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Cbd injuries

Biliary injuries

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Cbd injuries

  1. 1. Biliary Injuries/Choledochal Cysts
  2. 2. Historical perspective  First planned cholecystectomy in the world was performed by Carl Langenbuch in 1882.  First choledochotomy was performed by Couvoisser in 1890.  First iatrogenic bile duct injury was described by Sprengel in 1891.  Prof. Dr. Med Erich Muhe of Boblingen, Germany, performed the first laparoscopic cholecystectomy in 1985.
  3. 3. Biliary Anatomy a. Right hepatic duct. b. Left hepatic duct. c. Common hepatic duct. d. Portal vein. e. Hepatic artery. f. Gastroduodenal artery. g. Right gastroepiploic artery. h. Common bile duct. i. Fundus of the gallbladder. j. Body of the gallbladder. k. Infundibulum. l. Cystic duct. m. Cystic artery. n. Superior pancreaticoduodenal artery. Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.
  4. 4. Stewart et al. Bile Duct Injuries During Laparoscopic Cholecystectomy Classic anatomy of biliary tree is present in only 30% of individuals, so it may be said that anomalies are rule, not the exception. ( Maingot’s abdominal operations)
  5. 5. Anatomy  Calot's triangle bounded by cystic duct, cystic artery, and common hepatic duct.  Hepatocystic triangle bounded by gallbladder wall and cystic duct, liver edge, and common hepatic duct; the cystic artery (and hence Calot's triangle) lies within this space. (Maingot’s abdominal operation)
  6. 6. Laparoscopic cholecystectomy Pros and cons  General advantages Shorter stay in hospital Faster recovery period Reduced post-op recovery time Less postoperative pain Improved cosmetic outcome  Disadvantage Increase in serious bile duct complications and injuries
  7. 7. Introduction  Open cholecystectomy was standard practice for treatment of symptomatic gall bladder disease until late 1980’s.  At present 90% of cholecystectomies performed by LC which is one of the commonest surgical procedure in world.  widespread application of LC led to concurrent rise in incidence of major bile duct injuries (BDI),which are more complicated than after open procedures.  Since its introduction and routine use in 1990s, the incidence of biliary injuries has doubled from 0.2% to 0.4%.
  8. 8. Classic Laparoscopic Injury Mistaking common bile duct for the cystic duct
  9. 9. Thermal Injuries  Inappropriate use of electrocautery near biliary ducts  May lead to stricture and/or bile leaks  Mechanical trauma can have similar effects Lahey Clinic, Burlington, MA.1994
  10. 10. Bile duct injuries during cholecystectomy  In 1990s, high rate of biliary injury was due to learning curve effect.  Surgeon had 1.7% chance of a bile duct injury occuring in first case and 0.17% at the 50th case.  However most surgeons passed through learning curve, steady – state reached, but there has been no significant improvement in the incidence of biliary duct injuries.
  11. 11. Biliary Injuries during Cholecystectomy  Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative Biliary tract injuries.  On other hand LC has been associated with 2.5-fold to 4-fold increase in the incidence of postoperative BDI compared with OC.
  12. 12.  These preventable injuries can be devastating, increasing morbidity, mortality, and medical cost, while decreasing the patient’s quality of life.  Biliary injuries will always exist, and we need to be aware of the best methods to avoid, evaluate, and treat them.
  13. 13. Incidence of IBDI following cholecystectomy (%) Author IBDI incidence following OC IBDI Incidence following LC Mc Mohan et al,1995 0.2 0.81 Strassberg et al, 1995 0.07 0.5 Shea et al,1996 0.19-0.29 0.36-0.47 Targarona et al, 1998 0.6 0.95 Lillemoe et al, 2000 0.3 0.4-0.6 Gazzaniga et al, 2001 0.0-0.5 0.07-0.95 Savar et al,2004 0.18 0.21 Moore et al,2004 0.2 0.4 Misra et al,2004 0.1-0.3 0.4-0.6 Gentileschi et al,2004 0.0-0.7 0.1-1.1 Kaman et al,2006 0.3 0.6
  14. 14. Risk Factors for Biliary tract injury  Surgeon related factors  Lack of experience (learning curve)  Misidentification of biliary anatomy  Intraoperative bleeding  Lack of recognition of anatomical variations of biliary tree  Improper interpretation of IOC  Improperly functioning equipment
  15. 15. Risk for biliary tract injury  Patient related Acute and chronic cholecystitis Empyema Long standing recurrent disease -> fibrosis Porcelain gallbladder Obesity Previous surgery Male sex Advanced age
  16. 16. The Effect of Acute Cholecystitis on Lap. cholecystectomy complications  Complication rate three times greater than for elective LC.  Early cholecystectomy (72 h) outcome better than delayed cholecystectomy.  Conversion rate to open cholecystectomy is higher than elective cholecystectomy 35% vs 9%.
  17. 17. Risk Factors for biliary tract injuries Anatomic Variations Present in 18 – 39% cases Dangerous variations predisposing to BTI are present in only 3-6% of cases Abnormal biliary anatomy Short cystic duct, cystic duct entering in the right duct- Accessory right hepatic duct Arterial anomalies Right hepatic artery running parallel to the cystic duct Anomalous or accessory right hepatic artery
  18. 18. (Sabiston text book of surgery 19thedtn.)
  19. 19. Summary of Causes of Bile Duct Injuries  Misidentification of Common bile duct Common hepatic duct An aberrant duct (usually on the right side)  Technical failure such as Slippage of clips placed on the cystic duct Inadvertent thermal injury to CBD Tenting of CBD during clip placement Disruption of a bile duct entering directly into gallbladder fossa . (Goal of dissection should be conclusive identification of cystic structure within Calot triangle) (If the cystic duct and cystic artery are conclusively and correctly identified before dividing, more than 70% of bile duct injuries would be avoided )
  20. 20. Technique  Four methods of identification of cystic structures during cholecystectomy 1) Routine cholangiography 2) Critical view technique 3) Infundibular technique-> widely used 4) Dissection of main bile duct with visualization of cystic duct or common duct insertion-> ( increased chance of either thermal or retraction injury to CBD, aberrant insertion of cystic duct can also complicate this approach)
  21. 21. Routine intra-op cholangiogram (IOC) Laparoscopic ultrasonography  Performed routinely or not ?  Done via presumed cystic duct  If this happens to be CBD, injury has already occurred!!  IOC does not identify all aberrant ducts  Arterial anatomy not identified  IOC does not prevent BDI but may reduce its severity ( if correctly performed & interpreted, IOC can prevent complete CBD transection)  IOC  higher rate of intra-op identification of BDI  decreased cost of treatment & shorter hospital stay
  22. 22.  If critical view not obtained due to inflamation or hostile anatomy perform IOC prior to dividing cystic duct . Routine IOC reduces CBD injuries from 0.58% to 0.39% (American Medicare data base study)
  23. 23. Critical view of safety  Calot’s triangle dissected free of all tissue except cystic duct & artery  Base of liver bed exposed  When this view is achieved, the two structures entering GB can only be cystic duct & artery  Not necessary to see CBD
  24. 24. (A)Usual anatomy when infundibular technique applied. Cyst duct-gallbladder junction is characterized by a flaring tunnel shape(boldlines). Arrow represents circumferential dissection of CD-gallbladder junction during infundibular technique. (B) Inflammation can pull CBD on the gallbladder creating similar flaring tunnel shape. As a result, CBD mistaken for cystic duct, resulting in classic injuries. CD, cystic duct;CHD, common hepatic duct. (Strasberg S. Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg 2008;15(3):285;)
  25. 25. Cystic duct or CBD? 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 Vessels on --
  26. 26. Classical LC BDI
  27. 27. Strasburg Classification  Type A Cystic duct leaks or leaks from small ducts in liver bed  Type B Occlusion of aberrant right hepatic ducts  Type C Transection of aberrant right hepatic ducts  Type D Partial (<50%) transection of major bile duct  Type E Transection involve >50% Subdivided as per Bismuth classification into E1 to E5
  28. 28. Strasburg Classification, cont’d E: injury to main duct (Bismuth)  E1: Transection >2cm from confluence  E2: Transection <2cm from confluence  E3: Transection in hilum  E4: Seperation of major ducts in hilum  E5: Type C plus injury in hilum
  29. 29. Class I CBD mistaken for cystic duct, but error recognized before CBD is divided. Class II Damage to CHD from clips or cautery placed on duct. Often occurs where visibility is limited due to inflammation or bleeding. Class III Most common (60%), CBD mistaken for cystic duct. Common duct is transected and variable portion that includes junction of cystic and common duct is excised . Class IV Damage to right hepatic duct , either because this structure is mistaken for cystic duct, or injured during dissection.
  30. 30. Bile duct injury  Prevention should be main point  (much more important than treatment)  ALL laparoscopic cholecystectomies ARE difficult!  None of them is easy!  If injury occurred, … who should treat it? when should it be treated? how should it be treated?
  31. 31. 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  Intraoperative laparoscopic ultrasound (IOUS) . Mastery of Surgery 6th ed.
  32. 32. Changing the Culture of Cholecystectomy: Stopping Rules  Safety and avoiding BDI should be paramount concern to surgeon performing LC.  LC can be converted to open procedure or even aborted if local conditions present unacceptable risks of danger.  As Strasberg points out, the negative effects of conversion or even aborting procedure and placing a cholecystostomy tube are minor compared with the negative effect of a BDI.  Failure of progression of dissection, inability to grasp and retract gallbladder, anatomic ambiguity, poor visualization of field due to hemorrhage, should trigger the surgeon to consider alternate approach.  Conversion rate < 5% can be expected in hands of a well trained laparoscopic surgeon.
  33. 33. Timing of Identification • Intra-op • Unexpected ductal structures seen • Bile leak into field from lacerated or transected duct • Post-op • Depends on continuity of bile duct & • Presence or absence of bile leak
  34. 34. Presentation of Bile Duct Injuries  About 25% recognized intraoperatively.  About 25% discovered within 24 hours post- operative  About 50% present weeks to years post-operative.  Most BDI are not recognized intraoperatively, and patients sent home after or within 24 hours.  Patients who fails to recover within first few days or develop progressive vague abdominal symptoms.  Abdominal fullness, distension, nausea, vomiting, abdominal pain, fever and chills.  Symptoms can leads to bilomas, biliary fistula, cholangitis, sepsis, or multi organ system failure.  Clinical presentation- Biliary obstructions-> anorexia, jaundice, liver enzyme elevation Bile leaks Both can occur simultaneously Concomitant vascular injuries (complicate matter)  Obstruction secondary to biliary stricture appear weeks to month later and may present with recurrent colangitis, obstructive jaundice, or secondary biliary cirrosis.
  35. 35. Intraoperative Detection  If experienced, convert to Open Procedure and perform Cholangiography (determine extent of injury)  If not experienced, perform cholangiogram laparoscopically with intent of referring patient (placement of drains)  Consult an experienced hepatobiliary surgeon Quicker the repair, better the outcome!!!  Acute Management Biliary catheter for decompression of biliary tract and control of bile leaks Percutaneous drainage of intraperitoneal bile collection
  36. 36. 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 drain • Diffuse abdominal pain & persistent ileus several days post-op  high index of suspicion  possible unrecognized BDI
  37. 37. Post-Operative Detection Plan  Controlling sepsis, establish biliary drainage, postulate diagnosis, type and extent of bile duct injury.  Broad-spectrum antibiotics  No need for an urgent laparotomy. Biliary reconstruction in presence of peritonitis results a statistically worse outcome.  No need for urgent with reconstruction of biliary tree. Inflammation, scar formation and development of fibrosis take several weeks to subside.  Reconstruction of biliary tract is best performed electively after interval of at least 6 to 8 weeks.
  38. 38. BDI Management  Investigation  Ultrasonagraphy and CT -- Ductal dilatation intra-abdominal collection and dilatation of biliary tree.  Cholangiogram  ERCP—biliary anatomy and assess the injury  PTC—define biliary anatomy proximal to injury  MRCP—noninvasive (can miss minor leaks) HIDA scan -- If doubt exists, HIDA scan can confirm leak but not the specific leak site  MR angiography—vascular injuries
  39. 39. When realise that there is an injury, ASK for HELP! If possible do not try to repair, even you are experienced An experienced and FRESH surgeon should repair the injury. If it is impossible AND it is a difficult injury that you can not treat, place catheters and refer the patient. There is no ‘Tissue Lost’, primary repair (end to end CBD repair) over T-tube??? stricture rate is high!!! There is ‘Tissue Lost’, biliodigestive anastomosis: choledocoduodenostomy/ Roux-en-Y hepaticojejunostomy Primary repair  high incidence of failure  percutaneous or endoscopic balloon dilatation later
  40. 40. Preoperative Investigation and Preparation for the Procedure ■ Communication with previous surgeon ■ Previous surgical report ■ Laboratory tests: bilirubin, alkaline phosphatase, ALT, AST, albumin, coagulation parameters, white blood cell count Principles of Repair ■ Anastomosis should be tension free, with good blood supply, mucosa to mucosa and of adequate caliber. ■ Hepaticojejunostomy should be used in preference to either choledochocholedocotomy or choledochoduodenostomy. ■ Anterior longitudinal opening in the bile duct with a long side-to- side anastomosis is preferred. ■ Dissection behind the ducts should be minimized in order to minimize devascularization of the duct.
  41. 41. Timing of Repair Factors favoring immediate repair are: (1) Early referral (2) Lack of right upper quadrant bile collection (3) Simple injuries (4) No vascular injury and (5) Stable patient Factors favoring delayed repair are: (1) Late (less than 1week after injury) referral (2) Complex injuries (types E4, E5) (3) Thermal etiology (4) Concomitant ischemic injury
  42. 42. Strasburg classification Type A No reconstruction Treated endoscopicaly Type B & C Potentialy serious injuries More common since introduction of LC Type B Silent Asymptomatic atrophy of involved liver Compensated by hypertrophy of normally drained liver Pain or cholangitis many yrs. after injury Type C Biliary fistula Volume less Converted to silent Type B Persistence Reconstruction Type D <25% 25% - 50% or  Caused by diathermy or Small bile duct Type E (>50%) Repaired primarily Over T-tube Reconstruction by hepaticojejunostomy B,C and E1 to E5 are major biliary injuries
  43. 43. ERCP – multiple stents • Lateral 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
  44. 44. Simple injuries types A and D may be treated in community setting when discovered intraoperatively by endoscopic or percutaneous techniques when they present in postoperative period.  Complex injuries that require hepaticojejunostomy for repair (types B and C injuries and most to type E injuries). More complex injuries types E1 and E2 may also be treated by nonsurgical techniques when they present as strictures. Notations >2 cm and <2 cm in types E1 and E2 indicate length of common hepatic duct remaining.
  45. 45. Bile leak Immediate intra operative diagnosis Delayed diagnosis injurMinor y Major injury Repair over T-tube No experienced hepato-Biliary surgeon Clip open duct Drain IV antibiotics Transfer to tertiary centre Experienced hepatobiliary surgeon available Call second surgeon Roux-en-Y hepatico- jejunostomy Drainage Low -output High-output Observe Resolve < 5-7 days Continued ERCP Duct of Luschka Cystic duct stump leak Suspected CBD injury Sphinctrectomy Stent± sphincterectomy PTC to deliniate anatomy Control drainage Repair by experienced hepatobiliary surgeon
  46. 46. 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
  47. 47. ERCP – clips across CBD  CBD transection  normal-sized distal CBD upto site of transection  Percutaneous transhepatic cholangiography (PTC) necessary  Surgery
  48. 48. Intraoperative repair
  49. 49. Surgical repair Choledocho-choledochostomy
  50. 50. Surgical repair Choledocho-duodenostomy
  51. 51. Biliary enteric anastomosis  Most laparoscopic BDI – complete discontinuity of biliary tree  Surgical reconstruction, Roux-en-Y hepaticojejunostomy  Tension-free, mucosa- to-mucosa anastomosis with healthy, nonischemic bile duct
  52. 52. Surgical repair Hepatico-jejunostomy (Roux-en-Y)
  53. 53. Definitive management  Goal  Reestablishment of bile flow into proximal GIT  In a manner that prevents cholangitis, sludge or stone formation, restricturing & progressive liver injury  Bile duct intact & simply narrowed  percutaneous or endoscopic dilatation
  54. 54. Treatment summary  Strasberg 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 over a 5-F pediatric feeding tube to serve as a biliary stent
  55. 55. Summary • Multidisciplinary management of BDI  expertise of surgeons, radiologists & gastroenterologists • Mismanagement  lifelong disability & chronic liver disease • BDI with lap. Chole  results of operative repair, excellent in Specialist Centres
  56. 56. Choledochal Cysts • Choledochal cysts are focal or diffuse dilatations of the biliary tree • Most commonly present in childhood but increasingly being recognized in adults. • represent significant clinical challenges where proper evaluation and management are paramount to prevent serious clinical sequelae.
  57. 57. Epidemiology • incidence of choledochal cysts varies significantly throughout the world. • In Asia, incidence is as high as 1 in 1000 population with 50% cases representing from Japan • In Western Countries, choledochal cysts occur less frequently with reported cases ranging from 1:13,000 to 1:150,000 population.
  58. 58. • Occur more commonly in females with a M:F ratio of 1:3-4 • Classically present in childhood, but recent series report as many as 25% of cases presenting in adults.
  59. 59. Classification • Proper management of choledochal cysts requires consideratio of their classification. • Original Classification by Alonso-Lej and associates exclusively involved the extrahepatic duct • The classification was revised by Dr. Todani and colleagues in 1977 to include intrahepatic cystic anomalies
  60. 60. Todani Classification • Type I (50-85%): They are characterized by cystic or fusiform dilation of the common bile duct. • Type IA is defined by cystic dilation of the entire extrahepatic biliary tree, • Type IB is defined by focal, segmental (often distal) dilation of the extrahepatic bile duct. • Type IC is defined by smooth, fusiform (as opposed to cystic) dilation of the entire extrahepatic bile duct.
  61. 61. Todani Classification • Type II ( 2%): true diverticula of the extrahepatic bile duct and communicate with the bile duct through a narrow stalk. • Type III ( 5%) : Cystic dilatation of the intraduodenal portion of the extra hepatic common bile duct; also known as a choledochocele • Type IV (30-40%): Involve multiple cysts of the intrahepatic and extrahepatic biliary tree; IV A > IV B • Type V: Caroli’s Disease
  62. 62. • Type 1 A
  63. 63.  Type II
  64. 64.  Type III
  65. 65.  Type IV A
  66. 66.  Type IV B
  67. 67.  Type V
  68. 68. Pathogenesis • Cause not currently known. Most cysts are congenital in nature. • It is unclear whether cases of choledochal cysts diagnosed in adults are acquired or late manifestations of congenital cysts. • There may be multiple mechanisms involved in the creation of biliary cysts • The high incidence of biliary cysts in Asia suggests a role for either genetic or environmental factors.
  69. 69. • Congenital weakness in the bile duct wall • Abnormal biliary epithelial proliferation before bile duct cannulation is complete • Bile duct obstruction or distension in the prenatal or neonatal periods • Fetal viral infection • Pancreaticobiliary maljunction
  70. 70. APBJ – Babbit Theory • Pancreaticobiliary maljunction is defined as an extramural junction of the pancreatic and biliary ducts in the duodenum beyond the intramural sphincter function • characterized by a long common channel (typically over 2 cm) • Increased reflux of pancreatic juice into the biliary tree -- >
  71. 71. Associated Developmental Anomalies • Biliary atresia , Duodenal atresia, Colonic atresia, Imperforate anus • Pancreatic arteriovenous malformation, Heterotopic pancreatic tissue • Multiseptate gallbladder • OMENS plus syndrome • Ventricular septal defect, Aortic hypoplasia, • Congenital absence of the portal vein • Familial adenomatous polyposis • Autosomal recessive and autosomal dominant polycystic kidney disease
  72. 72. Presentation • Classic triad : pain, jaundice, and abdominal mass. ( ~ 10%) • Infants commonly present with elevated conjugated bilirubin (80%), failure to thrive, or an abdominal mass (30%). • In patients older than 2 years of age, abdominal pain is the most common presenting symptom. • Intermittent jaundice and recurrent cholangitis are also common, especially in patients with a type III cyst.
  73. 73. Diagnosis • U/S abdomen : to detect the presence • CT scan – more appropriate in adults. • MRCP • Cholangiography: gold standard , PTC or ERC in adults and intraoperative cholangiography in small children • Liver function tests
  74. 74. Operative Management • Type I: excision of the cyst with its mucosa and reconstruction by Roux-en-Y hepatico-jejunostomy • Type II: excision of the diverticulum and suturing of the CBD wall • Type III: endoscopic sphincterotomy is done. • Type IV: Extrahepatic biliary resection, cholecystectomy, and biliary reconstruction • Type V: Liver transplantation, hepatectomy