1. 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

2. 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:
2- Windsor JA, Pong J. Laparoscopic biliary injury: more than a learning curve problem. Aust NZ J Surg. 1998; 68:
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: )
4- Kern KA. Medicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery. Am J Surg. Am J Surg. 1994; 168:
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

3. 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): ,
2- Gentileschi P, Di Paola M , Catarci M, et al. Bile duct injuries during laparoscopic cholecystectomy. Surgical Endoscopy. 2004; 18 ( 2):
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:
Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

4. 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

5. 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 Oct;128(4):
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:
Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

6. 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

7. The experience at Ibn sina Hospital
Period: Jan 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

8. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university
Number: 85 patients Male: female : 3:82 Mean (±SD) age: 38.6 ± 10.66, range 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

9. Massage: High tendency towards over sewing or over clipping bleeders
bile leak jaundice Total Open chole Lap chole Total
Massage: High tendency towards over sewing or over clipping bleeders
Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

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

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

12. 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

13. 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

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

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

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

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

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

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

20. 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

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

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

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

24. 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) patients
Cirrhosis (Redo-surgery abroad) patients
Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

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

26. 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)
Cholangitis … (17.6%)
Cirrhosis … (8.2%)
PE … (1.2%)*
Septicaemia … ….
No complications (67%)
* Died
Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

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

28. Out come of ligation & transection P 0.001
Bile leak Jaundice Total
(n=54pts) (31pts)
Cholangitis
Cirrhosis PE
Septicaemia
No complications
Massage: IMBDI with bile leak tend to have poorer results
Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

29. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university
Adverse outcome
Died before reconstruction Patients
Left abroad (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

30. Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university
Where do we stand?
Series Number of repairs M&M re-stricture/cholangitis MacFadyen BV Jr (4.9%) Walsh RM (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 (25%) Johnson SR et al (33.3%) Al-Sebaye MI 17 7(41%) Topal B et al (25%) one of them died Karvonen J (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:
Prof. MAM Ibnouf, FRCSEd. Omdurman Islamic university

31. 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

32. 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

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