RECENT TRENDS INMAMNAGEMENT OF POST CHOLECYSTECTOMY COMMON BILE DUCT INJURY
Bahaa El-deen Ahmed;
Abstract
Cholecystectomy is one of the most commonly performed operations. Common bile duct (CBD) injuries remain one of the most devastating complications of both open and laparoscopic cholecystectomy.
There is association between abnormal anatomy and biliary tract injury, it was reported by Hasan ;et al. with biliary tract injury incidence of 6%.Hence, it is recommended that surgeons properly identify the EHBT anatomy intraoperatively in order to avoid injuries.
The most EHBT abnormality observed was short CD and accessory hepatic ducts, the second most common abnormality was left CD insertion. Less common abnormalities are CD inserted into RHD and duct ofLuschka .
There are several risk factors associated with bile duct injury, and these can be characterized as patient factors, local factors, and extrinsic factors.
The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries.
Classification of BDIs is important as the type of injury will dictate the management. Several classification systems have been proposed but none have been accepted as a universal standard.One of the most widely used classifications today is that of Strasberg.
The Amsterdam classification is a relatively practical to use and serves well for endoscopic purpose . The BDIs are divided into groups A, B, C and D.
To date, the best management strategy in terms of timing of repair remains controversial. Most authors agree that intraoperative recognition of BDI with immediate repair by specialized HPB surgeons offers the best results.IOC is the most classic method intraoperatively to detect CBD stones and injuries.
To obtain better outcomes if the original surgeon does not have enough experience or the possibility to be immediately supported by an HPB specialist, it is advisable to place drains in the biliary tree and subhepatic area and transfer the patient to an HPB referral center.
When the injuries are minor, by cold mechanisms and thin biliary ducts, the recommendation is primary suture and placement of abdominal drains in the area. The reconstruction with end to end anastomosis of the main bile duct with a T tube is recommended in cases of extensive or complete sections without thermal injury.
With iatrogenic injuries with extensive loss of tissue (>1 cm) or partial resection, the extrahepatic part of the efferent bile duct system is to be replaced with a hepaticoenterostomy.
Postoperatively, bile-duct injuries usually become apparent within the first two weeks. Ninety five percent of bile-duct injuries manifest themselves within the first year and a later diagnosis is an exception .
Imaging options include cholescintigraphy, ultrasonography, computed tomography (CT), magnetic resonance cholangiopancreatography(MRCP), endoscopic retrograde cholangiopancreatography(ERCP), percutaneous transhepatic cholangiography (PTC), and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter.
Magnetic resonance cholangiography is a sensitive (85%-100%) and non-invasive imaging modality for the biliary tract.
ERCP is a very useful method of investigation in imaging of damaged bile ducts and it allows the repair of small bile duct injuries by insertion of a biliary prosthesis.
When MBDI occurs, HJ seems to be the optimal treatment but should not be performed during a sepsis period. The adoption of the Hepp– Couinaud approach has improved the results of Roux-en-Y repair.
The preventive strategies can be divided into 1)-dissection and 2)-intraoperativeimaging techniques. The dissection of the cystic duct to the cystic duct common bile duct junction, and the so-called critical view of safety (CVS), have therefore been advocated. Techniques to image the common bile duct, either by cholangiography or ultrasonography, should be used liberally.An alternative to radiography for intraoperative assessment of biliary anatomy is laparoscopic ultrasonography (LUS).
In summary, the search is still ongoing for an optimal technique for intraoperative assessment of biliary anatomy that is safe, easy to perform, simple to interpret,
There is association between abnormal anatomy and biliary tract injury, it was reported by Hasan ;et al. with biliary tract injury incidence of 6%.Hence, it is recommended that surgeons properly identify the EHBT anatomy intraoperatively in order to avoid injuries.
The most EHBT abnormality observed was short CD and accessory hepatic ducts, the second most common abnormality was left CD insertion. Less common abnormalities are CD inserted into RHD and duct ofLuschka .
There are several risk factors associated with bile duct injury, and these can be characterized as patient factors, local factors, and extrinsic factors.
The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries.
Classification of BDIs is important as the type of injury will dictate the management. Several classification systems have been proposed but none have been accepted as a universal standard.One of the most widely used classifications today is that of Strasberg.
The Amsterdam classification is a relatively practical to use and serves well for endoscopic purpose . The BDIs are divided into groups A, B, C and D.
To date, the best management strategy in terms of timing of repair remains controversial. Most authors agree that intraoperative recognition of BDI with immediate repair by specialized HPB surgeons offers the best results.IOC is the most classic method intraoperatively to detect CBD stones and injuries.
To obtain better outcomes if the original surgeon does not have enough experience or the possibility to be immediately supported by an HPB specialist, it is advisable to place drains in the biliary tree and subhepatic area and transfer the patient to an HPB referral center.
When the injuries are minor, by cold mechanisms and thin biliary ducts, the recommendation is primary suture and placement of abdominal drains in the area. The reconstruction with end to end anastomosis of the main bile duct with a T tube is recommended in cases of extensive or complete sections without thermal injury.
With iatrogenic injuries with extensive loss of tissue (>1 cm) or partial resection, the extrahepatic part of the efferent bile duct system is to be replaced with a hepaticoenterostomy.
Postoperatively, bile-duct injuries usually become apparent within the first two weeks. Ninety five percent of bile-duct injuries manifest themselves within the first year and a later diagnosis is an exception .
Imaging options include cholescintigraphy, ultrasonography, computed tomography (CT), magnetic resonance cholangiopancreatography(MRCP), endoscopic retrograde cholangiopancreatography(ERCP), percutaneous transhepatic cholangiography (PTC), and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter.
Magnetic resonance cholangiography is a sensitive (85%-100%) and non-invasive imaging modality for the biliary tract.
ERCP is a very useful method of investigation in imaging of damaged bile ducts and it allows the repair of small bile duct injuries by insertion of a biliary prosthesis.
When MBDI occurs, HJ seems to be the optimal treatment but should not be performed during a sepsis period. The adoption of the Hepp– Couinaud approach has improved the results of Roux-en-Y repair.
The preventive strategies can be divided into 1)-dissection and 2)-intraoperativeimaging techniques. The dissection of the cystic duct to the cystic duct common bile duct junction, and the so-called critical view of safety (CVS), have therefore been advocated. Techniques to image the common bile duct, either by cholangiography or ultrasonography, should be used liberally.An alternative to radiography for intraoperative assessment of biliary anatomy is laparoscopic ultrasonography (LUS).
In summary, the search is still ongoing for an optimal technique for intraoperative assessment of biliary anatomy that is safe, easy to perform, simple to interpret,
Other data
| Title | RECENT TRENDS INMAMNAGEMENT OF POST CHOLECYSTECTOMY COMMON BILE DUCT INJURY | Other Titles | الطرق الحديثة في تشخيص وعلاج إصابات القناة المراريه المشتركة بعد عمليات استئصال المرارة | Authors | Bahaa El-deen Ahmed | Issue Date | 2015 |
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