BILIARY biliary biliary STRICTURES-1.pptx

biliary strictures

1. BILIARY STRICTURES S2 unit Under guidance of : Dr.N.Srinivasarao M.S ,Professor Dr.S.Mythili devi M.S , Associate professor Dr.V.Kiran M.S , Asst. Professor Dr.M.V.V.Harika M.S , Asst. professor

2. OVERVIEW : DEFINITION ETIOLOGY CLASSIFICATION CLINICAL FEATURES INVESTIGATIONS MANAGEMENT

3. BILIARY STRICTURE : A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile.

4. ETIOLOGY : CONGENITAL : Biliary atresia INFLAMMATORY : Stones Cholangitis Parasitic Pancreatitis Sclerosing cholangitis radiotherapy MALIGNANCY : Cholangiocarcinoma GB cancer IATROGENIC : Cholecystectomy Choledochotomy Hepatic resection transplantation Gastrectomy TRAUMA IDIOPATHIC

5. BILIARY ATRESIA : Progressive obliteration of extrahepatic and intrahepatic bile ducts Aetiology is unclear 1 in 12000 live births Male=female Untreated – death due to liver failure by age of 3 JAPANESE AND ANGLO-SAXON CLASSIFICATION (KASAI) : TYPE 1 : restricted to CBD TYPE 2 : atresia of CHD 2a: patent GB and patent CBD are noted 2b : GB , Cystic duct and CBD are obliterated TYPE 3 : atresia of RHD and LHD and entire extra hepatic biliary tree.

6. Clinical features : Jaundice at birth Bile stained meconium but later stools are pale and urine is dark Severe pruritus Clubbing and skin xanthomas Osteomalacia ( biliary rickets) Liver function tests – obstructive pattern and elevated ALP Associated anomalies : cardiac lesions , polysplenia , situs inversus , absent vena cava and preduodenal portal vein. Can be diagnosed prenatally if a cystic structure is noted in porta hepatis in prenatal scans .

7. Investigations: Fasting USG is gold standard Shrunken GB with hyperechogenic liver hilum (triangular cord sign ) A cyst at the liver hilum without bile duct dilation with associated anomalies support the diagnosis. MRCP is highly sensitive and specific Inflammatory cells with fibrotic liver parenchyma exhibiting signs of cholestasis and biliary neo ductal structures on biopsy Cholangiography is required to define surgical anatomy .

8. Treatment : Breast fed infants – introduce formula feeds using medium chain triglyceride based feeds and fat soluble vitamin supplementation Type 1 : patent segments of proximal bile ducts are found in 10 % - direct Roux-en-Y hepatico jejunostomy can be done , but progressive fibrosis results in poor long term results Type 2 Type 3 KASAI PROCEDURE ( HEPATICO PORTO ENTEROSTOMY ) Liver transplantation can be considered in cases of Kasai procedure failure with 5 year survival up to 70-80%.

9. PRIMARY SCLEROSING CHOLANGITIS Idiopathic and progressive biliary tract disease characterized by inflammation and destruction of intrahepatic and extrahepatic biliary ducts that can lead to liver fibrosis and cirrhosis. HLA B8/DR3 MUTATIONS Also associated with ulcerative colitis , hypergammaglobulinemia , anti smooth muscle antibodies Smoking is protective Increased risk of cholangiocarcinoma. Cholangiocytes are the target cell of injury in PSC. Males >females , mean age 30-60 years. Clinical features : Jaundice Fever Rt upper quadrant discomfort Pruritus Fatigue Course of relapses and remissions with quiescent periods between

10. Liver function tests: Elevated ALP AND GGTP Elevated ALT and AST Raise in TSB MRCP : Stricturing/beading of bile ducts Biopsy : Concentric periductal Onion peeling appearance Management : Medical management – antibiotics Vit K Cholestyramine Steroids Surgical – endoscopic stenting , liver transplantation in cases of cirrhosis .

11. BILE DUCT INJURIES : Cholecystectomy remains the most common cause Incidence : open 0.1-0.3% , laparoscopic 0.4-1.3% Injury incidence in laparoscopic cholecystectomy is more than open cholecystectomy CAUSES :

12. RISK FACTORS FOR INJURY : Obesity Acute or chronic inflammation : Acute cholecystitis, cholangitis , Mirizzi syndrome ,gall stone pancreatitis etc. 1.7% incidence Calots triangle is obliterated , fusion of cystic duct and CBD with GB neck Low threshold for conversion or use options like subtotal cholecystectomy Anatomic variations Vascular anomalies/injuries : 20% in normal population 0.6% incidence of vascular injury Mc is aberrant Rt hepatic artery – prone to injury at cystic duct –CBD junction Delayed stricture formation may occur due to extensive periductal dissection and consequent interruption of major ductal arterial supply Inexperience

13. Common anatomic variations :

14. 6.Dissection injury : Dissection should be done close to GB wall , avoid injury to liver parenchyma through cystic plate Small amounts of bleeding may obscure the field Care should be taken to notice the low lying sectoral duct , replaced right hepatic artery . R4U LINE : level of dissection should be above the line connecting the Rouvier’s sulcus and umbilical fissure. Lord Ganesha sign : Infundibular technique. 7.Traction injury : Excessive fundal traction injury to liver , GB Excessive lateral traction causes up tenting of CBD.

15. CLASSIFICATION: BISMUTH CLASSIFICATION Classification is useful for localization and prognosis after repair , but it doesn’t encompass all the possible injuries. No provision is made for biliary leaks or major ductal injuries without stricture. Strasberg and colleagues classification much broader. Type A : bile leaks from minor ducts still in continuity with CBD. (m/c leakage from cystic duct postop.) Type B : occlusion of part of biliary tree usually aberrant Rt sectoral hepatic duct Type C : transection of aberrant Rt sectoral duct without ligation Type D : lateral injury to extrahepatic bile duct Type E: biliary strictures

16. CLINICAL FEATURES After open cholecystectomy only 10% injuries are identified in the early postop period , 70% are diagnosed within first 6 months of surgery. Laparoscopic procedure complications are diagnosed earlier. Clinical presentation depends on the type of injury Types A,C,D generally present within the first week , some injuries may not be apparent immediately and they present late. Symptoms and Signs : Intraoperatively bile leak can be observed Pain abdomen Jaundice –most common Fever Bile leakage from incision site or drain. Weakness , anorexia . Abdominal distension Can present within several months with symptoms of cholangitis or cirrhosis. Mild elevation of LFTs , TSB <3mg/dl .

17. TYPE E injuries : usually identified intraoperatively , sometimes in postoperative period TYPE B injuries : generally present with non specific symptoms such as unexplained fevers , pain or general debilitation In some patients stricture may evolve slowly because of partial obstruction ; they present with nonspecific complaints such as pruritus and altered liver functions which warrant investigations.

18. Investigations : USG Abdomen IHBRD Collection detection Low sensitivity in detecting level of injury Helps in deciding for drainage Associated colour doppler for vascular injuries. CT abdomen : Best initial study to decide on management Detects collection / bilioma presence Assessment of ductal dilation Helps in locating level of injury Helps in drainage Assessment of liver atrophy.

19. CHOLANGIOGRAPHY: PTC : Complete ductal anatomy is delineated Intraoperative guidance Post anastomotic stenting Drainage catheters should be left in place post PCT if aa complex injury is identified , because palpation of catheter intraoperatively can help in identification of ductal structures . ERCP : Only therapeutic Helpful in cases of partial or complete transection of cystic duct or hepatic duct for stenting. MRCP : NON INVASIVE Provides accurate details regarding biliary anatomy. Iv contrast agents can be given for more detailed study : GADOLINIUM ETHOXY BENZYL DIETHYLENETRIAMINE PENTA ACETIC ACID (Gd –EOB-DTPA) to detect the site of injury with 80% accuracy. HIDA SCAN: After biliary drainage HIDA scan can be performed to check for persistent biliary leak HIDA scanning offers a dynamic and quantitative assessment of liver function and of the clearance of bile across anastomosis and stenosis. Can be used for follow up of patients after surgical repair Can distinguish between the biliary injury and intrinsic liver disease in cases of biliary obstruction.

20. PTC in a case of biliary injury . In this case biliary confluence is absent , left and right ducts are separately canulated to show the anatomy.

21. ARTERIOGRAPHY ABD PORTOGRAPHY : Assessment of vascular injury Assessment of lobar atrophy on cross sectional imaging – indicator of concomitant vascular injury . Pts with CBD injury along with vascular injury are at increased risk of severe complications like hepatic abscess and hepatic necrosis after reconstructive surgery .

22. PATHOLOGIC CONSEQUENCES: FIBROSIS : Obstruction- high local concentration of biliary salts –pathologic changes in liver – FIBROGENESIS -deposition of collagen and EC matrix proteins- fibrosis and scarring around bile ductules - leads to cholestasis. This Fibrosis is reversible after decompression of obstruction . ATROPHY : Segmental or lobar atrophy occurs after portal venous occlusion or bile flow obstruction in affected area. Unilobar atrophy is associated with hypertrophy of contralateral lobe and may present difficulty during surgery Commonly seen in benign strictures and may be associated with asymmetric involvement of lobar or sectoral hepatic ducts, interference with portal venous flow due to secondary fibrosis.

23. Presence of atrophy and compensatory hypertrophy present a significant challenge for operative repair Most common : rt lobe atrophy with compensatory left lobe hypertrophy Anastomosis in hilum region is made difficult due to rotational deformity and anatomic distortion induced by this condition Thoracoabdominal approach is preferred in such conditions to provide more direct exposure and access for repair. This is associated with longer surgery times , more bleeding risk and more requirement of blood transfusion.

24. PORTAL HYPERTENSION : Approximately 15-20% benign biliary stricture pts have concomitant portal hypertension. Occurs as a result of secondary fibrosis or direct damage to the portal vein. It can also be due to preexisting liver disease Outcome in pts with biliary injury with portal hypertension is much worse than isolated biliary injuries with an in hospital mortality rates of 25-40%. Sometimes adequate biliary drainage is associated with reduction of fibrosis and reduction in portal pressure.

25. MANAGEMENT : Preop preparation: IV antibiotics to treat cholangitis as per culture from biliary drainage Correction of anemia Correction of electrolyte and fluid imbalances due to loss of bile Nutritional correction . Definitive management : Injury detected during surgery Injury identified in the immediate postop period Injury noted in later periods

26. 1 . INJURY NOTED DURING SURGERY : If required convert to open surgery Intraoperative cholangiogram is useful in assessing the extent of injury and to delineate the anatomy Refer to a tertiary care center if management is not feasible. Basic aims : Maintain the duct length below the hilus without sacrificing the tissue Avoidance of uncontrolled postop bile leak

27. In cases of complete transection – TWO options can be considered 1. End to end repair : Feasible only if transected ends can be approximated without tension Requires full mobilization of duodenum and pancreas head Single layer absorbable suture material with T tube placement via different ductotomy. Associated with high risk of delayed stricture formation. (up to 60%) 2. Roux-en-Y hepaticojejunostomy: placement of T tube across the defect and bringing it out into jejunal loop and onto anterior abdominal wall is preferred Advantage is that the bile duct length is preserved and when the T tube is removed any bile leak drain directly into jejunum and not abdominal cavity.

28. 2. INJURY NOTED IN IMMIDIATE POSTOP PERIOD: Keep patient well nourished Care to prevent infection – prophylactic antibiotics Imaging to assess the extent and site of injury Continuous biliary drainage may be considered and a delayed repair (4-6 weeks) can be planned to let the inflammation settle Most of the times continuous drainage itself is sufficient in healing

29. 3. INJURY PRESENTING AFTER INTERVAL OF INITIAL SURGERY Principles of management of late bile duct strictures include Exposure of healthy proximal bile ducts draining all areas of liver Preparation of suitable segment of distal mucosa for anastomosis Creation of mucosa to mucosa sutured anastomosis of bile ducts to distal conduit , commonly a Roux-en-Y loop.

30. BILIARY ENTERIC REPAIR : Choledochoduodenostomy : strictures in retro pancreatic or supraduodenal portion of CBD Bismuth type 1/2 : direct anastomosis to hepatic duct stump feasible proximal duct should be identified , dissection of area lateral to the hepatic artery pulsation is helpful in identifying the proximal duct confluence. Type 3 : biliary enteric anastomosis to the left hepatic duct provides sufficient drainage of left and right ductal systems . Type 4 : confluence is damaged separate drainage to right ductal system is required .

31. MALIGNANT STRICTURES

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