INJURIES OF BILIARY DUCTS

INJURY OF BILIARY DUCT

Causes of biliary duct injuries

Most common causes of biliary tract or ducts injury are iatrogenic causes during abdominal operation of the gall bladder or common bile duct like open removal of the gall bladder( cholecystectomy) or laparoscopic removal of the gall bladder

ANATOMY OF BILIARY DUCTS

Other operation which found to have a role in injury of the bile duct are during mobilization of the duodenum during removal part or all of the stomach by operations called partial or total gastroectomy

Also during removal part of the liver by operation called liver resection this may occurs by dissection of the hepatic hilum of the liver

Other causes are penetrating trauma to the extrahepatic bile ducts but this is rare and may associated with other visceral injuries

Predisposing factors

These are many factors which may increase the ability to injury of the ducts especially during laparoscopic removal of the gall bladder

cholecytstecomy) such these factors are included the following

More obese patients

Acute or chronic inflammation of the gall bladder with severe adhesion which disturbed its anatomy and make its removal so difficult

Also bleeding during operation may mask the field of surgery

Anatomical variations or congenital abnormalities which may be present

Factors related to surgical technique

As inadequate exposure of the wound and failure to identify the structure before ligation or dividing like ligation and division of the common bile duct instead of the cystic duct which consider the most common causes of biliary tract injuries

The cystic duct may runs along side the common bile duct before joining it leading to the surgeon the wrong site

The cystic duct may enter the right hepatic duct which may passing through the( calot,s triangle) and then enter the common hepatic duct

Excessive traction on the gall bladder during retrograde removal of the gall bladder may align the cystic duct with the common bile duct which may be ligated and divided as a mistaken for the cystic duct

Misuse of the diathermy or electrocautery may lead to thermal injury

Dissection deep into the liver tissue may causes injury of the intrahepatic bile duct

Also loose ligation of the cystic duct during cholecystecomy the ligature may slipped

Symptoms and signs

Biliary leakage which may appear during the operation and the surgeon notice yellow colour fluid (bile) comes from the site of the injury biliary leakage are common from slipped cystic duct stump ,division of the hepatic duct or lateral injury to the common bile duct
Biliary leakage which may appear postoperative as bile come into the catheter drainage which inserted inside the abdomen of the patient at the site of operation to drain any residual collections after the operation this collection may become yellowish fluid this mean there is bile leak from the operation
Others patients may come so later months or years by picture of cholangitis in the form of fever jaundice right upper quadrant abdominal pain
May lead to liver cirrhosis due to biliary retention
These injuries may causes biliary stenosis or strictures and give a pictures of obstructive jaundice
biliary leakage into the peritoneal cavity causes peritonitis which it is fatal because bile very irritant and signs and symptoms of generalized peritonitis may present in the form of high grade fever abdominal distension constipation vomiting anaroxia abdominal tenderness and rigidity and etc

Investigations

Laboratory

Liver function test

Showing elevation of alkaline phosphatase enzyme and gamma aminotransferase also serum biliurbin raised due to obstruction and biliary stasis

Complete blood count

To show there is anemia or other abnormalities

for surgical fitness

urine analysis

may showing biliurbin in the urine normally there is no bilirubin in the urine

Radiological

Abdominal ultrasound and CT scanning

Both may showing any bile collection (bilioma ) at the site of operation (gall bladder area) or free fluid( bile) in the peritoneal cavity

also showing the dilated part of the biliary tree proximal to the site of stenosis or obstruction

also identify the level of extrahepatic bile duct obstruction

MRI scanning and MRI cholangiography

provides an excellent non invasive delineation of the biliary anatomy both proximal and distal to the injury

HIDA scanning

showing the site of biliary leakage and active leak of the bile its non invasive technique for more see here

Sinogram

In patient with surgical drain or percutneously placed catheter injection of the water soluble contrast media through the drainage tract this can often define the site of the leakage and the anatomy of the biliary tree

Percutaneous cholangiography

will demonstrated the anatomy and the proximal extend of the injury and allow decompression of the biliary tree with catheter or stent placement these in case of patient with jaundice and intraheaptic biliary dilatation

Endoscopic retrograde cholangiopancreatography ERCP

Which demonstrated the anatomy distal to the injury and allow for the placement of the stents across a stricture to relieve obstruction for more details see here

Treatment of biliary injury

the treatment of the biliary injuries depend on the type extend and the level of the injury and the time of its diagnosis

injury to the common bile duct or common hepatic duct

Lateral injury

If recognized at the time of the operation it is best treated with

T-tube placement if the injury is a small incision in the duct the T tube can be placed through this small incision as if it were a formal (choledochomy) opening done in the bile duct

If the injury more extensive the T tube should be placed through a separate choledochotomy and the injury closed over the T tube end to decrease the risk of subsequent stricture formation

Major bile duct injury such as transection of the common bile duct or common hepatic duct

Best treatment at the time of the injury

Treatment by biliary enteric anastomosis between the biliary duct and the intestine common jejunum

Either end to side Roux -en -Y choledochojejunostomy or more commonly a Roux-en-Y hepaticojejunostomy

Transhepatic biliary catheter are placed through the anastomosis to stent it and to provide access to the biliary tract for drainage and imaging

Injury distal to common bile duct

Treatment by choledochodoudenostomy

If there is no or minimal loss of duct length a duct to duct repair may be done over T- tube that is placed in a separate incision

Cystic duct leakage

Treated by percutaneous drainage of intra-abdominal bile collection followed by ERCP for stenting the biliary tract

Postoperative biliary duct injuries

Treated by transhepatic biliary catheter placement for biliary decompression and percutaneous drainage of the intra-abdominal bile collection after 6-8 week where the acute inflammation has resolved operative repair is performed

Treatment of biliary duct strictures

Either due to an injury or as a sequels of previous repair

Treated by transhepatic biliary drainage catheter placement for decompression and for defining the anatomy and location and the extend of the damage then an anastomosis is perforemed between the duct proximal to the injury and a Roux loop of jejunum

Ballon dilatation of a stricture usually required multiple attempts

Self expanding metal or plastic stents placed either percutaneously or by ERCP for temporary drainage may used as permanent drainage of the biliary tree in high risk patient

It should be remember that more distal stricture better than proximal one and give high success rate

Complications

Cholangitis external biliary fistula ,bile leakage ,subphrenic abscess and hemobilia these are common complications of bile duct repair

and recurrent stricture

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