Common Bile Duct Injury: Recognition and Management Jaime A Pineda, MD Division of Transplantation Department of Surgery University of Vermont Medical Center
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Is This Going to Happen to Me Laparoscopic Cholecystectomy 700,000 pts/year Pre-laparoscopic 0.2% in 42,000 0.3% in 25,500 Lap Chole 0.4 to 0.6% Lap era learning curve McPartland K and Pomposelli J, Iatrogenic Biliary Injuries: Classification, Identification and Management. Surg Clin N Am 88 (2008); 1329-1343
Beyond learning Curve New York State Planning and Research Cooperative System Longitudinal administrative database (SPARCS) 2005-2010 156.315 LC CBI was identifiers ICD-9 and CPT CBI 149 patients (0.08%) 24.8% Hepatectomy 32% Hepaticoenterostomy 43.2% Primary Repair Beyond the learning curve: Incidence of BDI following Laparoscopic Cholecystectomy normalize to open in the modern era. Surg Endosc (2016) 30:2239-2243
CBD Injuries: Surgeons Demographics Surgeons reporting an injury Older 52.8 vs. 51.3yrs (p<.0004) in practice longer Surgeons NOT reporting an injury More likely trained in laparoscopic chole in residency vs trained at an course Academic practice 7.9% vs 14.5% Routinely work with residents 18.7% vs 25.0% Nader N. Massarweh, Allison Devlin, Rebecca Gaston Symons, Jo Ann Broeckel Elrod, David R. Flum, Risk Tolerance and Bile Duct Injury: Surgeon Characteristics, Risk-Taking Preference, and Common Bile Duct Injuries, JACS, Volume 209, Issue 1, July 2009, Pages 17-24
Avoiding Misidentification of Biliary Structures during Laparoscopic Cholecystectomy Methods to ID cystic duct Cholangiography Critical View Technique Infundibular Technique Dissection of the CBD???
Identification of Danger The negative effects of conversion are minor compared to a CBD injury Factors to consider Failure of dissection progression Anatomic disorientation Inability to visualize field Comfort level with laparoscopic procedure Factors that should NOT play a role Negative stigmata of conversion Equipment Cosmetic and LOS outcomes Patient and family EARLY Intra-operative consultation and conversion to open are indicated
Variation of the Cystic Duct Berci 2200 intra op cholangiograms Lateral entry 17% Spiral 35% Posterior 41% Parallel 7% Trust no one and expect sabotage
Normal Biliary Tree Normal hepatic ductal anatomy fusion of draining duct of segment I Confluence of right posterior duct and right anterior duct. Cystic duct
Common Biliary Variant Mortele, Koenradd et al., Am J of Roent, August 2001.
Other Variants Mortele, Koenradd et al., Am J of Roent, August 2001.
Triangle of Calot the surgeon should work by sight and not by faith Jean-Francois Calot Surgeon at Hospital Rotschild 1890 to 1941 Famous for treatment of TB in children and spinal deformities of Paget s Multiple orthopedic surgery textbooks Modern boundaries CHD, cystic duct and undersurface of liver Original 1891 Thesis CHD, cystic duct and artery
The Critical View of Safety Technique Calot s triangle dissected free of all tissue except for the cystic duct and artery Base of the liver is exposed 2 structure entering the GB are Cystic Duct and Artery
Role of Routine Intraoperative Cholangiography Pros Cons Decreases CBD injury Inexpensive Minimal time Training of residents Does not prevent CBD injury Not cost effective Adds time onto procedure
Routine Intraoperative Cholangiogram: Perception and Reality Nader N. Massarweh, Allison Devlin, Jo Ann Broeckel Elrod, Rebecca Gaston Symons, David R. Flum, Surgeon Knowledge, Behavior, and Opinions Regarding Intraoperative Cholangiography, Journal of the American College of Surgeons, Volume 207, Issue 6, December 2008, Pages 821-830 Age 51.8 yrs 89.2% Men 55.3% private practice 27% routine cholangiogram Selective IOC Academic vs. private Low vol (<20/yr) vs high vol (>100/yr)
Routine Intraoperative Cholangiogram: Perception and Reality PERCEPTION REALITY Incidence of CBD Injury 1:500 to 1:1000 1:200 to 1:400 IOC cost $250 to $500 $100/pt IOC affect rate of CBDI >50% no change 40% risk reduc IOC adds significant time routine 1-10 min sel 21-30min 80% of surgeons would not clip or cut duct with abnormal anatomy 31.3% stated very likely would convert to an open procedure Nader N. Massarweh, Allison Devlin, Jo Ann Broeckel Elrod, Rebecca Gaston Symons, David R. Flum, Surgeon Knowledge, Behavior, and Opinions Regarding Intraoperative Cholangiography, Journal of the American College of Surgeons, Volume 207, Issue 6,
Cholangiogram to Identify Cystic Duct During Laparoscopic Cholecystectomy Cholangiography Complete technique Catheter insertion Contrast Fluoroscopy Table Interpretation Consult another surgeon An incomplete cholangiogram is not adequate
Cholangiogram
Classic Laparoscopic Bile Duct Injury
Excisional Injury Excision injury with ligation in 35-y/o woman who presented 1 week after laparoscopic cholecystectomy with right upper quadrant pain and jaundice. Khalid, Tahir et al., Am J of Roent, December 2001; 177:1347-1352.
Common Laparoscopic Bile Duct Injury Most common injury is Class III with excision of the CBD
Classification Systems Bismuth 1982 McMahon 1995 Strasberg s 1995 Amsterdam Academic Medical Center s 1996 Neuhaus 2000 Csendes 2001 Stewart-Way s System for Lap Bile Duct Injury 2004 CUHK - 2007 Bismuth Classification System - 1982
Strasberg s Classification System Bismuth Classification System - 1982
Post-Operative Presentations of CBD Injury Bile leak Biliary drainage from ports Biliary ascites with chemical peritonitis Bile leak loculation Biloma or abscess Duct ligation Elevated LFT and jaundice Rarely cholangitis Ductal strictures Months to years after Cholangitis Painless jaundice
Bismuth I Injury 39-y/o man with Bismuth type I injury 1 week after laparoscopic cholecystectomy. MRC showing stricture (arrow) at level of common hepatic duct more than 2 cm from biliary confluence. Patient was treated with hepaticojejunostomy. Ragozzino, Alfonso et al.. Am J of Roent, December 2004.
Bismuth III Injury 41-year-old woman with Bismuth type III injury 8 days after laparoscopic cholecystectomy. MRC showing stricture (arrow) at level of common hepatic duct, leaving biliary confluence intact. Patient was treated with hepaticojejunostomy. Ragozzino, Alfonso et al.. Am J of Roent, December 2004.
Bismuth IV Injury 63-y/o man with Bismuth type IV injury 10 days after laparoscopic cholecystectomy. MRC showing stricture at level of common hepatic duct with extension and partial destruction of biliary confluence (arrows). Patient was treated with hepaticojejunostomy. MRC maximum-intensity-projection image showing similar stricture at level of common hepatic duct with extension and partial destruction of biliary confluence (arrows). Ragozzino, Alfonso et al.. Am J of Roent, December 2004.
Injuries identified during laparoscopic cholecystectomy 15 30% of CBD injuries Conversion to open Consult Segmental or Accessory Ducts <3mm duct ligate >4mm duct enteric drainage CHD or CBD <180 degree transection: close over T-tube Complete transection: enteric drainage Transferring to Tertiary Center JP drain x 2 Intraoperative cholangiogram Call receiving surgeon Stewart L, Way L. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the result of treatment. Arch Surg. 1995;130:1123 9
Pre-Reconstruction Management Drain immobile bile Perc IR drain of biloma OR JP drain of leak PTC drainage of biliary tree with proximal ligation Extent of Injury Road Map ERCP With distal clip will not ID injury PTC With draining duct may have no ductal dilitation MRCP
Pre-Reconstruction Imaging
Tertiary Center Elective Repair Elective Repair After preoperative clinical optimization Hepaticojejunostomy to a Rouxen-Y limb of jejunum Biliary leak drained Sepsis controlled Percutaneous transhepatic biliary stent placement Stable electrolytes Tension free Tenants of biliary reconstruction for cancer do not apply Vascular supply Direct transfers <48 hrs Absence of sepsis Decreases hosp stay from 32 to 11d
Roux-en-Y Hepaticojejunostomy Operative Epidural Equipment Avoid too much dissection Injured duct free of burns IntraOp cholangiogram 40 to 60cm Roux limb No tension Anastamotic technique Retrocolic Perioperative Aggressive pulmonary toliet PT/OT Drain to gravity
Combined CBD and Vascular Injury Open chole 7% R hepatic artery ligation on autopsy R hepatic arterial injury 12 to 13.8% with CBD injury Routine arteriogram 39% open 47% lap chole
Combined CBD Injury and R Hepatic Artery Injury Repair Conflicting Data Alves 43 patients No difference in short and longterm outcomes Koffron Failed primary management 61% associated vascular injury Larger Series >10 and prospective show no difference
Management of the Combined CBD and Vascular Injury Identify injury Intra Op: doppler Post Op: CT Angiogram with biphasic contrast Intra Operative ID Primary repair IMA interposition graft Late Diagnosis of Arterial Ligation Recon will not prevent hepatic necrosis Influence of HJ -?
Lobar Ischemia Post BDI Injury repair with ligated R Hepatic Artery Monitor Talk to Pts Risk of hepatic necrosis, abscess and bile duct stricture Pt may require revision or R hepatic lobectomy CT scan, LFT and MRCP Stent
Longterm Outcomes of Operative Repair Early and late mortality 4% Biliary stricture rate 11% Level of injury predicts stricture Early repair predicts stricture Nonbiliary complications 40% R. Matthew Walsh, J. Michael Henderson, David P. Vogt, Nancy Brown, Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies, Surgery, Volume 142, Issue 4, October 2007, Pages 450-457, ISSN 0039-6060,
10 Year Survival After CBD Injury
Late Complications of CBI Biliary Obstruction Hepatic atrophy Cholangitis Intrahepatic Lithiasis Secondary Biliary Cirrhosis Liver Fibrosis Liver Transplant Cholangiocarcinoma??? Long-term consequences of bile duct injury after cholecystectomy. Journal of Visceral Surgery (2014), 151,269-279
Long-Term outcomes Long-Term outcomes of patients with CBD injury following laparoscopic cholecystectomy. Halbert et al. Surg Endosc (2016), 30:4294-4299
Long-Term outcomes Long-term outcome of Biliary reconstruction for BDI from laparoscopic Cholecystectomies. Walsh et al. Surgery 2007;142:450-7
FIGURE 2. (A) Outcomes by management (Strasberg B E). (B) Outcomes by management over time (Strasberg B E). FIGURE 3. (A) Outcomes by time period (Strasberg B E). (B) Outcomes by time period over time for surgery (Strasberg B E). Ann Surg 2013:258:490-499
J Am Coll Surg 2014;219:923-932
Long-Term Health Related Quality of Life
CBD Injury: Litigation Preoperative care Documentation of indication Consent Rationale and indications for procedure Description of procedure, expected periop course Details of pain and pain management, length of stay Conversion to open Cholangiography Risks of the procedure Bile duct injury Other serious complications (injury to vessels and hollow viscus) Wound infection Port site hernia Loss of stones Complications of abdominal surgery Alternatives to the proposed treatment Checklist
Operative Note and Family Should describe in detail and objectively Full disclosure to family and patient Indications Procedure Operative conditions Rationale for cystic duct and artery identification Dictated on the day of surgery Judgment about cause and extent should not be made If referring to a tertiary HB center surgeon should contact the accepting physician personally It is appropriate to dictate that the extent of injury is unknown Consultations and reasons for should be noted NEVER alter or delete any part of the med record
Conclusions Be intimate with the literature PreOp consent paper is NOT as important as consenting the patient Perform a safe lap chole Consult often and early Convert to open IntraOp detection repair immediately Transfer repair <48 hrs Long-term outcomes
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