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BILE DUCK INJURY : HOW TO REPAIR by veD51N22

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									            Warko Karnadihardja
Department of Surgery, Hasan Sadikin Hospital
         University of Padjadjaran
                  Bandung
          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)
 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
                                 Most lethal complications
• 0.25% vascular injuries
          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
      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
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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