Iatrogenic biliary tract injuries The First Congress of the Palestinian Society of Gastroenterology 20-21 May 2010 Ramallah Walid Sweidan MB, BCh, MRCPI, FRCP
Historical perspective• The first planned cholecystectomy in the world was performed by Carl Langenbuch in 1882.• The first choledochotomy was performed by Couvoissier in 1890• The first iatrogenic bile duct injury was described by Sprengel in 1891.• Prof Dr Med Erich Mühe of Böblingen, Germany, performed the first laparoscopic cholecystectomy in 1985.
Introduction Open cholecystectomy was the standard practice for treatment of Symptomatic gall bladder disease until late 1980’s . At present 90% of cholecystectomies are performed by Lap cholecystectomy which is one of the commonest surgical procedures in the world. Unfortunately , the widespread application of LC has led to a concurrent rise in the incidence of major bile duct injuries (BDI) which are more complicated than after the open procedures.
Laparoscopic cholecystectomy Pros and cons General advantages Shorter stay in hospital Reduced post-op recovery time Less postoperative pain Improved cosmetic outcome Disadvantage The reported increase in serious bile duct complications and injuriesLeBlanc, Karl et al. Management of Laparoscopic Surgical Complications, 1st ed., Marcel Dekker, 2004.
Biliary Injuries during CholecystectomyOpen cholecystectomy has been associatedhistorically with 0.2% to 0.5% risk of postoperativeBiliary tract injuries.On the other hand LC has been associated with2.5-fold to 4-fold increase in the incidence ofPostoperative bile duct injuries compared with OC Peters HJ et al : Ann surg 1991 Bailey Rw et al : Ann Sur 1991 Deziel DJ et al : Am J Surg 1913 MacFadyen BV Jr et al : Surg Endosc 1998
Incidence of IBDI injury following cholecystectomy (%)
Bile duct injuries during cholecystectomy• In the 1990s , high rate of biliary injury was due in part to learning curve effect.• A surgeon had a 1.7% chance of a bile duct injury occurring in the first case and a 0.17% chance of a bile duct injury at the 50th case.• However most surgeons passed through learning curve, “steady-state” reached , but there has been no significant improvement in the incidence of biliary duct injuries Moore M.J.; Bennett C.L , The American journal of surgery 1995 Mubasher H Khan et al Gastrointest Endosc 2007
Risk Factors for Biliary tract injurySurgeon related factors Lack of experience (learning curve) Misidentification of biliary anatomy Intraoperative bleeding Lack of recognition of anatomical biliary tree variations Improper interpretation of IOC
Risk Factors for biliary tract injuryPatient related Acute and chronic cholecystitis Empyema Long standing recurrent disease -> fibrosis Porcelain gallbladder Obesity Previous surgery
The Effect of Acute Cholecystitis on Lap cholecystectomy complications Complication rate when lap cholecystectomy is performed for acute cholecystitis three times greater than for elective lap cholecystectomy . Early cholecystectomy (72 h) outcome better than delayed cholecystectomy . Conversion rate to open cholecystectomy is higher than elective cholecystectomy 35% vs 9% Cho JY et al, Arch Surg. 2010 Apr;145(4):329-33; P. Pessaux et al , Surgical Endoscopy 2000 , 14 : 358
Risk Factors for biliary tract injuries Anatomic Variations Present in 18 - 39% of cases Dangerous variations predisposing to BTI are present in only 3-6% of cases Abnormal biliary anatomy Short cystic duct, cystic duct entering in the right hepatic duct - Accessory right hepatic duct Arterial anomalies Right hepatic artery running parallel to the cystic duct Anomalous or accessory right hepatic artery
Aberrant Biliary Ducts (Right) Aberrant right hepatic duct (arrow) emptying into common hepatic duct.(Left) Aberrant right hepatic duct (arrow) draining into cystic duct
Cystic Duct VariationsCommon variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cm withcommon hepatic duct (15-25%); E , G, H. Medial cystic duct insertion (10-17%).Uncommon variants: C. High fusion with hepatic duct; D. Fusion at right hepatic duct; F. No cystic duct. Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005. Mortele, Koenradd et al., Am J of Roent, August 2001.
Mechanism of CBD Injury Classic Mechanism: CBD is mistaken for cystic duct
Classification of Biliary tract injuries Strassberg Classification
Clinical Presentations of Bile Duct Injuries Bile leak Obstruction A combination of leak and obstruction
Presentation of Bile Duct Injuries About 25 % of injuries recognized intraoperatively About 25 % of injuries discovered within 24 hours post- operative About 50 % of injuries present weeks to years post-operative Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.
Management of bile duct leak Fundamental principles of managementDecompression of the biliary treeDrainage of any associated bile collections(bilomas)
Management Options Immediate recognition• Intraoperative cholangiography• Convert to open cholecystectomy Repair Options 1. Primary suture over a t-tube Tissues should be well vascularized and tension free 2. Roux-y hepatico-jejunostomy or Drainage, closure , and referral to tertiary care centre
Management options Delayed recognition of biliary leak Advise to surgeons ( keep your nerves ) Percutaneous drainage of bile collection No exploration before classification of the injury Understand the anatomy and origin of leak ( MRCP/ Cholangiography) Drain the duct preferably by ERCP / or PTC ?
ERCP and biliary tract injuries Allows precise anatomic diagnosis Allows therapy that obviates reoperation in most cases Identification & treatment of associated pathology
Management options Endoscopic management of bile leakThe objective is to negate the transpapillary pressuregradient that favours the flow of bile into the duodenumand not through the leak site >>> reduce extravasationand decompresses the biliary system .This is done by removing any physiological or pathologicalobstruction (the normal sphincter of Oddi pressure ora retained CBD stone).
Endoscopic options for drainage Nasobiliary drainage Sphincterotomy StentingAll means are safe and effective in BD leakThe choice of the best method remained controversialUntil recently . Costamagna G et al Gastrointest Endosc clin N Am 2003 Binmoeller KF et al Am J Gastroenterol 1991
Endoscopic options for drainage Stenting alone is as effective as stenting with ES in treatment of uncomplicated minor post LC bile leak Resolution of bile leak faster with use of a 7-Fr biliary stent than ES ( canine model ) Biliary leak resolution failure more in ES than stenting ( retrospective analysis ) Mavrogiannis et al Eur J Gastroenterol Hepatol 2006 Marks et al Surg Endosc 1998 Kaffes et al Gastrointest Endosc 2005
Endoscopic options for drainageNaso biliary drainage Advantage :Shorter duration (days) – repeated cholangio – no repeat ERCP procedure Disadvantage : discomfort – self extraction Sphincterotomy Advantage : removal of stones – no repeat procedure Disadvantage : complications – less effective than stents Biliary stent Advantage : better than ES – no ES required Disadvantage : long duration – repeat procedure
Novel methods• “Histoacryl” cyanoacrylate glue used for endoscopic occlusion of leaks (approved in Europe?• Botulinum toxin injection to sphincter of Oddi successful in canine models.• Biodegradable stent in the endoscopic treatment of cystic-duct leakage after cholecystectomy.
Surgery in Bile duct injuries Surgery performed in early post operative phase is associated with 80 % complication rate Surgery delayed 8-12 weeks has only 17% complication rate Surgery performed in tertiary referral centers is associated with higher success rate , less post- operative complications and shorter hospital Stay
Biliary Leak (not to CBD injury) Common complication Disruption of small biliary radicals - retained stone - Clip loosening - Duct of Luschka. Most resolve – nonspecific abdominal pain Collection should be drained Sphincterotomy and stenting
SummaryEndoscopic internal stenting is currently theprocedure of choice for treating bile ductleaks (usually types A, C and D).7Fr and 10 Fr stents can be inserted withoutsphincterotomy.A prompt therapeutic response with cessation of bile extravasation in 70-95% of cases withina period of 1-7 days.
Retrospective analysis performed on all patientsreferred for management of bile duct injuriessustained during laparoscopic cholecystectomy,open cholecystectomy or liver surgery over 12 yearsperiod ( 1996 - 2008 ) Number of patients 72 Number of ERCPs 1724 Percentage 4.2 %
Total number of injuries , number of injuries per 100 ERCPs year No of ERCPs Number of BDI Percentage % 1996 34 1 2.9% 1997 75 9 12% 1998 138 4 2.9% 1999 134 4 2.9% 2000 156 7 4.5% 2001 135 8 6% 2002 139 5 3.6% 2003 162 4 2.5% 2004 156 5 3.2% 2005 146 2 1.4% 2006 157 3 2% 2007 165 11 6.6% 2008 110 9 8% Total 1707 72 4.2%
Post operative biliary tract injuries July 1996 till December 2008 72 patients observed Women 49 Men 23 Mean age 46 years range 18-71
Type of surgeryLap cholecystectomy 41 57%Open Cholecystectomy 26 36%Other (hydatid & bullet) 5 7%
Time between surgery and ERCP Biliary leak patientsMedian 14 days range 4-50 days Biliary stricture patientsMedian 6 months range 3 months – 8 years
Mode of presentation for biliary leak patients Abdominal pain 60 % Ascites or bile collection 50 % Jaundice /deranged LFTs 27%
Post cholecystectomy acute injury• Type of injury number percentage• Type A 24 41%• Type D 15 25%• Type E 20 34%• Total 59 100%
Biliary stricture following type D injury and secondary repair over T tube
Patients outcomeReferral for surgery 27 patient 37.5%Endoscopic managements 45 patients 62.5%Sphincterotomy alone 2 patientsSphincterotomy and stent 23 patientsStent alone 20 patientsTotal stents 43
Conclusions A cooperative multidisciplinary approach is required Early diagnosis is imperative and imaging should not be delayed if any doubt exist to avoid sepsis & peritonitis. Various studies showed that endoscopic therapy can be successful in the majority of patients with biliary leak. Success of endoscopic therapy depend upon type of biliary injury 25% of patients still require percutaneous drainage of collection after ERCP , 4-6 % may still require open surgical drainage for loculated collection
ConclusionsThe best management of biliarytract injuries is really the avoidance of the injury ?
Lobes laws of medicineIf what youre doing is working , keep doing itIf what youre doing is not working , stop doing itIf you don’t know what to do , dont do anythingAbove all , never let a surgeon get your patient