Bdi

Pongsatorn Tangtawee, MDHPB division, Department of Surgery

Ramathibodi Hospital

Bile Duct Injury

From GBB rama Photo club

Hit to the Point (General board exam)

Introduction

Classification and type

Investigation

Management Immediately Late presentation

Prevention

Introduction

The first planned cholecystectomy in the world was performed by Langenbuch in 1882

The first Choledochotomy was performed by Couvoissier in 1890.

The first iatrogenic bile duct injury was described by Sprengel in 1891. He also reported the first choledochoduodenostomy (ChD) for calculi (1891)

The first surgical reconstruction (“end-to-side” ChD) of IBDI was performed by Mayo in 1905

Jabłońska B, World J Gastroenterol 2009;15(33): 4097-4104

Introduction

Biliary injury is the most common severe complication of cholecystectomy.

incidence of bile duct injuries has risen from 0.1%-0.2% to 0.4%-0.7% from the era OC to the era LC

BDI continue to appear by experience surgeons

Steven M. Strasberg, HPB 2011, 13, 1–14Wan-Yee Lau, Hepatobiliary Pancreat Dis Int 2007; 6: 459-463

Adamsen S,J AM Coll Surg, VOL184:571-578

Introduction


Risk Factors for BDI

Severe local risk factors acute cholecystitis, acute biliary pancreatitis, bleeding in Calot’s triangle severely scarred or shrunken gall bladder large impacted gallstone in Hartmann’s pouch, short cystic duct, and Mirizzi’s syndrome abnormal biliary anatomy

Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011

Risk Factors for BDI

Male sex and prolonged surgery for more than 120minutes

more than half of all such injuries occurred during the so called “easy” LC performed by an inexperienced surgeon


Clinical presentation of BDI

Depends on the type of injury and bile leaks or stricture

Bile leaks subhepatic bile collection (biloma) or abscess developsfever, abdominal pain and other signs of sepsis

Biliary strictures jaundice caused by cholestasis is the commonest


Clinical Presentation and Diagnosis

Kourosh F., Tech Gastrointest Endosc,2006,VOL 8:81-91

Classification

Classification

Starberg, J Am Coll Surg.,1995VOL180:101-125

Investigation

Intraoperative IOC ERCP

Early or late postoperative LFT Ultrasound CT : Unhelpful merely confirming the U/S ERCP (can treatment in some type) MRCP

Investigation

MRCP is a sensitive (85%-100%) and non-invasive imaging modality

Currently, it is the “gold standard” in preoperative diagnosis


MRCPPTC

A. R. MOOSSA, Ann. Surg., Vol. 2 15, No. 3, March 1992

Management

Initial Management

Concept of initial management Control of sepsis peritoneal and biliary PCD

Once sepsis is controlled complete cholangiogram site (in relation to the ductal confluence) nature (partial or complete) extent (loss of segment) of the injury

Sicklick et al, Annals of Surgery • Volume 241, Number 5, May 2005

Intraoperative management

Only 15% to 30% of biliary injuries are diagnosed during the surgical procedure

The surgeon should carefully consider his experience and ability to repair any injury that is immediately

Eduardo de Santibanes,HPB, 2008; 10: 412

Repaired by an experienced HPB surgeon This will reduce morbidity, shorten the stay in hospital, and decrease hospital costs

Savader SJ, Lillemoe KD, Ann Surg 1997;225:26873.

Intraoperative management

Townsend: Sabiston Textbook of Surgery, 18th ed.

Postoperative BDI management

Early or Elective should be consider

Controversial in HPB surgeon

-The Mayo clinic , early repair may be done in a patient with a ligated/ clipped duct after LC when there is no bile leak, no cholangitis, and good proximal dilatation

Murr MM,Arch Surg 1995;134:604–10.

Postoperative BDI management

3 out of 4 failures in 25 HJs occurred in patients who had undergone early reconstruction (within 6 weeks of cholecystectomy)

Boerma D, Ann Surg 2001;234:750–7.

We do not recommend early repair and have performed early (within 4 weeks) repair in only 11 out of 362 patients in whom we have performed HJ for BDI between 1989 and 2005

Vinay K, J Hepatobiliary Pancreat Surg (2007) 14:476–479

Strategy for management

Strasberg A injury

injuries maintain continuity with the rest of the bile ducts

Easily treated through endoscopic intervention to decrease intraductal pressure distal to the bile duct leak

If endoscopy is not available, a T tube could be useful

The last resource is to control the bile leak through subhepatic drains and refer

Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48

Strasberg B injury

Segmentary bile duct occlusion

If mild pain and elevation of LFT are present with no clinical impairmentconservative management

The presence of moderate and severe cholangitis makes the drainage of the occluded liver segment necessary PTBD Hepatectomy (cholangitis cannot controlled)

HJ technically hard to perform Long term prognosis is poorMercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48

Strasberg C injury

accessory right duct is sectioned but the proximal stump is not detected

Subhepatic collections are frequent in the postoperative setting must be drained

Bile leak is occluded spontaneously with no other intervention

If this does not happen, therapeutic options are the same that Strasberg B

Poor long term prognosisMercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48

Strasberg D injury

Partial injury of the common bile duct in its medial side

If a small injury with no devascularization is present, a 5-0 absorbable monofilament suture to close the defect is adequate

external drainage + mandatory endoscopic sphincterotomy + stent should be performed in rare case


Strasberg D injury

In the setting of a devascularized duct bile leak will develop during the first postoperative week with concomitant bile collections

Surgery is the last resource


external drainage + mandatory endoscopic sphincterotomy + stent should be performed

Strasberg E injury

Complete loss of common and/or hepatic bile duct continuity

Devascularization and loss of bile duct tissue

More complex and hard to surgical treatment


Consideration

Injuries that involve the hepatic duct confluence, i.e. Bismuth class III, IV, V (combined or not with common bile injury); or in Strasberg classification Type E3, E4, E5.

High stenosis with previous repair attempts

Any biliary injury associated with a vascular injury.

Biliary injuries associated with portal hypertension or secondary biliary cirrhosis


Algorithm for the management of postoperative diagnosed biliary stenosis


Key of successfully

Exposure of damaged area avoiding too much dissection

The end of injured bile duct has to be free from burns and attritions

Intraoperative cholangiography in every bile leakage

Vascular integrity should be confirmed

Hepaticojejunostomy with an isolated Roux-en-Y

Opposition of both mucosas with reabsorbable suture

Use of magnification

Blumgart LH, Arch Surg, 1999;134:76975.

Vasculobiliary injury

Steven M. Strasberg, HPB 2011, 13, 1–14

Vasculobiliary injury


vasculobiliary injury



Suggested algorithm for the management of bile duct injury combined with hepatic artery.

Carlo Pulitanò, The American Journal of Surgery (2011) 201, 238–244

An indication of the relative frequency of scenarios is given.

Right hepatic artery (RHA) vasculobiliary injury with collateral flow from left hepatic artery and atrophy of right liver. (A) Computed tomography scan of liver shortly after injury. The arterial phase shows no filling of right liver. (B) Arteriogram performed 2 years later. Abundant arterial collaterals extend from the left hepatic artery to the RHA along the hilar plexus (white arrowhead). The clip which occluded the RHA is also seen (black arrowhead). The arterial pattern of the right liver shows crowding (black arrows) indicative of atrophy of the right liver, whereas the arterial pattern of the left liver shows elongation and spreading characteristic of hypertrophy of the left liver. (Reproduction of original photographs from Mathisen et al. by permission


How to Avoid a Bile Duct Injury

Correct Exposure and Identification of Structures in Calot’s Triangle cystic lymph node, gall bladder neck, and Rouviere’s

sulcus

Wauben, World journal of surgery, vol.3 issue4, 2008

Critical view of safety(1995)

From Dr. Paramin, HPB division, Surgery department, Ramathibodi

How to Avoid a Bile Duct Injury

To Avoid Thermal Injury

To Avoid Blind Haemostasis

Awareness of Anatomic Variation

Conversion to Open Approach When Necessary


“Caterpillar turn” or “Moynihan hump”

Incidence of variation is variable, and may be as high as 50%

Adams DB.,Surg Clin N America,1993,Vol73;861-71

Surgeons Characteristics of Risk Taking

Tendency and BDI

Casual approach, overconfidence, and ignorance of difficult situations

better training and standard use of safety measures with Surgical simulation to be helpful

L. W. Way, L. Stewart, Annals of Surgery, vol. 237, no. 4, pp. 460–469, 2003

N. N. Massarweh, Journal of the American College of Surgeons, vol. 209, no. 1, pp. 17–24,2009

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Surgical technique

What is Starsberg type?

From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi

What is Starsberg type?





Hepp-Couinaud

Soupault -Couinaud WEDGE SEGMENT III

LONGMIRE PROCEDURE

Roux-en-Y hepaticojejunostomy with a blind subcutaneous jejunal loop

Quintero,World J. Surg. 16:1178, 1992

Summary

BDI poor prognosis

Multiple risk factor Most important Blind surgical management in Calot’s triangle

Clinical presentation Leak, stricture, vasculobiliary injury

Investigation : immediately IOC “Do not assume” Late MRCP is Gold standard

Summary

Concept treatment Control of sepsis peritoneal and biliary PCD,

PTBD Once sepsis is controlled complete cholangiogram

Mapping and classified type manage follow by type

“Repaired by an experienced HPB surgeon This will reduce morbidity, shorten the stay in hospital, and

decrease hospital costs”



Thank You

Bdi

Education

bile duct leak

world j gastroenterol

world j gastrointest

iatrogenic bile duct

injury injuries

introduction biliary

type of injury

biliary injuries