Ia Iatr trogenic ogenic bile duct bile duct injur injury Eduard - - PowerPoint PPT Presentation

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ia iatr trogenic ogenic bile duct bile duct injur injury
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Ia Iatr trogenic ogenic bile duct bile duct injur injury Eduard Jonas Surgical Gastroenterology Unit University of Cape Town and Groote Schuur Hospital Cape Town, South Africa Conflict of Interest I declare I have no conflict of interest

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Ia Iatr trogenic

  • genic bile duct

bile duct injur injury

Eduard Jonas

Surgical Gastroenterology Unit University of Cape Town and Groote Schuur Hospital Cape Town, South Africa

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Conflict of Interest

I declare I have no conflict of interest

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Social Media

You are welcome to share details of this presentation responsibly and with due credit on social media.

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Bile duct injury (BDI)

  • Significant associated

morbidity and mortality

  • Significantly increasing

cost of treatment

  • Common causes of

litigation in general surgery

  • It severely decreases QOL

for the patient

“ ”

OC era1 0.20% “Learning curve” 2-4 0.3% – 0.82% Beyond the curve5,6 0.22% – 0.4%

BDI incidence Time

1 Roslyn et al. Ann Surg. 1993;218(2):129-37 2 Nuzzo et al. Arch Surg. 2005;140(10):986-92 3 Karvonen et al. Surg Endosc. 2011;25(9):2906-10 4 Tornqvist et al. BMJ. 2012;345:e6457 5 Barret et al. Surg Endosc. 2018;32:1683-88 6 Fong et al. JACS. 2018;226(4):568-76

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Classification

Strasberg ATOM

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Management

Spectrum of deranged physiology Time of detection

– Intraoperative – Post-operative – Late

Timing of repair

– Immediate – Early – Delayed – Late

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Patient case 1

  • 45 year old male presented to peripheral hospital (100

km away) with sudden onset abdominal pain

  • early cholecystitis - laparoscopic cholecystectomy
  • telephone call from theatre

– divided cystic duct – divided cystic artery – dissecting gallbladder - encountered and severed another duct

  • What now?
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Management options

  • Repair by the injuring surgeon
  • Experienced surgeon travel to do repair
  • Immediate referral to a specialist center
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Injuring surgeon repair

Stewart L, et al. Arch Surg. 1995 Oct;130:1123-8 Carroll BJ, et al. Surg Endosc. 1998;12:310-3

Successful long-term outcome

Primary surgeon repair - 27% Referred patients - 79%

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(Travel) immediate repair

  • Not playing a home match
  • Suboptimal conditions
  • Extent of the injury may not be

evident

  • Limited investigation possibilities
  • Creating more havoc looking for

the missing parts in the puzzle

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Immediate repair

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Referral to specialist center

Advice to injuring surgeon

  • Stop operating!
  • Control/exteriorize the leak
  • Closed (suction) drain
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Work-up

  • Physiology of the patient
  • Extent of the bile duct injury
  • Associated vascular injury
  • Free fluid / fluid collections
  • Status of the liver
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Imaging

  • Cross-sectional imaging

– CE-MDCT – CE-MRI / MRCP

  • Interventional imaging

– ERCP – PTC

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CE-MDCT

  • Dilated bile ducts

(cholangiogram)

  • Free fluid
  • Vascular injury
  • Perfusion defects
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99mTc-IDA

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CE-MRI/MRCP

T2-weighted T1-weighted

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PTC?

  • Diagnostic information
  • Obstructed duct decompression
  • Act as infra-hepatic drain
  • Facilitate intra-operative

identification of bile ducts

  • Decompression of peri-

anastomotic duct

  • Allows post-reconstruction

imaging

  • Definitive management?
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Patient case 1 cont.

  • Clinically well
  • Soft abdomen
  • WCC slightly raised
  • LFTs minimally deranged
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Patient case 1 cont.

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Surgery

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Technique

  • Minimal dissection especially behind ducts
  • Tension free mucosa to mucosa anastomosis

to well perfused duct

  • Hepaticojejunostomy preferred
  • Proximal anastomosis
  • Hepp-Couinaud approach
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Technique

Atlas of Upper Gastrointestinaland Hepato-Pancreato-Biliary Surgery. Springer-Verlag Berlin Heidelberg 2007

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Technique

Atlas of Upper Gastrointestinaland Hepato-Pancreato-Biliary Surgery. Springer-Verlag Berlin Heidelberg 2007

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Intra-operative PTC

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Postoperative course

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Coexistence of anomalies

With arterial anomalies (non-Michel 1) approximately 70% of patients will have some form biliary anomaly Absent RHD 35% RPSD drains into LHD 20% RPSD low insertion 20%

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Patient case 2

  • 33-year-old morbidly obese female BMI 53
  • elective laparoscopic cholecystectomy
  • BDI diagnosed on post-operative day 22
  • laparotomy with washout and drainage
  • arrived on day 28 post-injury
  • uncontrolled sepsis
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Patient case 2 cont.

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Patient case 2 cont.

Lindemann J, et al. Int J Surg Case Rep. 2019;60:340-344

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Patient case 2 cont.

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Patient case 2 cont.

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Patient case 2 cont.

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Timing of repair

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Summary

  • Multidisciplinary management
  • Individualize patient treatment
  • Manage the patient
  • Optimal pe-operative information
  • Correct physiology and nutritional status
  • Early repair preferable, delay when necessary