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BILE DUCT INJURY ASSOCIATED WITH LAPAROSCOPIC CHOLECYSTETOMY: A NOVEL MANAGEMENT APPROACH AND A NEW CLINICALLY RELEVANT CLASSIFICATION IN OUR AREA OF PRACTICE
Pankaj N. Desai*, Keyur Bhatt, Dhaval Mangukiya
Endoscopy, Surat Institute Of Digstive Sciences, Surat, Gujarat, India
METHODS:
Number of pts referred to us from October 2010 to May 2017 with bile duct injury ( BDI ) 178
Mean age - 51 years ( 30-74).
Easy cholecystectomy 45%
Difficult' 55 %
Intraop Recognition: 19 (10.7%)
Average referreal time - 7th post op day
New Proposed Classifiaction:
TYPE I: Cystic duct stump blow out.
TYPE II: Partial clip on CBD with or without cystic duct stump blow out or lateral injury.
TYPE III: a. Segment loss of CBD < 2cm.
b. CBD / CHD > 2 cm extending upto hilum.
c. Hilar injury with separate sectoral ducts.
d. Any of above with ligation of right hepatic artery.
TYPE IV: Isolated sectoral duct injury.
Management
All Type I - ERC, papillotomy & 7Fr stenting - 102 ( 57.3% )
25 (24.5%)- Had CBD stones
Type II - 12 of 34 (35.2%)- ERC and stenting
Drains present - 91 (89.2%)
Bilioma drained -11 9 (10.7%)
Rest Type II - 22 ( 64.7% )- Surgery
All Type III and IV - 42 ( 65.6% )-Surgery
Total Surgery - 64 (35.9%)
First 12 pts of 64 ( 18.8%) who underwent surgery - Exploration, complete diversion of bile with T tube feeding jejunostomy ( FJ )
Next 42 ( 65.6%) - New protocol. Internal drainage with 7 Fr plastic stents one in each right and left ducts with no FJ
Drain kept cases
Revision surgery Hepatico Jejunostomy ( HJ ) - 34 (53.1%)
ERC with multiple stents - 30 ( 46.8%)
Avgerage time for revision- 62 days
Mortality: 2 (1.1%)
Patient 1: Referred -11 after re do laparoscopy done on post of day 6, in sepsis, ARDS & MODS. Revision surgery done. Not slavaged
Patient 2 : Referred - post op day 12 with biliary fistula & peritonitis with liver failure. Had Type 3 B injury with portal vein clipping & complete thrombosis with ischemic liver. Died of liver failure with sepsis
CONCLUSION:
Bile duct injury following laparoscopic cholecystectomy is a complex management problem and results in significant postoperative morbidity.
Bile duct injury recognized intraoperatively always does better irrespective of severity of injury.
More complex injuries are better drained first and then later date reconstruction is advisable.
We propose use of endobiliary plastic stents for internal drainage and repair of bile duct over stent without use of conventional T tube and if required later date hepatico jejunostomy can be done.
ERC is used in type I and II injury and also the use of multiple stents after a salvage surgery are highly effective to prevent revision surgery ( 46.8%) cases.
In presence of biliary sepsis and peritonitis, surgical lavage and endobiliary stenting is advisable before subjecting patients to ERC.
Our results show less morbidity with our new surgical and endoscopic management protocol for bile duct injury. We are getting excellent results. So may be we need more controlled trials to value its worth.
Patients according to New Classification
| Type of Injury | Number of Patients | | Type I | 102 (57.3%) | | Type II | 34 ( 19.1%) | | Type III A | 19 (10.7%) | | Type III B | 15 ( 8.4%)
| | Type III C | 4 (2.2%) | | Type III D | 2 (1.1%) | | Type IV | 2 (1.1%) |
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