Dr. Sreenath KDept of surgery, RIMS Imphal

Introduction

Bile duct injury (BDI) Rare but potentially devastating condition Biliary peritonitis & sepsis, cholangitis, portal

hypertension & secondary biliary cirrhosis Significant morbidity & mortality

Iatrogenic BDI Increased financial burden (patient or hospital)

Anatomy

Calot’s triangle – between inferior surface of liver, Cystic duct & CHD

Contents – Cystic artery, RHA, Cystic lymph node

Bile Duct Injuries (BDI)Iatrogenic injury

Cholecystectomy Gastrectomy Pancreatectomy ERCP

TraumaDuodenal ulcer

Risk factorsInflammation in the porta,Variable biiary anatomy,Inappropriate exposure,Aggressive attempts at hemostasis,Surgeon inexperience. 97% due to visual misperception, only 3% accounts for

technical skills and knowledge.

Misperception ..

With sufficient cephalad retraction of the gall bladder fundus ,the cystic duct overlies the common hepatc duct running in a parrellel path. without inferolateral traction of the gallbladder infundibulum to dossociate this structures, the dissection of apparent cystic duct may actually include CBD…

Classical LC BDI

Laparoscopic cholecystectomy (LC) Gold standard for management of benign gallbladder diseaseCompared with laparotomy

Less post-op pain Shorter hospital stay Earlier return to normal activity Better cosmesis Iatrogenic bile duct injury rate

0.1% to 0.2% (open) vs 0.4% to 0.6% (lap)‘’Learning curve phenomenon’’

LC & Bile duct injury (BDI)LC most common cause of BDI

More severe than those seen with Open chole

’Learning curve phenomenon’’

BDI after LC stable around 0.6 to 0.7%, 4 times that of open chole – high for a benign condition

Classificationlocation of injury mechanism & type of injuryeffect on biliary continuitytiming of identification

Each plays significant role in determining appropriate management & operative repair

Classification of BDIBismuth classification (1982)Era of Open CholeBased upon level of biliary strictures with respect to hepatic

bifurcationType 1-5.Helps surgeon choose appropriate site for repairDegree of injury correlates with surgical outcomes

Strasberg classification(1995)Type Criteria

A Leak from Cystic duct or small ducts in liver bed

B Injury to sectoral duct(aberrant RHD) with obstruction

C Injury to sectoral duct with consequent bile leak

D Lateral injury to extrahepatic ductE1 Transection >2 cm from the confluenceE2 Transection <2 cm from the confluenceE3 Transection at the confluenceE4 Separation of major ducts in the confluenceE5 Complete occlusion of all bile ducts.

Strasberg classification

Clinical Presentation (post-op)Obstruction

Clip ligation or resection of CBD obstructive jaundice, cholangitis

Bile Leak Bile from intra-op drain or More commonly, localized biloma or free bile ascites /

peritonitis, if no drainFever,abd pain , jaundice, or bile leakage from incision. Diffuse abdominal pain & persistent ileus several days

post-op high index of suspicion possible unrecognized BDI

Classical LC BDI

ReasonsMisidentification

CBD or aberrant RHD mistaken for cystic duct Risk factors inexperience, inflammation or aberrant

anatomy Infundibular technique – flaring of cystic duct as it

becomes infundibulum misleading in inflammation

Technical errors Cautery induced injury

Prevention 30° laparoscope, high quality imaging equipment Firm cephalic traction on fundus & lateral traction on

infundibulum, so cystic duct perpendicular to CBD Dissect infundibulo-cystic junction Expose “Critical view of safety” before dividing cystic duct Convert to open, if unable to mobilise infundibulum or

bleeding or inflammation in Calot’s triangle Routine intra-op cholangiogram “Fundus-first” dissection

Critical view of safetyCalot’s triangle dissected free

of all tissue except cystic duct & artery

Base of liver bed exposedWhen this view is achieved,

the two structures entering GB can only be cystic duct & artery

Cystic duct or CBD?

Cystic duct CBD Caution

2 – 3mm wide 5mm wide CD > 5mm – Is it CBD?Even with low cystic duct insertion, CD rarely goes behind duodenum

CBD goes behind duodenum

Duct behind duodenum must be CBD

Double cystic duct very rare

-- 2 ducts seem to go towards inflammed Gallbladder – one must be CBD

No vessels on surface

Vessels on surface

--

Management

Recognized at the Time of CholecystectomyConversion to an open operation and use of

cholangiography.

Goals .. Maintenance of ductal length, elimination of any bile

leakage that would affect subsequent management, and creation of a tension-free repair.

Ducts smaller than 3 mm drain only a single segment or subsegment of liver..simple ligation.

Ducts larger than 3 mm usually drain more than a single segment of liver,if transected.. should be reimplanted into the biliary tree.

Injury occurs to a larger duct, but is not caused by electrocautery and involves less than 50% of the circumference of the wall, a T tube placed through the injury

 Low injuries to the bile duct can be reimplanted into the duodenum.

Most injuries to the bile duct occur higher in the biliary tree, close to the hilum, thus not allowing for tension-free anastomosis to the duodenum. Therefore, in almost all cases of bile duct injury, a resection of the injured segment with mucosa to mucosa anastomosis using a Roux-en-Y jejunal limb (end-to-side choledochojejunostomy ) is preferred.

Transanastomotic stenting has been shown to improve anastomotic patency.

Identified After CholecystectomyGoals of Therapy in Iatrogenic Bile Duct Injury 1.Control of infection limiting inflammation Parenteral antibiotics

Percutaneous drainage 2.Clear and thorough delineation of entire biliary anatomy. MRCP/PTC , ERCP3.Re-establishment of biliary enteric continuity Tension-free, mucosa-to-mucosa anastomosis

Roux-en-Y hepaticojejunostomy Long-term transanastomotic stents if involving

bifurcation or higher

Approach..Should undergo imaging to assess for a fluid collection and

evaluate the biliary tree. Ultrasonography can achieve both these goals.

Cross-sectional imaging via CT will generally provide more useful data.

Radionucleotide scanning to confirm bile leakage, but with any documentation of a leak, CT will be necessary to plan management.

CT or U/S guided (or surgical) drainage

Sepsis control Broad-spectrum antibiotics & percutaneous biliary drainage to control any bile leak most fistulas will be controlled or even close.

1.5% mortality rate due to uncontrolled sepsis

No rush to proceed with definitive management of BDI.

Delay of several weeks allows local inflammation to resolve & almost certainly improves final outcome.

Definitive management is to reestablish durable biliary enteric drainage.

Combination of percutaneous and endoscopic biliary dilations and stenting may establish continuity.

Surgical reconstruction has the highest patency rates.

performed between a minimally inflamed bile duct to intestines in a tension-free, mucosa to mucosa fashion.

If the anastomosis is within 2 cm of the hepatic duct bifurcation, or involves intrahepatic ducts, long-term stenting appears to improve patency

If the bifurcation is involved, stenting of both right and left ducts should be performed

When the reconstruction involves the common bile duct or common hepatic duct more than 2 cm from the bifurcation, stenting is not necessary.

Interventional Radiologic and Endoscopic Techniques

Using balloon dilation techniques, the stricture is dilated and a catheter is left in place to decompress the system, allow healing, document resolution and, if necessary guide repeat dilations.

This approach is successful in up to 70% of patients.

Endoscopic balloon dilation of bile duct strictures is generally reserved for those with primary bile duct strictures or patients who have undergone choledochoduodenostomy for reconstruction, because the Roux limb does not usually allow for endoscopic strategies.

Two large retrospective reviews have been performed and both have shown higher success rates from surgical therapy, with lower morbidity and lower mortality following operative management compared with those for nonoperative strategies

ERCP – multiple stentsLateral duct wall injury or

cystic duct leak transampullary stent controls leak & provides definitive treatment

Distal CBD must be intact to augment internal

drainage with endoscopic stent

ERC – clips across CBD CBD transection

normal-sized distal CBD upto site of transection

Percutaneous transhepatic cholangiography (PTC) necessary

Surgery

Cholangiography (ERCP + PTC)Percutaneous transhepatic cholangiography (PTC)

Defines proximal anatomy Allows placement of percutaneous transhepatic biliary

catheters to decompress biliary tree treats or prevents cholangitis & controls bile leak

MRCP / CT cholangiographyNoninvasive

May avoid invasive procedures like ERCP or PTC

Do not allow intervention

Interpretatation in presence of bile collection difficult

Biliary enteric anastomosisMost laparoscopic BDI –

complete discontinuity of biliary tree

Surgical reconstruction, Roux-en-Y hepaticojejunostomy

tension-free, mucosa-to-mucosa anastomosis with healthy, nonischemic bile duct

Treatment summaryStrasberg Type A – ERCP + sphincterotomy + stent

Type B & C – traditional surgical hepaticojejunostomy

Type D – primary repair over an adjacently placed T-tube (if no evidence of significant ischemia or cautery damage at site of injury)

More extensive type D & E injuries – Roux an-Y

hepaticojejunostomy with biliary stent

Risk Factors for BDI

Acute inflammation at Calot’s triangleAtypical anatomy

aberrant RHD (most common) complex cystic duct insertion

Conditons that impair “Critical view of safety” Obesity & periportal fat Complex biliary disease – choledocholithiasis ,

gallstone pancreatitis, cholangitis Intra-op bleeding

ReasonsMisidentification

CBD or aberrant RHD mistaken for cystic duct Risk factors inexperience, inflammation or aberrant

anatomy Infundibular technique – flaring of cystic duct as it

becomes infundibulum misleading in inflammation

Technical errors Cautery induced injury

Anatomic illusion?Misperception (97%) rather than technical error (3%)

Everyone is susceptible – experience, knowledge & technical skill alone may not be adequate

All BDI may not represent “substandard practice”

Improvements may have to depend on technology

Summary

Multidisciplinary management of BDI expertise of surgeons, radiologists & gastroenterologists

Mismanagement lifelong disability & chronic liver disease

BDI with lap. Chole results of operative repair is excellent in Specialist Centres

Thank

you…