Recent Trends in Management of biliary ducts injuries
Taha Ismaiel Al sayed;
Abstract
Bile duct injuries and subsequent leaks can occur following laparoscopic and open cholecystectomies and also during other hepatobiliary surgeries. Various patient related and technical factors are implicated in the causation of biliary injuries. It is a morbid, costly, and occasionally fatal complication. The assessment of the cause of biliary injuries is based on the symptoms, clinical examination and imaging. (Kaffes, et al., 2005)
The incidence of injury has risen with the advent of laparoscopic cholecystectomy (0.1-0.2% for open to 0.4-0.6% for laparoscopy). ( Russell, et al., 2003) Despite increasing experience with laparoscopy, a review of 1.6 million cholecystectomies demonstrated an unchanging 0.5% incidence of bile duct injury, report after many days post operation, of abdominal pain, bile leak, jaundice or cholangitis. Only 30% of injuries are recognized at the time of operation. ( Way, et al., 2003)
Variations in the anatomy of gallbladder, bile ducts and the arteries that supply them and liver are important to the surgeon because failure to recognize them may lead to inadvertent ductal ligation, biliary leaks and strictures after laparoscopic cholecystectomy(Marcos, 2000). Congenital anomalies of extra hepatic biliary tree have long been recognized (Lamah, et al., 2001) but are rare (Bayraktar, et al., 2006) and may be of clinical importance because they may provide surgeons with an unusual surprise during laparoscopic cholecystectomy. (Yu, et al., 2006)
Injury of the extra hepatic biliary system after blunt trauma is a relatively rare entity. (Jaik, et al., 2008) The first report of bile duct rupture was in 1799 by Wainwright ( Turney, et al., 1974). Bourque et al ( Shorthouse, et al., 1978) in his review of the literature in 1989 found only 125 cases reported since 1806, one third of which were in the pediatric population.( Kelly, et al., 2008) Dawson reported 1 case of bile duct injury in 10,500 consecutive trauma patients. Complete Common bile duct transection is particularly rare too. (Dawson, 2001)
Biliary injuries are commonly associated with vascular injuries, especially arterial injuries. (Davidoff, et al., 2002) In 1948, Shapiro and Robillard theorized that arterial injury might induce biliary ischaemia and thereby worsen a biliary injury. Thus, a second concept began to emerge: namely, that a biliary injury, which disrupted collateral arteries running along the biliary tree, could exacerbate hepatic ischaemia caused by an arterial injury. (Iannelli, et al., 2003)
Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. ( Flum, et al., 2003) Imaging options include ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter.( Reuver, et al., 2008) ( Lau, et al., 2010) Magnetic resonance cholangiopancreatography can provide high resolution imaging of the hepatic hilum and has been used to identify biliary injury following blunt liver trauma.( Kelly, et al., 2008)
The goal of treatment is to restore the bile conduit, and to prevent short and long term complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis and secondary biliary cirrhosis. Endoscopic therapy by reducing the transpapillary pressure gradient helps in reducing the leak.( Lai and Lau, 2006) Endoscopic therapy with biliary sphincterotomy alone or with additional placement of a biliary stent/ nasobiliary drainage is advocated. Endoscopic interventions are useful in situations where there is leak with associated common bile duct calculus or a foreign body, peripheral bile duct injury, cystic duct stump leak and partial bile duct injury with leak/ narrowing of the lumen. Endotherapy is not useful in case of complete transection (total cut off) and complete stricture involving common hepatic or common bile ducts.( Strasberg, et al., 2005)
Bile duct injuries, particularly strictures, have traditionally been managed by surgical reconstruction (Roux-en-Y hepaticojejunostomy). The reported occurrence of symptomatic anastomotic strictures after long-term follow-up of surgical reconstruction ranges from 9-25 %. ( Lillemoe, et al., 2000)Surgery is definitely associated with significant morbidity and mortality. Endoscopic treatment has demonstrated results comparable to those achieved with surgery, with lower morbidity and mortality.( Tocchi, et al., 2000)
The incidence of injury has risen with the advent of laparoscopic cholecystectomy (0.1-0.2% for open to 0.4-0.6% for laparoscopy). ( Russell, et al., 2003) Despite increasing experience with laparoscopy, a review of 1.6 million cholecystectomies demonstrated an unchanging 0.5% incidence of bile duct injury, report after many days post operation, of abdominal pain, bile leak, jaundice or cholangitis. Only 30% of injuries are recognized at the time of operation. ( Way, et al., 2003)
Variations in the anatomy of gallbladder, bile ducts and the arteries that supply them and liver are important to the surgeon because failure to recognize them may lead to inadvertent ductal ligation, biliary leaks and strictures after laparoscopic cholecystectomy(Marcos, 2000). Congenital anomalies of extra hepatic biliary tree have long been recognized (Lamah, et al., 2001) but are rare (Bayraktar, et al., 2006) and may be of clinical importance because they may provide surgeons with an unusual surprise during laparoscopic cholecystectomy. (Yu, et al., 2006)
Injury of the extra hepatic biliary system after blunt trauma is a relatively rare entity. (Jaik, et al., 2008) The first report of bile duct rupture was in 1799 by Wainwright ( Turney, et al., 1974). Bourque et al ( Shorthouse, et al., 1978) in his review of the literature in 1989 found only 125 cases reported since 1806, one third of which were in the pediatric population.( Kelly, et al., 2008) Dawson reported 1 case of bile duct injury in 10,500 consecutive trauma patients. Complete Common bile duct transection is particularly rare too. (Dawson, 2001)
Biliary injuries are commonly associated with vascular injuries, especially arterial injuries. (Davidoff, et al., 2002) In 1948, Shapiro and Robillard theorized that arterial injury might induce biliary ischaemia and thereby worsen a biliary injury. Thus, a second concept began to emerge: namely, that a biliary injury, which disrupted collateral arteries running along the biliary tree, could exacerbate hepatic ischaemia caused by an arterial injury. (Iannelli, et al., 2003)
Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. ( Flum, et al., 2003) Imaging options include ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter.( Reuver, et al., 2008) ( Lau, et al., 2010) Magnetic resonance cholangiopancreatography can provide high resolution imaging of the hepatic hilum and has been used to identify biliary injury following blunt liver trauma.( Kelly, et al., 2008)
The goal of treatment is to restore the bile conduit, and to prevent short and long term complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis and secondary biliary cirrhosis. Endoscopic therapy by reducing the transpapillary pressure gradient helps in reducing the leak.( Lai and Lau, 2006) Endoscopic therapy with biliary sphincterotomy alone or with additional placement of a biliary stent/ nasobiliary drainage is advocated. Endoscopic interventions are useful in situations where there is leak with associated common bile duct calculus or a foreign body, peripheral bile duct injury, cystic duct stump leak and partial bile duct injury with leak/ narrowing of the lumen. Endotherapy is not useful in case of complete transection (total cut off) and complete stricture involving common hepatic or common bile ducts.( Strasberg, et al., 2005)
Bile duct injuries, particularly strictures, have traditionally been managed by surgical reconstruction (Roux-en-Y hepaticojejunostomy). The reported occurrence of symptomatic anastomotic strictures after long-term follow-up of surgical reconstruction ranges from 9-25 %. ( Lillemoe, et al., 2000)Surgery is definitely associated with significant morbidity and mortality. Endoscopic treatment has demonstrated results comparable to those achieved with surgery, with lower morbidity and mortality.( Tocchi, et al., 2000)
Other data
| Title | Recent Trends in Management of biliary ducts injuries | Other Titles | الجديد في علاج أصابات القنوات المرارية | Authors | Taha Ismaiel Al sayed | Issue Date | 2015 |
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