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Bile Duct Injury

Pongsatorn Tangtawee, MD
HPB division, Department of Surgery
Ramathibodi Hospital

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


Jaboska 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, 114


Wan-Yee Lau, Hepatobiliary Pancreat Dis Int 2007; 6: 459-463
Adamsen S,J AM Coll Surg, VOL184:571-578

Introduction

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

Risk Factors for BDI


Severe local risk factors
acute cholecystitis,
acute biliary pancreatitis,
bleeding in Calots triangle
severely scarred or shrunken gall bladder
large impacted gallstone in Hartmanns

pouch,
short cystic duct, and Mirizzis 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

Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011

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

Jaboska B, World J Gastroenterol 2009;15(33): 40974104

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

Jaboska B, World J Gastroenterol 2009;15(33): 40974104

MRC
P

PTC

A. R. MOOSSA, Ann. Surg., Vol. 2 15, No. 3, March 19

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;134:60410.

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;234:7507.
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)


14:476479

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): 4348

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 poor
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 4348

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 prognosis
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 4348

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
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 4348

Strasberg D injury
In the setting of a devascularized duct

bile leak will develop during the first


postoperative week with concomitant bile
collections

external drainage + mandatory endoscopic


sphincterotomy + stent should be performed

Surgery is the last resource


Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 4348

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

Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 4348

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


Eduardo de Santibanes,HPB, 2008; 10:
412

Algorithm for the management of postoperative diagnosed biliary


stenosis

Eduardo de Santibanes,HPB, 2008; 10:


412

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.

Steven M. Strasberg, HPB 2011, 13, 114

Vasculobiliary injury

Vasculobiliary injury

Steven M. Strasberg, HPB 2011, 13, 114

vasculobiliary injury

Steven M. Strasberg, HPB 2011, 13, 114

Steven M. Strasberg, HPB 2011, 13, 114

Suggested algorithm for the


management of bile duct injury
combined with hepatic artery.

An indication of the relative frequency of


scenarios is given.
Carlo Pulitan, The American Journal of Surgery (2011) 201,
238244

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
Steven M. Strasberg, HPB 2011, 13, 114
spreading characteristic of

How to Avoid a Bile Duct


Injury
Correct Exposure and Identification of

Structures in Calots Triangle


cystic lymph node, gall bladder neck, and

Rouvieres sulcus

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

Critical view of safety(1995)

From Dr. Paramin, HPB division, Surgery department,

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

Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011

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


L. W. Way, L. Stewart, Annals of Surgery, vol. 237, no. 4, pp. 460469, 2003

better training and standard use of safety

measures with Surgical simulation to be


helpful
N. N. Massarweh,
Journal of the American College of Surgeons, vol. 209, no. 1,
pp. 1724,2009

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Surgical technique

What is Starsberg type?

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

What is Starsberg type?

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

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

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


Ramathibodi

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

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 Calots


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

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


Ramathibodi

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


Ramathibodi

Thank You