Biliary Injury in Lap Chole - TAddona

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    Causes of Biliary Injury in LC

    Failure to properly occl. the cystic ductInjury to the ducts in the liver bed caused by entering a plane too deep to the gallbladderCautery Misuse thermal necrosis ductaltissue loss

    Pulling forcefully up on the gallbladder whenclipping the cystic duct tenting injury to thejunction of the CBD & common hepatic duct

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    Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury

    during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan; 180 (1) : 101-25.

    Reviews revealed the incidence of biliary injury during open CCY to be 0.1-0.3%1995 Strasbergs study which incl. more than124,000 laparoscopic cholecystectomies (LC)reported in the literature found the incidence of major bile duct injury to be 0.5%.

    Biliary Injuries DuringCholecystectomy (CCY)

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    The Effect of Acute Cholecystitison Biliary Injury

    The incidence of bile leakage after emergency LC for acute cholecystitis is higher than that forelective.

    1.37% in acute chole v. 0.09% in elective

    n = 3300 (10yrs); retrospective (Taipei)

    Lien et al. Management of bile leakage after LC based onetiologic classification. Surg Today (2004) 34:326 330

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    Diagnosis of Bile Leaks

    Persistent fullness, anorexia, abdominal pain,fever & tenderness,jaundice, elev WBCHigh level of suspicion following surgery Bile draining from a drain left in the operativefield

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    Radiographic Diagnosis of BiliaryInjury

    US/CT detect bilomas (poss. perc drainage)

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    Radiographic Diagnosis of BiliaryInjury

    US/CT detect bilomas (poss. perc drainage)HIDA presence of active bile leak (physiologic)MRCP demonstrate dilated/stenotic biliary tract; retained stones..not physiologic northerapeutic

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    ERCP

    Provides exact anatomical diagnosis of bile ductleak; while allowing treatment w/decompression of the biliary tree.Principal of treatment is to establish a pressuregradient that will favor flow into the duodenumnot the leak site; may entail removal of retainedstone or internal stenting +/- sphincterotomy

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    Internal stenting is currently the procedure of choice for treating bile duct leaks ( types A & D)

    Cessation of bile extravasation in 70-95% of cases w/in 7 days

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    Detection in post-op period

    Abx, nutrition support, percutaneous drainageof bile collex (US or CT)MRCP, PTC or ERCP to delineate location of injury.

    Once sepsis and leaks are controlled, then may perform definitive reconstruction w/ R-Y hepaticojejunostomy

    Kaman et al. Management of Major Bile Duct Injuries

    following LC. Surg Endosc (2004)18:1196 1199