Endoscopic management of Laparos

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Transcript Endoscopic management of Laparos

Journal Presentation on
Endoscopic management of
Laparoscopic cholecystectomy-associated
bile duct injuries
Published online:31 july 2010
Japanese Society of Hepato-Biliary-Pancreatic Surgery and Springer 2010
• In the past decade laparoscopic cholecystectomy (LC) has
gained wide spread acceptance and replaced conventional
open cholecystectomy as the treatment for cholecystolithiasis.
• However, LC is associated with a higher incidence of bile duct
injuries that is major bile duct injury is 0.1-0.5% during LC
performed for any indication. A review of 1.6 million
cholecystectomies in Medicare patients in United States
demonstrated a.0.5%incidence of bile duct injury, unchanged
between 1992-1999.
• These data suggest that the occurrence of bile duct injury in LC
has not decreased despite increasing experience.
• Traditionally, bile duct injuries have been managed by surgical
reconstruction with biliary enteric anastomosis.
• The reported symptomatic anastomotic strictures ranges from 9
to 25%.
• Meanwhile ,endoscopic treatment has demonstrated resolution
of complications comparable to that achieved with surgery , but
with lower morbidity and mortality.
• This study views 11-year experience with the endoscopic
approach to all types of bile duct injuries from LC.
• Files from April 1997 to June 2008 were reviewed from an
ERCP database maintained and during the study period, LC
was performed on 1797 patients and biliary tract injuries
occurred in 21 (1.17%) patients.
• This study addressed a total of 17 patients. there were 11 men
and 6 women with a median age of 60 years( range 41-84
• Inclusion criteria for this study were:
- biliary leakage,
-biliary strictures, or
-biliary transection
PATIENTS (contd.)
that were judge by gastroenterologist participant in the study to
be secondary to the prior LC..
• Exclusion criteria included the followings
-History other than LC that involve the biliary tract and
- Injuries recognized during surgery in patients who
never presented for ERCP.
Table :1 Defined classification of suspected major bile duct injuries
after initial ERCP
• Type A: cystic duct or peripheral hepatic leakage
• Type B: major hepatic duct injury leakage
• Type C: stricture of the common hepatic duct with or without
• Type D: complete transection of the common hepatic duct
• Type E: others
An ERCP catheter was inserted deep into bile duct ,and a
0.035-in. guide wire (Jagwire ,Terumo) was advanced in to the
bile duct. For patients with the leakage , a 5-to 7F endoscopic
nasobiliary drainage (ENBD) tube was placed without
endoscopic sphincterotomy (EST).
Improvement of the leakage was assessed using
cholangiography through an ENBD tube 1 week later. If
improvement of leakage and no signs of secondary ductal
stenosis were confirmed ,the ENBD tube was removed.
However if the leakage had not improved, a single 7F plastic
stent was placed for additional 1-2months.
METHODS (contd.)
For patients with stenosis, a single 7F plastic stent was placed
for 1-2months without EST. Repeat ERCP along with the stent
removal and cholangiography via the ENBD was performed.
If improvement of the stenosis was confirmed, the tube was
removed and the treatment protocol was concluded. If
improvement of the stenosis was not confirmed new 7F plastic
stent was placed for an additional 1-2months.
METHODS (contd.)
Endoscopic intervention was not attempted in patients with
complete biliary transection or occlusion , as they were deemed
unsuitable for endoscopic therapy; rather they under went
percutaneous transhepatic biliary drainage (PTBD) or surgical
Fig. 1: Major hepatic duct injury leakage (type B). a. One day after laparoscopic
cholecystectomy, Endoscopic Retrograde Cholangiopancreatography (ERCP) showed
extravasation of contrast dye from an aberrant segmental extrahepatic branch of the right
hepatic duct (arrow). b. X-ray of 5F endoscopic nasobiliary drainage (ENBD) without
sphincterotomy. c. One week after ENBD placement, resolution of leak was confirmed (arrow)
and the ENBD was removed.
Fig. 2 Stricture of the common hepatic duct without leakage (type
C). a Eight days post-laparoscopic cholecystectomy, ERCP was
performed to evaluate a new elevation in serum hepatobiliary enzyme
levels. Stricture of the common hepatic duct (arrows) was observed.
b This stricture was managed with the placement of a single plastic 7F
stent for almost 2 months. c After the stenting, resolution of the
stricture (arrows) and normalization of serum hepatobiliary enzyme
levels were confirmed
• The profiles of all seventeen patients with bile duct injuries
incurred during LC are
-symptomatic gallstone disease 15 (88.2%),
-acalculous cholecystitis
01 and
-emphysematous cholecystitis 01.
• 7 of the 15 patients(41.2%) suffered from acute cholecytitis
and three of these cases were severe enough to necessitate
percutaneous transhepatic gallbladder drainage (PTGBD).
• Table 2:Profiles of the 17 patients with bile duct injury
Indication for LC
Symptomatic gallstone
Cholecystitis without gallstone
Emphysematous cholecystitis
LC converted to open cholecystectomy
With surgical primary repair
Without surgical primary repair
Injury manifestations
Bile leak
Excessive postoperative pain and fever
Dilated bile duct on imaging
RESULT (contd.)
In the 8 of the 15 patients, LC was converted to open
cholecystectomy; five of these patients primary repair of bile
duct injuries and the remaining of the three patients were
converted to open repair for indications other than bile duct
injury (eg; adhesion )
• Manifestation of bile duct injury included
-bile leak in 13(76.5%)
-exacerbated postoperative pain and fever in 2(11.8%).
-Jaundice in 1(5.9%) and
-dilated bile duct on imaging in (5.9%)patient.
The cases were classified after initial ERCP:
RESULT (contd.)
• Nine patients with the leakage underwent ENBD as initial
• Two other patients were underwent placement of a single
plastic 7F stent.
• Seven patients (77.8%)improved clinically and on imaging over
an average of 5.2(range4-7 )days .Two patients had not
completely improved after 1 week with ENBD, but they
improved after the placement of a 7F stent . The cumulative
success rate was 100%.
• Four patients with stricture successfully underwent insertion of
a single 7F stent on the first attempt, and all patient improved
clinically and imaging 56-111 days (mean 62.0 days). Total
clinical success rate was 100% with EBS.
RESULT (contd.)
Fifteen patients were available for evaluation after
stent removal .The mean follow up period was 2436
days( range 173-4674).All patients experienced
complete resolution of symptoms without recurrence.
• Table -6 : Long-term follow-up after stent removal
Type A +B
Type C
Symptomatic recurrence
Secondary stricture
Other factors associated
with bile duct injury
• The incidence of bile duct injury during LC is higher than that of
laparotomy . Despite the fact that many studies have addressed
the prevention of bile duct injuries ,their incidence is still higher
,at 0.5% for LC.
• Only 30%of these injuries are recognized at the time of
operation and the consequences of a major bile duct injuries
can be severe. Surgical repair of bile duct injury has been the
main stay of treatment for many decades. In general the result
of bilioenteric bypass operations are good in 80-95% of
patients, But the peri-operative mortality rate is 20%-42%, with
a mortality rate of 6%-20%.
• In addition, during long term follow up, after surgical repair, 5%25% of patients will have relapsing symptoms because of
recurrent stricture formation at the anastomosis site.
• Most authors have advocated endoscopic placement of plastic
stent to manage bile duct leakage (North America and Europe,),
• In Japan, ENBD is selected as initial treatment
• Some authors advocate sphincterotomy while performing
• In this study,
the biliary sphincter whenever possible
preserved, specially in younger patients to avoid post operative
 First, the intervention was not blinded.
 Second, this was a single center study and the result may not
be generalized.
 Third, the numbers in this study were too small to perform a
multivariate analysis for evaluation of condition of patients, the
time of the procedure or the length of the follow up.
• ENBD for leakage and biliary strictures are safe and effective
treatment for LC associated injuries.
• Interventional ERCP with ENBD as the initial treatment for
leakage and biliary stenting for stricture is safe and effective for
LC associated biliary injuries and this procedure can be
considered an alternative to a biliary anastomosis in patients
without complete biliary duct transection.