UNIVERSITÀ DI PADOVA DIPARTIMENTO DI SCIENZE ONCOLOGICHE E CHIRURGICHE CLINICA CHIRURGICA II^ Direttore: Prof. Donato Nitti Donato Nitti La calcolosi della

UNIVERSITÀ DI PADOVADIPARTIMENTO DI SCIENZE ONCOLOGICHE E

CHIRURGICHECLINICA CHIRURGICA II^

Direttore: Prof. Donato Nitti

Donato Nitti

La calcolosi della VPB oggi

TRATTAMENTO DELLE COMPLICANZE DELLA CHIRURGIA

MININVASIVA

LAPAROSCOPIC CHOLECYSTECTOMY

IATROGENIC INJURIES

• Bleeding from the liver bed: 8%

• Bile duct injuries: 0.4 - 0.6%• Minor vascular injuries (branches of the epigastric

vessels, mesenteric and omental vessels): 0.1 - 0.2%

• Major vascular injuries (aorta, iliac vessels, vena cava, inferior mesenteric arteries and lumbar arteries): 0.07 - 0.4%

• Bowel lesions: 0.07 - 0.7%

• Abdominal wall hematoma: case reports

Catarci, Surg Endosc 2001

Shamiyeh, Langenbecks Arch Surg 2004

IATROGENIC BILIARY INJURIES

IATROGENIC BILIARY INJURIES• A bile duct injury or stricture is the most serious complication

of laparoscopic cholecystectomy (LC)• This incidence appears to be 2-4 times higher than that of open

cholecystectomy (OC) (0.1-0.2%)

Biliary injuries that occur during LC tend to be more severe than those encountered with OC

LC is generally performed in a retrograde fashion, the level of injury can be proximal and enter into the second- and third-order bile ducts within the liver parenchyma

McPartland, Surg Clin N Am 2008

IATROGENIC BILIARY INJURIESAUTHOR BDI incidence following OC BDI incidence following LC

McMahon, 1995 0.2 0.81

Strasberg, 1995 0.7 0.5

Shea, 1996 0.19-0.29 0.36-0.47

Targaroma, 1998 0.6 0.95

Lillemoe, 2000 0.3 0.4-0.6

Gazzaniga, 2001 0.0-0.5 0.07-0.95

Savar, 2004 0.18 0.21

Moore, 2004 0.2 0.4

Misra,2004 0.1-0.3 0.4-0.6

Gentileschi, 2004 0.0-0.7 0.1-1.1

Kaman, 2006 0.3 0.6

Jablonska, World J Gastroenterol 2009

Factors associated with an increased risk of BDI

Anatomical anomalies of the bile ducts and hepatic

arteries

Chronic inflammation around the gallbladder

Obesity

Poor exposure

Bleeding in the surgical area

IATROGENIC BILIARY INJURIESMECHANISM

McPartland, Surg Clin N Am 2008 Jablonska, World J Gastroenterol 2009

IATROGENIC BILIARY INJURIESMECHANISM

•70-80% of all IBDI are a consequent of misidentification of biliary anatomy before clipping, dividing and ligating structures•The most common type of BDI during LC is the so-called “classical” laparoscopic BDI that occurs when a portion of the common bile duct is resected with the gallbladder

inflammation in the area of the triangle of Calot can result in close approximation of the cystic duct and common bile ducts

excessive cepahalad retraction on the gallbladder fundus or insufficient lateral retraction on the gallbladder infundibulum

Nuzzo, Am J Surg 2008

IATROGENIC BILIARY INJURIESCLASSIFICATION

IS BASED ON THE MOST DISTAL LEVEL AT WHICH HEALTHY BILIARY MUCOSA IS AVAILABLE FOR ANASTOMOSIS DURING REPAIR OF BILIARY INJURY

BISMUTH CLASSIFICATION

TYPE CRITERIA

1 Low common hepatic duct stricture with a length of common hepatic duct stump of > 2 cm

2 Proximal common hepatic duct stricture with hepatic duct stump < 2 cm

3 Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved

4 Hilar stricture with involvement of confluence and loss of communication between right and left hepatic duct

5 Involvement of an aberrant right sectorial duct alone or with concomitant stricture of the common hepatic duct


STRATIFIES INJURIES FROM TYPE “A” TO “E”, WITH TYPE “E” INJURIES BEING FURTHER SUBDIVIDED INTO E1 THROUGH E5 ACCORDING TO THE BISMUTH CLASSIFICATION SYSTEM

STRASBERG CLASSIFICATION

TYPE CRITERIAA Cystic duct leak or leak from small ducts in the liver bed

B Occlusion of an aberrant right hepatic duct

C Transection without ligation of an aberrant right hepatic duct

D Lateral injury to a major bile duct

E1 Transection > 2 cm from the hilum

E2 Transection < 2 cm from the hilum

E3 Transection in the hilum

E4 Separation of major ducts in the hilum

E5 Type C injury plus injury in the hilum


IS BASED PRIMARILY ON THE ANATOMIC PATTERN AND MECHANISM OF A PARTICULAR INJURY, INCLUDING THE PRESENCE OF ASSOCIATED VASCULAR INJURY

STEWART-WAY CLASSIFICATION

IATROGENIC BILIARY INJURIESINTRAOPERATIVE IDENTIFICATION OF BDI

< 15-20% OF BDI ARE DETECTED DURING LC

INTRAOPERATIVE IDENTIFICATION OF BDI :

• Sudden unexpected leakage of bile from the liver or soft tissue adjacent to the porta hepatis• Persistent bile leakage after transection of an apparent cystic duct

Gouma, Dig Surg 2002Lillemoe,

IATROGENIC BILIARY INJURIESPOSTOPERATIVE IDENTIFICATION OF BDI

Sicklick, Ann Surg 2005 Jablonska, World J Gastroenterol 2009

SYMPTOMS:

LABORATORY: Indicators of cholestasis and liver funcion:

bilirubin, ALP, AST, ALT, gGT

IATROGENIC BILIARY INJURIESPOSTOPERATIVE IDENTIFICATION OF BDI

IMAGING:

US-doppler Abdominal CT:

free-fluid BILE LEAK hepatic artery and portal vein injuries

ERCP: confirm BDI Percutaneous transhepatic

cholangiography (PTC): confirm BDIdefine biliary antomy

ColangioMRI: sensitivity 85-100% gold standard before surgical repair

IATROGENIC BILIARY INJURIES POSTOPERATIVE IDENTIFICATION OF BDI

IMAGING:







IMAGING:







IMAGING:







study the biliary anatomy: COLANGIOGRAPHY (PTC / ERCP)

YES

NO

successful repair in 96-98%

unsuccessful repair in 98%

Any suspect of BDI ?

Wald, Surg Clin N Am 2008

Lillemoe, Br J Surg 2008

IATROGENIC BILIARY INJURIESMANAGEMENT

INITIAL GOAL

CONTROL OF SEPSIS

CONTROL ONGOING BILE LEAK

IATROGENIC BILIARY INJURIES ENDOSCOPIC AND RADIOLOGIC TREATMENT

Sicklick, Ann Surg 2005


Percutaneus transhepatic cholangiography (PTC): define the biliary anatomy decompress the biliary system

ERCP: confirm BDI temporary internal stent


LONG-TERM GOAL

RE-ESTABILISHMENT OF BILE FLOW INTO THE GI TRACT

PREVENT STRICTURE

PREVENT CHOLANGITIS

PREVENT LIVER INJURY

PREVENT STONE FORMATION


SURGICAL TREATMENT

IMMEDIATE

DELAYED

IATROGENIC BILIARY INJURIESIMMEDIATE SURGICAL REPAIR

LESS THAN 1/3 OF BDI ARE DETECTED DURING LC

try to define the extent of the injury

if the level of injury is clearly defined and the surgeon is comfortable with biliary reconstruction, immediate repair can be performed

IATROGENIC BILIARY INJURIESIMMEDIATE SURGICAL REPAIR

Simple leak from the cystic duct stump found during LC placement of an additional clip or a suture ligature loop

videolaparoscopy / laparotomy

Complex biliary injuries CONVERT TO LAPAROTOMY

STRASBERG CLASSIFICATION


SURGICAL TREATMENT

IMMEDIATE

DELAYED

IATROGENIC BILIARY INJURIESDALAYED SURGICAL REPAIR

Who? 75% of primary surgeon attempt to repair the injury themselves 17% are successfulIf first repair performed in a hepatobiliary third level center 94% are successful

When?Some surgeons suggest waiting 4-6 weeks to stabilize patientOther surgeons suggest to repair the injury as soon as possible to avoid formation of adeshions

Schmidt, Br J Surg 2005

Flum, JAMA 2003


IATROGENIC BILIARY INJURIESDALAYED SURGICAL REPAIR

How? Lateral ductal injuries (Strasberg type D) without a

complete transaction repaired primarly over an adjacently place T-tube as long as there is no evidence of significant ischemia or cautery damage

More extensive Strasberg type D and E biliary enteric anastomosis for reconstruction

Schmidt, Br J Surg 2005


IATROGENIC BILIARY INJURIESSURGICAL REPAIR

END-TO-END ANASTOMOSIS: feasible if injured segment is 1-2 cm and the 2 ends

can be opposed without tension

Kocher maneuver allows tension-free anastomosis

Connor, Br J Surg 2006

Jablonska, World J Gastroenterol 2009


ROUX HEPATICOJEJUNOSTOMY:(most performed anastomosis)

- preferable choice in lesions between the hepatic duct and the lobar ducts (less tension of the anastomosis)

- lower number of strictures

Sicklick, Ann Surg 2005McPartland, Surg Clin N Am 2008


PRO: - normal physiology → less ulcers and malabsorbtion- only one anastomosis: easier and faster to perform - post-operatory control through endoscope- no secondary biliary cirrhosis reported

Moraca, Arch Surg 2002Sicklick, Ann Surg 2005

HEPATICO-DUODENOSTOMY:

CONTRA: - difficult to perform for proximal bile duct lesions (75% of lesions)- need to an experienced surgeon- risk of cholangitis

IATROGENIC BILIARY INJURIESCLINICA CHIRURGICA 2 EXPERIENCE

1993-2008: 850 laparoscopic cholecystectomy

1 aortic lesion (0.11%)

1 jejunal perforation (0.11%)

1 hepatic hematoma (0.11%)

3 bile duct injuries (BDI) (0.35%)

1993-2008: 6 bile duct injuries refferred from other hospital


Age SexTiming

(days)Symptoms

Type of BDI

Imaging Surgery

48 F 15 Bile leak I CT, ERCP HJ

44 M 62 Cholangitis II CT, ERCP E-E + T-tube

60 F 28 Jaundice IV CT, ERCP HJ

59 M 32 Cholangitis II CT, ERCP HJ

49 F 9 Sepsis, bile leak

III CT, PTC ERCP

HJ

51 F 24 Cholangitis II CT, ERCP HJ

46 F IO Bile leak II E-E + T-tube

52 F 7 Bile leak II CT HJ

53 F 3 Bile leak IV CT, ERCP HJ

STEWART-WAY

CLASSIFICATION


OUTCOME

COMPLICATION n° Management

SHORT TERM (<1mo)

Bile collection 2 Percutaneous drainage

Wound infection 1 Antibiotics

LONG TERM (1yrs)

Stricture 1 ERCP + stent

IATROGENIC BILIARY INJURIESSTEWART-WAY II

IATROGENIC BILIARY INJURIESSTEWART-WAY II


P.O. CHOLANGIOGRAPHY (+10 D)

AFTER HEPATICOJEJUNOSTOMY

IATROGENIC BILIARY INJURIESSTEWART-WAY III

IATROGENIC BILIARY INJURIESSTRATEGIES TO PREVENT BDI DURING LC CAREFUL DISSECTION AND IDENTIFICATION OF STRUCTURES BEFORE TRANSECTION IS THE BEST MEANS OF A FAVORABLE OUTCOME

1. Meticulus dissection of the triangle of Calot to estabilish the “critical view of safety” before the division of any structures: when the cystic duct and cystic artery are clearly seen, safe clipping and division can be performed

2. Dissection of the cystic duct–common duct junction

3. The role of intraoperative colangiography during cholecystecomy is controversial, but is an effective means to delineate the biliary anatomy.

"...whenever the anatomy of the triangle of

Calot cannot be clearly defined, conversion

to an open procedure is indicated and should

not be viewed as a failure or a complication."



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UNIVERSITÀ DI PADOVA DIPARTIMENTO DI SCIENZE ONCOLOGICHE E CHIRURGICHE CLINICA CHIRURGICA II^ Direttore: Prof. Donato Nitti Donato Nitti La calcolosi della