Primary biliary tract malignancies affect one in every 100,000 people per year in the united states. The main condition favoring injury is an unclear anatomy of the biliary tract due to local peritonitis, inflammation, or bleeding during the operation. Classification based on the principles of surgical treatment. Bile duct injuries explained liver and pancreas surgeon. Bile duct injury is a severe and potentially lifethreatening complication of laparoscopic cholecystectomy. There are several causes of benign bile duct strictures, the most common being iatrogenic injury after cholecystectomy. Finally, repair of the biliary injury depends on the type and mechanism of injury. A stent is a small plastic or metal tube that is used to keep your bile duct open. More than 95% of these malignancies are cholangiocarcinomas epithelial adenocarcinomas frequently found in the extrahepatic biliary tree. The article describes the manifestations, diagnosis, classification, and management of iatrogenic bile duct injuries, with emphasis on the role of the interventional radiologist.
Management of bile duct problems treatment overview bile duct obstruction bile duct or biliary obstruction occurs for numerous reasons. Bile duct injuries are the most common serious complication of cholecystectomy. Biliary injuries themselves are also among the most difficult. Management of bile duct injurybenign biliary stricture should be done at a biliary. Four hundred seventytwo consecutive patients with postcholecystectomy biliary. A scientific sounding excuse for mistakes happen is not an effective. Using mr cholangiopancreatography to evaluate iatrogenic bile.
The failure to identify the anatomical landmarks within the calots triangle is the most frequent reason of the bile duct injury. As an authoritative text on the clinical care of patients with benign biliary stenosis, management of benign biliary stenosis and injury. Racgp biliary pain workup and management in general. Elimination of bile duct injury in cholecystectomy.
The amsterdam classification proposed by bergman et al in 1996 9 is also very commonly used in many articles, especially among endoscopists. The first aspect is proper identification of when an injury has occurred. This classification is very helpful in prognosis after repair. Laparoscopic management of bile duct injury strasberg type d. A comprehensive guide is a valuable resource for all practitioners involved in the care of these patients, including gastroenterologists, gastrointestinal surgeons, surgical oncologists, and transplant. To evaluate biliary injuries management in major referral hepatobiliary center. Better outcomes of such injuries have been shown in cases managed in a specialized center. References thomson bn, nardino b, gumm k, robertson aj, knowles bp, collier na, judson r. The frequency of biliary injury, from least often to most often, is laparoscopic cholecystectomy lc, liver resection, and liver transplantation lt. A second variant is a simple tenting injury of the cbd. The terms cholangiocarcinoma and bile duct cancer are often used interchangeably. A bile duct obstruction, also known as biliary obstruction, is when one of the ducts that carry bile from the liver to the intestine via the gallbladder becomes blocked. A paucity of research studies on primary sclerosing cholangitis was noted in this. Mediated bile duct injury in murine biliary atresia.
It can be used to relieve a blockage in the bile duct, either permanently or as a temporary solution before definite treatment such as surgery. Management of major bile duct injury after laparoscopic. Endoscopic management of complications from laparoscopic. The mirizzi syndrome major cause for biliary duct injury during laparoscopic cholecystectomy ludmil marinov md. The approach to the patient depends upon the nature and extent of the injury, the presence or absence of biloma, and the timing of discovery.
Even interested and tertiary care centers have a learning curve. Traumatic liver and bile duct injuries radiology case. An update on iatrogenic biliary injuries surgical clinics. Most commonly occurring during laparoscopic cholecystectomy, and to the common bile duct on the biliary tree, bile ducts can get cut, burned, or pinched leading to painful and sometimes fatal symptoms if not treated. During the procedure, a stent is placed into your blocked bile duct.
Biliary trauma is rare and includes injury to the bile ducts or gallbladder. In the postoperative period, relaparoscopy can identify the biliary injury, drainage of any intraabdominal collection, and exclusion of injury to other surrounding organs. Iatrogenic bile duct injuries journal of the american college of. The management of bile duct injuries bdis is a critical knowledge base for surgeons performing laparoscopic cholecystectomy. Biliary injury bile duct injury is the traumatic damage of the bile ducts. Accidental traumas are responsible only for 15% of the total number of biliary injuries. Management of common bile duct injury springerlink. The risk of biliary injury is more during laparoscopic cholecystectomy than during open. Common bile duct injuries represent a serious and challenging surgical complication.
It is most commonly an iatrogenic complication of cholecystectomy surgical removal of the gallbladder, but can also be caused by other operations or by major trauma. Using mr cholangiopancreatography to evaluate iatrogenic. This classification includes four types of ductal injury. These complex injuries are most often a consequence of. Bile duct injury bdi represents an important clinical problem in terms of morbidity and mortality following biliary surgery. As a result of the injury, the bile duct no longer. The bismuth classification is a simple classification based on the location of the injury in the biliary tract. Pdf classification and management of bile duct injuries. Biliary disease refers to diseases affecting the bile ducts, gallbladder and other structures involved in the production and transportation of bile. Abstract bile duct injury bdi during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication.
Obstruction can occur at different levels of the bile duct tree figure 1a. Bile is a fluid produced by the liver that aids digestion. Endoscopic biliary stenting aftercare instructions. Longterm outcome after early repair of iatrogenic bile duct injury. Congenital anomalies and normal variants involving the biliary tract include aberrant or accessory biliary ducts, aberrant cystic duct insertion. Specifically with respect to the definition of a minor bile duct injury, a minor bile duct injury was an injury that was able to be repaired primarily, such as a small ductotomy or laceration, and a major bile duct injury was one that required a biliaryenteric bypass. Avoidance of bile duct injury is a key aim of biliary surgery.
Iatrogenic bile duct injuries ibdi after laparoscopic cholecystectomy lc, being one of the most. Clinicians should have a high index of suspicion in patients who sustain significant right upper quadrant blunt or penetrating injury. Bile duct injuries represent a complex clinical scenario seen with increased frequency owing to aberrant anatomy and more lap cholecystectomies being performed incidence. The first classification of bile duct injury is authored by h. Diagnosis is often delayed, which may increase associated morbidity and mortality. Initially, rates of injury were significantly more common in laparoscopic cholecystectomies. Up to now, a number of classifications have been proposed by different authors. The rate of these injuries has been reported to be as high as 1 in 200 cases of laparoscopic cholecystectomy. Gallbladder disease is common in the general adult population 1,2, making cholecystectomy one of the most commonly performed procedures in the united states and worldwide 3. A successful outcome was achieved in a high proportion of patients 42 of 47 when repair of the bile duct injury was undertaken in a unit experienced in the management of biliary injury. In selected patients, early repair within the first 2 weeks resulted in a similar outcome to that of delayed repair. Predisposing factors are surgical inexperience, acute pathology and unrecognised abnormal anatomy. The purpose of this paper is to describe laparoscopic cholecystectomy from the viewpoint of three conceptual goals. Before the advent of lc, the most frequent lesion to biliary tract was represented by bile duct stricture, and biliary injuries were classified using the.
A bile duct injury is damage to the bile ducts that happens during gallbladder surgery. From initial classification published by bismuth, there have been many classifications of common bile duct injury. Classification and management of bile duct injuries ncbi. Using mr cholangiopancreatography to evaluate iatrogenic bile duct injury. The mirizzi syndrome major cause for biliary duct injury during laparoscopic. Causes can include cancerous and noncancerous processes as well as injuries from medical procedures or operations. Presence or absence of biliary dilatation, excision injury, stricture, fluid collection, and free fluid was noted. If you have a bile duct obstruction, it can be caused by enlarged lymph nodes. Duplicated common bile duct, often associated with conditions like lithiasis, biliary cysts and pancreatobiliary maljunction, could result in highly. Early specialist repair of biliary injury thomson 2006. Diagnosis and treatment of biliary fistulas in the. Recent classifications of the common bile duct injury kwangsik chun department of surgery, chungnam national university hospital, daejeon, korea laparoscopic cholecystectomy is now a gold standard treatment modality for gallstone diseases. Successful management of bile duct injury requires a multidisciplinary team approach incorporating experienced biliary endoscopists, interventional radiologists, and hepatobiliary surgeons. In such instances, we recommend that the bile duct be freed from the tumor by careful dissection of hilum and clear identification of.
A bile duct injury is damage to the bile duct during gallbladder surgery. Iatrogenic bile duct injuries are not the inevitable result of haptic misperception. Early after its introduction in the late 1980s, laparoscopic cholecystectomy became the standard of care due to its advantages of reduced pain and hospital length of stay, reduced general complications wound and. Department of surgery, 37 military hospital, accra. There are several methods of confirming the presence of an injury. Depending on the type of injury, appropriate management methods may include endoscopic, percutaneous, and surgical interventions.
Iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. Bile duct injury is an injury to a major bile duct draining the liver. Endoscopic biliary stenting is a procedure done to open your blocked bile duct tube. However, the incidence rate of bile duct injury has not been changed for many years. Bile duct injuries most commonly occur after primary operations on the gallbladder or biliary tree. Biliary drainage is performed with a tube or catheter called a biliary drain, biliary stent or biliary catheter by a surgeon or, commonly, an interventional radiologist. Decreased bile duct injury rate during laparoscopic. The mirizzi syndrome major cause for biliary duct injury. Typical changes include lymphocytic cholangitis associated with alterations to the bile duct epithelial cells, eventually leading to ductopenia. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. Bile duct injury during laparoscopic cholecystectomy classification of iatrogenic bile duct injury repair of common bile duct injury over a t tube kocher maneuver transhepatic biliary drain placement biliary reconstruction with rouxeny hepaticojejunostomy related topics. Recent classifications of the common bile duct injury. Bile drains from the liver through bile ducts to the first part of the small intestine, or duodenum, and eventually back to the bile ducts and liver.
A biliary drain inserted during ptc is also seen arrowheads. Biliary injury during hepatic resection is uncommon in experienced hands, but it can occur, particularly when resection is done for lesions near the hilus. The incidence of bile duct injuries bdi has approximately doubled 0. Diagnosis and treatment of iatrogenic bile duct injuries. The vast majority of bile duct injuries is iatrogenic and occurs during abdominal surgeries or other interventions such as endoscopic or percutaneous cannulation of the biliary tree. As a result of an injury, the bile duct will not be able to work right, leaking bile into the abdomen or blocking the normal flow of bile from the. Summary understanding the intricacies of the inflammatory mechanisms culminating in bile duct epithelial injury are crucial to the future development of therapies aimed at halting the ongoing biliary tract destruction found in immunemediated cholangiopathies.
Management of bile duct problems treatment overview. In a 20year period, 510 complex circumferential injuries have been. Presence or absence of biliary dilata tion, excision injury, stricture, fluid collection, and. Bile duct injury, hepatojejunoanastomosis, biliary repair. Biliary duct definition of biliary duct by medical. The annual incidence of bile duct injuries increased from approximately 0. Before the advent of lc, the most frequent lesion to biliary tract was represented by bile duct stricture, and biliary injuries.
Classification and management of bile duct injuries. Ercp was attempted before ptc but did not allow visualization of the biliary tree proximal to the injury site. Bile duct injury during laparoscopic cholecystectomy citeseerx. The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of major bile duct injuries after laparoscopic. Additional papers were identified by a manual search of the references from the key articles.
A biliary obstruction blocks the bile ducts, which carry bile to the small intestine for digestion and waste removal. These were major injuries involving the com mon bile duct cbd, main biliary confluence, or main bile ducts in 178 patients 75. Biliary reconstruction options for bile duct stricture in. Pathological patterns of biliary disease lewis 2017. Delphi consensus on bile duct injuries during laparoscopic. Bile duct injuries are an infrequent but potentially devastating complication of biliary tract surgery, with cholecystectomy accounting for the largest proportion of such injuries. The diagnosis of noniatrogenic traumatic bile duct injuries is challenging as current crosssectional imaging tests are.
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