Direct repair of the common bile duct for share

Direct repair of the Direct repair of the common bile duct (CBD) common bile duct (CBD) in iatrogenic injuriesin iatrogenic injuries

ByBy Youssri S. GaweeshYoussri S. Gaweesh

Prof. of surgeryProf. of surgery Alexandria universityAlexandria university

Iatrogenic CBD injuriesIatrogenic CBD injuries

It has long been considered that It has long been considered that iatrogenic injuries can best be iatrogenic injuries can best be repaired with biliary enteric repaired with biliary enteric anastomosis between a Roux loop anastomosis between a Roux loop of jejunum and the proximally of jejunum and the proximally dissected segment of the extra dissected segment of the extra hepatic biliary tree.hepatic biliary tree.


The traditional teaching includes a The traditional teaching includes a mucosa to mucosa tension free mucosa to mucosa tension free anastomosis with or without stenting anastomosis with or without stenting between the biliary segment and the between the biliary segment and the defunctionalized jejunal loop, to defunctionalized jejunal loop, to avoid ascending reflux cholangitis.avoid ascending reflux cholangitis.


The idea of using the proximal and the The idea of using the proximal and the distal biliary tree is tempting because of the distal biliary tree is tempting because of the use of the mechanism of the sphincter use of the mechanism of the sphincter located down around the insertion of the located down around the insertion of the CBD to avoid reflux cholangitis and to CBD to avoid reflux cholangitis and to regulate the entry of bile into the regulate the entry of bile into the duodenum together with pancreatic duodenum together with pancreatic secretions to effect the best mix between secretions to effect the best mix between digestive enzymes and food. digestive enzymes and food.


It has long been considered that the It has long been considered that the distal part of the CBD is not distal part of the CBD is not dissectible from within the pancreas dissectible from within the pancreas which proved not to be true because which proved not to be true because of the presence of a definite fascial of the presence of a definite fascial sheath around it helping dissection sheath around it helping dissection without endangering the blood supply without endangering the blood supply

Iatrogenic CBD injuriesIatrogenic CBD injuries Proper Khorization of the Proper Khorization of the

duodenum ,after distal segment duodenum ,after distal segment dissection can compensate for at dissection can compensate for at least 3 cm length, thus the distal least 3 cm length, thus the distal segment reaching the proximal one segment reaching the proximal one without tension and enabling the without tension and enabling the surgeon to do a mucosa to mucosa surgeon to do a mucosa to mucosa tension free anastomosis tension free anastomosis


A T tube inserted in the distal A T tube inserted in the distal segment and bridging the segment and bridging the anastomotic line with part of the anastomotic line with part of the horizontal limb of the T tube is horizontal limb of the T tube is enough as a stent for the enough as a stent for the anastomosis .anastomosis .

Alternative stentingAlternative stenting

If using a T tube is difficult or impossible for If using a T tube is difficult or impossible for small diameter of the distal limb, one can small diameter of the distal limb, one can use plastic stents used in ERCPuse plastic stents used in ERCP

Either 7 french or 10 french stents are usedEither 7 french or 10 french stents are used Insertion starts first in the distal limb until it Insertion starts first in the distal limb until it

protrudes into the duodenumprotrudes into the duodenum The stent is cut to allow two cm length to be The stent is cut to allow two cm length to be

introduced proximallyintroduced proximally

Alternative stentingAlternative stenting

Three or four 4/0 or 5/0 vicryl sutures are Three or four 4/0 or 5/0 vicryl sutures are inserted without approximation first in order to inserted without approximation first in order to assure a mucosa to mucosa suturing assure a mucosa to mucosa suturing

Approximation is done with the stent Approximation is done with the stent introduced to the proximal cut end with introduced to the proximal cut end with direction towards the right duct direction towards the right duct

With the assistant pushing the kochirzed With the assistant pushing the kochirzed duodenum upwards to assure tension free duodenum upwards to assure tension free anastomosis anastomosis

ResultsResults

The results of ten cases done The results of ten cases done within the last year (August 2004 within the last year (August 2004 to July 2015) are showing perfect to July 2015) are showing perfect outcome with only one case outcome with only one case needing reoperation for hepatico needing reoperation for hepatico duodenal anastomosis.duodenal anastomosis.

ERCP done for second case (N.M.) demonstrating complete cut of distal segment

T tube cholangiography done 3 months after repair before tube extraction (second patient N.M.)

MRI after one year , patient is presenting by itching without jaundice

MRI after one year , patient is presenting by itching without jaundice

ERCP tried twice to dilate and insert a stent and failed

Reexploration after a year showing the stricture most probably at the site of the insertion of the T tube

Two stays with exploration of the relatively dilated duct above the stricture

After incision of the stricture with a tube in the distal duct

Start of choleduchoduodenostomy

T tube cholangiography of forth patient (A.S.) done 3 months after repair before extraction.

T tube cholangiograhy done for the sixth patient one month after repair and before extraction

MRI demonstrating complete transection

10 days after repair with stent 7 french splinting the anastomosis

Lessons to be learnedLessons to be learned The most common injury is excision of a The most common injury is excision of a

segment of the CBD ( the CBD is usually segment of the CBD ( the CBD is usually narrow enough to be recognized as the narrow enough to be recognized as the cystic duct) with short cystic or sessile gall cystic duct) with short cystic or sessile gall bladder.bladder.

Direct anastomosis is almost always Direct anastomosis is almost always feasible with no tension on suture line if feasible with no tension on suture line if adequate mobilization of the distal segment adequate mobilization of the distal segment was done with adequate Khorization of the was done with adequate Khorization of the duodenum duodenum

Lessons to be learnedLessons to be learned

The distal segment is ensheathed in a special sheath The distal segment is ensheathed in a special sheath which separates it from pancreatic tissue with loose which separates it from pancreatic tissue with loose areolar tissue separating it from that sheath, and areolar tissue separating it from that sheath, and dissection in this plane is very easy without endangering dissection in this plane is very easy without endangering the blood supply of the duct. There are no blood vessels the blood supply of the duct. There are no blood vessels transecting that loose areolar tissue which suggests that transecting that loose areolar tissue which suggests that the blood supply of that segment is intramural and is not the blood supply of that segment is intramural and is not segmental.segmental.

This is contrary to the proximal segment where the This is contrary to the proximal segment where the presence of two Terbelanche vessels running along the presence of two Terbelanche vessels running along the lateral borders of the CBD suggests segmental blood lateral borders of the CBD suggests segmental blood supply ( a point for further research)supply ( a point for further research)


The sooner the surgeon gets into the The sooner the surgeon gets into the field the easier and better was the field the easier and better was the dissection of both the proximal and distal dissection of both the proximal and distal parts of the biliary tree. Waiting for 6 parts of the biliary tree. Waiting for 6 weeks is no more accepted as a policy.weeks is no more accepted as a policy.

The T tube should be inserted from a The T tube should be inserted from a separate incision in the distal part of the separate incision in the distal part of the CBD with only part of the horizontal limb CBD with only part of the horizontal limb stenting the anastomosis stenting the anastomosis


The anastomosis is done using only four sutures The anastomosis is done using only four sutures of four zero vicryl to be tighten after inserting the of four zero vicryl to be tighten after inserting the t tube in the distal part and directing the stent into t tube in the distal part and directing the stent into the right duct in most of the times.the right duct in most of the times.

The T tube is not necessarily be made of The T tube is not necessarily be made of silicone, a latex tube will do.silicone, a latex tube will do.

The Stay of three months does not look The Stay of three months does not look mandatory however; further cases are needed to mandatory however; further cases are needed to make this clearmake this clear

Lessons to be learnedLessons to be learned A t tube cholangiography can easily demonstrate A t tube cholangiography can easily demonstrate

the adequacy of the healing before extracting a t the adequacy of the healing before extracting a t tube stenting such anastomosis.tube stenting such anastomosis.

A plastic stent can be used if T tubes are difficult A plastic stent can be used if T tubes are difficult to useto use

Low molecular weight heparin prophylaxis is Low molecular weight heparin prophylaxis is mandatory because of the manipulation of the mandatory because of the manipulation of the area of the IVC to avoid massive pulmonary area of the IVC to avoid massive pulmonary embolism.embolism.

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Direct repair of the common bile duct for share