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

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, 137:889-894)

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 2002,89,385-386)

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

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, 137:889-894)

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

NEUHAUS CALSSIFICATION OF BILE DUCT INJURIES AFTER LAP - CHOLE Neuhaus P, Humbolt Univ. of Berlin BJS.2005.92. 76-82

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

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

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

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

MANNER OF CONFLUENCE RIGHT SECTORAL DUCTS Blumgart LH. Surg Clin N Am. 1994.74.4

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

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

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

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

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

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 ?

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

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)

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

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

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

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

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

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

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.74 1994 Lahey Clinic, Burlington, MA.1994

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

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

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 1.1993-Januari 1. 2002 Arch Surg, vol 137, Aug.2002

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

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

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

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

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

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

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

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

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

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

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

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 2002.89

“ 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

“ 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

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

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

CT – guided percutaneous drainage

Hepaticojejunostomy with a trans-enteric stent

Three weeks after repair, just before removing stent

FOLLOW UP Two weeks after discharged

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

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

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

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