Current Management of Bile Duct Injuries

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abdaal on Feb 18, 2012 Says :

pretty good. should have included classified the injuries according to Strasberg.

manash on Aug 08, 2010 Says :

excellent

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ALSUMERY, favourited this 2 Years ago.

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The Current Management of BileDuct InjuriesThe European Surgical AssociationApril 2008 Keith D. Lillemoe, MD Professor / Chairman Department of Surgery

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Laparoscopic Bile Duct Injuries Laparoscopic Cholecystectomy 700,000 cholecystectomies performed each year 90% performed laparoscopically

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Laparoscopic Bile Duct Injuries Bile Duct Injuries - Incidence Open Cholecystectomy Scandanavian data 1975-81 0.1% *Roslyn, et al 42,474 cholecystectomies U.S. data* 1989 0.2%

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Laparoscopic Bile Duct Injuries Bile Duct Injuries - Incidence Laparoscopic Cholecystectomy Surveys Deziel (1993) - 0.6% Wherry (1994) - 0.5% Wherry (1996) - 0.4% Nuzzo (2005) - 0.4% Waage (2006) - 0.4% (0.40 / 0.32 / 0.47 )

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Bile Duct Injuries Suspicion Atypical anatomy “Accessory” duct Unsuspected bile leakage Abnormal cholangiogram

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Don’t panic Bile Duct Injuries Preoperative Management Laparoscopic Bile Duct Injuries Control sepsis Drainage of abscess/collections Control biliary leak

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Surgical Management of Bile Duct Injuries Sustained During Laparoscopic Cholecystectomy: Perioperative Results in 200 Patients Jason K. Sicklick, MD, Melissa S. Camp, MD, Keith D. Lillemoe, MD†, Genevieve B. Melton, MD, Charles J. Yeo, MD, Kurtis A. Campbell, MD, Mark A. Talamini, MD, Henry A. Pitt, MD†, JoAnn Coleman, CRNP, Patricia A. Sauter, CRNP, and John L. Cameron, MD Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD †Department of Surgery, Indiana University, Indianapolis, IN

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Prospective database: All patients with a major BDI sustained during LC that were treated at Johns Hopkins Hospital between January 1, 1990 and April 13, 2003 was maintained BDI included all transections or lacerations of the CHD, CBD, and major segmental HDs at the porta hepatis Cystic duct or gallbladder bed leaks excluded Data analyzed with Intercooled Stata Methods

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200 Pts Treated Over > 13 Years

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Age Distribution

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25 Patients Did Not Undergo Operation * Misra et al., J Am Coll Surg, 2004.

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175 Operative Repairs

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Postoperative Outcomes

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Role of Postoperative Interventional Radiology 50% 50%

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Postoperative LOS

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Timing of Operation Early (< 1 month after referral) Intermediate (1 - 12 months after referral) Delayed (> 12 months after referral) Presenting Symptoms Jaundice Bile leak/biloma Cholangitis Pain None History of Prior Repair Do Not Influence the Most Common Post-op Complication Rates or LOS

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Year Results of Surgical Management of Bile Duct Strictures Laparoscopic Bile Duct Injuries Institution # of Patients Success Follow-up 1982 1984 1986 1988 1989 1993 UCLA UCSF Cleveland Clinic Ohio State St. George’s 1988 Johns Hopkins Mannheim Clinic 66 60 105 22 163 25 64 86% 78% 82% 95% 72% 88% 75% 60 mos 102 mos 60 mos 72 mos 133 mos 57 mos 99 mos

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88 patients with major bile duct injuries Factors Influencing Outcome Laparoscopic Bile Duct Injuries (Stewart/Way, 1995) Primary repair: 96% unsuccessful with no pre-op cholangiography 69% unsuccessful with incomplete cholangiographic data 84% successful with complete cholangiographic data

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Factors Influencing Outcome Laparoscopic Bile Duct Injuries (Stewart/Way, 1995) 88 patients with major bile duct injuries Primary end-to-end repair over t-tube unsuccessful in 100% of cases Roux-en-Y hepaticojejunostomy successful in 63% of cases Primary repair by primary surgeon - successful in 17% of cases Secondary repair by primary surgeon - 0% successful Primary repair by tertiary care biliary surgeon - successful in 94% of cases

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POSTOPERATIVE BILE DUCT STRICTURES: MANAGEMENT AND OUTCOME IN THE 1990S Keith D. Lillemoe, Genevieve B. Melton, John L. Cameron, Henry A. Pitt, Kurtis A. Campbell, Mark A. Talamini, Patricia A. Sauter, JoAnn Coleman, Charles J. Yeo The Johns Hopkins Medical Institutions

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120 women (77%) Age range 15 - 83 years (mean 43 years) 145 patients (93%) underwent original operation at on outside hospital 11 patients (7%) underwent original operation at JHH 156 Patients POSTOPERATIVE BILE DUCT STRICTURES

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145 Patients Referred from Outside Hospitals POSTOPERATIVE BILE DUCT STRICTURES Original Operation Prior Repair (60 patients - 41%) Laparoscopic Cholecystectomy 109 patients (75%) Open Cholecystectomy 27 patients (19%) Other 9 patients (6%) End-to-end ductal 21 patients (35%) Hepaticojejunostomy 33 patients (55%) Other 6 patients (10%)

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Two deaths prior to completing treatment (one postoperative death - 0.6%) Twelve patients (8%) have not completed treatment and remain stented 142 patients have completed treatment with follow-up Range 11-119 months Mean 57.5 months Median 54.7 months Outcomes - 156 patients POSTOPERATIVE BILE DUCT STRICTURES

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Outcomes POSTOPERATIVE BILE DUCT STRICTURES

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Treatment failures - 13 patients (9.2%) One reoperation - success 12 percutaneous balloon dilatations 9/12 successful 3 patients remain stented Overall treatment outcome Success in 139/142 patients (98%) Outcomes POSTOPERATIVE BILE DUCT STRICTURES

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MAJOR BILE DUCT INJURIES ASSOCIATED WITH LAPAROSCOPIC CHOLECYSTECTOMY: EFFECT OF SURGICAL REPAIR ON QUALITY OF LIFE Genevieve B. Melton, MD, Keith D. Lillemoe, MD, John L. Cameron, MD, Patricia K. Sauter, CRNP, JoAnn Coleman, CRNP, Charles J. Yeo, MD The Johns Hopkins Department of Surgery

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Methods QUALITY OF LIFE AFTER SURGICAL REPAIR OF LAP CHOLE INJURY Validated QOL questionnaire sent to patients following successful surgical repair of major bile duct injuries after laparoscopic cholecystectomy and completion of treatment at JHH between 1990 and 2000 (n = 89). 30 items on a visual-analog scale were categorized into three domains: -- physical (15 items) -- psychological (10 items) -- social (5 items) Scores reported as a continuous percentile, with 100% being the highest possible score.

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Demographics and Follow-up Time of Study Populations BDI= Bile duct injury, LC= Laparoscopic cholecystectomy, HC=Healthy control QUALITY OF LIFE AFTER SURGICAL REPAIR OF LAP CHOLE INJURY

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Overall Quality of Life Assessment * p < 0.05 versus LC or HC patients QUALITY OF LIFE AFTER SURGICAL REPAIR OF LAP CHOLE INJURY

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Impact of Different Parameters on Quality of Life in Bile Duct Injury Patients QUALITY OF LIFE AFTER SURGICAL REPAIR OF LAP CHOLE INJURY

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Correlation of Lawsuit with Quality of Life Assessment BDI=Bile Duct Injury, LC=Lap Chole, HC=Healthy Control, LS=Lawsuit * p<0.05 compared to BDI † p<0.01 compared to No LS, LC, or HC QUALITY OF LIFE AFTER SURGICAL REPAIR OF LAP CHOLE INJURY

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Factors Associated with Lawsuit QUALITY OF LIFE AFTER SURGICAL REPAIR OF LAP CHOLE INJURY

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Laparoscopic Bile Duct InjuriesSummary Life threatening complications can occur as a result of delayed referral. Postoperative mortality is rare following surgical reconstruction. Perioperative complications are frequent but most can be managed nonoperatively. Surgical reconstruction can result in over a 90% success rate at follow-up of 5 years. Level of injury, clinical presentation, prior repair, and length of stenting do not influence outcome following surgical reconstruction.

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Patients with successful reconstruction after bile duct injury have quality of life scores comparable in the social and physical domains but worse in the psychological domain to those of control patients. The pursuit of a lawsuit appears to result in a poorer quaility of life assessment. Laparoscopic Bile Duct Injuries Summary II

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