Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university The Iatrogenic Major Bile Duct Injuries: Experience at Ibn Siena Hospital MAM Ibnouf AM Masaad Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university MBDI Bile duct injury was estimated 1-3/1000 in Open Cholecystectomy 4-6/1000 Laparoscopic Cholecystectomy 1- Nuzzo G. Giuliante F. Giovannini,I et al. Bile Duct Injury During Laparoscopic Cholecystectomy. Results of an Italian National Survey on 56 591 Cholecystectomies. Arch Surg. 2005;140:986-992. 2- Windsor JA, Pong J. Laparoscopic biliary injury: more than a learning curve problem. Aust NZ J Surg. 1998; 68: 186-189. 3- Calvete J, Sabater L, Camps B et al. Bile duct injury during laparoscopic cholecystectomy: myth or reality of the learning curve? Surg Endosc. 2000; 14: 608-611.) 4- Kern KA. Medicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery. Am J Surg. Am J Surg. 1994; 168: 217-222. 5- Howes N, Chagla L, Thorpe M, et al. Surgical practice is evidence based. British Journal of Surgery 1997;84:1220–3. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university This rate may reach 14/10001,2 mortality as high as 11/10003. 1- Gronroos J M. Unsuccessful Endoscopic Stenting in Iatrogenic Bile Duct Injury: Remember Rendezvous Procedure. Surgical Laparoscopy, 2007; 17(3):186-189, 2- Gentileschi P, Di Paola M , Catarci M, et al. Bile duct injuries during laparoscopic cholecystectomy. Surgical Endoscopy. 2004; 18 ( 2): 232-236. 3- Buanes T, Mjaland O, Waage A, et al. A population-based survey of biliary surgery in Norway: relationship between patient volume and quality of surgical treatment. Surg Endosc. 1998;12:852-855. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Learning curve “The incidence of BDI significantly decreased with increasing number of LCs performed, ranging from 0.9% for surgeons who had performed fewer than 150 LCs to 0.3% for those who had performed more than 450 LCs”*. *Howes N, Chagla L, Thorpe M, et al. Surgical practice is evidence based. British Journal of Surgery 1997;84:1220–3. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Mortality The mean mortality rate in 15 case series composed of a total of 602 IMBDIs with a follow up period 1-7 years was 17(2.8%)1. Poor results are associated with: 1- delayed referrals, 2- biliary peritonitis 3- associated vascular injury 4-other co-morbid factors resulting in as high as 9.4% mortality rate2 1- Johnson SR, Koehler A, Pennington LK, Hanto DW. Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery. 2000 Oct;128(4):668-77. 2- Flum DR, Koespsell T, Heagerty P et al. Common Bile Duct Injury During Laparoscopic Cholecystectomy and the Use of Intraoperative Cholangiogram: adverse outcome or preventable error. Arch Surg. 2001; 136:1287-1292. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university The mortality rate in 39 cases of Bisthmus type III and IV was reported to be 25%*. *Chaudhary A, Chandra A, Negi SS, Sachdev A. Reoperative surgery for postcholecystectomy bile duct injuries. Dig Surg. 2002;19(1):22-7. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

The experience at Ibn sina Hospital Period: Jan 1998 to date Exclusion criteria: 1- Residual CBD stone retrieved by ERCP 2- Post cholecystectomy bile duct injuries managed successfully with endoscopic stenting Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Number: 85 patients Male: female : 3:82 Mean (±SD) age: 38.6 ± 10.66, range 22- 66 years Type of surgery: Open Chole 73(85.8%) LC 12(14.2%) Mode of presentation: Jaundice:54(63.5%) Bile leak:31(36.5%) Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Massage: High tendency towards over sewing or over clipping bleeders bile leak jaundice Total Open chole 27 46 73 Lap chole 4 8 12 Total 31 54 85 Massage: High tendency towards over sewing or over clipping bleeders Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Method of diagnosis ERCP 47 patients MRCP 28 “ Both 15 “ Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Massage: Most of the cases are high injuries Types of injuries Bisthmus III and IV 68 cases Bisthmus type II 15 cases Unkown 02 cases Massage: Most of the cases are high injuries Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Period of delay: Range 00 days* – 1 year * 3 occurred at Ibn Siena Hospital: One in laparoscopic workshop and the second by a surgeon under training and one by registrar to right bile duct Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Poor referrals reports Massage ERCP does show the surgeon the site and size of the upper stump he should use for reconstruction Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university MRCP Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university MRCP Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university MRCP Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university MRCP Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Bisthmus IV: high narrow ducts Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Biliary peritonitis Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Management Initial drainage 23 patients Rodney Smith (Mucosal graft) 55(64.7%) Hepatico-jejunostomy 23(27%) Repaired over T-tube 2(2.3%) Died before reconstruction 2(2.3%) Left abroad 3(3.5%) Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Post-operative stenting 3 months 58pts 6 months 18pts 1.5-2 months 3pts Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Hospitalization period: Before surgery: 3-10 days After surgery: 10 days -3 weeks Operative time: 2.5 - 4 hours Massage: reconstruction of IMBDI is technically difficult and has very high costs Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Follow up Stricture: 22 patients Specific complications: Recurrent Cholangitis 15(17.6%) Biliary cirrhosis: 7(8.2%) Intra-hepatic duct stones (Redo-surgery) 2 patients Cirrhosis (Redo-surgery abroad) 1 patients Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Stricture with stones Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Type of surgery and outcome was dictated by the level of injury complications Rodney-Smith Hepatico-jej T-tube Total (n=55) (n=23) (n=2) 80 Cholangitis 13 2 … 15(17.6%) Cirrhosis 6 1 … 7(8.2%) PE 1 0 … 1(1.2%)* Septicaemia 0 0 … …. No complications 35 20 2 57(67%) * Died Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Outcome after 3 years follow up No complications 57(67%) Recurrent Cholangitis 15(17.6) Cirrhosis 7(8.2% Pulmonary embolisim 2(2.3%) Died Septicaemia 2(2.3%) Died Advanced cirrhosis  hepatic failure 1(1.1% Massage: Morbidity rate 22(25.9%) Mortality rate 5(5.9%) Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Out come of ligation & transection P 0.001 Bile leak Jaundice Total (n=54pts) (31pts) 85 Cholangitis 12 3 15 Cirrhosis 6 1 7 PE 1 1 Septicaemia 2 2 No complications 33 29 60 Massage: IMBDI with bile leak tend to have poorer results Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Adverse outcome Died before reconstruction 2 Patients Left abroad 3(1.5%) Massage: In hospital death after reconstruction 1 Patient Massage: 2 out of 3 Died after reconstruction abroad Massage: Mortality rate 5(5.9%) Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Where do we stand? Series Number of repairs M&M re-stricture/cholangitis MacFadyen BV Jr 1998 561 27(4.9%) Walsh RM 2004 133 46(35%) Slater K et al 131 2(1.5%) one of them died Ibn Siena Hospital 85 22(25.9%) five of them died Chaudhary A et al 41 3(7%) one of them died Walsh RM et al 1998 34 18(25%) Johnson SR et al 2000 21 7(33.3%) Al-Sebaye MI 17 7(41%) Topal B et al 1999 16 4(25%) one of them died Karvonen J 2007 14 3(26%) one of them died Massage: Ibn Sina Series is the 4th biggest series and the 4th in the rate of complications MAM Ibnouf1, A.Majid M. Massaad2 Iatrogenic Major Bile duct Injuries Injury. Sudan JMS Vol. 2, No. 3, Sep. 2007 Mohammad A M Ibnouf, A. M. Massaad, Sulaiman S Fediel "Iatrogenic major bile duct injury in Sudan" Sudan Med. J. (19) 3; 2001: 36-39. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Conclusion 1- IMBDI leads to life long morbidity and high chances for mortality 2- High injuries are common in OC and LC and are difficult to repair. 3- Injuries leading to bile leak prevent ductal dilatation and hence are associated with high rate of re-stricture. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university Conclusion 4- Stents should be left till maturation of the fibrous tissue of the anastomotic line matures. 5- Results of reconstructive surgery at Ibn Siena is comparable to reported literature. 6- National Cholecystectomy Registry: to evaluate the real magnitude of the IMBDI. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

A/Magid M Masaad MAM Ibnouf Thank you A/Magid M Masaad MAM Ibnouf Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university