Hacking You… Tube – Part 2

Beware of little expenses. A small leak will sink a ship.

Benjamin Franklin

We left things halfway last time so that we could resume the journey from here.

Clinical Manifestation

Almost 80-85% of injuries are not recognized during the primary surgical procedure. According to data, 70% are diagnosed within 6 months, and 80% within 12 months after the initial operation. An atypical postoperative course “not going perfectly” should raise suspicion of a possible bile duct injury. 

Biliary leakage

If a drain has been placed, the fistula should manifest externally by the drain in the immediate postoperative period. If there is no drain, abscess formation, biliary ascites or biliary peritonitis will occur, leading to intense abdominal pain, bloating, nausea, and vomiting. 

Analytical alterations

Elevated cholestasis enzymes secondary to stenosis at the level of the duct, with elevated bilirubin and GGT. In addition, at the clinical level, there is evidence of jaundice, acholia, choluria, and pruritus. We can also find cases of dissociated cholestasis in cases of late injuries (due to thermal injury) causing chronic stenosis of the bile duct and simulating secondary sclerosing cholangitis with (single) biliary stenosis. 

Subacute clinic

As cases of secondary biliary cirrhosis, secondary to intrahepatic fibrosis. Some authors indicate that the time required to develop common bile duct stenosis ranges from 8 to 14 months, and it manifests clinically like any cirrhosis with or without portal hypertension.

Acute liver failure
It’s a very rare situation, but if the biliary lesion is not treated properly acute liver failure may develop.

Diagnosis 

• Laboratory tests: Indicators of cholestasis and liver function (i.e. serum bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase, alanine, and aspartate aminotransferases) play the most important role. In patients in whom the liver is not damaged, indicators of cholestasis are increased, but aminotransferases are not. Pathological levels of aminotransferases, hypoalbuminemia, and coagulation defects are present in cases of secondary biliary cirrhosis or vascular lesions with acute liver failure.

• Abdominal CT: Higher sensitivity than ultrasound (96% vs. 70%) for diagnosis of intra-abdominal collections. It is also the main exam for assessing vascular lesions. If there are doubts about the vascular lesion, arteriography can be performed.

• Magnetic Resonance Cholangiopancreatography (MRCP): This is a very sensitive (85-100%) non-invasive test to define the anatomy of the biliary tract proximal and distal to the injury. It is currently the diagnostic exam of choice in these patients prior to surgical reconstruction. It can demonstrate the presence of collections, strictures, and bile duct injuries with fistula. More, after contrast administration, it can identify an arterial lesion.

• Other: 
  • Drainage or tutor cholangiography: a technique that can accurately delineate a proximal duct injury, common duct transections/ligations, and lesions to an anomalous right hepatic bile duct. It can be performed intraoperatively by introducing a tutor through the injured radical(s) and percutaneously when the patient is postoperative and has external drains.
  • Percutaneous trans-parietal-hepatic cholangiography: useful in the evaluation of the proximal injury, especially in the case of clips and ligation of the common bile duct or common hepatic duct. In the case of partial stenosis, it could be both diagnostic and therapeutic and is most useful in patients requiring biliary tract decompression. 
  • Endoscopic retrograde cholangiopancreatography (ERCP): invasive test and, in cases of section or complete obstruction of the main bile duct, can only detail the anatomy distal to the site of the biliary injury. It is very useful for assessing damaged bile ducts and identifying the site of the fistula and its size. In addition, it allows the repair of small bile duct injuries manifested as fistula or partial stenosis by insertion of drainage catheters or biliary prostheses. 

Treatment 

The Strasberg classification will be used for therapeutic purposes.

Depending on the time of diagnosis there are two scenarios:

1) Immediate repair – In these situations, we can consider repair at the injury moment if we have intraoperative cholangiography in which the hepatic ducts are correctly shown, It is a well-defined injury and we have the support of an experienced surgical team. 

• Injury to the minor bile duct (Strasberg A-D): We would perform an immediate repair on a T-tube along with abdominal drainage.
• Injury to the major bile duct (Strasberg E): Roux-en-Y hepaticojejunostomy.

2) Deferred repair – If there is the slightest doubt about the anatomy of the injury or if the team is not experienced in hepatobiliary surgery, we should perform a deferred repair. 

We should place an abdominal drain and a tutor in the proximal end and refer the patient to a more experienced center (or wait for an experienced surgeon). 

It is important to note that if the surgery is being performed laparoscopically and there is evidence of an iatrogenic lesion that we are not going to repair at that time, we should not convert to open surgery, but would do as above and perform a deferred repair.

Conversion to open will only complicate even more the next re-operation because of adhesions!

Referring to a specialized center is not abandonment. On the contrary, it is to be very concerned about the patient, as these are very complicated procedures that require the experience of a super-specialized multidisciplinary team (surgeons, endoscopists, and interventional radiologists). Furthermore, if there is a major damage that we try to repair, we may be creating second injuries! 

Step down from the surgeon’s ego throne and refer the patient. The best results are obtained in a center with experienced hepatobiliary teams! The patient has “only” one shot to repair the hole!

One of the most important questions is: When is the best time to repair the injury? And what can I offer the patient? 

Some authors recommend that the repair should be performed at 24-48 hours as it has been shown to be effective in experienced hands, but there are many other authors who advocate better results when the repair is performed after 3-6 weeks. The truth is that it is not that simple. If the patient’s condition is optimal and the repair is performed in an experienced center, both early and late repair have comparable long-term results. Therefore, rather than talking about formal hours or weeks, the important thing is to perform the repair at the most appropriate time! This will be when the inflammatory state is resolved, and the patient is physiologically normal (aka stabilized). 

The localized inflammatory state is one of the main determinants of the prognosis of definitive repair surgery. The ideal repair or reconstruction procedure should be performed without inflammation. 

The therapeutic arsenal for iatrogenic bile duct injury repair includes non-operative solutions, endoscopic or radiological approaches, and surgical treatment. The treatment will depend on the type of injury and ranges from conservative treatment with a biliary fistula to hepaticojejunostomy with liver resection or liver transplantation. In addition, we must also take into account the patient’s physiological situation, comorbidities, and the availability of a surgeon with experience in hepato-bilio-pancreatic surgery. 

Interventional Radiology

Non-surgical treatment of bile duct lesions can be used as a temporary measure before surgical repair or as definitive treatment. 

The bilioma can be drained under CT or ultrasound guidance. 

Leaks or common hepatic duct injuries can be drained with a trans-parietal-hepatic external drain.  

Hilar lesions with high-grade stenosis of the right and left ducts can be resolved with the placement of bilateral external drains.

In patients with episodes of acute cholangitis, excessive manipulation of the bile duct should be avoided and trans-parietal-hepatic drainage along with antibiotic treatment could be placed. 

Stenosis of the proximal bile ducts or stenosis after surgical reconstruction can be treated with prostheses placed by interventional radiology.

Endoscopic Treatment

The other type of management we have is endoscopic. It has been found to be the therapy of choice for biliary fistulas with a success rate of more than 90% in the case of bile duct indemnity. The main objective of this type of management is to decompress the bile duct to reduce the pressure to allow the fistula to close, and this is most often obtained with the placement of internal biliary drains. 

The leaks that respond most favorably to endoscopic treatment are those located at the end of a cystic duct stump or a duct of Luschka, usually low-debit fistulas.

If ERCP is not possible, it is preferable to stabilize the patient completely and then refer him/her, as soon as the general condition allows it, to centers of excellence in hepatobiliary surgery where ERCP with stenting can be performed. 

It can also perform endoscopic management of biliary strictures. The goal of the treatment of biliary strictures is to relieve obstruction, prevent restenosis, and avoid secondary hepatocellular damage. For a less aggressive approach, techniques such as pneumatic dilatation (not currently recommended due to the high restenosis rate of up to 47%) and stenting have been proposed. According to the literature, the success of endoscopic (72%) and surgical (83%) management is comparable. However, restenosis is more frequent with endoscopic/radiological treatment. Therefore, if the patient presents with repeated episodes of cholangitis, attempts at resolution with endoscopic/radiological management, or the presence of intrahepatic lithiasis, surgical treatment should be chosen.

Surgical Treatment

Surgery is reserved for the most complex biliary lesions or when the other techniques have failed.

The most suitable technique for repair in general is the performance of a terminal-lateral Roux-en-Y hepaticojejunostomy. It is performed using non-tensioned resorbable stitches. The anastomosis must be performed at the bifurcation, under well-perfused tissue, without tension, and with a para-duodenal loop. 

However, there are injuries with indemnity of the bile duct such as partial lacerations (non-thermal, as they are associated with high rates of stenosis) in which surgical repair can be done with a simple suture on a T-tube. In addition, there are lesions in which it has been described that a terminal-terminal anastomosis can be performed, but these lesions must meet a series of requirements: clear anatomy, well-vascularized tissues, no extensive loss of tissue, and injuries that are detected during the index surgical procedure. 

Treatment Algorithm According to the Type of Strasberg Injury (Let’s Sum Up!!!)

Type A Injury (i.e. cystic duct leak)

If ERCP is available, it is preferable to perform it together with endoscopic sphincterotomy, followed by placement of a biliary stent of suitable characteristics (caliber, material, anchoring system). With this approach, the chances of resolution are maximized. If ERCP is not possible, it is preferable to stabilize the patient and then refer him/her to a center where ERCP with stenting can be performed. Stabilization measures should include placement of peritoneal drainage in the proximal juxtaposition of the biliary injury (usually in the subhepatic space), intravenous fluid and electrolyte support, nasogastric tube, antibiotic medication, and so on…

Type B and C Injuries

If there is mild pain and elevated liver function tests without clinical deterioration, conservative treatment can be followed. The presence of moderate and severe cholangitis mandates drainage of the occluded hepatic segment. Percutaneous drainage or surgical resections may be performed when cholangitis is not controlled by medical treatment. As in the Strasberg B injury, an accessory right duct is severed, but the proximal stump is missed and occluded, with inadvertent biliary leakage as a consequence. There is no continuity with the rest of the bile duct system, leaving endoscopy out of the therapeutic options. Subhepatic collections are frequent in the postoperative period. These must be drained to avoid biliary peritonitis and septic shock. It is common for the biliary leak to occlude spontaneously without any further intervention to maintain a controlled biliary leak through external drains. If this does not occur, the therapeutic options are the same as for Strasberg B injury, biliodigestive bypass to segmental ducts (also with poor long-term prognosis), percutaneous drainage, and hepatectomy.

Type D Injuries

In this situation, we have three different settings.

If we have a type D injury without associated vascular damage, and the diameter of the defect is between 3 and 5 mm, the first option includes primary suturing with a 4/0-5/0 absorbable monofilament and proximal drainage for control. This solution can be performed laparoscopically (especially if the lesion is immediately identified intraoperatively) or with an open approach. 

If the area of the duct injury has been deprived of vascular support (over a variable length) by concomitant vascular involvement, primary suturing is considered prohibitive because of bile leakage and consecutive chole-peritoneum. These events are very likely to occur from the first postoperative week onwards. Therefore, radiology-guided endoscopic stenting is indicated in these situations. 

If the initial injury has progressed from class D to class E, open surgical reintervention is the most advisable choice, and the options available are those discussed in the following section.

Type E Injuries

– Type E1: end-to-lateral enteric shunt.

– Type E2 and E3: It may be necessary to lower the hilar liver plate and extend the repair along a short stretch of the right or left hepatic duct to allow for a common biliary enteric anastomosis.

– Type E4: resection of segment 4b or 5 is often necessary to perform separate right and left biliary enteric anastomoses. 

– Type E5: the most common procedure is the Roux-en-Y hepaticojejunostomy with trans-anastomotic tutors. Regarding the use of biliary tutors, their use and the timing of their removal remain controversial. Therefore, Mercado et al. recommends their use when there is a bile duct less than 4 mm in diameter or there is inflammation within the anastomotic borders. The removal of the drain is also controversial. Still, for most authors, the optimal duration is approximately 3 months.

Other Treatments

Hepatic resection has good results with success rates of up to 94%. It would be performed in cases of vascular injuries affecting liver segments or lobules, and in cases of hepatic abscesses, repeated cholangitis, or intrahepatic lithiasis formation, because the repair of the affected bile duct would be unsuccessful, so the ideal is to perform a hepatectomy.

Liver transplantation would be required in exceptional cases such as secondary biliary cirrhosis, acute liver failure, or sepsis with severe stenosis. 

Conclusions

In order to avoid this type of injury, prevention is essential, as these injuries have non-negligible morbidities and mortality rates. We must bear in mind that we only have one chance, which is why we should not be afraid to refer these patients to experienced centers, as they have a higher success rate. These are patients who must be followed up for a long time, as they tend to develop late complications in the form of recurrent cholangitis, intra-abdominal abscesses, etc… In addition, two-thirds of biliary strictures recur 2-3 years after surgical reconstruction. 

This has been a long and scary journey. As always, we hope this will help you and your patients!

See you next time… 

Namaste!

References

1. de’ Angelis N, et al. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021;16.
2. Fingerhut A, et al. ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy. Surg Endosc 2013;27:4608-19.
3. Schreudera AM, et al. Impact of iatrogenic bile duct injury. Dig Surg 2020;37:10-21.
4. Strasberg SM, et al. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9:543-7.
5. Moldovan C, et al. Clinical and surgical algorithm for managing iatrogenic bile duct injuries during laparoscopic cholecystectomy: a multicenter study. Experimental and Therapeutic Medicine 2021;22:1385.
6. Pesce A, et al. Iatrogenic bile duct injury: impact and management challenges. Clinical and Experimental Gastroenterology 2019;12:121-8.
7. Brunt LM, et al. Safe cholecystectomy multi-society practice guideline and state of the art consensus conference on prevention of bile duct injury during cholecystectomy. Ann Surg 2020;272:3-23.
8. Mascagni P, et al. Artificial intelligence for surgical safety: automatic assessment of the critical view of safety in laparoscopic cholecystectomy using deep learning. Ann Surg 2022;275:955-61.
9. Traverso LW, et al. Intraoperative cholangiography lowers the risk of bile duct injury during cholecystectomy. Surg Endosc 2006,20:1659-61.
10. López-López V, et al. Lesiones iatrogénicas de la vía biliar. Diploma de especialización en bases de la cirugía hepatobiliopancreática y trasplante. Módulo 3. Patología de las vías biliares.

How to Cite This Post

Galofré C, Marrano E, Bellio G. Hacking You… Tube – Part 2. Surgical Pizza. Published on August 28, 2023. Accessed on September 10, 2023. Available at [https://surgicalpizza.org/rescue/hacking-you-tube-part-2/].