The First Congress of the Palestinian Society of Gastroenterology 20-21 May 2010 Ramallah Walid Sweidan MB, BCh, MRCPI, FRCP

1. Iatrogenic biliary tract injuries
The First Congress of the Palestinian
Society of Gastroenterology
20-21 May 2010
Ramallah
Walid Sweidan MB, BCh, MRCPI, FRCP

2. Historical perspective
• The first planned cholecystectomy in the world was
performed by Carl Langenbuch in 1882.
• The first choledochotomy was performed by
Couvoissier in 1890
• The first iatrogenic bile duct injury was described by
Sprengel in 1891.
• Prof Dr Med Erich Mühe of Böblingen, Germany,
performed the first laparoscopic cholecystectomy in
1985.

3. Introduction
 Open cholecystectomy was the standard practice for
treatment
of Symptomatic gall bladder disease until late 1980’s .
At present 90% of cholecystectomies are performed by Lap
cholecystectomy which is one of the commonest surgical
procedures in the world.
 Unfortunately , the widespread application of LC has led to a
concurrent rise in the incidence of major bile duct injuries (BDI)
which are more complicated than after the open procedures.

4. Laparoscopic cholecystectomy
Pros and cons
General advantages
Shorter stay in hospital
Reduced post-op recovery time
Less postoperative pain
Improved cosmetic outcome
Disadvantage
The reported increase in serious bile duct
complications and injuries
LeBlanc, Karl et al. Management of Laparoscopic Surgical Complications, 1st ed., Marcel Dekker, 2004.

5. Biliary Injuries during Cholecystectomy
Open cholecystectomy has been associated
historically with 0.2% to 0.5% risk of postoperative
Biliary tract injuries.
On the other hand LC has been associated with
2.5-fold to 4-fold increase in the incidence of
Postoperative bile duct injuries compared with OC
Peters HJ et al : Ann surg 1991
Bailey Rw et al : Ann Sur 1991
Deziel DJ et al : Am J Surg 1913
MacFadyen BV Jr et al : Surg Endosc 1998

6. Incidence of IBDI injury following cholecystectomy (%)

7. Bile duct injuries during cholecystectomy
• In the 1990s , high rate of biliary injury was due
in part to learning curve effect.
• A surgeon had a 1.7% chance of a bile duct
injury occurring in the first case and a 0.17%
chance of a bile duct injury at the 50th case.
• However most surgeons passed through
learning curve, “steady-state” reached , but
there has been no significant improvement in
the incidence of biliary duct injuries
Moore M.J.; Bennett C.L , The American journal of surgery 1995
Mubasher H Khan et al Gastrointest Endosc 2007

8. Risk Factors for Biliary tract injury
Surgeon related factors
 Lack of experience (learning curve)
 Misidentification of biliary anatomy
 Intraoperative bleeding
 Lack of recognition of anatomical biliary
tree variations
 Improper interpretation of IOC

9. Risk Factors for biliary tract injury
Patient related
 Acute and chronic cholecystitis
 Empyema
 Long standing recurrent disease -> fibrosis
 Porcelain gallbladder
 Obesity
 Previous surgery

10. The Effect of Acute Cholecystitis on Lap
cholecystectomy complications
 Complication rate when lap cholecystectomy is
performed for acute cholecystitis three times
greater than for elective lap cholecystectomy .
 Early cholecystectomy (72 h) outcome better than
delayed cholecystectomy .
 Conversion rate to open cholecystectomy is higher
than elective cholecystectomy 35% vs 9%
Cho JY et al, Arch Surg. 2010 Apr;145(4):329-33;
P. Pessaux et al , Surgical Endoscopy 2000 , 14 : 358

11. Risk Factors for biliary tract injuries
Anatomic Variations
 Present in 18 - 39% of cases
 Dangerous variations predisposing to BTI
are present in only 3-6% of cases
 Abnormal biliary anatomy
 Short cystic duct, cystic duct entering in the right hepatic
duct - Accessory right hepatic duct
 Arterial anomalies
 Right hepatic artery running parallel to the cystic duct
Anomalous or accessory right hepatic artery

12. Aberrant Biliary Ducts
(Right) Aberrant right hepatic duct (arrow) emptying into common hepatic duct.
(Left) Aberrant right hepatic duct (arrow) draining into cystic duct

13. Cystic Duct Variations
Common variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cm with
common hepatic duct (15-25%); E , G, H. Medial cystic duct insertion (10-17%).
Uncommon variants: C. High fusion with hepatic duct; D. Fusion at right hepatic duct;
F. No cystic duct.
Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.
Mortele, Koenradd et al., Am J of Roent, August 2001.

14. Mechanism of CBD Injury
Classic Mechanism: CBD is mistaken for
cystic duct

15. Classification of Biliary tract injuries
Strassberg Classification

16. Biliary tract injuries
Strassberg Classification

17. Clinical Presentations of Bile Duct
Injuries
 Bile leak
 Obstruction
 A combination of leak and obstruction

18. Presentation of Bile Duct Injuries
 About 25 % of injuries recognized intraoperatively
 About 25 % of injuries discovered within 24 hours
post- operative
 About 50 % of injuries present weeks to years
post-operative
Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

19. Management of bile duct leak
Fundamental principles of management
Decompression of the biliary tree
Drainage of any associated bile collections
(bilomas)

20. Management Options
Immediate recognition
• Intraoperative cholangiography
• Convert to open cholecystectomy
Repair Options
1. Primary suture over a t-tube
Tissues should be well vascularized and tension free
2. Roux-y hepatico-jejunostomy
or
Drainage, closure , and referral to tertiary care
centre

21. Management options
Delayed recognition of biliary leak
 Advise to surgeons ( keep your nerves )
 Percutaneous drainage of bile collection
 No exploration before classification of the injury
 Understand the anatomy and origin of leak ( MRCP/
Cholangiography)
 Drain the duct preferably by ERCP / or PTC ?

22. ERCP and biliary tract injuries
 Allows precise anatomic diagnosis
 Allows therapy that obviates reoperation in most
cases
 Identification & treatment of associated pathology

23. Management options
Endoscopic management of bile leak
The objective is to negate the transpapillary pressure
gradient that favours the flow of bile into the duodenum
and not through the leak site >>> reduce extravasation
and decompresses the biliary system .
This is done by removing any physiological or pathological
obstruction (the normal sphincter of Oddi pressure or
a retained CBD stone).

24. Endoscopic options for drainage
 Nasobiliary drainage
 Sphincterotomy
 Stenting
All means are safe and effective in BD leak
The choice of the best method remained controversial
Until recently .
Costamagna G et al Gastrointest Endosc clin N Am
2003
Binmoeller KF et al Am J Gastroenterol 1991

25. Endoscopic options for drainage
 Stenting alone is as effective as stenting with ES in
treatment of uncomplicated minor post LC bile leak
 Resolution of bile leak faster with use of a 7-Fr
biliary stent than ES ( canine model )
 Biliary leak resolution failure more in ES than
stenting ( retrospective analysis )
Mavrogiannis et al Eur J Gastroenterol Hepatol 2006
Marks et al Surg Endosc 1998
Kaffes et al Gastrointest Endosc 2005

26. Endoscopic options for drainage
Naso biliary drainage
Advantage :Shorter duration (days) – repeated
cholangio – no repeat ERCP procedure
Disadvantage : discomfort – self extraction
Sphincterotomy
Advantage : removal of stones – no repeat procedure
Disadvantage : complications – less effective than
stents
Biliary stent
Advantage : better than ES – no ES required
Disadvantage : long duration – repeat procedure

27. Novel methods
• “Histoacryl” cyanoacrylate glue used for
endoscopic occlusion of leaks (approved in Europe?
• Botulinum toxin injection to sphincter of Oddi
successful in canine models.
• Biodegradable stent in the endoscopic treatment
of cystic-duct leakage after cholecystectomy.

28. Surgery in Bile duct injuries
 Surgery performed in early post operative phase is
associated with 80 % complication rate
 Surgery delayed 8-12 weeks has only 17%
complication rate
 Surgery performed in tertiary referral centers is
associated with higher success rate , less post-
operative complications and shorter hospital Stay

29. Biliary Leak (not to CBD injury)
 Common complication
 Disruption of small biliary radicals - retained
stone - Clip loosening - Duct of Luschka.
 Most resolve – nonspecific abdominal pain
 Collection should be drained
 Sphincterotomy and stenting

30. Summary
Endoscopic internal stenting is currently the
procedure of choice for treating bile duct
leaks (usually types A, C and D).
7Fr and 10 Fr stents can be inserted without
sphincterotomy.
A prompt therapeutic response with cessation
of bile extravasation in 70-95% of cases within
a period of 1-7 days.

31. Retrospective analysis performed on all patients
referred for management of bile duct injuries
sustained during laparoscopic cholecystectomy,
open cholecystectomy or liver surgery over 12
years
period ( 1996 - 2008 )
Number of patients 72
Number of ERCPs 1724
Percentage 4.2 %

32. Total number of injuries , number of injuries per 100 ERCPs
year No of ERCPs Number of BDI Percentage %
1996 34 1 2.9%
1997 75 9 12%
1998 138 4 2.9%
1999 134 4 2.9%
2000 156 7 4.5%
2001 135 8 6%
2002 139 5 3.6%
2003 162 4 2.5%
2004 156 5 3.2%
2005 146 2 1.4%
2006 157 3 2%
2007 165 11 6.6%
2008 110 9 8%
Total 1707 72 4.2%

33. Post operative biliary tract injuries
July 1996 till December 2008
72 patients observed
Women 49 Men 23
Mean age 46 years range 18-71

34. Type of surgery
Lap cholecystectomy 41 57%
Open Cholecystectomy 26 36%
Other (hydatid & bullet) 5 7%

35. Time between surgery and ERCP
Biliary leak patients
Median 14 days range 4-50 days
Biliary stricture patients
Median 6 months range 3 months – 8 years

36. Mode of presentation for biliary leak patients
Abdominal pain 60 %
Ascites or bile collection 50 %
Jaundice /deranged LFTs 27%

37. Post cholecystectomy acute injury
• Type of injury number percentage
• Type A 24 41%
• Type D 15 25%
• Type E 20 34%
• Total 59 100%

38. Type A injury
Duct of Luschka

39. Type A injury
Cystic duct leak

40. Type D injury

41. Type D Injury

42. Type D injury

43. Type E injury

44. Type E injury

45. Biliary stricture following type D injury
and secondary repair over T tube

46. Patients outcome
Referral for surgery 27 patient 37.5%
Endoscopic managements 45 patients 62.5%
Sphincterotomy alone 2 patients
Sphincterotomy and stent 23 patients
Stent alone 20 patients
Total stents 43

47. Conclusions
 A cooperative multidisciplinary approach is required
 Early diagnosis is imperative and imaging should not be
delayed if any doubt exist to avoid sepsis & peritonitis.
 Various studies showed that endoscopic therapy can be
successful in the majority of patients with biliary leak.
 Success of endoscopic therapy depend upon type of
biliary injury
 25% of patients still require percutaneous drainage of
collection after ERCP , 4-6 % may still require open
surgical drainage for loculated collection

48. Conclusions
The best management of biliary
tract injuries is really the
avoidance
of the injury ?

49. Lobe's laws of medicine
If what you're doing is working , keep doing it
If what you're doing is not working , stop doing it
If you don’t know what to do , don't do anything
Above all , never let a surgeon get your patient