This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Bile duct injuries represent a complex clinical scenario seen with increased frequency owing to
aberrant anatomy
more lap cholecystectomies being performed
Incidence :
0.1-0.2 % in open cholecystectomy
0.4-0.6 % in lap cholecystectomy
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Bile duct injuries represent a complex clinical scenario seen with increased frequency owing to
aberrant anatomy
more lap cholecystectomies being performed
Incidence :
0.1-0.2 % in open cholecystectomy
0.4-0.6 % in lap cholecystectomy
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.
Sleeve gastrectomy surgery is the best option for weight loss.Dr.Ramesh is an icon in the field of medical science. He has a lot of experience in the field of surgery.
The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.
BILE DUCT INJURY DURING LAPAROSCOPIC cholecystectomy- causes-detection;manage...fiaz fazili
Bile duct injuries (BDI) take place in a wide spectrum of clinical settings. The mechanisms of injury, previous attempts of repair, surgical risk and general health status importantly influence the diagnostic and therapeutic decision-making pathway of every single case. A multidisciplinary approach including hepatobiliary surgeon , endoscopy and interventional radiology specialists is required to properly manage this complex disease-the best treatment is prevention--do no more harm-have low threshold for conversion;call for help of seniors or expertise or refer to higher center
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.
Sleeve gastrectomy surgery is the best option for weight loss.Dr.Ramesh is an icon in the field of medical science. He has a lot of experience in the field of surgery.
The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.
BILE DUCT INJURY DURING LAPAROSCOPIC cholecystectomy- causes-detection;manage...fiaz fazili
Bile duct injuries (BDI) take place in a wide spectrum of clinical settings. The mechanisms of injury, previous attempts of repair, surgical risk and general health status importantly influence the diagnostic and therapeutic decision-making pathway of every single case. A multidisciplinary approach including hepatobiliary surgeon , endoscopy and interventional radiology specialists is required to properly manage this complex disease-the best treatment is prevention--do no more harm-have low threshold for conversion;call for help of seniors or expertise or refer to higher center
Bile duct injury:How safe is emergency laparoscopic cholecystectomy?KETAN VAGHOLKAR
laparoscopic cholecystectomy has become the gold standard . But its safety in acute cholecystitis is debatable. The traditional dictum to wait for 6 weeks before contemplating removal of the gall bladder still remains the safest option rather than removing the gall bladder on an emergency basis and heightening the chances of bile duuct injury leading to a surgical disaster.The presentation outlines the evaluation and management of bile duct injuries.
Como agradecer os parabéns: Dicas e ModelosSabrynnamonter
Modelos para agradecer os parabéns. Agradecimento para Amigos, namorado, ou colegas de trabalho.Modelos de Agradecimento de parabéns para Fecebook. Veja os melhores modelos.
Biliary complications after liver transplantationApollo Hospitals
Liver transplantation (LT) has become the established means of treating patients with end-stage liver disease. However, biliary complications remain a significant cause of postoperative morbidity and possibly mortality. Biliary strictures and leaks are the most common complications following liver transplantation. The incidence of biliary tract complications after orthotopic LT (OLT) varies from 11% to 34%. The reported incidence of biliary complications is 5–15% after deceased donor liver transplantation (DDLT) and 20–34% after right lobe living-related liver transplant (LRLT). There are several predisposing risk factors for development of biliary complications post transplant with a higher risk in LRLT compared to DDLT. Bile duct strictures occur in 4–13% of patients after DDLT and account for approximately 40% of all biliary complications where as the incidence of biliary leaks after LT ranges between 2% and 25%. Biliary strictures after liver transplantation have been classified as anastomotic strictures (AS) and non-anastomotic strictures (NAS). Most bile leaks and strictures can be resolved nonoperatively with early endoscopic intervention. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment at our center for both bile leaks as well strictures. However, in spite of excellent results surgery is required in small proportion of patients.
Comments Excellent paper. It’s obvious that you put quite a bit of .docxdrandy1
Comments: Excellent paper. It’s obvious that you put quite a bit of work into this. Unfortunately, your paper needs adequate citations in the body of the text to meet our standards on plagiarism. You need to cite each textbook from your bibliography whenever you quote or use some information from the textbook or other resource. For example, writing (Jones 285) after the quote or information used means that you got it from the book whose author was Jones and the info came from page 285.
Laparoscopic cholecystectomy is a procedure in which laparoscopic techniques remove the gallbladder. It is the standard of care for symptomatic gallbladder disease, of which most are performed for symptomatic cholelithiasis. Other indications include acute cholecystitis, biliary dyskinesia, and gallstone pancreatitis.
Describe the reasons a patient might have the selected surgical procedure
The typical reason a cholecystectomy is a treatment of choice is inflammatory changes of gallbladder or blockage of bile flow by gallstones. Symptomatic cholelithiasis is the most common reason where gallstones in the gallbladder are blocking the bile flow and cause inflammation. The patient usually complains of episodic epigastric pain and right upper quadrant pain that radiates to the right shoulder. This pain is found to occur several hours after heavy meals and the patient experiences nausea, vomiting, bloating, fever, and right upper quadrant tenderness. Another condition is acute cholecystitis, where inflammation and symptoms are more prominent. The patient may have a fever, constant pain, positive Murphy's sign, or leukocytosis. Acute cholecystitis may be caused by calculous biliary tract disease with confirmed gallstones in the abdominal US. Acute acalculous cholecystitis usually occurs in critically ill patients, those with prolonged total parenteral nutrition, and some immunosuppressed patients. Patients with episodes of right upper quadrant pain (which are ‘classic' for biliary pain without evidence of cholelithiasis of US or ERCP) may also be referred for laparoscopic cholecystectomy. Gallstone pancreatitis (when small stones pass through the cystic duct) confirmed by cholangiography is another indication for laparoscopic cholecystectomy.
Describe the reasons a patient might be disqualified for this surgery and the options for the patient if any
A patient might be excluded for laparoscopic cholecystectomy due to acute general conditions that are a contraindication for any surgery such as an acute cardiac failure, uncontrolled hypertension, acute renal failure, pneumonia, etc. The condition should be treated by a primary care provider or specialist and the patient should be stable prior surgery. Additional contraindications may include the inability to tolerate general anesthesia, significant portal hypertension, uncorrectable coagulopathy, and multiple prior operations.
List the diagnostic tests and lab work that an attending surgeon might order and desc.
Comments Excellent paper. It’s obvious that you put quite a bit of .docxcargillfilberto
Comments: Excellent paper. It’s obvious that you put quite a bit of work into this. Unfortunately, your paper needs adequate citations in the body of the text to meet our standards on plagiarism. You need to cite each textbook from your bibliography whenever you quote or use some information from the textbook or other resource. For example, writing (Jones 285) after the quote or information used means that you got it from the book whose author was Jones and the info came from page 285.
Laparoscopic cholecystectomy is a procedure in which laparoscopic techniques remove the gallbladder. It is the standard of care for symptomatic gallbladder disease, of which most are performed for symptomatic cholelithiasis. Other indications include acute cholecystitis, biliary dyskinesia, and gallstone pancreatitis.
Describe the reasons a patient might have the selected surgical procedure
The typical reason a cholecystectomy is a treatment of choice is inflammatory changes of gallbladder or blockage of bile flow by gallstones. Symptomatic cholelithiasis is the most common reason where gallstones in the gallbladder are blocking the bile flow and cause inflammation. The patient usually complains of episodic epigastric pain and right upper quadrant pain that radiates to the right shoulder. This pain is found to occur several hours after heavy meals and the patient experiences nausea, vomiting, bloating, fever, and right upper quadrant tenderness. Another condition is acute cholecystitis, where inflammation and symptoms are more prominent. The patient may have a fever, constant pain, positive Murphy's sign, or leukocytosis. Acute cholecystitis may be caused by calculous biliary tract disease with confirmed gallstones in the abdominal US. Acute acalculous cholecystitis usually occurs in critically ill patients, those with prolonged total parenteral nutrition, and some immunosuppressed patients. Patients with episodes of right upper quadrant pain (which are ‘classic' for biliary pain without evidence of cholelithiasis of US or ERCP) may also be referred for laparoscopic cholecystectomy. Gallstone pancreatitis (when small stones pass through the cystic duct) confirmed by cholangiography is another indication for laparoscopic cholecystectomy.
Describe the reasons a patient might be disqualified for this surgery and the options for the patient if any
A patient might be excluded for laparoscopic cholecystectomy due to acute general conditions that are a contraindication for any surgery such as an acute cardiac failure, uncontrolled hypertension, acute renal failure, pneumonia, etc. The condition should be treated by a primary care provider or specialist and the patient should be stable prior surgery. Additional contraindications may include the inability to tolerate general anesthesia, significant portal hypertension, uncorrectable coagulopathy, and multiple prior operations.
List the diagnostic tests and lab work that an attending surgeon might order and desc.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ocular injury ppt Upendra pal optometrist upums saifai etawah
Iatrogenic biliary tract injuries
1. Iatrogenic biliary tract injuries
The First Congress of the Palestinian
Society of Gastroenterology
20-21 May 2010
Ramallah
Walid Sweidan MB, BCh, MRCPI, FRCP
2. 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.
3. 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.
4. 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 injuries
LeBlanc, Karl et al. Management of Laparoscopic Surgical Complications, 1st ed., Marcel Dekker, 2004.
5. Biliary Injuries during Cholecystectomy
Open cholecystectomy has been associated
historically with 0.2% to 0.5% risk of postoperative
Biliary tract injuries.
On the other hand LC has been associated with
2.5-fold to 4-fold increase in the incidence of
Postoperative 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
7. 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
8. Risk Factors for Biliary tract injury
Surgeon 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
9. Risk Factors for biliary tract injury
Patient related
Acute and chronic cholecystitis
Empyema
Long standing recurrent disease -> fibrosis
Porcelain gallbladder
Obesity
Previous surgery
10. 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
11. 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
12. Aberrant Biliary Ducts
(Right) Aberrant right hepatic duct (arrow) emptying into common hepatic duct.
(Left) Aberrant right hepatic duct (arrow) draining into cystic duct
13. Cystic Duct Variations
Common variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cm with
common 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.
14. Mechanism of CBD Injury
Classic Mechanism: CBD is mistaken for
cystic duct
17. Clinical Presentations of Bile Duct
Injuries
Bile leak
Obstruction
A combination of leak and obstruction
18. 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.
19. Management of bile duct leak
Fundamental principles of management
Decompression of the biliary tree
Drainage of any associated bile collections
(bilomas)
20. 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
21. 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 ?
22. ERCP and biliary tract injuries
Allows precise anatomic diagnosis
Allows therapy that obviates reoperation in most
cases
Identification & treatment of associated pathology
23. Management options
Endoscopic management of bile leak
The objective is to negate the transpapillary pressure
gradient that favours the flow of bile into the duodenum
and not through the leak site >>> reduce extravasation
and decompresses the biliary system .
This is done by removing any physiological or pathological
obstruction (the normal sphincter of Oddi pressure or
a retained CBD stone).
24. Endoscopic options for drainage
Nasobiliary drainage
Sphincterotomy
Stenting
All means are safe and effective in BD leak
The choice of the best method remained controversial
Until recently .
Costamagna G et al Gastrointest Endosc clin N Am
2003
Binmoeller KF et al Am J Gastroenterol 1991
25. 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
26. Endoscopic options for drainage
Naso 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
27. 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.
28. 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
29. 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
30. Summary
Endoscopic internal stenting is currently the
procedure of choice for treating bile duct
leaks (usually types A, C and D).
7Fr and 10 Fr stents can be inserted without
sphincterotomy.
A prompt therapeutic response with cessation
of bile extravasation in 70-95% of cases within
a period of 1-7 days.
31. Retrospective analysis performed on all patients
referred for management of bile duct injuries
sustained during laparoscopic cholecystectomy,
open cholecystectomy or liver surgery over 12
years
period ( 1996 - 2008 )
Number of patients 72
Number of ERCPs 1724
Percentage 4.2 %
32. 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%
33. Post operative biliary tract injuries
July 1996 till December 2008
72 patients observed
Women 49 Men 23
Mean age 46 years range 18-71
34. Type of surgery
Lap cholecystectomy 41 57%
Open Cholecystectomy 26 36%
Other (hydatid & bullet) 5 7%
35. Time between surgery and ERCP
Biliary leak patients
Median 14 days range 4-50 days
Biliary stricture patients
Median 6 months range 3 months – 8 years
36. Mode of presentation for biliary leak patients
Abdominal pain 60 %
Ascites or bile collection 50 %
Jaundice /deranged LFTs 27%
37. Post cholecystectomy acute injury
• Type of injury number percentage
• Type A 24 41%
• Type D 15 25%
• Type E 20 34%
• Total 59 100%
46. Patients outcome
Referral for surgery 27 patient 37.5%
Endoscopic managements 45 patients 62.5%
Sphincterotomy alone 2 patients
Sphincterotomy and stent 23 patients
Stent alone 20 patients
Total stents 43
47. 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
49. Lobe's laws of medicine
If what you're doing is working , keep doing it
If what you're doing is not working , stop doing it
If you don’t know what to do , don't do anything
Above all , never let a surgeon get your patient