Updated management of iatrogenic biliary injuries
Abdelmoneem Abdelhafeiz Alsaify;
Abstract
The extra-hepatic bile ducts are represented by the extra hepatic segments of the right and left hepatic ducts joining to form the biliary confluence and the main biliary channel draining to the duodenum. The accessory biliary apparatus, which constitute a reservoir, comprises the gall bladder and cystic duct.
Anomalies of the gallbladder and extrahepatic bile ducts can occur in relation to number, position or shape. Several of these anomalies have clinical significance. The knowledge of such anomalies is essential not only for the diagnosis of biliary disease but also with respect to the growing abundance of minimally invasive therapeutical strategies in the treatment of gall bladder and extrahepatic bile duct diseases.
There are several risk factors associated with bile duct injury, and these can be characterized as patient factors, local factors, and extrinsic factors. Patient factors include but are not limited to obesity, advanced age, male sex, and adhesion. Local factors include severe inflammation and/or infection, aberrant anatomy, and hemorrhage. Extrinsic factors include surgeon's experience and properly functioning equipment.
Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification, which originated from the era of open surgery, is intended to help the surgeons to choose the appropriate technique for the repair, and it has a good correlation with the final outcome after surgical repair. However, the Bismuth's classification does not encompass the whole spectrum of injuries that are possible. Bile duct injury during LC tends to be more severe than those with OC. Strasberg’s classification made Bismuth’s classification much more comprehensive by including various other types of extrahepatic bile duct injuries.
Early recognition of bile duct injury is of paramount importance. However, most injuries are not recognized at the index surgery and patients may present weeks, months or even years later. The majority of patients with bile duct injury present initially with non-specific symptoms such as abdominal pain or abdominal distension, nausea, vomiting and ileus. Some patients present with jaundice, sepsis or bile peritonitis. It is important that patients who have undergone laparoscopic cholecystectomy and failed to recover as expected should be evaluated for the possibility of bile duct injury.
The clinical manifestation of BDI was biliary fistula (bilious drainage from an operatively placed drain), bile peritonitis, and jaundice
From the surgical point of view, imaging modalities of the biliary tree are requested to differentiate between obstructive and non-obstructive cases of jaundice and to determine the level of obstruction ,it is also important to identify the specific nature of the obstructing lesion.
Bile duct injuries can be diagnosed by many imaging methods included abdominal ultrasonography (US), multislice computed tomography (CT), magnetic resonance cholangiography (MRC), percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio-pancreatography (ERCP), T tube cholangiography.
Management and outcome of BDI depends on the timing of recognition of injury, the extent of bile duct injury, the patient's condition and the availability of experienced hepatobiliary surgeons. Immediate detection and repair are associated with an improved outcome, and the minimum standard of care after recognition of a bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair.
Anomalies of the gallbladder and extrahepatic bile ducts can occur in relation to number, position or shape. Several of these anomalies have clinical significance. The knowledge of such anomalies is essential not only for the diagnosis of biliary disease but also with respect to the growing abundance of minimally invasive therapeutical strategies in the treatment of gall bladder and extrahepatic bile duct diseases.
There are several risk factors associated with bile duct injury, and these can be characterized as patient factors, local factors, and extrinsic factors. Patient factors include but are not limited to obesity, advanced age, male sex, and adhesion. Local factors include severe inflammation and/or infection, aberrant anatomy, and hemorrhage. Extrinsic factors include surgeon's experience and properly functioning equipment.
Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification, which originated from the era of open surgery, is intended to help the surgeons to choose the appropriate technique for the repair, and it has a good correlation with the final outcome after surgical repair. However, the Bismuth's classification does not encompass the whole spectrum of injuries that are possible. Bile duct injury during LC tends to be more severe than those with OC. Strasberg’s classification made Bismuth’s classification much more comprehensive by including various other types of extrahepatic bile duct injuries.
Early recognition of bile duct injury is of paramount importance. However, most injuries are not recognized at the index surgery and patients may present weeks, months or even years later. The majority of patients with bile duct injury present initially with non-specific symptoms such as abdominal pain or abdominal distension, nausea, vomiting and ileus. Some patients present with jaundice, sepsis or bile peritonitis. It is important that patients who have undergone laparoscopic cholecystectomy and failed to recover as expected should be evaluated for the possibility of bile duct injury.
The clinical manifestation of BDI was biliary fistula (bilious drainage from an operatively placed drain), bile peritonitis, and jaundice
From the surgical point of view, imaging modalities of the biliary tree are requested to differentiate between obstructive and non-obstructive cases of jaundice and to determine the level of obstruction ,it is also important to identify the specific nature of the obstructing lesion.
Bile duct injuries can be diagnosed by many imaging methods included abdominal ultrasonography (US), multislice computed tomography (CT), magnetic resonance cholangiography (MRC), percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio-pancreatography (ERCP), T tube cholangiography.
Management and outcome of BDI depends on the timing of recognition of injury, the extent of bile duct injury, the patient's condition and the availability of experienced hepatobiliary surgeons. Immediate detection and repair are associated with an improved outcome, and the minimum standard of care after recognition of a bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair.
Other data
| Title | Updated management of iatrogenic biliary injuries | Other Titles | العلاج الحديث لإصابات القنوات المرارية الناتج عن الخطأ الجراحى | Authors | Abdelmoneem Abdelhafeiz Alsaify | Issue Date | 2014 |
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