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งานRamathibodi surgical forum revisitedครั้งที่ 1

งานRamathibodi surgical forum revisitedครั้งที่ 1

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  • 1. Bile Duct Injury Pongsatorn Tangtawee, MDHPB division, Department of Surgery Ramathibodi Hospital
  • 2. From GBB rama Photo club
  • 3. Hit to the Point (General board exam)  Introduction  Classification and type  Investigation  Management  Immediately  Late presentation  Prevention
  • 4. Introduction The first planned cholecystectomy in the world was performed by Langenbuch in 1882 The first Choledochotomy was performed by Couvoissier in 1890. The first iatrogenic bile duct injury was described by Sprengel in 1891. He also reported the first choledochoduodenostomy (ChD) for calculi (1891) The first surgical reconstruction (“end-to-side” ChD) of IBDI was performed by Mayo in 1905 Jabłooska B, World J Gastroenterol 2009;15(33): 4097-4104
  • 5. Introduction Biliary injury is the most common severe complication of cholecystectomy. incidence of bile duct injuries has risen from 0.1%-0.2% to 0.4%-0.7% from the era OC to the era LC BDI continue to appear by experience surgeons Steven M. Strasberg, HPB 2011, 13, 1–14 Wan-Yee Lau, Hepatobiliary Pancreat Dis Int 2007; 6: 459-463 Adamsen S,J AM Coll Surg, VOL184:571-578
  • 6. IntroductionJabłooska B, World J Gastroenterol 2009;15(33): 4097-4104
  • 7. Risk Factors for BDI Severe local risk factors  acute cholecystitis,  acute biliary pancreatitis,  bleeding in Calot’s triangle  severely scarred or shrunken gall bladder  large impacted gallstone in Hartmann’s pouch,  short cystic duct, and Mirizzi’s syndrome  abnormal biliary anatomy Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011
  • 8. Risk Factors for BDI Male sex and prolonged surgery for more than 120minutes more than half of all such injuries occurred during the so called “easy” LC performed by an inexperienced surgeon Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011
  • 9. Clinical presentation of BDI Depends on the type of injury and bile leaks or stricture Bile leaks  subhepatic bile collection (biloma) or abscess developsfever, abdominal pain and other signs of sepsis Biliary strictures jaundice caused by cholestasis is the commonest Jabłooska B, World J Gastroenterol 2009;15(33): 4097-4104
  • 10. Clinical Presentation and Diagnosis Kourosh F., Tech Gastrointest Endosc,2006,VOL 8:81-91
  • 11. Classification
  • 12. ClassificationStarberg, J Am Coll Surg.,1995VOL180:101-125
  • 13. Investigation Intraoperative  IOC  ERCP Early or late postoperative  LFT  Ultrasound  CT : Unhelpful merely confirming the U/S  ERCP (can treatment in some type)  MRCP
  • 14. Investigation MRCP is a sensitive (85%-100%) and non-invasive imaging modality Currently, it is the “gold standard” in preoperative diagnosis Jabłooska B, World J Gastroenterol 2009;15(33): 4097-4104
  • 15. MRCP PTC
  • 16. A. R. MOOSSA, Ann. Surg., Vol. 2 15, No. 3, March 1992
  • 17. Management
  • 18. Initial Management Concept of initial management  Control of sepsis  peritoneal and biliary  PCD Once sepsis is controlled  complete cholangiogram  site (in relation to the ductal confluence)  nature (partial or complete)  extent (loss of segment) of the injury Sicklick et al, Annals of Surgery • Volume 241, Number 5, May 2005
  • 19. Intraoperative management Only 15% to 30% of biliary injuries are diagnosed during the surgical procedure The surgeon should carefully consider his experience and ability to repair any injury that is immediately Eduardo de Santibanes,HPB, 2008; 10: 412 Repaired by an experienced HPB surgeon This will reduce morbidity, shorten the stay in hospital, and decrease hospital costs Savader SJ, Lillemoe KD, Ann Surg 1997;225:26873.
  • 20. Intraoperative management Townsend: Sabiston Textbook of Surgery, 18th ed.
  • 21. Postoperative BDI management Early or Elective should be consider Controversial in HPB surgeon-The Mayo clinic , early repair may be done in apatient with a ligated/ clipped duct after LC whenthere is no bile leak, no cholangitis, and goodproximal dilatation Murr MM,Arch Surg 1995;134:604–10.
  • 22. Postoperative BDI management3 out of 4 failures in 25 HJs occurred in patients whohad undergone early reconstruction (within 6 weeksof cholecystectomy) Boerma D, Ann Surg 2001;234:750–7.We do not recommend early repair and haveperformed early (within 4 weeks) repair in only 11out of 362 patients in whom we have performed HJfor BDI between 1989 and 2005 Vinay K, J Hepatobiliary Pancreat Surg (2007) 14:476–479
  • 23. Strategy for management
  • 24. Strasberg A injury injuries maintain continuity with the rest of the bile ducts Easily treated through endoscopic intervention to decrease intraductal pressure distal to the bile duct leak If endoscopy is not available, a T tube could be useful The last resource is to control the bile leak through subhepatic drains and refer Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
  • 25. Strasberg B injury Segmentary bile duct occlusion If mild pain and elevation of LFT are present with no clinical impairmentconservative management The presence of moderate and severe cholangitis makes the drainage of the occluded liver segment necessary PTBD  Hepatectomy (cholangitis cannot controlled) HJ technically hard to perform  Long term prognosis is poor Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
  • 26. Strasberg C injury accessory right duct is sectioned but the proximal stump is not detected Subhepatic collections are frequent in the postoperative setting  must be drained Bile leak is occluded spontaneously with no other intervention If this does not happen, therapeutic options are the same that Strasberg B Poor long term prognosis Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
  • 27. Strasberg D injury Partial injury of the common bile duct in its medial side If a small injury with no devascularization is present, a 5-0 absorbable monofilament suture to close the defect is adequate external drainage + mandatory endoscopic sphincterotomy + stent should be performed in rare case Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
  • 28. Strasberg D injury In the setting of a devascularized duct  bile leak will develop during the first postoperative week with concomitant bile collections external drainage + mandatory endoscopic sphincterotomy + stent should be performed Surgery is the last resource Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
  • 29. Strasberg E injury Complete loss of common and/or hepatic bile duct continuity Devascularization and loss of bile duct tissue More complex and hard to surgical treatment Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 43-48
  • 30. Consideration Injuries that involve the hepatic duct confluence, i.e. Bismuth class III, IV, V (combined or not with common bile injury); or in Strasberg classification Type E3, E4, E5. High stenosis with previous repair attempts Any biliary injury associated with a vascular injury. Biliary injuries associated with portal hypertension or secondary biliary cirrhosis Eduardo de Santibanes,HPB, 2008; 10: 412
  • 31. Algorithm for the management of postoperative diagnosed biliary stenosis Eduardo de Santibanes,HPB, 2008; 10: 412
  • 32. Key of successfully Exposure of damaged area avoiding too much dissection The end of injured bile duct has to be free from burns and attritions Intraoperative cholangiography in every bile leakage Vascular integrity should be confirmed Hepaticojejunostomy with an isolated Roux-en-Y Opposition of both mucosas with reabsorbable suture Use of magnification Blumgart LH, Arch Surg, 1999;134:76975.
  • 33. Steven M. Strasberg, HPB 2011, 13, 1–14 Vasculobiliary injury
  • 34. Vasculobiliary injury Steven M. Strasberg, HPB 2011, 13, 1–14
  • 35. vasculobiliary injury Steven M. Strasberg, HPB 2011, 13, 1–14
  • 36. Steven M. Strasberg, HPB 2011, 13, 1–14
  • 37. Suggested algorithm for the management of bile duct injury combined with hepatic artery.An indication of the relative frequency of scenarios is given. Carlo Pulitanò, The American Journal of Surgery (2011) 201, 238–244
  • 38. Right hepatic artery (RHA) vasculobiliary injurywith collateral flow from left hepatic artery andatrophy of right liver. (A) Computed tomographyscan of liver shortly after injury. The arterialphase shows no filling of right liver. (B) Arteriogram performed 2 years later.Abundant arterial collaterals extend from theleft hepatic artery to the RHA along the hilarplexus (white arrowhead). The clip whichoccluded the RHA is also seen (blackarrowhead). The arterial pattern of the rightliver shows crowding (black arrows) indicative ofatrophy of the right liver, whereas the arterialpattern of the left liver shows elongation andspreading characteristic of hypertrophy of theleft liver. (Reproduction of original photographsfrom Mathisen et al. by permission Steven M. Strasberg, HPB 2011, 13, 1–14
  • 39. How to Avoid a Bile Duct Injury Correct Exposure and Identification of Structures in Calot’s Triangle  cystic lymph node, gall bladder neck, and Rouviere’s sulcus Wauben, World journal of surgery, vol.3 issue4, 2008
  • 40. Critical view of safety(1995)From Dr. Paramin, HPB division, Surgery department, Ramathibodi
  • 41. How to Avoid a Bile Duct Injury To Avoid Thermal Injury To Avoid Blind Haemostasis Awareness of Anatomic Variation Conversion to Open Approach When Necessary Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011
  • 42. “Caterpillar turn” or “Moynihan hump” Incidence of variation is variable, and may be as high as 50% Adams DB.,Surg Clin N America,1993,Vol73;861-71
  • 43. Surgeons Characteristics of Risk Taking Tendency and BDI  Casual approach, overconfidence, and ignorance of difficult situations L. W. Way, L. Stewart, Annals of Surgery, vol. 237, no. 4, pp. 460–469, 2003  better training and standard use of safety measures with Surgical simulation to be helpfulN. N. Massarweh, Journal of the American College of Surgeons, vol. 209, no. 1, pp. 17–24,2009
  • 44. Surgical technique
  • 45. What is Starsberg type? From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
  • 46. What is Starsberg type? From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
  • 47. From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
  • 48. From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
  • 49. From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
  • 50. Hepp-Couinaud
  • 51. Soupault -Couinaud WEDGE SEGMENT III
  • 52. LONGMIRE PROCEDURE
  • 53. Roux-en-Y hepaticojejunostomy with a blind subcutaneous jejunal loop Quintero,World J. Surg. 16:1178, 1992
  • 54. Summary BDI  poor prognosis Multiple risk factor  Most important  Blind surgical management in Calot’s triangle Clinical presentation  Leak, stricture, vasculobiliary injury Investigation : immediately  IOC “Do not assume” Late  MRCP is Gold standard
  • 55. Summary  Concept treatment  Control of sepsis  peritoneal and biliary  PCD, PTBD Once sepsis is controlled  complete cholangiogram  Mapping and classified type  manage follow by type“Repaired by an experienced HPB surgeon This willreduce morbidity, shorten the stay in hospital, and decrease hospital costs”
  • 56. From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
  • 57. From Aj. Somkit Mingphruedhi, M.D., HPB division, Surgery department, Ramathibodi
  • 58. Thank You