Transcript 投影片 1 - Introduction

Joint Hospital Surgical Grand Round
September 2007
Bile duct injury during laparoscopic
cholecystectomy
Dr. Law Sze Hong
Tuen Mun Hospital
Introduction
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Bile duct injury following
cholecystectomy is an iatrogenic
catastrophe associated with significant
perioperative morbidity and mortality,
reduced long-term survival and quality
of life, and high rates of subsequent
litigation
Introduction
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Numerous reports have demonstrated
that the incidence of bile duct injuries
has risen from 0.1-0.2% to 0.4-0.7%
between the era of open
cholecystectomy and the era of
laparoscopic cholecystectomy (Strasberg SM. An
analysis of the problem of biliary injury during laparoscopic cholecystectomy. J
Am Coll Surg 180:101-125)
New type of injury
New type of injury
Prevention
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One-third of biliary injuries happen after
the surgeon has performed more than
200 cases
Therefore, it is more than inexperience
that leads to bile duct injuries
Commonest cause is misidentification of
biliary anatomy (70-80%)
Prevention
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Hunter and Troidl proposed:
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30 degree telescope
Avoidance of diathermy close to CHD
Dissection close to gallbladder-cystic
junction
Conversion to open when uncertain
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Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy Am J Surg
1991;162:71-76
Troidl H. Disasters of endoscopic surgery and how to avoid them: error analysis. World J Surg
1999;23:846-855
Main theme
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Management of bile duct injuries
detected intraoperatively
Bile leakage detected in the early
postoperative period
Biliary strictures will not be discussed
Intraoperative management
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In general, 75-90% of the injuries are
not recognized intraoperatively
Intraoperative identification of injury
may occur by recognition of bile in the
field, indicating a cut bile duct; by
cholangiography; or rarely by direct
observation of a divided duct
Role of intraoperative
cholangiography (IOC)
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There is good evidence to show that
intraoperative cholangiography is likely
to identify the injury at the time of
surgery (Archer SB. Bile duct injury during laparoscopic cholecystectomy:
results of a national survey. Ann Surg 2001;234:549-559)
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Early recognition of biliary injury and
appropriate repair is associated with
improved outcome (Savader SJ. Laparoscopic
cholecystectomy-related bile duct injuries: a health and financial disaster. Ann
Surg 1997;225:268-273)
Intraoperative management
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If injury to the biliary tree is recognized
at the time of initial cholecystectomy,
the surgeon should consider his or her
experience and ability to repair it
immediately
Intraoperative management
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Substantial evidence suggests that
immediate open conversion and repair
by an experienced surgeon is
associated with reduced morbidity,
shorter duration of illness, and lower
cost (Bile duct injuries during laparoscopic cholecystectomy: factors
that influence the results of treatment. Stewart L, Way LW. Arch Surg
1995;130:1123-1129)
Intraoperative management
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Each failed repair is associated with some loss
of bile duct length and greatly exacerbates an
already difficult situation
If the surgeon cannot effect a reasonable
repair, and competent help is unavailable,
drains should be placed to control any biliary
leak, and the patient should be referred to a
specialist centre
Intraoperative management
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In cases of injuries of the biliary tract
with minimal tissue loss, primary repair
can be performed
Hepaticojejunostomy is required for
major duct transection with tissue loss
Intraoperative management
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Early recognition of bile duct injury is
important as primary repair can be
performed at the same operation and in
expert hands, the long term outcome is
favorable
Management of bile leak in
early postoperative period
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Patients with bile leaks generally
present within the first week after
operation, but some may not become
apparent for several weeks
These patients usually present with
abdominal pain coupled with fever or
other signs of sepsis
Management of bile leak in
early postoperative period
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Elevated alkaline phosphatase levels are
characteristic, as is hyperbilirubinemia,
but jaundice is very uncommon
A few patients present only with vague
symptoms such as distension, malaise,
anorexia, complaints of discomfort, or
requirements for more than the usual
amount of analgesia
Management of bile leak in
early postoperative period
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Such complaints are all too easy to
dismiss, but they might be the only
manifestations of a serious biliary injury
Successful management of bile duct
injuries recognized in the postoperative
period requires thorough investigation
and optimal patient preparation
Investigations
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Ultrasonography (USG)
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An excellent, noninvasive means of
showing intrahepatic ductal dilatation and
intraperitoneal fluid collection
If a bile collection is suspected,
percutaneous aspiration or drain placement
can confirm that the fluid is bile and serve
as a step to control the effects of the bile
leak
Investigations
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Computed tomography (CT)
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Able to show a dilated biliary tree, identify
fluid collections and help localize the level
of ductal obstruction in patients with
strictures
More sensitive than USG (96% Vs 70%)
Probably the best initial study in biliary
injuries
Investigations
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Endoscopic retrograde
cholangiopancreatography (ERCP)
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Has a role in the diagnosis and treatment
of patients with bile leakage from the cystic
duct stump or from a laceration of the
common duct
Helpful for incomplete strictures
Investigations
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Little value in cases of complete proximal
bile duct strictures because there is often
discontinuity of the common bile duct
preventing visualization of the intrahepatic
ductal system
Investigations
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Percutaneous transhepatic
cholangiography (PTC)
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Defines the anatomy of the proximal biliary
tree to be used in the surgical
reconstruction
Can be followed by placement of
percutaneous transhepatic catheters, which
can be useful in decompressing the biliary
system
Investigations
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These catheters also will be of assistance
in the surgical reconstruction
Technically difficult in patients with
nondilated biliary tree
Optimal patient preparation
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Sepsis must be controlled with boardspectrum antibiotics
Intraperitoneal bile collection should be
drained
Optimization of nutritional status of the
patients ensured
Management of bile leak in
early postoperative period
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After thorough investigations and
optimal patient preparation, treatment
of the biliary injuries can be started
The treatment options will depend on
the type of biliary injuries
Management of bile leak in
early postoperative period
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For biliary leakage from the cystic duct
stump, liver bed, or minor lacerations of
major bile ducts, reducing intrabiliary
pressure by endoscopic sphincterotomy
with placement of a stent is usually
adequate
The value of ERCP in patients
with bile leak
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24 consecutive patients were studied
over a 4-year period (2003 – 2006) in
Tuen Mun Hospital
A total of 981 laparoscopic
cholecystectomies were performed
Incidence: 2%
The value of ERCP in patients
with bile leak
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The median age of the patients is 55
years (31-77) with no gender difference
ERCP was performed after a median of
4 days postoperatively (3-8 days)
Presenting symptoms
4
20
15
Fever
Abdominal Pain
Cholestasis
Distribution of leakage site
2
3
10
3
3
Cystic Duct Stump leak
Rt IHD leak
3
CHD leak
Gall bladder bed leak
CBD leak
No leak identified
Treatment
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All patients (except the two without any
leakage site identified with ERCP) were
treated successfully with endoscopic
sphincterotomy and subsequent stent
placement
Follow-up ERCP at 6 weeks showed no
more bile leak in all patients
Conclusion
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ERCP is a safe and valuable method to
detect bile leak and provide treatment
Summary
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Bile duct injury is a very serious
complication of laparoscopic
cholecystectomy
High index of suspicion when patients
do not recover uneventfully after
laparoscopic cholecystectomy
If biliary injuries occur, seek specialist
help