Classification and management of bile duct injury Good morning senior and my fellow colleague, my name is Ray, I am from the department of surgery of Prince of Wales Hospital currently rotating in the hepatobiliary and pancreatic surgery Welcome to the joint hospital grand round. Today my presenting topic will be classification and management of bile duct injury It is a very large topic and hopefully in this 12 minutes of time I will be able to give you a very brief idea on what to do when you are facing a case of bile injury unluckily. Dr. Hung Ka Wai Ray Team 1 Hepatobiliary and Pancreatic Surgery Prince of Wales Hospital

Introduction Laparoscopic cholecystectomy Standard treatment of symptomatic gallstone disease > 750, 000 were performed annually in the United States Less pain, fewer wound complication, quicker recovery The only potential disadvantage is a higher incidence of major bile duct injury [1], 0.3% open vs 0.6% laparoscopic [1] Acute bile duct injury. The need for a high repair. Surg Endosc 2003;17: 1351-1355 Nowadays, laparosopic cholecystectomy is considered as the standard treatment of managing symptoamtic gallstone disease. > 750,000 of lap. chole were performed every year in the United States. It is world known to be associated with less pain, fewer wound complication and quicker recovery when compared to open chole. However, it was found to be associated with a high incidence of major bile duct injury , according to the lithture, the incidence of duct bile duct injury is 0.3% in open cholecsytectomy vs 0.6% in lap. Chole

Introduction Bile duct injury is a very serious complication that lead to mortality, significant morbidity and impaired quality of life Causes: Iatrogenic Cholecysectomy (80-85%) [2] Gastrectomy Pancreatectomy ERCP Trauma Duodenal ulcer [2] Bile duct injuries during laparoscopic cholecystectomy: primary and long term results from a single institution. Surg Endosc 2007; 21: 1069-1073 Bile duct injury, although not common, is a very seriuos complication that lead to mortality and morbidity. It also significantly affect the QOL of the patient. Iatrogenic injury account for most of the cases and ~ 80-85% are occuring during cholecystectomy. Other iatrogenic cause including injury during gastrectomy, pancreatectomy, ERCP Non iatrogenic cause include trauma and duodenal ulcer

Presentation Intraoperative Postoperative Direct observation of a divided duct Bile in the operative field Abnormal intra-operative cholangiography Postoperative Bile leak Bile in the drain Biloma, biliary fistula, or bile ascites Bile peritonitis in severe cases Biliary obstruction Obstructive jaundice Cholangitis As the presentation of the bile duct injury can be very subtle, in order to establish the diagnosis, one need to very cautios about that. Intraoperative identification account for a minority of cases, we may be seeing a divided duct directly. There may be bile leakage in the operative field. Or it may also be cofirmed by an abnormal intraopeartive cholangiography Post operative identification account for the majority of the cases. The patient usually present with bile leak or bile duct obstruction. There may be bile seen in the drain, or a biloma found in the ultrasound / CT scan. In very severe cases, the patient can present with bile peritonitis In cases of biliary obstruction, the patient may presented with OJ / cholangitis

Classification Bismuth Strasberg et al. Stewart et al. McMahon et al. AMA Neuhaus et al. Csendes et al. Hanover Lau and Lai Siewert et al. Cannon et al. Kapoor Sandha et al. EAES In the litheture, a lot of different classification has been reported Bismuth classification had been used for a long time in the era of open cholecystectomy. Nowadays, for bile duct injury in laparoscopic cholecytectomy, Stragsberg classification is widely used.

Strasberg et al. Starsberg classification is divided into 9 type A-E And type E is further divided into E 1-5

Strasberg et al. Type A refer to cystic duct leaks or leaks from small ducts in the liver bed Type B refer to occlusion of a part of the biliary tree, almost invariably the abberrant right hepatic duct Type C refer to transection without ligation of the aberrant right hepatic ducts Type D refer to lateral injuries to major bile ducts

Strasberg et al. For type E1-E5, actually it is referring to the Bismuth classification 1-5 E1 is the low CHD injury with stump > 2 cm E2 is the low CHD injury with stump < 2 cm E3 refer to hilar injury with a preserved communication between the left and right IHD E4 refer to hilar injury with loss of communication between the left and right IHD E5 refer to aberrant right hepatic duct alone or concomitantly with CHD

Management Depend on the timing of recognition of the injury Intraoperative vs postoperative recognition For the management, it depend on then timing of recognition and can be divided into intraoperative vs postoperative group

Intraoperative recognition Account for 25%–32.4% [3] First consult an experienced hepatobiliary surgeon Convert to laparotomy with cholangiography Define the nature of the injury If expertise a/v Immediate repair can minimize the morbidity Higher successful rate, fewer morbidty and mortality [4] If expertise not a/v Injudicious attempts at exploration may cause further biliary and vascular injury Subhepatic drain to prevent collection External biliary drainage Refer to a specialized hepatobiliary unit [3] Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch. Surg. 1995; 130: 1123–8. [4] Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann. Surg 2005;241:786-90 Injuries identify during the intraoperative period account for ~ 25% of cases. The first thing we should do is not repair of the injury but consult an experienced hepatobiliary surgeon when we are facing a bile duct injury. We should also convert to laparotomy and perform a cholangiorahpy to confirm and identify the injury When expertise a/v immediate repair always can minimize the morbidity. It is found that, if the injury is repaired by a HBP surgeon, it is associated with a higher successful rate, fewer morbidity and mortality However, when expertise is not a/v, injudicious attempts at exploration only cause further biliary and vascular injury. The patient should be managed with subhepatic drainage to prevent collection and external biliary drainage for diversion and refer to a specialized HBP unit.

Postoperative recognition Aim of management Control sepsis and limit inflammation Delineate the biliary anatomy and associated vascular injury Re-establish the biliary enteric continuity On the other hand, majority of the injury usually identify during the postoperative period. The aim of the management can be divided into 3 stages, Stage one will be control the sepsis and limit inflammation Stage 2 will be delineate the biliary anatomy and associated vascular injury Stage 3 will be re-establish the biliary enteric continuity Factors influencing the success rate are the complete eradication of abdominal infection, complete cholangiography, use of correct surgical technique and repair by an experienced biliary surgeon [5] Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes, HBP2009, 11, 516-522

Control sepsis Fluid resuscitation Broad spectrum antibiotic Investigation USG / CT to asses collection +/- drainage For the control of sepsis, the patient should be managed with fluid resuscitation, started on broad spectrum antiboitc Imaging including USG / CT should be performed to look for and collection and drainage should be arranged if necessary

Delineate the biliary anatomy Cholangiography ERCP PTC MRCP For delineation of the biliary anatomy, cholangiography including ERCP, PTC, MRCP should be arranged

Associated vascular injury CTA / MRA Incidence is around 16.7%-47%[6] Most commonly involving the right hepatic artery Does not usually lead to early significant complications Impact on bile duct injury [7] Associated with increased intraoperative bleeding during repair Difficult reconstruction Higher incidence of anastomotic stricture due to bile duct ischamemia Delayed repair if VBI is present [6] Management and outcome of patinets with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 2004; 135: 613-8 [7] Management of bile duct injury after laparoscopic cholecystectomy: a review, ANZ J Surg 80 (2010) 75-81 Beside cholangiography, angiograhpy such as CTA / MRA should also be arranged to look for associated vascular injury. Associated vascular injury is occurred in ~ 16.7-47% and most commonly involving the right hepatic artery Due to the dual supply of the liver, it usually does not cause early significant complication However, it is shown that it is associated with increased intraoperative bleeding during repair, difficult reconstruction and the incidence of anastomotic stricture is also higher due to bile duct ischaemia Therefore, in case of concomitant vascular injury, delayed repair should be consider and it is also found to be associated with less complication and a higher successful rate

Re-establish the biliary enteric continuity According to the type of injury Surgery vs endoscopic treatment Once the patient is stabilized and other factor including inflammation, detailed anatomy of the injury is established, we can consider to re-establish the biliary enteric continuity The management is depend on the type of injury Both surgical and sometime endoscopic treatment can be used for treatment.

Re-establish the biliary enteric continuity Strasberg classification Surgical treatment A ERCP + sphincterotomy + stent B Hepaticojejunostomy C D Primary repair if small injury with no devascularization Hepaticojejunostomy if extensive injury E For type A, as there is no loss of biliary continuity, it can be management with ERCP + sphincterotomy + stenting For type B and C, as it involve injury to the biliary system and loss of continuity, HJ is needed For type D, lateral injury of the CBD, in case of small injury, it can be treated with primary repair. However, for more extensive injury, A HJ is also needed For type E, bile duct injury of the CHD, HJ is needed to re-establish the biliary enteric continutiy

Treatment of Complication Stricture Balloon dilatation and biliary stenting Hepaticojejunostomy has higher successful rate Secondary biliary cirrhosis Liver transplantation A very small group of patient can remain asymptomatic for a long period of time and being diagnosed years after the index surgery. They usually presented to us for biliary obstruction due to stricture. In the mild case, it can be treated with endoscopic dilatation and biliary stenting Of course HJ still remain the gold standard of treatment with a higher successful rate For severe case with secondary biliary cirrhosis, liver transplantation is the last resort for them.

Reference [1] Acute bile duct injury. The need for a high repair. Surg Endosc 2003;17: 1351-1355 [2] Bile duct injuries during laparoscopic cholecystectomy: primary and long term results from a single institution. Surg Endosc 2007; 21: 1069-1073 [3] Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy.Factors that influence the results of treatment. Arch. Surg. 1995; 130: 1123–8. [4] Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann. Surg 2005;241:786-90

Reference [5] Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes, HBP2009, 11, 516-522 [6] Management and outcome of patinets with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 2004; 135: 613-8 [7] Management of bile duct injury after laparoscopic cholecystectomy: a review, ANZ J Surg 80 (2010) 75-81