biliary strictures
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Transcript of biliary strictures
Biliary stricture
Dr N SURENDRA BABU jr resident dept. of gen surgeryTIRUMALA HOSPITALS
Biliary stricture
definition
A biliary stricture is an abnormal narrowing of the bile duct, the tube that moves bile (A substance that helps in digestion) from the liver to the small intestine
Anatomy of biliary tree
Pathological effects of biliary obstruction
Biliary obstructionHigh local
concentration of bile salts
inflammation
Pathological effects of biliary obstruction
Fibrosis and
scarring
Biliary fistula
Biliary stasis
Liver atrophy
Repeated cholangiti
s
Biliary cirrhosis
and PHTN
Causes of benign stricture
I. Congenital strictures Biliary atresia II. Bile duct injuries A. Postoperative strictures (1) Cholecystectomy or common bile duct exploration (accounting 80% of nonmalignant stricture) (2) Biliary-enteric anastomosis (3) Hepatic resection (4) Portocaval shunt (5) Pancreatic surgery (6) Gastrectomy (7) Liver transplantation B. Stricture after blunt or penetrating trauma
Causes of benign stricture
C. Strictures after endoscopic or percutaneous biliary intubation III. Inflammatory strictures A. Cholelithiasis or choledocholithiasis B. Chronic pancreatitis C. Chronic duodenal ulceration D. Abscess or inflammation of liver or subhepatic space E. Parasitic infection F. Recurrent pyogenic cholangitis (Oriental cholangiohepatitis)IV. Primary sclerosing cholangitis
V. Radiation-induced stricture
Causes of malignant stricture
Primary tumors1. Cholangiocarcinoma2. GB Cancer3. Pancreatic
adenocarcinoma4. Ampullary
carcinoma5. Hepatoma6. Gastric carcinoma
Metastatic tumors
1. pancreatic adenocarcinoma
2. Colon cancer3. Breast cancer4. Lung cancer5. Melanoma6. Ovarian cancer
Bile duct injury at cholecystectomy
Incidence 1.open cholecystectomy
0.1 -0.2% 2.lap cholecystectomy
0.4 -1.3% 80% of benign strictures occurs
following injury during a cholecystectomy.
A major factor is surgeons inexperience-learning curve effect
causes Anatomic variations Technical factors Pathologic factors
Anatomic variations(failure to recognize abnormal anatomy &anomalies)
Technical factors Experience of surgeon Improper assistance Extensive dissection Excess use of cautery Misplacement of clips Excess traction on gall bladder Subvesical duct of luschka in 1-2 % patients CBD Exploration-use of metal bougies Attempts to achieve hemostasis
Pathologic factorsAcute cholecystitis inflammation leads to edema in the
porta hepatis and calots triangle—distortion of anatomy
Chronic cholecystitis chronic inflammation leads to
fibrosis, adherence, contracted fibrotic gall bladder, cholecystocholedochal fistula
(partial cholecystectomy, cholecystostomy, and cholecystocholedochoduodenostomy are options)
Laparoscopic specific- Classification of Causes of Laparoscopic Biliary Injuries 1. Misidentification of the bile ducts as the cystic duct a. Misidentification of the common bile duct as the cystic duct b. Misidentification of an aberrant right sectoral hepatic duct as the cystic duct 2. Technical causes a. Failure to occlude the cystic duct securely b. Plane of dissection away from gallbladder wall into the liver bed c. Injudicious use of electrocautery for dissection or bleeding control d. Excessive traction on cystic duct with tenting upward of common hepatic duct e. Injudicious use of clips to control bleeding f. Improper techniques of ductal exploration
Laparoscopic specificProper exposure –maximum cephalad traction on fundus with concomitant lateral traction on infundibulum
Location &classification
1. Bismuth`s classification—based on location of biliary stricture with respect to the hepatic duct confluence
2. Strasberg`s classification—is of laparoscopic biliary injuries, is applicable for acute injuries with bile leak, lateral injuries and transection.
3. Hannover classification—combine Bismuth and Strasberg classification and has also addressed the vascular injuries—most refined
Bismuth`s classification
Strasberg`s classification
Strasberg`s classification
Hannover`s classification
Clinical presentation
Clinical presentation
investigations
investigations
cholangioscopy
Benign Malignant Benign
Surgical treatment of BDI Recognized at operation
Immediate open conversion and repair by an experienced surgeon
If competent help unavailable, put a drain & should be referred to a specialist center
End to end repair over T- tubeRoux –en –Y hepaticojejunostomy(silk sutures should be avoided for all
biliary reconstructions, because they can act as nidus for stone formation)
Surgical treatment of BDI Recognized in immediate postoperative period
Avoid early reoperationBile leak from cystic duct, subvesical duct of
luschka or from noncircumferential laceration with no distal obstruction to bile flow may close spontaneously (1to 3 weeks)
Endoscopic sphincterotomy with stenting-hasten closure
For severe lacerations and complete transactions –delayed approach is best (timing of surgical intervention 4-10 weeks)
Surgical treatment of BDI injury presenting at an intervalPresented as late bile duct stenosis
and strictureConsider nonoperative biliary
drainage proceduresConsider surgery if no resolution in
12 -24 monthsAlmost always requires Roux –en –Y
hepaticojejunostomy
end t
Roux-en-Y HepaticojejunostomyCommon method of repair of bile duct
injuryProper exposure of healthy ,well
vascularised proximal bile ductRoux- en –Y Limb of jejunum >60 cmMucosa to mucosa tension free
anastomosisSide to side or end to side
hepaticojejunostomy using left hepatic duct
• Factors associated with poor outcome after surgery
Proximal stricture (Bismuth type 3 and 4) Multiple prior attempts at repair Portal hypertension Hepatic parenchymal disease (cirrhosis or hepatic fibrosis) End-to-end biliary anastomosis Surgeon inexperience Intrahepatic or multiple strictures Concurrent cholangitis or hepatic abscess Intrahepatic stones External or internal biliary fistula Intra-abdominal abscess or bile collection Hepatic lobar atrophy Advanced age or poor general health Many authors have advocated the use of anasto
Prevention is the best treatment of biliary strictures.