Bile Duct Injury during Lap Chole. Bile Duct Injury during cholecystectomy TOPICS. 1. Prevalence, mechanisms, prevention and diagnosis

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1 Bile Duct Injury during cholecystectomy Catherine HUBERT Jean-Fran François GIGOT Benoît t NAVEZ Division of Hepato-Biliary Biliary-Pancreatic Surgery Department of Abdominal Surgery and Transplantation Strasbourg, IRCAD, October 2010 Bile Duct Injury during Lap Chole TOPICS 1. Prevalence, mechanisms, prevention and diagnosis 2. Treatment strategies: a. primary surgical repair b. postoperative biliary fistula c. biliary peritonitis d. biliary stricture

2 Local risk factors of BDI Multicenter Belgian Surveys Authors Period Patients type of clinical BDI rate procedure presentation Vereecken LC all type t 0.50 % Gigot < LC all type 0.50 % Vandesande LC all type 0.37 % all type all type 0.58 % Vandesande LC all typet 0.31 % all type all type 0.54 % Navez LC acute cholecystitis 1 % X 2 THE RISK FACTORS for BDI during LAP. CHOLE are MULTIFACTORIAL 1. factors inherent to the laparoscopic approach 2. inadequate training of the surgeon 3. local risk factors 4. Technical factors

3 1.RISK FACTORS INHERENT TO THE LAPAROSCOPIC APPROACH loss of depth perception loss of manual palpation surgeon's dependance to the equipment limited field easily obscured by bile or blood (loss of vision) blind manipulation of instruments. Nb of BDI anonymous survey on 9959 LC 65 patients with BDI (0.5 %) SURGEON EXPERIENCE and LOCAL RISK FACTORS * Surgeon s s experience (Nb of LC)! absent present < 50 cases : 55 % 45 % > 50 cases : 24 % 76 % p = 0.03 GIGOT, Surg Endosc 1997, 11 :

4 Laparoscopic belgian survey misidentification of cystic duct : the «classical» injury with CBD duct during IOC 6 % during dissection 35 % 43 % with cystic artery 1.5 % cystic duct avulsion CBD tenting Clipping during urgent haemostasis h DIFFICULT 3. LOCAL RISK FACTORSAND BILE DUCT INJURIES 3 acute or severe chronic inflammation!!! (65 %) 3 large impacted i stone in the Hartman pouch (16 %) 3 MIRIZZI syndrome +/- bilio-biliary biliary fistula (4%) 3 Morbid obesity 3 Anatomical anomalies complete cholangiogram!

5 In SEVERE CHOLECYSTITIS with anomalous RHD You can perform a Subtotal cholecystectomy leave a piece of gallbladder wall on the Calot triangle and at the level of the Hartman Pouch BDI during LC SEVERITY SITE ( BISMUTH classif. ) * lateral injury : 48% * complete transsection : 32% * resection : 10% * thermal : 11% * type I : 51% * type II : 28% * type III : 9% * type IV : 3% * type V : 9% 52% 21% GIGOT, Surg Endosc 1997; 11: 1171

6 BDI during LC : the Belgian Registry 65 patients CLINICAL PRESENTATION peroperative detection (29) : 44.5 % external biliary leak (8): 12% biliary peritonitis : - localized (biloma) (3): 6% - diffuse (19) : 29 %!!! biliary stricture : - early (3): 4.5% - late (3) : 4.5% 51 % Bile Duct Injury during Lap.Chole. TIMING of REPAIR * IMMEDIATE REPAIR : * small caliber of non dilated ducts (during the 1st op) * but absence of local inflammation * EARLY REPAIR : * non dilated ducts!!! (<2months) * local inflammation * sepsis and poor patients condition * LATE REPAIR : * optimized conditions (>2 months) * presence of ductal dilatation with fibrotic tissues

7 1.Early REPAIR of BDI risk factors for late stricture THERMAL INJURY In 1/3 of BDI VASCULAR INJURY 30-50% type IV : 60 % Stewart et al. Ann Surg 2003; 237: 460 Patients Mortality Biliary Reinterv. FU (mo) Recurrent complic. median Stricture. Perop. detect. : 7 % 24 % 14 % %. Peritonitis : 20 % 50 % 23 % % 29 % 47 % PHILOSOPHY of TREATMENT Laparoscopic cholecystectomy = minimally invasive procedure BDI = maximally invasive situation change your philosophy treat properly medico legal consequences

8 Bile Duct Injury during Lap.Chole. MANAGEMENT of BILE DUCT INJURY DIAGNOSED EARLY after LAPAROSCOPIC CHOLECYSTECTOMY 3 types of postoperative clinical presentations : external biliary fistula bile peritonitis obstructive jaundice from biliary stricture 1. Postoperative Biliary Fistula RADIOLOGICAL EVALUATION PURPOSE AVOID to REOPERATE before complete evaluation 1. to define site and severity of BDI 2. to evaluate the intraabdominal bile leakage 3. to detect coexistent injury TYPE of IMAGING STUDIES 1. CT with contrast injection is superior to US 2. MRI is a all-in exam (cholangio + angio-mri) to define lesions 3. ERCP is the most useful tool in partial injury (excepted if complete obstruction or transsection)

9 CT or (MRI) diffuse bile peritonitis SURGERY localized biloma Percut. RX drainage if - persistant > 1 week or worsening - LFTs elevated (obstruction?) - total biliary diversion * no o collection * good clinical condition WAIT - amount of bile / 24 h. - evolution of biliary leak ERCP to define ERCP type / site / severity cystic, Luchka * partial injury * complete transsection ducts * lat. clipping * resection ES + prosthesis ES + prosthesis or surgery SURGERY ENDOSCOPIC Efficient endoscopic MANAGEMENT management

10 2.POST- OPERATIVE BILIARY PERITONITIS! High suspicion s for BDI B should be maintained for any patient who do not recover normally and quickly after LC. The mean delay for reoperation in the Belgian registry was 11 days (1 21) MANAGEMENT of BILIARY PERITONITIS EMERGENCY TREATMENT * septic condition ( infected bile) * long standing peritonitis * good clinical condition * recent peritonitis ERCP LAPAROTOMY * peritoneal lavage * biliary drainage - bilio- digestive anastomosis.. if possible - otherwise, external diversion complete laceration partial laceration, cystic or Luchka duct 1. endoprosthesis 2. percutaneous or surgical drainage (lap or open) clinical improvement no residual bile collections on repeat CT examination

11 classification of injury by IOC -type - severity partial injury complete transsection wide resection thermal necrosis suture suture+ T tube HJA. excise and HJA + T tube T HJA. diversion partial laceration of the choledochus

12 END-to to-end BILIARY REPAIR CAUSES of FAILURES * loss of ductal tissue * tension on the suture line * inadequate blood supply (thermal injury) * small caliber of the ducts * proximal location of BDIB BDI due to an ANOMALOUS R. HEPATIC DUCT lateral BDI to anomalous RLD during delayed LC for severe cholecystitis primary repair by suture with T-tube T insertion

13 BDI due to to an ANOMALOUS R. R. HEPATIC DUCT STRATEGY OF TREATMENT do a selective cholangiography!! if limited biliary sector and thin duct if large biliary sector and large stoma if large biliary sector and thin duct then, close it permanently make a repair (suture + Tube or HJA) clip temporary and come back later, when dilated TOTAL BILIARY DIVERSION INDICATIONS when a biliary repair is impossible or unsafe - proximal thermal necrosis - severe inflammation - tiny proximal duct TECHNIQUE drain into the proximal biliary stump multiples large sub-hepatic drains.. NOT too close of the hepatoduodenal ligament.. risk of vascular injury! (large sub-hepatic omentoplasty)

14 Hepatico-jejunal anastomosis: The HEPP-COUINAUD APPROACH Hepatico-jejunal anastomosis: The HEPP-COUINAUD APPROACH «mucosa-to to-mucosa» hepatico-jejunostomy

15 BILE DUCT INJURY during LAP. CHOLE Long-term follow-up (at( least 10 years) is mandatory before definitive conclusions about the outcome of BDI. Female, 74y 1994: type IV BDI post lap chole Hepp Couinaud HJA FU once a year in outpatient clinic (biology and cholangiomri) Completely asymptomatic with normal follow up untill june 2009 April and June 2009: Cholangitis Normal LFT (after cholangitis) MRI:! Stenosis at the level of the LHD CLINICAL CASES

16 Clinical case : 1 CT SCAN ERCP Female, 35y D1: abdominal pain CRP: 22 WBC: Normal LFT WHAT SHOULD YOU DO? 1. Wait and see 2. Percutaneous drain alone 3. Endoprothesis alone 4. Percutaneous drain and endoprothesis 5. Open Hepatico-jejunostomy and peritoneal lavage

17 Clinical case : 1 Answer: 4.Endoprothesis and percutaneous drain Clinical case 2 * F 30 years-old * Lap chole 9 days ago Bile peritonitis Sepsis++ ERCP

18 1.Wait and see 2. Endoprothesis and percutaneous drain 3.Surgical exploration Answer: 3. Surgical exploration D9: Surgical exploration: excision ion of EHBD and main biliary convergence Diffuse Biliary peritonitis

19 1. Peritoneal lavage and direct end to end suture 2. Peritoneal lavage and suture with T-tube insertion 3. Peritoneal lavage and hepatico-jejunal anastomosis 4.Peritoneal lavage and external biliary diversion Clinical case : 2 Answer: 4.Peritoneal lavage and external biliary diversion

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