DUCTULAR PROLIFERATION AND FIBROSIS AS INDICATORS OF HEPATIC FAILURE IN PATIENTS WITH BILE DUCT INJURY
Patricio R. Sanchez Fernandez*1,2,3
1Gastrointestinal Surgery, Instituto Mexicano del Seguro Social-Universidad Nacional Autónoma de México, Mexico City, Mexico City, Mexico; 2American College of Surgeons, Mexico City, Mexico City, Mexico; 3Academia Mexicana de Cirugia, Mexico City, Mexico City, Mexico
Background: The bile duct injury is a rare but very serious injury associated with cholecystectomy. The incidence of iatrogenic bile duct injury is currently estimated to be 0.4% to 0.6%. The time the bile duct remains obstructed and the presence or absence of cholangitis, play an important role in liver histological changes. The purpose of the study is to identify through liver biopsy the degree of histological injury at the time of biliodigestive reconstruction and its relationship to the development of liver failure.
Methods: prospective cohort study of patients with post-cholecystectomy bile duct injury tested for biochemical liver function and hepatobiliary isotope scanning before and after reconstructive surgery and trans-surgical liver biopsy which was classified according to the index of histological activity: inflammation, cholestasis, ductular proliferation and fibrosis. In order to evaluate the outcome, the McDonald classification, was used 3, 6 and 12 months after reconstructive surgery.
Results: 207 patients were included, all of them classified as Strasberg E. Time of evolution was significant ( p=0.000) predominating ductular proliferation and fibrosis in those with more than 120 days. Also, 62% of them had vascular injury associated while only 2.2% of those with inflammation (p=0.000). In the cholestasis, ductular proliferation and fibrosis groups, the mechanisms of injury that caused obstruction of the bile flow were obstruction with suture, staple or burn at 59.7%, 86.6% and 100% respectively (p=0.000).
By correlating histological damage with hepatic impairment at 3, 6 and 12 months it was observed, in the inflammation group that at 3 months 82.2% had McDonald B and at 12 months 100% had McDonald A. In the cholestasis group, at 3 months 96.1% had McDonald B and at 12 months 86.3% of the total of patients in the group were classified as McDonald A. At 3 months, 73.3 % with ductular proliferation was classified as McDonald C-D and at 12 months 97.6% had B and 2.4% A. In the fibrosis group, 100% had McDonald C-D at 3 months and at 12 months 84.2% reverted to McDonald B.
When analyzing liver function in each histological degree with the Kaplan-Meier method, all patients had liver failure upon admission. After biliodigestive reconstruction, in the inflammation group, the percentage of patients with liver failure decreased to 8% at 3 months and none had it from 6 months on. In the cholestasis group, liver failure was present in 20% of the patients at 3 months and only 2% from 6 months on. In the ductular proliferation group, 60% persisted with liver failure at 3 months, 20% at 6 months and 2% at 12 months. And in the fibrosis group, 88% of the patients had it at 3 months, 50% at 6 months and 18% at 12 months. Discussion: liver biopsy must be done at the time of bilioenteric repair to correlate with liver function in their follow-up.
Back to 2020 Abstracts