biliary strictures

various causes of biliary strictures

1. Biliary stricture Dr N SURENDRA BABU jr resident dept. of gen surgery TIRUMALA HOSPITALS

2. Biliary stricture

3. definition A biliary stricture is an abnormal narrowing of the bile duct, the tube that moves bile (A substance that helps in digestion) from the liver to the small intestine

4. Anatomy of biliary tree

5. Pathological effects of biliary obstruction

6. Pathological effects of biliary obstruction

7. 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

8. 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

9. 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

10. Bile duct injury at cholecystectomy Incidence 1.open cholecystectomy 0.1 -0.2% 2.lap cholecystectomy 0.4 -1.3% 80% of benign strictures occurs following injury during a cholecystectomy. A major factor is surgeons inexperience-learning curve effect

11. causes Anatomic variations Technical factors Pathologic factors

12. Anatomic variations ( failure to recognize abnormal anatomy &anomalies)

13. Technical factors Experience of surgeon Improper assistance Extensive dissection Excess use of cautery Misplacement of clips Excess traction on gall bladder Subvesical duct of luschka in 1-2 % patients CBD Exploration-use of metal bougies Attempts to achieve hemostasis

14. Pathologic factors Acute cholecystitis inflammation leads to edema in the porta hepatis and calots triangle—distortion of anatomy Chronic cholecystitis chronic inflammation leads to fibrosis, adherence, contracted fibrotic gall bladder, cholecystocholedochal fistula (partial cholecystectomy, cholecystostomy, and cholecystocholedochoduodenostomy are options)

15. Laparoscopic specific - Classification of Causes of Laparoscopic Biliary Injuries 1. Misidentification of the bile ducts as the cystic duct a. Misidentification of the common bile duct as the cystic duct b. Misidentification of an aberrant right sectoral hepatic duct as the cystic duct 2. Technical causes a. Failure to occlude the cystic duct securely b. Plane of dissection away from gallbladder wall into the liver bed c. Injudicious use of electrocautery for dissection or bleeding control d. Excessive traction on cystic duct with tenting upward of common hepatic duct e. Injudicious use of clips to control bleeding f. Improper techniques of ductal exploration

16. Laparoscopic specific Proper exposure –maximum cephalad traction on fundus with concomitant lateral traction on infundibulum

17. Location &classification Bismuth`s classification—based on location of biliary stricture with respect to the hepatic duct confluence Strasberg`s classification—is of laparoscopic biliary injuries, is applicable for acute injuries with bile leak, lateral injuries and transection. Hannover classification—combine Bismuth and Strasberg classification and has also addressed the vascular injuries—most refined

18. Bismuth`s classification

19. Strasberg`s classification

20. Strasberg`s classification

21. Hannover`s classification

22. Clinical presentation

23. Clinical presentation

24. investigations

25. investigations

26. cholangioscopy

27. Benign Malignant Benign

28. Surgical treatment of BDI Recognized at operation Immediate open conversion and repair by an experienced surgeon If competent help unavailable, put a drain & should be referred to a specialist center End to end repair over T- tube Roux –en –Y hepaticojejunostomy (silk sutures should be avoided for all biliary reconstructions, because they can act as nidus for stone formation)

29. Surgical treatment of BDI Recognized in immediate postoperative period Avoid early reoperation Bile leak from cystic duct, subvesical duct of luschka or from noncircumferential laceration with no distal obstruction to bile flow may close spontaneously (1to 3 weeks) Endoscopic sphincterotomy with stenting -hasten closure For severe lacerations and complete transactions –delayed approach is best (timing of surgical intervention 4-10 weeks)

30. Surgical treatment of BDI injury presenting at an interval Presented as late bile duct stenosis and stricture Consider nonoperative biliary drainage procedures Consider surgery if no resolution in 12 -24 months Almost always requires Roux –en –Y hepaticojejunostomy

31. end t

32. Roux-en-Y Hepaticojejunostomy Common method of repair of bile duct injury Proper exposure of healthy ,well vascularised proximal bile duct Roux- en –Y Limb of jejunum >60 cm Mucosa to mucosa tension free anastomosis Side to side or end to side hepaticojejunostomy using left hepatic duct

33. Factors associated with poor outcome after surgery Proximal stricture (Bismuth type 3 and 4) Multiple prior attempts at repair Portal hypertension Hepatic parenchymal disease (cirrhosis or hepatic fibrosis) End-to-end biliary anastomosis Surgeon inexperience Intrahepatic or multiple strictures Concurrent cholangitis or hepatic abscess Intrahepatic stones External or internal biliary fistula Intra-abdominal abscess or bile collection Hepatic lobar atrophy Advanced age or poor general health Many authors have advocated the use of anasto

34. Prevention is the best treatment of biliary strictures .