2. دانشيار دانشگاه علوم پزشكي قزوين
BILE DUCT INJURY : HOW TO REPAIR
دكتر پرويز فلاح عابد
دانشيار دانشگاه علوم پزشكي قزوين

3. BILE DUCT INJURY (I)
Any injury to the bile duct during cholecystectomy is a dreaded complication.
Major bile duct injuries may require biliary-enteric reconstruction
Many patients, their consultans, and their lawyers believe these treatments result in a lifetime of disability (Moraca R.J et al : Arch Surg 2003, 137: )

4. BILE DUCT INJURY (2)
The occurrence of an accidental bile duct injury strikes the patient and surgeons with great force, as neither is prepared for this complication
Often the surgeons is not immediately aware of disaster, and a delayed diagnosis adds further difficulty to the potentially disturbed relationship between doctor and patient. (Gouma DJ and Obertrop H : BJS 2002,89, )

5. 1.2% laparotomy for treatment of complications
Complications of Laparoscopic Cholecystectomy : A National Survey of 4,292 Hospitals and an Analysis of 77,604 Cases
Deziel D J et al Chicago Illinois - Am J of Surg 165 January 1993
1.750 respondents
1.2% laparotomy for treatment of complications
0.6% mean rate of bile duct injury (exclusive of cystic duct), that will be lowered after performing > 100 LC
50% of bile duct injury was recognized postoperatively, required anastomotic repair
33 pts died, 18 of them due to operative injury
0.14% bowel injuries
0.25% vascular injuries
Most lethal complications

6. BILE DUCT INJURY (3)
Since 35 years ago, bile duct reconstructions were performed in every imaginable way : end-to-end repair, hepatico gastrotomy, hepatico-duodenostomy (HD), loop hepatico-jejunostomy, and hepatico-jejunostomy Roux-en-Y (HJ)
Analysis of the results showed that HD and HJ produced the lowest rates of recurrent stricture formation, and these two have been the accepted operations eversince
(Moraca R.J et al : Arch Surg 2003, 137: )

7. Bile Duct Injuries Bismuth classification of bile duct strictures
Lahey Clinic, Burlington, MA.1994

8. NEUHAUS CALSSIFICATION OF BILE DUCT INJURIES AFTER LAP - CHOLE
Neuhaus P, Humbolt Univ. of Berlin
BJS

9. Way LW et al: An Surg, vol 237 No.4. 460-465, 2003

10. Thermal injuries leading to late stricture
Lahey Clinic, Burlington, MA.1994

11. CHD DRAINS FREELY IN TO THE PERITONEAL CAVITY
Lahey Clinic, Burlington,MA 1994

12. Common varians of bile duct anatomy
Lahey Clinic, Burlington, MA.1994

13. MANNER OF CONFLUENCE RIGHT SECTORAL DUCTS
Blumgart LH. Surg Clin N Am

14. CLINICAL PRESENTATION
Many injuries are unrecognizes at the time of the initial operation, and their presentation will vary
Those with associated bile leak will present early and often acutely ill from bile peritonitis or subhepatic abscess

15. BILE LEAK IS RECOGNIZED EARLIER
Presentation:
Acutely ill
Gut failure
Warko karnadihardja- 2004

16. CLINICAL PRESENTAION
Those with an injury but not leak, usually develop jaundice sometime after discharge from hospital, depending of the nature of the injury
Some injuries evolve slowly or cause partial obstruction
Stricture may involve principally the right or left hepatic duct or one of the right sectorial hepatic ducts

17. TIPS & TRICKS TO DIAGNOSE BILE DUCT INJURY
History of unexplained fevers, pain, abnormal liver function test results, or pruritus
Should prompt an investigation

18. MANAGEMENT OF BILE DUCT INJURY (1)
IMPORTANCE
Preoperative investigation
Patient Preparation
BEFORE OPERATION
The surgeon must define completely the extent of injury and treat co existing conditions that will increase operative morbidity and reduce the likelihood of a successful repair

19. MANAGEMENT OF BILE DUCT INJURY (2)
Preoperative imaging
Is there subhepatic abscess or collection?
Is there ongoing bile leakage ?
What is the level of biliary injury ?
Are there associated vascular injuries /
Is there evidence of lobar atrophy ?

20. TYPES OF IMAGING INVESTIGATION (1)
Doppler Ultrasonography : May reveal the level of:
ductul injury and an associated vascular injury or fluid collection
Inadequate to define the extent of stricture
Of little value if bile ducts are decompressed

21. TYPES OF IMAGING INVESTIGATION (2)
Cholangiography
PTC is superior to ERCP
MRCP : Noninvasive, provides striking images of biliary tree
Arteriography and Splenoportography
If any suspection of vascular injury or portal hypertension
Isotopic scanning
Functional assessment of incomplete stricture or strictures of a sectoral hepatic duct (Bismuth types)

22. TYPES OF IMAGING INVESTIGATION (3)
Contrast-enchanced CT
Probably the best initial study
May define level of injury, fluid collection or ascites
May suggest the possibility of vascular damage
Reveal lobar atrophy

23. IMAGING OF BILE DUCT INJURY
PTC
MRCP: Surgical Clip
After Multiple Attempts to Repair (MD-CT)
Radiologist Society of North America :Radiology 1998

24. ATROPHY OF THE LEFT HEPATIC LOBE WITH DILATED AND CROWDED INTRAHEPATIC DUCTS
Jarnagin WR and Blumgart LH; Arch Surg 134,1999

25. RIGHT LOBE ATROPHY AND COMPENSATORY LEFT LOBE HYPERTROPHY
Blumgart,LH,Surg Clin North Am. 1994,vol 74 no.4

26. OPENING THE UMBILICAL FISSURE BY DIVIDING THE BRIDGE OF LIVER TISSUE THAT CONNECTS SEGMENT III AND IV
Blumgart, LH, Surgery of the Liver and Biliary tract, 1994

28. EXPOSING THE HILAR PLATE
Blumgart. LH, Surg Clin North Am,1994. vol 74 no.4

29. MOBILIZATION OF HILAR PLATE FOR HIGH BILIARY STRICTURES
Extension of bile duct opening to permit wide biliary enteric anastomosis
Blumgart LH: Surg Clin N Am.1984 vo
Lahey Clinic, Burlington, MA.1994

31. Lahey Clinic, Burlington, MA.1994
CREATING A SEPTA BETWEEN MULTIPLE BILE DUCTS TO FORM A COMMON CHANNEL TO BE ANASTOMOSED TO SINGLE OPENING OF THE JEJUNUM
Lahey Clinic, Burlington, MA.1994

32. ANTERIOR AND POSTERIOR ROW OF SUTURES
Blumgart LH, Surg of the Liver & Biliary tract, 1994

33. When surgically feasable, we prefer HD to HJ
Depart of General, Vascular and Thoracic Surgery, Virginia Mason Medical Center, Seatle, Wash
Biliary function to be normal at more than 4 years after biliary-enteric reconstruction for bile duct injury
When surgically feasable, we prefer HD to HJ
9 years study: February Januari
Arch Surg, vol 137, Aug.2002

34. OPERATIVE TECHNIQUE (1)
A generous incision-full mobilization of the inferior surface of the liver identify the site of bile duct injury
Avoid dissection that might devascularize the remaining bile duct, that is of the hepatic arterial and portal venous systems
Sharp debridement was used for damaged or devitalized bile duct wall to the level of normal mucosa
Identify each patients unique anatomy for the right and left hepatic ducts and their relationship to the bifurcation by : Surgical Instrumentation, cholangiography or choledochoscopy
Virginia Mason Medical Center, Seattle, Wash

35. OPERATIVE TECHNIQUE (2)
Biliary enteric anastomosis were performed using magnification for a mucosa-to- mucosa anastomosis with the use of single layer of multiple, fine, interrupted, absorbable sutures for a watertight closure
Temporary transanastomotic stents were various used including
Percutaneous transhepatic
Percutaneous trans-enteric
Internal small silicone stents anchored to mucosa
Or no stent
Virginia Mason Medical Center, Seatle. Wash.2002

36. TEMPORARY TRANSANASTOMOTIC STENTS
A. Percutaneous trans-enteric
B. Percutaneous transhepatic
C. U tube
D. Internal small silicone stent
anchored to mucosa
Blumgart LH : Surg N Am; 1994, vol. 74 no. 4

37. OPERATIVE TECHNIQUE (2)
For Hepaticoduodenostomy
Wide Kocherization of the duodenum to create a tension free anastomosis end to side was accomplished
Roux-en-Y Jejunal Limbs
Were made intentionally short so that postoperatively endoscopic inspection of the anastomotic site could be attempted when indicated
Hepaticojejunostomy was done end-to-side

38. ROUX-EN-Y HEPATICO JEJUNOSTOMY WITH EXTENDED ACCESS LOOP
“Burried Subcutaneous Stoma”, marked by clip
Open skin stoma
Warko Karnadihardja-BDG
Blumgart LH,Surgery of the Liver and Biliary Tract, 1994

39. OPERATIVE TECHNIQUE (3)
A generous incision-full mobilization of the inferior surface of the liver identify the site of bile duct injury
Avoid dissection that might devascularize the remaining bile duct, that is of the hepatic arterial and portal venous systems
Sharp debridement was used for damaged or devitalized bile duct wall to the level of normal mucosa
Identify each patients unique anatomy for the right and left hepatic ducts and their relationship to the bifurcation by : Surgical Instrumentation, cholangiography or choledochoscopy
Virginia Mason Medical Center, Seattle, Wash 2002

40. Kegunaan kombinasi Kent & sweetheart retractors
Tersedia hampir di semua Rumah Sakit di Bandung (peralatan standar)

41. OPERATIVE TECHNIQUE (4)
Closed suction drains were placed below and near biliary-enteric anastomosis
All transanatomotic stents were removed postoperatively within 3 weeks after cholangiography demonstrated patent anastomoses
Internal anastomotic stents are allowed to pass spontaneously
No long-term stenting
Patients with HJ were treated with long-term prophylactic medication to avoid peptic ulceration
Virginia Mason Medical Center, Seattle, Wash 2002

42. COROSION CAST OF ADULT LIVER
BLOOD SUPPLY TO CBD
Van Damme and Bonte J : Vascular Anatomy of in
Abdominal Surg. Thieme 1990
Surgical Clin N. Am,1994

43. GOOD VASCULARIZATION OF THE PROXIMAL JEJUNUM
Vascularization of the duodenojejunal angle
Van Damme J P and Bonte J : Vascular Anatomy of in Abdominal Surgery Thieme, 1990

44. MORE RESEARCH ON OPERATIVE REPAIR OF BILE DUCT INJURIES TO BETTER OUTCOME ON LONG-TERM QUALITY OF LIFE

45. Department of Surgery Academic Medical Centre Amsterdam
“ More careful and accurate communication between doctor and patient, before and after primary surgery as well as before and after surgery, may help to prevent disappointing results”
“ Studies not only to have focused on outcome in terms of laboratory and imaging results, rather than in terms of general well-being or quality of life”
British Journal of Surg

46. “ A stricture of the biliary tree can be one of the most challenges that a surgeon can face”
“If unrecognized or managed improperly, life-threatening complications, such as biliary cirrhosis, portal hypertension and cholangitis can develop”
“Management with pre-op cholangiography to delineate the anatomy and placement of percutaneous biliary catheters, followed by surgical reconstruction with a Roux-en-Y hepaticojejunostomy, is associated with a successful outcome in up to 98% of patients”
John Hopkins Hospital, Baltimore, Maryland. Ann Surg, September 2000

47. “ The initial management of patients with proximal bile duct injuries will depend on the type of injury and time of recognition”
“ If the injury is recognized immediately, surgeons must consider their ability to repair it immediately”
“ If the surgeon is unable to effect a reasonable repair and competent help is not available, then the patient should undergo adequate drainage and be referred to a more experienced surgeons
Arch Surg vol 134, July 1999

48. A dilema not answered ?
Mercado MA et al depart Surg, INCMNSZ, Mexico City
“ Good results are obtained with a Roux-en-y hepatico jejunostomy after complex injuries’
“The use at of transanastomotic stents has to be selective according to the individual characteristics of each patient and the experience of each surgeon”
We recommend their use when unhealthy ie: ischemic, scarred and small ducts < 4 mm are found”
Arch Surg vol 137, July 2002

49. Damage control surgery for uncontroled bleeding of hepatic rupture, bile leakage and sepsis

50. CT – guided percutaneous drainage

51. Hepaticojejunostomy with a trans-enteric stent

52. Three weeks after repair, just before removing stent

53. FOLLOW UP
Two weeks after discharged

54. Bile leakage after laparoscopic cholecystectomy and after laparotomy repair, stenting CBD with small stent 7 F Continuing SIRS and Sepsis

55. Replacing drainage for source control with bigger CBD stent 10 F, before definitive surgery

56. CONCLUSIONS
Bile duct injury during cholecystectomy, either laparoscopic or open, is a complex and a dreaded complication
The proximal bile duct is at greater risk for injury in laparoscopic surgery and may require biliary-enteric reconstruction
Many patients, their consultants and their lawyers believe these treatments result in a lifetime of disability
Among the surgical strategies for repair, hepatico jejunostomy yields the most favorable results, as far as we consider the good principles of surgery, such as, should be tension free, good vascularization, healty duct and the widest diameter of bile duct available

57. Thank You