Bile duct injuriesCBDstricture, biliary fistula.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also. See notes for bibliography.

2. Introduction

3. Introduction Bile duct injury (BDI) Rare but potentially devastating condition Biliary peritonitis & sepsis, cholangitis, portal hypertension & secondary biliary cirrhosis Significant morbidity & mortality Iatrogenic BDI Increased financial burden (patient or hospital)

4. Anatomy

5. Anatomy Calot’s triangle – between inferior surface of liver, Cystic duct & CHD Contents – Cystic artery, RHA, Cystic lymph node

6. Bile Duct Injuries (BDI)

7. Bile Duct Injuries (BDI) Iatrogenic injury Cholecystectomy Gastrectomy Pancreatectomy ERCP Trauma Duodenal ulcer

8. Risk factors

9. Risk factors Inflammation in the porta , Variable biiary anatomy, Inappropriate exposure, Aggressive attempts at hemostasis , Surgeon inexperience. 97% due to visual misperception, only 3% accounts for technical skills and knowledge .

10. Classification

11. Classification location of injury mechanism & type of injury effect on biliary continuity timing of identification Each plays significant role in determining appropriate management & operative repair

12. Classification of BDI Bismuth classification (1982) Era of Open Chole Based upon level of biliary strictures with respect to hepatic bifurcation Type 1-5. Helps surgeon choose appropriate site for repair Degree of injury correlates with surgical outcomes

13. Strasberg classification(1995) Type Criteria A Leak from Cystic duct or small ducts in liver bed B Injury to sectoral duct(aberrant RHD) with obstruction C Injury to sectoral duct with consequent bile leak D Lateral injury to extrahepatic duct E1 Transection >2 cm from the confluence E2 Transection <2 cm from the confluence E3 Transection at the confluence E4 Separation of major ducts in the confluence E5 Complete occlusion of all bile ducts.

14. Clinical Presentation (post-op)

15. Clinical Presentation (post-op) Obstruction Clip ligation or resection of CBD  obstructive jaundice, cholangitis Bile Leak Bile from intra-op drain or More commonly, localized biloma or free bile ascites / peritonitis, if no drain Fever,abd pain , jaundice, or bile leakage from incision. Diffuse abdominal pain & persistent ileus several days post-op  high index of suspicion  possible unrecognized BDI

16. Strasberg classification

17. Prevention

18. Prevention 30° laparoscope , high quality imaging equipment Firm cephalic traction on fundus & lateral traction on infundibulum, so cystic duct perpendicular to CBD Dissect infundibulo-cystic junction Expose “Critical view of safety ” before dividing cystic duct Convert to open, if unable to mobilise infundibulum or bleeding or inflammation in Calot’s triangle Routine intra-op cholangiogram “ Fundus-first ” dissection

19. Critical view of safety Calot’s triangle dissected free of all tissue except cystic duct & artery Base of liver bed exposed When this view is achieved, the two structures entering GB can only be cystic duct & artery

20. Management

21. Recognized at the Time of Cholecystectomy Conversion to an open operation and use of cholangiography. Goals .. Maintenance of ductal length, elimination of any bile leakage that would affect subsequent management, and creation of a tension-free repair .

22. Ducts smaller than 3 mm drain only a single segment or subsegment of liver.. simple ligation .  Ducts larger than 3 mm usually drain more than a single segment of liver,if transected.. should be reimplanted into the biliary tree. Injury occurs to a larger duct, but is not caused by electrocautery and involves less than 50% of the circumference of the wall, a T tube placed through the injury

23.   Low injuries to the bile duct can be reimplanted into the duodenum. Most injuries to the bile duct occur higher in the biliary tree, close to the hilum , thus not allowing for tension-free anastomosis to the duodenum. Therefore, in almost all cases of bile duct injury, a resection of the injured segment with mucosa to mucosa anastomosis using a Roux-en-Y jejunal limb (end-to-side choledochojejunostomy ) is preferred.  Transanastomotic stenting has been shown to improve anastomotic patency.

24. Identified After Cholecystectomy

25. Identified After Cholecystectomy Goals of Therapy in Iatrogenic Bile Duct Injury 1.Control of infection limiting inflammation      Parenteral antibiotics      Percutaneous drainage 2.Clear and thorough delineation of entire biliary anatomy. MRCP/PTC , ERCP 3.Re-establishment of biliary enteric continuity Tension-free, mucosa-to-mucosa anastomosis    Roux-en-Y hepaticojejunostomy      Long-term transanastomotic stents if involving bifurcation or higher

26. Approach.. Should undergo imaging to assess for a fluid collection and evaluate the biliary tree.  Ultrasonography can achieve both these goals. Cross-sectional imaging via CT will generally provide more useful data. Radionucleotide scanning to confirm bile leakage, but with any documentation of a leak, CT will be necessary to plan management.

27. CT or U/S guided (or surgical) drainage Sepsis control  Broad-spectrum antibiotics & percutaneous biliary drainage to control any bile leak  most fistulas will be controlled or even close. 1.5% mortality rate due to uncontrolled sepsis No rush to proceed with definitive management of BDI. Delay of several weeks allows local inflammation to resolve & almost certainly improves final outcome.

28. Definitive management is to reestablish durable biliary enteric drainage. Combination of percutaneous and endoscopic biliary dilations and stenting may establish continuity. Surgical reconstruction has the highest patency rates. performed between a minimally inflamed bile duct to intestines in a tension-free, mucosa to mucosa fashion.

29. Interventional Radiologic and Endoscopic Techniques

30. Interventional Radiologic and Endoscopic Techniques Using balloon dilation techniques, the stricture is dilated and a catheter is left in place to decompress the system, allow healing, document resolution and, if necessary guide repeat dilations. This approach is successful in up to 70% of patients. Endoscopic balloon dilation of bile duct strictures is generally reserved for those with primary bile duct strictures or patients who have undergone choledochoduodenostomy for reconstruction, because the Roux limb does not usually allow for endoscopic strategies.

31. MRCP / CT cholangiography Noninvasive May avoid invasive procedures like ERCP or PTC Do not allow intervention Interpretatation in presence of bile collection difficult

32. Biliary enteric anastomosis Most laparoscopic BDI – complete discontinuity of biliary tree Surgical reconstruction, Roux-en-Y hepaticojejunostomy tension-free, mucosa-to-mucosa anastomosis with healthy, nonischemic bile duct

33. Treatment summary

34. Treatment summary Strasberg Type A – ERCP + sphincterotomy + stent Type B & C – traditional surgical hepaticojejunostomy Type D – primary repair over an adjacently placed T-tube (if no evidence of significant ischemia or cautery damage at site of injury) More extensive type D & E injuries – Roux an-Y hepaticojejunostomy with biliary stent

35. Causes of benign stricture I. Congenital strictures Biliary atresia II. Bile duct injuries A. Postoperative strictures (1) Cholecystectomy or common bile duct exploration (accounting 80% of nonmalignant stricture) (2) Biliary-enteric anastomosis (3) Hepatic resection (4) Portocaval shunt (5) Pancreatic surgery (6) Gastrectomy (7) Liver transplantation B. Stricture after blunt or penetrating trauma

36. Causes of benign stricture

37. Causes of benign stricture C. Strictures after endoscopic or percutaneous biliary intubation III. Inflammatory strictures A. Cholelithiasis or choledocholithiasis B. Chronic pancreatitis C. Chronic duodenal ulceration D. Abscess or inflammation of liver or subhepatic space E. Parasitic infection F. Recurrent pyogenic cholangitis (Oriental cholangiohepatitis) IV. Primary sclerosing cholangitis V. Radiation-induced stricture

38. Causes of malignant stricture

39. Causes of malignant stricture Primary tumors Cholangiocarcinoma GB Cancer Pancreatic adenocarcinoma Ampullary carcinoma Hepatoma Gastric carcinoma Metastatic tumors pancreatic adenocarcinoma Colon cancer Breast cancer Lung cancer Melanoma Ovarian cancer

40. Biliary Fistula

41. Biliary Fistula A fistula is an epithelium-lined tract between 2 epithelium-lined surfaces. cholecystocutaneous fistula is an abnormal epithelial tract that allows communication between the gallbladder and the skin. Biliary fistulae can be internal or external. 

42. External biliary fistulae, in turn, can be further subdivided based on etiology into spontaneous, therapeutic, traumatic, and iatrogenic fistulae.  spontaneous or deliberate as in the case of a therapeutic percutaneous cholecystostomy used to treat cholecystitis or empyema of the gallbladder, 

43. Spontaneous cholecystocutaneous fistula is a rare complication of neglected calculous biliary disease    adenocarcinoma of the gall bladder.

44. Pathophysiology

45. Pathophysiology The cystic duct or gallbladder is almost always obstructed in patients with spontaneous cholecystocutaneous fistula.

46. Examination

47. Examination The patient may be febrile and diaphoretic because of the infection. The external opening is usually in the right upper quadrant, although external openings in the periumbilical area, the lumbar area, and even the gluteal area

48. Examination Discharge may be purulent in the presence of empyema , mucoid in the presence of a mucocele because of obstruction, or bilious in the absence of obstruction. Small stones within the discharge often confirm the diagnosis.

49. Differential diagnosis

50. Differential diagnosis Infected epidermal inclusion cyst Discharging tuberculoma Pyogenic granuloma Chronic osteomyelitis of ribs with sequestrum Metastatic carcinoma

51. Treatment

52. Treatment Conservative Infection obstruction Both the gallbladder and fistula need to be resected to achieve a cure.

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54. Get this ppt in mobile

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