POLSKI PRZEGLĄD CHIRURGICZNY 2014, 86, 1, 17–25
10.2478/pjs-2014-0004
Iatrogenic bile duct injuries – clinical problems Stanisław Głuszek1,2, Marta Kot1, Norbert Bałchanowski1, Jarosław Matykiewicz1,2, Jakub Kuchinka1, Dorota Kozieł2, Iwona Wawrzycka1,2 Department of General, Oncological and Endocrinological Surgery, Provincial Hospital in Kielce1 Kierownik: prof. dr hab. S. Głuszek Department of Surgery and Surgical Nursing with the Scientific Research Laboratory Faculty of Health Sciences Jan Kochanowski University in Kielce2 Kierownik: prof. dr hab. S. Głuszek Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures in surgical wards. Iatrogenic bile duct injuries (IBDI) incurred during the procedures are among postoperative complications that are most difficult to treat. The risk of bile duct injury is 0.2–0.4%, and their consequences are unpleasant both for the surgeon and for the patient. The aim of the study was analysis of iatrogenic bile duct injuries and methods of their repair,taking into consideration the circumstances, under which the injuries occur. Material and methods. The study group consisted of 16 patients who had suffered IBDI during surgery. The analysed parameters included sex, age, indications for surgery, the setting of the surgical procedure and the type of bile duct injury. Additionally, the time of injury diagnosis, type of repair and treatment outcome were assessed. The IBDI analysis used the EAES classification of injuries. The time of IBDI repair was defined as immediate, early or late,depending on the time that had passed from the injury. The analysis included complications seen after bile duct repair. Results. The study group consisted of 10 women and 6 men, aged 29–84. Patients underwent 6 classic cholecystectomies, 8 laparoscopic cholecystectomies, one gastrotomy to remove oesophageal prosthesis and one laparotomy due to peptic ulcer. IBDI was diagnosed intraoperatively in 4 patients. In 12 patients IBDI was diagnosed within 1–7 days. The diagnosis was based on endoscopic retrograde cholangiopancreatography and the results of biochemistry tests. According to the EAES classification, the injuries were of type 1 (4 patients), type 2 (8 patients), type 5 (3 patients) and type 6 (1 patients). Reconstruction procedures were performed during the same anaesthesia session in 3 patients, and in the early period in 13 patients. The main procedure was Roux-en-Y anastomosis (12 patients), with the remaining including bile-duct suturing over a T-tube (3 patients) and underpinning of an accessory bile duct in the pocket left after gallbladder removal (1 patient). The most common reconstruction complications included bile leak (3 patients), recurrent cholangitis (3 patients) and bile duct stricture (2 patients). Mortality in the study group was 12.5%. Conclusions. The procedures of laparoscopic and classic cholecystectomy are associated with a risk of IBDI, especially in the presence of inflammatory state of the gall-bladder. IBDI is a complex complication: its treatment poses a challenge for the operating surgeon, and even the most careful treatment adversely affects the patient’s lifedue to complications. Key words: laparoscopic surgery, cholecystectomy, iatrogenic bile duct injury
Classic and laparoscopic cholecystectomy procedures are associated with a risk of iatrogenicbile duct injuries (IBDI). Iatrogenic bile duct injuries incurred during laparoscopic cholecystectomy, which has become a standard method of treating symptomatic cholelithiasis, are a problem encountered by surgeons around
the world. The current risk of bile duct injury during laparoscopic cholecystectomy in Poland is estimated to be 0.21–0.4% (1, 2, 3). Risk factors for iatrogenic bile duct injuries depend upon: 1) the conditions of surgery (whether the procedure was performed due to emergency indications with the presence of
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acute inflammatory state); 2) the operating surgeon’s experience; 3) good visibility within the surgical field; 4) adhesions existing near the operated area; 5) insufficient knowledge of anatomical relationships in the surgical field; 6) haste; 7) failure to consider the possibility of atypical routes of vessels and bile ducts; 8) existing changes in the anatomical conditions due to ongoing disease processes (1, 2, 3). Currently it is believed that the main causes of IBDI are: incorrect interpretation of atypical anatomy and, less frequently, lack of the surgeon’s care. The incorrect interpretation accounts for 66-97% of injury causes; the risk is higher in a thin personwith a narrow main bile duct, which can be erroneously recognised as the cystic duct. In 70-80% cases of IBDI the operating surgeon is unaware of having incurred the injury (3). Only a leak of biliary content from a drain, postoperative hyperbilirubinaemia, local or diffuse peritonitis or septic symptoms in a patient indicate the possibility of biliary tract injury. This is associated with the necessity of injury repair. Depending on when the injury is diagnosed, this can be done immediately during the same anaesthesia session, in the early period, i.e. 1 to 45 days after the injury, or in the late period,i.e. after 45 days of the injury. The time of performing repair surgery is still an object of discussion, althoughin a paper by Iannelli it was demonstrated that late repair is associated with the lowest number of complications (4). The site requiring repair is also important. Iannelli claims that the success of repair surgery is also associated with the possibility of being performed by a surgeon experienced in biliary tract surgeries. Where this is not possible, it is indicated to thoroughly drain the area of injury. Careful surgical technique is of key importance for IBDI prevention. Correct spatial visualisation of the Calot’s triangle means careful preparation of the cystic duct and safe gall-bladder removal. Examination of 70 corpses revealed that the cystic artery may be: double – 14%, additional – 10% or duplicated – 13% (37% in total). The groove that runs through the visceral surface of the liver, above the carina, and the initial sections of the hepatic ducts is visible in approx. 80% of patients undergoing surgery. Visualisation of this groove is one of the conditions of safe surgery
during cholecystectomy (3). According to Strasberg, another factor contributing to injuries is skipping of intraoperative cholangiography (5). The main aim of the examination is to avoid the risk IBDI or to recognise it immediately, with the secondary purpose being identification of choleductolithiasis. Light cholangiography might be considered (introduction of a duodenoscope to the main bile duct (MBD) and illuminating it from the inside) as well as methylene blue cholangiography (injection of 50% methylene blue solution to the gall-bladder (GB) bottom will cause bluish staining of the bile ducts). With the intent to help avoid IBDI, various training sessions and courses are offered; this includes even simulation training sessions to promote safe surgery. One of the types of IBDI complications, manifesting usuallya long time after the surgery, is MBD stricture. This condition develops through injury of the MBD axial vessels, leading to chronic ischaemia of its walls (1, 2, 3). The objective of the study was clinical analysis of a group of patients who had suffered iatrogenic bile duct injuries, with special attention dedicated to the intraoperative circumstances of the injury, diagnosis and reconstruction treatment of the injury as well ase the fate of the patients. MATERIAL AND METHODS The study group consisted of 16 patients who had suffered iatrogenic bile duct injury. Analysis of the group was performed retrospectively. The study group included all patients treated in one facility, supervised by one surgeon (S.G.). Demographic analysis was performed (sex, age), involving the patients in the analysed group, as well as analysis of preoperative diagnoses and concomitant diseases. The analysis additionally included: 1) intraoperative conditions of the procedure, during which the bile duct injury occurred; 2) the type of bile duct injury; 3) the time when the injury was diagnosed (intraoperatively, immediately after surgery in the operating room setting, postoperatively); 4) reconstruction treatment used, time between the IBDI and repair surgery; 5) early reconstruction treatment outcomes; 6) distant outcomes seen in patients. Bile duct injury was defined as injury of the extrahepatic bile ducts, irrespective of their
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Iatrogenic bile duct injuries – clinical problems
anatomy (normal or altered). The injuries were classified according to the Strasberg and EAES classification. The classification of bile duct injuries (according to Strasberg) in the analysed group (5): A – an injury of small ducts in the pocket left after gall-bladder removal or originating from the cystic duct, with retained integrity of the main bile duct; B and C – injuries of atypical variations of the right hepatic duct; D – partial injury of the main bile duct, with retained integrity of the duct; E – complete interruption of the main bile duct at the level of the common bile duct, the common hepatic duct or the junction site of the left and right hepaticducts. Another system used for classification of bile duct injuries is one prepared by EAES (6). According to this system, injuries are classified depending upon: (1) Anatomical localisation within the bile ducts (types 1-6) Type 1 – injury of the main bile duct occurring 2 cm distally from the junction of the hepatic ducts. Type 2 – injury of the main bile duct occurring 2 cm proximally from the junction of the bile ducts. Type 3 – injury of the main bile duct involving the junction of the hepatic ducts, with retention of this junction. Type 4 – injury of the main bile duct involving the junction of the hepatic ducts, with interruption of the connection between the right and left hepatic ducts. Type 5 – injury of the left or right hepatic duct without injury of their junction. Type 6 – injury of accessory bile ducts, e.g. in the gall-bladder pocket, without injury of the main bile duct. (2) The extent of the injury: complete (C), major (M) (above 25% of the circumference) and partial (P) (below 25% of the circumference). (3) Accompanying injuries, e.g. vascular injuries. (4) The size of the defect in the course of bile ducts. Bile duct repair was performed immediately, in the early period or in the late period: immediate, early (within 45 days of injury) or late
repair (after 45 days of injury). The types of repair surgeries performed included: endoscopic intervention and introduction of a prosthesis in the bile ducts (ERCP), simple suturing of the bile ducts and Roux-en-Y anastomosis. Due to the small size of the study group, descriptive statistics was used in calculations. RESULTS The study group consisted of 16 patients who had suffered bile duct injury. In 15 patients the repair procedures were performed in our Department, by one surgeon. One patient underwent reconstruction surgery directly after the primary surgical procedure, in the facility where the patient was treated. Because of a postoperative problem (major bile leak in the anastomosis), the patient was sent to our Department. In the study group of 16 patients there were 10 women aged 29-84 and 6 men aged 65-84. The patients initially underwent 8 classic procures involving laparotomy and 8 laparoscopic procedures. The 8 cases of primary classic procedures involving laparotomy included: six classic cholecystectomies, one patient operated due to migration of an oesophageal prosthesis previously implanted due to oesophageal stricture and one patient operated due to peptic ulcer. In the latter two patients, the injury of the common bile duct occurred in especially difficult anatomical conditions during gastrotomy and stomach resection due to peptic ulcer. In case of classic cholecystectomy, the procedures were performed in acute inflammatory state or after cholecystitis. According to the operating surgeons’ account, the intraoperative conditions were difficult or very difficult in terms of identification of anatomical structures. In 3 cases the bile duct injury was an adverse event that occurred during a seemingly controlled procedure of cholecystectomy. The surgeon was convinced they were dissecting the cystic duct, while in realitythe dissected structure was the common bile duct erroneously recognised as cystic duct. As regards laparoscopic cholecystectomies, 4 procedures were performed in the elective setting; in one patient the cystic duct originated from the right hepatic duct, and the surgeon identified the common origin as the cystic duct; in another patient the cystic duct was very short,
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and here as well the surgeon erroneously assessed the anatomical situation. In other two young patients, surgeons incorrectly identified narrow common bile ducts as cystic ducts, damaging these structures. Intraoperative bile duct injury was diagnosed intraoperatively in 4 patients:during laparoscopic cholecystectomy, classic cholecystectomy, gastrotomy and stomach resection. In 12 patients the diagnosis was established within 1-7 days after surgery, duringthe hospital stay. In all patients the examination of choice to confirm the injury was endoscopic retrograde cholangiopancreatography (ERCP). Biochemistry tests were used as a supplement (bilirubin concentration, activity levels of asparagine aminotransferase (AspAT) andalanine aminotransferase (AlAt), gamma-glutamyl transpeptidase (GGTP), alkaline phosphatase (ALP), assessment of the coagulation system and renal function as well as imaging examinations, such as ultrasonography, tomography and, after the surgery, cholangioNMR) (tab. 1, 2). According to the Strasberg classification, type A injuries were present in one patient, type B or C – in 3 patients, type E in 12 patients (common hepatic duct injuries occurring less than 2 cm from the bifurcation of the left and right hepatic ducts – 7; common bile duct injuries – 5). The most common site of injury was the main bile duct, through the mechanism of complete resection of its fragment after clipping the two ends. The operating surgeons reported that they had identified the bile duct as the cystic duct. The main type of injury according to the EAES classification was type 2 injurywith a defect of integrity of the main bile duct (12 patients); other types were less frequent (type 5 – 3 patients; type 6 –1 patient). According to the EAES classification, most frequent were CBD injuries occurring more than 2 cm from the junction of the hepatic ducts (type 1 – 4 patients, type 2 – 8 patients) and injuries of the right or left hepatic duct (type 5 – 3 patients). One patient incurred injury of an accessory bile duct (type 6). Reconstruction procedures were performed immediately after diagnosis, during the same anaesthesia session, in 3 patients, and in the early period (1–7 days) in 13 patients, after careful preparation and thorough diagnosis of the injury type.
The surgical procedure began with thorough inspection of the surgical field and visualisation of injured bile ducts, which was not easy given the short period from the primary surgery and was usually associated with serious difficulties. After visualisation of the site of injury, intraoperative cholangiography was performed to assess the bile duct anatomy and to make appropriate intraoperative decisions. Most of bile duct reconstruction procedures were performed through anastomosis of the bile ducts, most commonly the main hepatic duct, with creating a loop of the small intestine (Roux-Y loop) (tab. 3). Mortality in the study group was 12.5% (2/16). The mean hospitalisation time after the reconstruction procedure was 17 days (10-48 days). Intraoperative bile duct injuries were diagnosed in 5 patients and (during the same anaesthesia session) a reconstruction procedure was performed, 1 patient was diagnosed with the injuryand underwent reconstruction on the day following the procedure, after performing ERCP. In 9 patients ERCP was performed before the reconstruction procedure, a method that plays an important rolein establishing the final diagnosis. In the analysed group of patients, cholangio-NMR was used during followup visits after the reconstruction procedure (tab. 4, 5). DISCUSSION Iatrogenic bile duct injury is a major clinical problem, as well as a professional problem for the surgeon who performed the unfortunate procedure and for surgeons who reconstruct the bile ducts. For the patients, on the other hand, it is a particularly difficult disease, associated with recurring health problems (4, 7, 8). In the study group, 8 procedures were performed due to cholecystitis,6 due to symptomatic cholelithiasis without inflammation and 2 due to other indications. According to the literature, inflammatory state in the gallbladder, involving also the bile ducts, increases the risk of bile duct injury. One of circumstances, a very controversial one, which can promote IBDI is cholecystectomy performed from the bottom of the gall-
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CHD – 2
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laparoscopic cholecystec- CHD – 2 tomy
8
7
MS, age: 75
classic cholecystectomy – acute surgery due to cholecystitis oesophageal prosthetic replacement due to stricture migration of the prosthesis to the stomach laparotomy-gastrotomy, injury of the duodenum and the main bile duct I S-B, laparoscopic cholecystec- CHD – 2 age: tomy – elective 34
6
LS, age: 61 EP, age: 84
5
laparoscopic cholecystectomy
Roux-en-Y choledochojejunostomy anastomosis
Roux-en-Y hepaticojejunostomy anastomosis
Reconstruction procedure
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Roux-en-Y hepaticojejunostomy anastomosis
Roux-en-Y hepaticojejunostomy anastomosis
14
1
Roux-en-Y hepaticojejuno- on the day of stomy anastomosis surgery, after completing lap. chol. transection of a bile ERCP – a small bile leak 6 ductule in the at one of the clips. pocket left after Laparotomy – underpingall-bladder remo- ning of an accessory bile val (duct of Lusch- ductule (duct of Luschka) ka) – 6 in the pocket left after gall-bladder removal. CHD at the RBD/ Roux-en-Y hepaticojejuno43 LBD junction site stomy anastomosis –2 CBD/PWW – 1 suturing of the main bile on the day of the duct over a T-tube primary surgery
laparoscopic CBD – 1 cholecystectomy – elective surgery laparoscopic Right bile duct – 5 cholecystectomy
laparoscopic cholecystectomy
Site of MBD injury Injury type according to EAES
MS, age: 68
AG, age: 29 CJ, age: 65 IK, age: 57
Pa- Type of surgical procedutient re
4
3
2
1
No.
10
10
30
11
10
9
19
1 – follow-up cholangio-NMR: normal duodenal flow to the duodenum. Bile leak. After two weeks the drain was removed 2 – follow-up after one year – good overall condition 1 – perioperative bile leak – partial parenteral nutrition Cessation of the leak 2 – follow-up after one year – good overall condition
1 – the postoperative period was uncomplicated 2 – several hospitalisations due to recurrent cholangitis 1 – cholangiography through the T-tube, after two weeks – no bile leak was identified 6th day after the procedure – duodenal fistula, parenteral nutrition; healing of the fistula – oral nutrition 2 – patient’s death 4 months after the procedure
1 – the postoperative course was uncomplicated 2 – follow-up after one year – good overall condition
1 – the postoperative course was uncomplicated 2 – follow-up after one year – good overall condition
patient’s death on the 13th day after the surgery due to massive gastrointestinal haemorrhage
Time from bile Time of duct injury after hospitalisation Patient’s fate which the reconafter recon1 – postoperative course struction procedustruction 2 – distant outcomes re was performed surgery (days) (days) 7 10 1 – the postoperative course was uncomplicated 2 – follow-up after one year – good overall condition
Table 1. Analysis of a group of patients with bile duct injuries
Iatrogenic bile duct injuries – clinical problems
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MS, age: 84
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Roux-en-Y hepaticojejunostomy anastomosis
14
4
classic cholecystectomy classic
CHD transection – 2 Roux-en-Y hepaticojejuno- procedure perforstomy anastomosis med on the day of the primary surgery
CBD transection – 1 CBD suturing over a Ttube
Roux-en-Y hepaticojejunoCHD near the RBD/ stomy anastomosis 17 LBD junction site –2
incision of the right Suturing of the right on the day of the hepatic duct – 5 hepatic over a little drain. procedure
right bile duct – 5
Roux-en-Y hepaticojejunostomy anastomosis
procedure performed on the day of the primary surgery stomach resection due to resection of a frag- the first procedure: after several peptic ulcer ment of the CBD intussusception of the CBD months near the head of with the head of pancreas pancreas with to the small intestine subsequent resecThe second procedure: tion of a part of the after several months, due head of pancreas – 1 to jaundice – cholecystointestinal bypass classic cholecystectomy CHD transection – 2 Roux-en-Y hepaticojejuno- 10 stomy anastomosis
classic cholecystectomy due to cholecystitis
classic cholecystectomy – acute surgery due to cholecystitis
classic cholecystectomy; removal of a cyst in the right hepatic duct classic cholecystectomy
laparoscopic cholecystec- CHD – at the tomy – elective or acute junction (resection surgery of a bile duct fragment) – 2
LIST OF ABBREVIATIONS USED IN THE TABLE AND PAPER: Iatrogenic bile duct injuries – IBDI Common hepatic duct – CHD Common bile duct – CBD Endoscopic retrograde cholangiopancreatography – ERCP Main bile duct – MBD Left bile duct – LBD Right bile duct – RBD
15 ST, age: 70 16 KZ, age: 62
14 KL, age: 60
13 CA, age: 62
10 EM, age: 40 11 SŚ, age: 38 12 WJ, age: 49
9
cholangitis rec reoperation – side-to-side cholecystointestinal anastomosis 1 – immediately after a procedure in a different facility, bile leak of up to 100 ml, conservative treatment, drainage, follow-up MRCP, gradual decrease in the amount of the drained contents, no need for reoperation 2 – distant follow-up – good overall condition
14 30
1 – the patient was discharged in good overall condition 2 – distant follow-up after 2 months of the procedure, good overall condition
1 – cholangitis rec. Qualified for reoperation due to anastomosis stricture after 2 years of the reconstruction procedure – external drainage of the hepatic ducts was performed 2 – death 33 months after the initial reconstruction procedure (the autopsy revealed ca pancreatis) 1 – discharged with a T-tube after 2 weeks 2 – recurrent cholangitis
1 – the postoperative course was uncomplicated 2 – distant follow-up – good overall condition
1 – on the 5th day after surgery, symptoms of biliary fistula – treated with drainage; on the 21th day bleeding to the lumen of the upper part of the gastrointestinal tract 2 – patient’s death on the 24th day due to cerebral stroke 1 – small bile leak after the procedure 2 – distant follow-up – recurrent cholangitis
10
14
48
10
14
24
22 S. Głuszek et al.
Iatrogenic bile duct injuries – clinical problems Table 2. Time of bile duct repair surgery Bile duct repair surgery Number of surgeries (according to the time criterion) performed Immediate 5 Early 11
Table 3. The method of the performed bile duct repair procedure Bile duct repair surgery Number of surgeries (according to the repair performed procedure type) Rouxa-en-Y anastomosis 12 Suturing of the main bile 3 duct over a T-tube (2) or other drain (1) Underpinning of an accessory 1 bile duct in the pocket left after gall-bladder removal Table 4. Post-operative complications Post-operative complications Biliary fistula Spontaneously subsiding bile leak NFrequently recurring bile duct infections Bile duct stricture requiring surgical correction Bile duct stricture not requiring surgical correction
Number of patients 1 3 3 1 1
Table 5. Summary classification of injuries according to EAES Summary classification of injuries according to EAES Type 1 Type 2 Type 5 Type 6
Number of patients 4 2 3 1
bladder in the course of cholecystitis. Inflammatory state may lead to conditions, under which the wall of the gall-bladder (GB), main bile duct (MBD) and hilum vessels appear to be one structure. This is sometimes the way the operating surgeon sees it “from the bottom”, thinking that they are still treating the GB wall, while in reality they are gradually separating the MBD and the hilum vessels. However, in such an intraoperative situation, the surgeon should use a wider arsenal of techniques and manual surgical methods al-
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lowing for correct identification of the structures. One of the pitfalls is using a technique that visualises the site of entry of the cystic duct to the GB only in an image plane visible on a monitor (3). In this surgical method the cause of IBDI might be wrong interpretation of the image by the operating surgeon, since the MBD is hidden behind the neck of the GB from the side of the hilum. Changing the gallbladder’s position in the surgical field in a “flag-like” manner makes it possible to create safe conditions for gall-bladder removal. This allows for reliable identification of the two structures within the Calot’s triangle (the artery and the cystic duct) (2, 3, 12 ,14). In our facility, we use the flag technique. Injuries incurred during laparoscopic cholecystectomy were caused by using three trocars toto perform the procedure. Laparoscopic cholecystectomy is currently the standard treatment of cholelithiasis. It is a surgical procedure that, according to the literature, is associated with 2.5 to 4 times greater risk of bile duct injury than the open technique. Out of 9,358 laparoscopic cholecystectomies performed in 1993–2007 in Świętokrzyskie Province, bile duct injuries occurred in 21 patients, which makes 0.22% of all laparoscopic cholecystectomies. This means nearly 1 injury per 500 cholecystectomies. One needs to note, however, that in all complication summaries data sets might not be estimated. Patients, and this was also observed in the analysedgroup, develop numerous problems associated with the iatrogenic disease, especially recurrent bile duct infections, bile duct strictureswith jaundice, biliary cirrhosis as well as further consequences requiring subsequent surgical procedures, including even liver transplantation. Dageforde et al. (9) believe that early repair of bile duct injuries occurs only in 30% cases, since this figure is close to the percentage of cases diagnosed during the primary surgery. Repair procedures performed by surgeons responsible for the injuries are associated with worse outcomes thanreconstructions conducted by teams experienced in bile duct surgery. The risk of death increases to 11%, and the efficacy of the procedure is estimated to be approx. 20%. Even after successful repair the patients’ quality of life is decreased, which is associated with higher morbidity and mortality. In the study group, immediate repair was performed in 3
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patients (this included bile duct prosthesis placement and 2 procedures of suturing) and early repair was performed in 13 patients (12 procedures of Roux-en-Y anastomosis and 1 procedure of suturing). Bile duct injury repair is associated with 4.5 to 26 times higher cost than uncomplicated laparoscopic cholecystectomy (9). An important problem is the technique of cholecystectomy after retrograde cholangiopancreatography (ERCP) performed due to choleductolithiasis or other indications. As in our experiences, Siert et al. (10) more frequently converted to classic cholecystectomy after ERCP thanin a patient group where cholecystectomy was not preceded by this procedure. Such difficulties can be associated with abnormal function of the sphincter of Oddi, secondary bacterial colonisation of the bile ducts, inflammation and subsequent scarring of the hepatoduodenal ligament, which impedes preparation within the Calot’s triangle. In approx. 60% of patients after ERCP, the bile ducts are colonised by bacteria. A surgical procedure performed after ERCP is more difficult, makes it more difficult to treat the cystic duct and place clips(which are more prone to fall off); what is more, bile leaks from the cystic duct are more frequent. In such cases, a suture should be placed or the cystic duct should be ligated. Our experiences, like those of Siert et al. (10), indicate that such cholecystectomy should be considered more difficult and performed by an experienced surgeon. A systematic review of 45 studies involving 2,626 patients undergoing single incision laparoscopic cholecystectomy yielded the percentage of 0.72% of bile duct injuries incurred in elective surgeries (6). A review of other registries performed by the same team (Eikermann et al.) demonstrated a dangerously high percentage of bile duct injuries: 0.9% (German Hospital Quality Report – 172,368 pts), 0.25% (Danish Cholecystectomy Database In Denmark – 24,240 pts), 0.9% (Finnish cohort – 8,349 cholecystectomies, 1,616 open and 6,733 laparoscopic cholecystectomies), 0.11% (from Kaiser Permanente Northern California). Similarly to our observations (2, 11), the cited studies reveal patient-related factors and local factors increasing the risk of IBDI. These include: age, sex, acute cholecystitis, the presence of a calculus in the Hartmann’s pouch, a
short or absent cystic duct, anatomical differentiation of the bile duct arragnement, a thick wall of the gall-bladder, a widened common bile duct, extensive scarring of the Calot’s triangle area, numerous adhesions after previous surgeries. An increased risk of injuries was seen in men compared with women. In our group there were more women (10/16), who underwent surgery mostly due to cholecystitis (8/10 procedures). Eikermann et al. (6) recommend certain rules of intraoperative conduct, whichare largely similar to our previous guidelines published in Pol Przegl Chir (2). The team (8) recommends using oblique plane imaging, which allows for better visualisation of the bile ducts. Multidirectional straining of the gallbladder (frontal, lateral, caudal) allows for better visualisation of the anatomical conditions of the main bile duct. It is best to start preparation and incision of the peritoneum from the infundibulum level; one should pay continuous attention to the hepatic parenchyma. Preparation should be continued towards the cystic duct, releasing the Hartmann’s pouch using the so-called flag technique. Monopolar coagulation should be used with caution, in short periods of 1–2 s. Surgeons, depending on their experience, use a hook electrode, scissors, dissector or ultrasonic knife. Only after obtaining of a clear image of the two duct structures, separation of the structures and demonstration that they communicate with the gall-bladder, is it possible to ligate or clip those structures. The marker of the cystic artery is the Cloquet’s node. In case of intraoperative difficulties, anatomical conditions should be reassessed: first, the gallbladder should be separated from the liver, and then the Calot’s triangle should be re-explored. Such means might be insufficient; intraoperative cholangiography or ultrasonography should be used to allow approximation of the anatomical conditions (12, 13, 14, 15). In the group in question, routine intraoperative cholangiography was not performed during the primary procedure. This method is considered by some authors to be a way to avoid IBDI. Only a suspicion of bile duct injury was an indication for cholangiography. Possibly, the option of intraoperative cholangiography should be used more extensively during cholecystectomy, if there is no reliable identification of anatomical structures (3, 14,
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Iatrogenic bile duct injuries – clinical problems
15, 16). What is more, in such situations one should consider preparation starting from the bottom and convert when in doubt. It needs to be emphasised that the time factor is of great importance. If the surgeon cannot identify the anatomy within 30–45 minutes, they should covert to the open method. While separating the gallbladder from the bed, it is important to properly treat the ducts of Luschka. Visible duct structures should be ligated; coagulation should be avoided to reduce the risk of bile leaks. Cholecystectomy performed as part of an elective or acute procedure is associated with a risk of IBDI, especially if signs of cholecystitis are present.
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All preventive measures aimed at reducing the risk of bile duct injury are extremely important. CONCLUSIONS Iatrogenic bile duct injury is a complex complication, in the case of which – even when it is treated early and in the best possible manner – there is no guarantee that complications will not occur after a longer period of time. Such complications are associated with recurrent cholangitis, stricture of the anastomosis site as well as other factors and they adversely affect the patients’ quality of life.
references 1. Jakimowicz T, Świercz, Szmidt J: Działalność oddziałów chirurgii ogólnej w Polsce. Pol Przegl Chir 2009; 81: 532-43. 2. Głuszek S, Stanowski E, Herjan L: Cholecystektomia laparoskopowa w Polsce – wyniki i powikłania. Pol Przegl Chir 1995; 67: 386-94. 3. Kozicki I, Durowicz S, Tarnowski W: Czynniki sprzyjające jatrogennym urazom dróg żółciowych podczas cholecystektomii laparoskopowej i sposoby w ich zapobieganiu. Postępy Nauk Medycznych 2011; 1: 42-48. 4. Iannelli A, Paineau J, Hamy A et al.: Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie. HPB 2013; 15: 611-16. 5. Strasberg SM, Hertl M, Soper NJ: An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180: 101-25. 6. Eikermann M, Siegel R, Broeders et al.: Neugebauer Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc online (06 oct 2012). 7. Lee AY, Gregorius J. Kerlan RK et al.: Percutaneous Transhepatic Balloon Dilation of BiliaryEnteric Anastomotic Strictures after Surgical Repair of Iatrogenic Bile Duct Injuries. Plosone 2012; 7(10): 1-5. 8. Törnqvist B, Strömberg C, Persson G et al.: Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study.
BMJ 2012; 345 – http://dx.doi.org/10.1136/bmj. e6457 (11 oct 2012). 9. Dageforde LA, Landman MP, Feurer ID et al.: A Cost-Effectiveness Analysis of Early vs Late Reconstruction of Iatrogenic Bile Duct Injuries. J Am Coll Surg 2012; 214: 919-27. 10. Siert J, Reinders K, Gouma DJ et al.: Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography. HPB 2013; 15: 230-34. 11. Głuszek S, Bonek Z: Stan wideochirurgii kamicy żółciowej w województwie świętokrzyskim. Wideochirurgia 2008; 3(3): 11-18. 12. Sarno G, Al-Sarira AA, Ghaneh P et al.: Poston Cholecystectomy-related bile duct and vasculobiliary injuries. Br J Surg 2012; 99: 1129-36. 13. Virinder K, Bansal AK, Mahesh C et al.: Factors Affecting Short-Term and Long-Term Outcomes After Bilioenteric Reconstruction for Post- cholecystectomy Bile Duct Injury: Experience at a Tertiary Care Centre. Indian J Surg 2013 – DOI: 10.1007/ s12262-013-0880-x. 14. Hiroshi S, Itaru E, Kazuhiro S et al. Kensuke Kubota The current diagnosis and treatment of benign biliary stricture. Surg Today 2012; 42: 1143-53. 15. Zhu-lin L, Long C, Jian-Dong R et al.: Progressive balloon dilatation following hepaticojejunostomy improves outcome of bile duct stricture after iatrogenic biliary injury. BMC Gastroenterology 2013; 13: 70. 16. Addeo P, Oussoultzoglou E, Fuchshuher P et al.: Reparative surgery after repair of postcholecystectomy bikle duct injuries: is it worthwhile. World J Surg 2013; 37: 573-81.
Received: 31.10.2013 r. Adress correspondence: 25-736 Kielce, ul. Grunwaldzka 45 e-mail: [email protected]
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10.2478/pjs-2014-0004
Iatrogenic bile duct injuries – clinical problems Stanisław Głuszek1,2, Marta Kot1, Norbert Bałchanowski1, Jarosław Matykiewicz1,2, Jakub Kuchinka1, Dorota Kozieł2, Iwona Wawrzycka1,2 Department of General, Oncological and Endocrinological Surgery, Provincial Hospital in Kielce1 Kierownik: prof. dr hab. S. Głuszek Department of Surgery and Surgical Nursing with the Scientific Research Laboratory Faculty of Health Sciences Jan Kochanowski University in Kielce2 Kierownik: prof. dr hab. S. Głuszek Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures in surgical wards. Iatrogenic bile duct injuries (IBDI) incurred during the procedures are among postoperative complications that are most difficult to treat. The risk of bile duct injury is 0.2–0.4%, and their consequences are unpleasant both for the surgeon and for the patient. The aim of the study was analysis of iatrogenic bile duct injuries and methods of their repair,taking into consideration the circumstances, under which the injuries occur. Material and methods. The study group consisted of 16 patients who had suffered IBDI during surgery. The analysed parameters included sex, age, indications for surgery, the setting of the surgical procedure and the type of bile duct injury. Additionally, the time of injury diagnosis, type of repair and treatment outcome were assessed. The IBDI analysis used the EAES classification of injuries. The time of IBDI repair was defined as immediate, early or late,depending on the time that had passed from the injury. The analysis included complications seen after bile duct repair. Results. The study group consisted of 10 women and 6 men, aged 29–84. Patients underwent 6 classic cholecystectomies, 8 laparoscopic cholecystectomies, one gastrotomy to remove oesophageal prosthesis and one laparotomy due to peptic ulcer. IBDI was diagnosed intraoperatively in 4 patients. In 12 patients IBDI was diagnosed within 1–7 days. The diagnosis was based on endoscopic retrograde cholangiopancreatography and the results of biochemistry tests. According to the EAES classification, the injuries were of type 1 (4 patients), type 2 (8 patients), type 5 (3 patients) and type 6 (1 patients). Reconstruction procedures were performed during the same anaesthesia session in 3 patients, and in the early period in 13 patients. The main procedure was Roux-en-Y anastomosis (12 patients), with the remaining including bile-duct suturing over a T-tube (3 patients) and underpinning of an accessory bile duct in the pocket left after gallbladder removal (1 patient). The most common reconstruction complications included bile leak (3 patients), recurrent cholangitis (3 patients) and bile duct stricture (2 patients). Mortality in the study group was 12.5%. Conclusions. The procedures of laparoscopic and classic cholecystectomy are associated with a risk of IBDI, especially in the presence of inflammatory state of the gall-bladder. IBDI is a complex complication: its treatment poses a challenge for the operating surgeon, and even the most careful treatment adversely affects the patient’s lifedue to complications. Key words: laparoscopic surgery, cholecystectomy, iatrogenic bile duct injury
Classic and laparoscopic cholecystectomy procedures are associated with a risk of iatrogenicbile duct injuries (IBDI). Iatrogenic bile duct injuries incurred during laparoscopic cholecystectomy, which has become a standard method of treating symptomatic cholelithiasis, are a problem encountered by surgeons around
the world. The current risk of bile duct injury during laparoscopic cholecystectomy in Poland is estimated to be 0.21–0.4% (1, 2, 3). Risk factors for iatrogenic bile duct injuries depend upon: 1) the conditions of surgery (whether the procedure was performed due to emergency indications with the presence of
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S. Głuszek et al.
acute inflammatory state); 2) the operating surgeon’s experience; 3) good visibility within the surgical field; 4) adhesions existing near the operated area; 5) insufficient knowledge of anatomical relationships in the surgical field; 6) haste; 7) failure to consider the possibility of atypical routes of vessels and bile ducts; 8) existing changes in the anatomical conditions due to ongoing disease processes (1, 2, 3). Currently it is believed that the main causes of IBDI are: incorrect interpretation of atypical anatomy and, less frequently, lack of the surgeon’s care. The incorrect interpretation accounts for 66-97% of injury causes; the risk is higher in a thin personwith a narrow main bile duct, which can be erroneously recognised as the cystic duct. In 70-80% cases of IBDI the operating surgeon is unaware of having incurred the injury (3). Only a leak of biliary content from a drain, postoperative hyperbilirubinaemia, local or diffuse peritonitis or septic symptoms in a patient indicate the possibility of biliary tract injury. This is associated with the necessity of injury repair. Depending on when the injury is diagnosed, this can be done immediately during the same anaesthesia session, in the early period, i.e. 1 to 45 days after the injury, or in the late period,i.e. after 45 days of the injury. The time of performing repair surgery is still an object of discussion, althoughin a paper by Iannelli it was demonstrated that late repair is associated with the lowest number of complications (4). The site requiring repair is also important. Iannelli claims that the success of repair surgery is also associated with the possibility of being performed by a surgeon experienced in biliary tract surgeries. Where this is not possible, it is indicated to thoroughly drain the area of injury. Careful surgical technique is of key importance for IBDI prevention. Correct spatial visualisation of the Calot’s triangle means careful preparation of the cystic duct and safe gall-bladder removal. Examination of 70 corpses revealed that the cystic artery may be: double – 14%, additional – 10% or duplicated – 13% (37% in total). The groove that runs through the visceral surface of the liver, above the carina, and the initial sections of the hepatic ducts is visible in approx. 80% of patients undergoing surgery. Visualisation of this groove is one of the conditions of safe surgery
during cholecystectomy (3). According to Strasberg, another factor contributing to injuries is skipping of intraoperative cholangiography (5). The main aim of the examination is to avoid the risk IBDI or to recognise it immediately, with the secondary purpose being identification of choleductolithiasis. Light cholangiography might be considered (introduction of a duodenoscope to the main bile duct (MBD) and illuminating it from the inside) as well as methylene blue cholangiography (injection of 50% methylene blue solution to the gall-bladder (GB) bottom will cause bluish staining of the bile ducts). With the intent to help avoid IBDI, various training sessions and courses are offered; this includes even simulation training sessions to promote safe surgery. One of the types of IBDI complications, manifesting usuallya long time after the surgery, is MBD stricture. This condition develops through injury of the MBD axial vessels, leading to chronic ischaemia of its walls (1, 2, 3). The objective of the study was clinical analysis of a group of patients who had suffered iatrogenic bile duct injuries, with special attention dedicated to the intraoperative circumstances of the injury, diagnosis and reconstruction treatment of the injury as well ase the fate of the patients. MATERIAL AND METHODS The study group consisted of 16 patients who had suffered iatrogenic bile duct injury. Analysis of the group was performed retrospectively. The study group included all patients treated in one facility, supervised by one surgeon (S.G.). Demographic analysis was performed (sex, age), involving the patients in the analysed group, as well as analysis of preoperative diagnoses and concomitant diseases. The analysis additionally included: 1) intraoperative conditions of the procedure, during which the bile duct injury occurred; 2) the type of bile duct injury; 3) the time when the injury was diagnosed (intraoperatively, immediately after surgery in the operating room setting, postoperatively); 4) reconstruction treatment used, time between the IBDI and repair surgery; 5) early reconstruction treatment outcomes; 6) distant outcomes seen in patients. Bile duct injury was defined as injury of the extrahepatic bile ducts, irrespective of their
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Iatrogenic bile duct injuries – clinical problems
anatomy (normal or altered). The injuries were classified according to the Strasberg and EAES classification. The classification of bile duct injuries (according to Strasberg) in the analysed group (5): A – an injury of small ducts in the pocket left after gall-bladder removal or originating from the cystic duct, with retained integrity of the main bile duct; B and C – injuries of atypical variations of the right hepatic duct; D – partial injury of the main bile duct, with retained integrity of the duct; E – complete interruption of the main bile duct at the level of the common bile duct, the common hepatic duct or the junction site of the left and right hepaticducts. Another system used for classification of bile duct injuries is one prepared by EAES (6). According to this system, injuries are classified depending upon: (1) Anatomical localisation within the bile ducts (types 1-6) Type 1 – injury of the main bile duct occurring 2 cm distally from the junction of the hepatic ducts. Type 2 – injury of the main bile duct occurring 2 cm proximally from the junction of the bile ducts. Type 3 – injury of the main bile duct involving the junction of the hepatic ducts, with retention of this junction. Type 4 – injury of the main bile duct involving the junction of the hepatic ducts, with interruption of the connection between the right and left hepatic ducts. Type 5 – injury of the left or right hepatic duct without injury of their junction. Type 6 – injury of accessory bile ducts, e.g. in the gall-bladder pocket, without injury of the main bile duct. (2) The extent of the injury: complete (C), major (M) (above 25% of the circumference) and partial (P) (below 25% of the circumference). (3) Accompanying injuries, e.g. vascular injuries. (4) The size of the defect in the course of bile ducts. Bile duct repair was performed immediately, in the early period or in the late period: immediate, early (within 45 days of injury) or late
repair (after 45 days of injury). The types of repair surgeries performed included: endoscopic intervention and introduction of a prosthesis in the bile ducts (ERCP), simple suturing of the bile ducts and Roux-en-Y anastomosis. Due to the small size of the study group, descriptive statistics was used in calculations. RESULTS The study group consisted of 16 patients who had suffered bile duct injury. In 15 patients the repair procedures were performed in our Department, by one surgeon. One patient underwent reconstruction surgery directly after the primary surgical procedure, in the facility where the patient was treated. Because of a postoperative problem (major bile leak in the anastomosis), the patient was sent to our Department. In the study group of 16 patients there were 10 women aged 29-84 and 6 men aged 65-84. The patients initially underwent 8 classic procures involving laparotomy and 8 laparoscopic procedures. The 8 cases of primary classic procedures involving laparotomy included: six classic cholecystectomies, one patient operated due to migration of an oesophageal prosthesis previously implanted due to oesophageal stricture and one patient operated due to peptic ulcer. In the latter two patients, the injury of the common bile duct occurred in especially difficult anatomical conditions during gastrotomy and stomach resection due to peptic ulcer. In case of classic cholecystectomy, the procedures were performed in acute inflammatory state or after cholecystitis. According to the operating surgeons’ account, the intraoperative conditions were difficult or very difficult in terms of identification of anatomical structures. In 3 cases the bile duct injury was an adverse event that occurred during a seemingly controlled procedure of cholecystectomy. The surgeon was convinced they were dissecting the cystic duct, while in realitythe dissected structure was the common bile duct erroneously recognised as cystic duct. As regards laparoscopic cholecystectomies, 4 procedures were performed in the elective setting; in one patient the cystic duct originated from the right hepatic duct, and the surgeon identified the common origin as the cystic duct; in another patient the cystic duct was very short,
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and here as well the surgeon erroneously assessed the anatomical situation. In other two young patients, surgeons incorrectly identified narrow common bile ducts as cystic ducts, damaging these structures. Intraoperative bile duct injury was diagnosed intraoperatively in 4 patients:during laparoscopic cholecystectomy, classic cholecystectomy, gastrotomy and stomach resection. In 12 patients the diagnosis was established within 1-7 days after surgery, duringthe hospital stay. In all patients the examination of choice to confirm the injury was endoscopic retrograde cholangiopancreatography (ERCP). Biochemistry tests were used as a supplement (bilirubin concentration, activity levels of asparagine aminotransferase (AspAT) andalanine aminotransferase (AlAt), gamma-glutamyl transpeptidase (GGTP), alkaline phosphatase (ALP), assessment of the coagulation system and renal function as well as imaging examinations, such as ultrasonography, tomography and, after the surgery, cholangioNMR) (tab. 1, 2). According to the Strasberg classification, type A injuries were present in one patient, type B or C – in 3 patients, type E in 12 patients (common hepatic duct injuries occurring less than 2 cm from the bifurcation of the left and right hepatic ducts – 7; common bile duct injuries – 5). The most common site of injury was the main bile duct, through the mechanism of complete resection of its fragment after clipping the two ends. The operating surgeons reported that they had identified the bile duct as the cystic duct. The main type of injury according to the EAES classification was type 2 injurywith a defect of integrity of the main bile duct (12 patients); other types were less frequent (type 5 – 3 patients; type 6 –1 patient). According to the EAES classification, most frequent were CBD injuries occurring more than 2 cm from the junction of the hepatic ducts (type 1 – 4 patients, type 2 – 8 patients) and injuries of the right or left hepatic duct (type 5 – 3 patients). One patient incurred injury of an accessory bile duct (type 6). Reconstruction procedures were performed immediately after diagnosis, during the same anaesthesia session, in 3 patients, and in the early period (1–7 days) in 13 patients, after careful preparation and thorough diagnosis of the injury type.
The surgical procedure began with thorough inspection of the surgical field and visualisation of injured bile ducts, which was not easy given the short period from the primary surgery and was usually associated with serious difficulties. After visualisation of the site of injury, intraoperative cholangiography was performed to assess the bile duct anatomy and to make appropriate intraoperative decisions. Most of bile duct reconstruction procedures were performed through anastomosis of the bile ducts, most commonly the main hepatic duct, with creating a loop of the small intestine (Roux-Y loop) (tab. 3). Mortality in the study group was 12.5% (2/16). The mean hospitalisation time after the reconstruction procedure was 17 days (10-48 days). Intraoperative bile duct injuries were diagnosed in 5 patients and (during the same anaesthesia session) a reconstruction procedure was performed, 1 patient was diagnosed with the injuryand underwent reconstruction on the day following the procedure, after performing ERCP. In 9 patients ERCP was performed before the reconstruction procedure, a method that plays an important rolein establishing the final diagnosis. In the analysed group of patients, cholangio-NMR was used during followup visits after the reconstruction procedure (tab. 4, 5). DISCUSSION Iatrogenic bile duct injury is a major clinical problem, as well as a professional problem for the surgeon who performed the unfortunate procedure and for surgeons who reconstruct the bile ducts. For the patients, on the other hand, it is a particularly difficult disease, associated with recurring health problems (4, 7, 8). In the study group, 8 procedures were performed due to cholecystitis,6 due to symptomatic cholelithiasis without inflammation and 2 due to other indications. According to the literature, inflammatory state in the gallbladder, involving also the bile ducts, increases the risk of bile duct injury. One of circumstances, a very controversial one, which can promote IBDI is cholecystectomy performed from the bottom of the gall-
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CHD – 2
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laparoscopic cholecystec- CHD – 2 tomy
8
7
MS, age: 75
classic cholecystectomy – acute surgery due to cholecystitis oesophageal prosthetic replacement due to stricture migration of the prosthesis to the stomach laparotomy-gastrotomy, injury of the duodenum and the main bile duct I S-B, laparoscopic cholecystec- CHD – 2 age: tomy – elective 34
6
LS, age: 61 EP, age: 84
5
laparoscopic cholecystectomy
Roux-en-Y choledochojejunostomy anastomosis
Roux-en-Y hepaticojejunostomy anastomosis
Reconstruction procedure
25
Roux-en-Y hepaticojejunostomy anastomosis
Roux-en-Y hepaticojejunostomy anastomosis
14
1
Roux-en-Y hepaticojejuno- on the day of stomy anastomosis surgery, after completing lap. chol. transection of a bile ERCP – a small bile leak 6 ductule in the at one of the clips. pocket left after Laparotomy – underpingall-bladder remo- ning of an accessory bile val (duct of Lusch- ductule (duct of Luschka) ka) – 6 in the pocket left after gall-bladder removal. CHD at the RBD/ Roux-en-Y hepaticojejuno43 LBD junction site stomy anastomosis –2 CBD/PWW – 1 suturing of the main bile on the day of the duct over a T-tube primary surgery
laparoscopic CBD – 1 cholecystectomy – elective surgery laparoscopic Right bile duct – 5 cholecystectomy
laparoscopic cholecystectomy
Site of MBD injury Injury type according to EAES
MS, age: 68
AG, age: 29 CJ, age: 65 IK, age: 57
Pa- Type of surgical procedutient re
4
3
2
1
No.
10
10
30
11
10
9
19
1 – follow-up cholangio-NMR: normal duodenal flow to the duodenum. Bile leak. After two weeks the drain was removed 2 – follow-up after one year – good overall condition 1 – perioperative bile leak – partial parenteral nutrition Cessation of the leak 2 – follow-up after one year – good overall condition
1 – the postoperative period was uncomplicated 2 – several hospitalisations due to recurrent cholangitis 1 – cholangiography through the T-tube, after two weeks – no bile leak was identified 6th day after the procedure – duodenal fistula, parenteral nutrition; healing of the fistula – oral nutrition 2 – patient’s death 4 months after the procedure
1 – the postoperative course was uncomplicated 2 – follow-up after one year – good overall condition
1 – the postoperative course was uncomplicated 2 – follow-up after one year – good overall condition
patient’s death on the 13th day after the surgery due to massive gastrointestinal haemorrhage
Time from bile Time of duct injury after hospitalisation Patient’s fate which the reconafter recon1 – postoperative course struction procedustruction 2 – distant outcomes re was performed surgery (days) (days) 7 10 1 – the postoperative course was uncomplicated 2 – follow-up after one year – good overall condition
Table 1. Analysis of a group of patients with bile duct injuries
Iatrogenic bile duct injuries – clinical problems
21
MS, age: 84
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Roux-en-Y hepaticojejunostomy anastomosis
14
4
classic cholecystectomy classic
CHD transection – 2 Roux-en-Y hepaticojejuno- procedure perforstomy anastomosis med on the day of the primary surgery
CBD transection – 1 CBD suturing over a Ttube
Roux-en-Y hepaticojejunoCHD near the RBD/ stomy anastomosis 17 LBD junction site –2
incision of the right Suturing of the right on the day of the hepatic duct – 5 hepatic over a little drain. procedure
right bile duct – 5
Roux-en-Y hepaticojejunostomy anastomosis
procedure performed on the day of the primary surgery stomach resection due to resection of a frag- the first procedure: after several peptic ulcer ment of the CBD intussusception of the CBD months near the head of with the head of pancreas pancreas with to the small intestine subsequent resecThe second procedure: tion of a part of the after several months, due head of pancreas – 1 to jaundice – cholecystointestinal bypass classic cholecystectomy CHD transection – 2 Roux-en-Y hepaticojejuno- 10 stomy anastomosis
classic cholecystectomy due to cholecystitis
classic cholecystectomy – acute surgery due to cholecystitis
classic cholecystectomy; removal of a cyst in the right hepatic duct classic cholecystectomy
laparoscopic cholecystec- CHD – at the tomy – elective or acute junction (resection surgery of a bile duct fragment) – 2
LIST OF ABBREVIATIONS USED IN THE TABLE AND PAPER: Iatrogenic bile duct injuries – IBDI Common hepatic duct – CHD Common bile duct – CBD Endoscopic retrograde cholangiopancreatography – ERCP Main bile duct – MBD Left bile duct – LBD Right bile duct – RBD
15 ST, age: 70 16 KZ, age: 62
14 KL, age: 60
13 CA, age: 62
10 EM, age: 40 11 SŚ, age: 38 12 WJ, age: 49
9
cholangitis rec reoperation – side-to-side cholecystointestinal anastomosis 1 – immediately after a procedure in a different facility, bile leak of up to 100 ml, conservative treatment, drainage, follow-up MRCP, gradual decrease in the amount of the drained contents, no need for reoperation 2 – distant follow-up – good overall condition
14 30
1 – the patient was discharged in good overall condition 2 – distant follow-up after 2 months of the procedure, good overall condition
1 – cholangitis rec. Qualified for reoperation due to anastomosis stricture after 2 years of the reconstruction procedure – external drainage of the hepatic ducts was performed 2 – death 33 months after the initial reconstruction procedure (the autopsy revealed ca pancreatis) 1 – discharged with a T-tube after 2 weeks 2 – recurrent cholangitis
1 – the postoperative course was uncomplicated 2 – distant follow-up – good overall condition
1 – on the 5th day after surgery, symptoms of biliary fistula – treated with drainage; on the 21th day bleeding to the lumen of the upper part of the gastrointestinal tract 2 – patient’s death on the 24th day due to cerebral stroke 1 – small bile leak after the procedure 2 – distant follow-up – recurrent cholangitis
10
14
48
10
14
24
22 S. Głuszek et al.
Iatrogenic bile duct injuries – clinical problems Table 2. Time of bile duct repair surgery Bile duct repair surgery Number of surgeries (according to the time criterion) performed Immediate 5 Early 11
Table 3. The method of the performed bile duct repair procedure Bile duct repair surgery Number of surgeries (according to the repair performed procedure type) Rouxa-en-Y anastomosis 12 Suturing of the main bile 3 duct over a T-tube (2) or other drain (1) Underpinning of an accessory 1 bile duct in the pocket left after gall-bladder removal Table 4. Post-operative complications Post-operative complications Biliary fistula Spontaneously subsiding bile leak NFrequently recurring bile duct infections Bile duct stricture requiring surgical correction Bile duct stricture not requiring surgical correction
Number of patients 1 3 3 1 1
Table 5. Summary classification of injuries according to EAES Summary classification of injuries according to EAES Type 1 Type 2 Type 5 Type 6
Number of patients 4 2 3 1
bladder in the course of cholecystitis. Inflammatory state may lead to conditions, under which the wall of the gall-bladder (GB), main bile duct (MBD) and hilum vessels appear to be one structure. This is sometimes the way the operating surgeon sees it “from the bottom”, thinking that they are still treating the GB wall, while in reality they are gradually separating the MBD and the hilum vessels. However, in such an intraoperative situation, the surgeon should use a wider arsenal of techniques and manual surgical methods al-
23
lowing for correct identification of the structures. One of the pitfalls is using a technique that visualises the site of entry of the cystic duct to the GB only in an image plane visible on a monitor (3). In this surgical method the cause of IBDI might be wrong interpretation of the image by the operating surgeon, since the MBD is hidden behind the neck of the GB from the side of the hilum. Changing the gallbladder’s position in the surgical field in a “flag-like” manner makes it possible to create safe conditions for gall-bladder removal. This allows for reliable identification of the two structures within the Calot’s triangle (the artery and the cystic duct) (2, 3, 12 ,14). In our facility, we use the flag technique. Injuries incurred during laparoscopic cholecystectomy were caused by using three trocars toto perform the procedure. Laparoscopic cholecystectomy is currently the standard treatment of cholelithiasis. It is a surgical procedure that, according to the literature, is associated with 2.5 to 4 times greater risk of bile duct injury than the open technique. Out of 9,358 laparoscopic cholecystectomies performed in 1993–2007 in Świętokrzyskie Province, bile duct injuries occurred in 21 patients, which makes 0.22% of all laparoscopic cholecystectomies. This means nearly 1 injury per 500 cholecystectomies. One needs to note, however, that in all complication summaries data sets might not be estimated. Patients, and this was also observed in the analysedgroup, develop numerous problems associated with the iatrogenic disease, especially recurrent bile duct infections, bile duct strictureswith jaundice, biliary cirrhosis as well as further consequences requiring subsequent surgical procedures, including even liver transplantation. Dageforde et al. (9) believe that early repair of bile duct injuries occurs only in 30% cases, since this figure is close to the percentage of cases diagnosed during the primary surgery. Repair procedures performed by surgeons responsible for the injuries are associated with worse outcomes thanreconstructions conducted by teams experienced in bile duct surgery. The risk of death increases to 11%, and the efficacy of the procedure is estimated to be approx. 20%. Even after successful repair the patients’ quality of life is decreased, which is associated with higher morbidity and mortality. In the study group, immediate repair was performed in 3
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S. Głuszek et al.
patients (this included bile duct prosthesis placement and 2 procedures of suturing) and early repair was performed in 13 patients (12 procedures of Roux-en-Y anastomosis and 1 procedure of suturing). Bile duct injury repair is associated with 4.5 to 26 times higher cost than uncomplicated laparoscopic cholecystectomy (9). An important problem is the technique of cholecystectomy after retrograde cholangiopancreatography (ERCP) performed due to choleductolithiasis or other indications. As in our experiences, Siert et al. (10) more frequently converted to classic cholecystectomy after ERCP thanin a patient group where cholecystectomy was not preceded by this procedure. Such difficulties can be associated with abnormal function of the sphincter of Oddi, secondary bacterial colonisation of the bile ducts, inflammation and subsequent scarring of the hepatoduodenal ligament, which impedes preparation within the Calot’s triangle. In approx. 60% of patients after ERCP, the bile ducts are colonised by bacteria. A surgical procedure performed after ERCP is more difficult, makes it more difficult to treat the cystic duct and place clips(which are more prone to fall off); what is more, bile leaks from the cystic duct are more frequent. In such cases, a suture should be placed or the cystic duct should be ligated. Our experiences, like those of Siert et al. (10), indicate that such cholecystectomy should be considered more difficult and performed by an experienced surgeon. A systematic review of 45 studies involving 2,626 patients undergoing single incision laparoscopic cholecystectomy yielded the percentage of 0.72% of bile duct injuries incurred in elective surgeries (6). A review of other registries performed by the same team (Eikermann et al.) demonstrated a dangerously high percentage of bile duct injuries: 0.9% (German Hospital Quality Report – 172,368 pts), 0.25% (Danish Cholecystectomy Database In Denmark – 24,240 pts), 0.9% (Finnish cohort – 8,349 cholecystectomies, 1,616 open and 6,733 laparoscopic cholecystectomies), 0.11% (from Kaiser Permanente Northern California). Similarly to our observations (2, 11), the cited studies reveal patient-related factors and local factors increasing the risk of IBDI. These include: age, sex, acute cholecystitis, the presence of a calculus in the Hartmann’s pouch, a
short or absent cystic duct, anatomical differentiation of the bile duct arragnement, a thick wall of the gall-bladder, a widened common bile duct, extensive scarring of the Calot’s triangle area, numerous adhesions after previous surgeries. An increased risk of injuries was seen in men compared with women. In our group there were more women (10/16), who underwent surgery mostly due to cholecystitis (8/10 procedures). Eikermann et al. (6) recommend certain rules of intraoperative conduct, whichare largely similar to our previous guidelines published in Pol Przegl Chir (2). The team (8) recommends using oblique plane imaging, which allows for better visualisation of the bile ducts. Multidirectional straining of the gallbladder (frontal, lateral, caudal) allows for better visualisation of the anatomical conditions of the main bile duct. It is best to start preparation and incision of the peritoneum from the infundibulum level; one should pay continuous attention to the hepatic parenchyma. Preparation should be continued towards the cystic duct, releasing the Hartmann’s pouch using the so-called flag technique. Monopolar coagulation should be used with caution, in short periods of 1–2 s. Surgeons, depending on their experience, use a hook electrode, scissors, dissector or ultrasonic knife. Only after obtaining of a clear image of the two duct structures, separation of the structures and demonstration that they communicate with the gall-bladder, is it possible to ligate or clip those structures. The marker of the cystic artery is the Cloquet’s node. In case of intraoperative difficulties, anatomical conditions should be reassessed: first, the gallbladder should be separated from the liver, and then the Calot’s triangle should be re-explored. Such means might be insufficient; intraoperative cholangiography or ultrasonography should be used to allow approximation of the anatomical conditions (12, 13, 14, 15). In the group in question, routine intraoperative cholangiography was not performed during the primary procedure. This method is considered by some authors to be a way to avoid IBDI. Only a suspicion of bile duct injury was an indication for cholangiography. Possibly, the option of intraoperative cholangiography should be used more extensively during cholecystectomy, if there is no reliable identification of anatomical structures (3, 14,
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Iatrogenic bile duct injuries – clinical problems
15, 16). What is more, in such situations one should consider preparation starting from the bottom and convert when in doubt. It needs to be emphasised that the time factor is of great importance. If the surgeon cannot identify the anatomy within 30–45 minutes, they should covert to the open method. While separating the gallbladder from the bed, it is important to properly treat the ducts of Luschka. Visible duct structures should be ligated; coagulation should be avoided to reduce the risk of bile leaks. Cholecystectomy performed as part of an elective or acute procedure is associated with a risk of IBDI, especially if signs of cholecystitis are present.
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All preventive measures aimed at reducing the risk of bile duct injury are extremely important. CONCLUSIONS Iatrogenic bile duct injury is a complex complication, in the case of which – even when it is treated early and in the best possible manner – there is no guarantee that complications will not occur after a longer period of time. Such complications are associated with recurrent cholangitis, stricture of the anastomosis site as well as other factors and they adversely affect the patients’ quality of life.
references 1. Jakimowicz T, Świercz, Szmidt J: Działalność oddziałów chirurgii ogólnej w Polsce. Pol Przegl Chir 2009; 81: 532-43. 2. Głuszek S, Stanowski E, Herjan L: Cholecystektomia laparoskopowa w Polsce – wyniki i powikłania. Pol Przegl Chir 1995; 67: 386-94. 3. Kozicki I, Durowicz S, Tarnowski W: Czynniki sprzyjające jatrogennym urazom dróg żółciowych podczas cholecystektomii laparoskopowej i sposoby w ich zapobieganiu. Postępy Nauk Medycznych 2011; 1: 42-48. 4. Iannelli A, Paineau J, Hamy A et al.: Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie. HPB 2013; 15: 611-16. 5. Strasberg SM, Hertl M, Soper NJ: An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180: 101-25. 6. Eikermann M, Siegel R, Broeders et al.: Neugebauer Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc online (06 oct 2012). 7. Lee AY, Gregorius J. Kerlan RK et al.: Percutaneous Transhepatic Balloon Dilation of BiliaryEnteric Anastomotic Strictures after Surgical Repair of Iatrogenic Bile Duct Injuries. Plosone 2012; 7(10): 1-5. 8. Törnqvist B, Strömberg C, Persson G et al.: Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study.
BMJ 2012; 345 – http://dx.doi.org/10.1136/bmj. e6457 (11 oct 2012). 9. Dageforde LA, Landman MP, Feurer ID et al.: A Cost-Effectiveness Analysis of Early vs Late Reconstruction of Iatrogenic Bile Duct Injuries. J Am Coll Surg 2012; 214: 919-27. 10. Siert J, Reinders K, Gouma DJ et al.: Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography. HPB 2013; 15: 230-34. 11. Głuszek S, Bonek Z: Stan wideochirurgii kamicy żółciowej w województwie świętokrzyskim. Wideochirurgia 2008; 3(3): 11-18. 12. Sarno G, Al-Sarira AA, Ghaneh P et al.: Poston Cholecystectomy-related bile duct and vasculobiliary injuries. Br J Surg 2012; 99: 1129-36. 13. Virinder K, Bansal AK, Mahesh C et al.: Factors Affecting Short-Term and Long-Term Outcomes After Bilioenteric Reconstruction for Post- cholecystectomy Bile Duct Injury: Experience at a Tertiary Care Centre. Indian J Surg 2013 – DOI: 10.1007/ s12262-013-0880-x. 14. Hiroshi S, Itaru E, Kazuhiro S et al. Kensuke Kubota The current diagnosis and treatment of benign biliary stricture. Surg Today 2012; 42: 1143-53. 15. Zhu-lin L, Long C, Jian-Dong R et al.: Progressive balloon dilatation following hepaticojejunostomy improves outcome of bile duct stricture after iatrogenic biliary injury. BMC Gastroenterology 2013; 13: 70. 16. Addeo P, Oussoultzoglou E, Fuchshuher P et al.: Reparative surgery after repair of postcholecystectomy bikle duct injuries: is it worthwhile. World J Surg 2013; 37: 573-81.
Received: 31.10.2013 r. Adress correspondence: 25-736 Kielce, ul. Grunwaldzka 45 e-mail: [email protected]
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