum.

Strasburg ClassificationStrasberg classification

laparoscopic injuries to the biliary tract.

Type A injuries originate from small bile ducts that are entered in the liver bed or from the cystic duct.

Type B and Type C injuries are almost always involved aberrant right hepatic duct.

Type A, C, D, and some E injuries may cause bilomas or fistulas.

Type B and other type E injuries occlude the biliary tree and bilomas do not occur.

Misidentification injuries: 2 main types.

1) Common duct is mistaken for cystic duct and is clipped and divided.

2) The segment of an aberrant right hepatic duct, between entry of the cystic duct and junction of the common hepatic, is mistaken to be the cystic duct.

Intra-op Cholangiogram 1999 Fletcher et al. found that

intraoperative cholangiography had a protective effect for complications of cholecystectomy in a retrospective study of 19,000 cholecystectomies.

Operative cholangiography is best at detecting misidentification of the common bile duct as the cystic duct and will prevent excisional injuries of bile ducts if the cholangiogram is correctly interpreted.

Poor at detecting aberrant right ducts, which unite with the cystic duct before joining the common duct

Management

Simple type D injuries are repaired by closure of the defect using fine absorbable sutures over a T- tube and placement of a closed suction drain in the vicinity of the repair.

Type D injuries that are thermal in origin or that are complex are best repaired by hepaticojejunostomy.

Significant postoperative bile leaks occur in up to 1% of patients undergoing laparoscopic cholecystectomy compared to 0.5% in open cholecystectomy.

Usually present within first week but can manifest up to 30 days after surgery.

Diagnosis Clinical- abdominal tenderness, generalized malaise and

anorexia. Dx of bile leak should be suspected whenever persistent

bloating and anorexia > few days Failure to recover as smoothly as expected is the most

common early symptom of an intraabdominal bile collection. Minor bile leakage is common after open or lap

cholecystectomy and is often related to disruption of small branches of the right intrahepatic duct entering the gallbladder bed.

These leaks, usually from the liver, occurred in 25% of 105 patients prospectively evaluated with ultrasonography by Elboim et al.

Such leaks may require no therapy Surgical placement of a drain at the time of the original

procedure, or subsequent placement of a percutaneous drain for symptomatic bilomas that are recognized postoperatively.

Diagnostic Imaging Noninvasive imaging (US/CT scan) is essential to define biloma

that may require percutaneous or surgical drainage. HIDA scan may show presence of an active bile leak and general

anatomic site of leakage. MRCP also provides imaging of the biliary tract, demonstrating

dilation or stenosis of the biliary tract, and stones in the cystic duct remnant, the pancreas, and the pancreatic ducts; however, it does not allow concomitant therapeutic measures or physiologic assessment of bile flow (so cannot detect if a leak is active).

ERCP and percutaneous transhepatic cholangiography (PTC) can provide an exact anatomical diagnosis of bile duct leak, while at the same time allowing for treatment of the leak by appropriate decompression of the biliary tree.

Treatment The principle of treatment is to reestablish a

pressure gradient that will favor the flow of bile into the duodenum and not out of the leak site.

This means removing any physiological or pathological obstruction such as the normal sphincter of Oddi pressure or a retained bile duct stone.

In cases where there is a bile duct stone, removal of the stone with sphincterotomy is treatment of choice.

If there is no stone, then internal stenting with or without sphincterotomy has shown to be effective in treating bile leaks.

Treatment A retrospective study by De Palma et al. in 2002 showed

that sphincterotomy alone was highly effective in producing closure of bile fistulas by reducing endobiliary pressure.

Endoscopic internal stenting is currently procedure of choice for treating bile duct leaks (usually types A, C and D).

7Fr and 10 Fr stents can be inserted without sphincterotomy.

A prompt therapeutic response with cessation of bile extravasation in 70-95% of cases within a period of 1-7 days.

In the past, nasobiliary drains were used because they did not require sphincterotomy, and removal did not require second endoscopic procedure.

Nasobiliary drains are poorly tolerated and they are not able to transport more than 1/3 of daily bile production which makes them less effective than internal stents.

PTC Another method of non-surgical treatment of bile leaks is PTC

drainage. However, bile ducts are usually of normal caliber when there is

leakage, which makes the procedure difficult. PTC is usually reserved for instances when ERCP is

unsuccessful or in preparation for surgical repair. Intrahepatic bile duct injuries are not easily accessible by the

retrograde route. In certain instances, the distal part of the injured bile duct may be

closed and ERCP, therefore, may fail to reveal any contrast extravasation. Bile can thus continue to leak from the proximal part of the injury, and response to endoscopic treatment will be lacking.

In this case, PTC may be useful, or repair surgically.

Experimental

’’Histoacryl” glue approved in Europe for the sealing of biliary fistulae

Botulinum toxin injection to sphincter of Oddi successful in canine models.

The End