MANAGEMENT OF BILE DUCT INJURIES ; CONVENTIONAL AND SURGICAL METHODS AND THEIR SHORT OUTCOME

Fady m. Habib, hassan ashour, tamer mohamed el shahidy and loay m. Gertallah. Lecturers of General surgery, Faculty of Medicine, Zagazig University. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 20 October 2018 Final Accepted: 22 November 2018 Published: December 2018


ISSN: 2320-5407
Int. J. Adv. Res. 6(12), 1324-1333 1325 of anatomy of the biliary tract resulted in a plethora of bile duct injuries. It was found that the incidence of BDIs was about 0.1-0. 3, with the open procedure, but there is a higher risk of injury after laparoscopic cholecystectomies, almost 2%. With the increasing experience of specialized laparoscopic surgeons and the availability of better operating instruments, iatrogenic BDIs rate have markedly decreased to <0.5% and laparoscopic cholecystectomy has become the best procedure for management of symptomatic gall stones [2].
There are several classifications which have been proposed for BDIS, but none of them was universally accepted as each one of them has its own limitation. Patient's general condition, time of recognition of the injury and the presence of perioperative sepsis are not included in these classification systems. Among these classification systems the commonest classifications that were used by clinicians are Bismuth's classification and Strasberg's classification [3].
Aim of the work was to evaluate different modalities of management of Bile duct injuries (BDI) which are following cholecystectomy and discuss their short outcome.

Patients & Methods:-
Between the period from October 2016 and October 2018 in the Department of General Surgery Zagazig University Hospitals, we included 28 patients that were complaining of biliary injuries complicating cholecystectomy; open cholecytectomy was the primary performed procedure in 16 patients, while laparoscopic cholecytectomy was the primary performed procedure in 12 patients.

Intra-operative diagnosed patients:
1. Six biliary injuries were diagnosed intra-operatively where 2 cases resulted from open cholecytectomy and 4 cases resulted from laparoscopic cholecystectomy. 2. In the 2 patients that were diagnosed intra-operatively during performing open cholecytectomy: right kocher's incision was widened for better evaluation of the anatomy, site and degree of injury. We performed intraoperative cholangiogram through the cystic duct stump to confirm the diagnosis of BDI and to detect any other type of injury. 3. In one case we have detected BDI which was located above the level of cystic duct (Strasberg's type D). 4. The other case we have detected BDI located just below the level of cystic duct (Strasberg's type D). 5. In both cases there were no evidence of tissue loss and the vascularity was good. End-to-end anastomosis was done by using 4/0 vicryl interrupted sutures over T-tube that was brought through separate incision in the main bile duct. 6. In the 4 cases which were diagnosed intra-operatively during laparoscopic cholecytectomy: 7. Three cases were converted to open surgery & intra-operative cholangiogram was done in the three cases and revealed CBD injury (Strasberg's type D) one case underwent end-to-end anastomosis over T-tube while, the other two cases underwent end to side Roux-en-Y hepatico jejunostomy. 8. One case underwent ERCP in the same setting which revealed the presence of perforation of CHD just above the cystic duct stump (Strasberg's type D) sphincterotomy & stenting were done.

Postoperative diagnosed patients:
There were 22 patients diagnosed postoperatively from the 1 st day to the 3 rd month.

Time of diagnosis and presentation:
Early postoperative: 1. nineteen patients were diagnosed at the early postoperative period (during the 1 st week postoperatively): 2. Five patients presented mainly by jaundice. 3. Three of them were presented with jaundice and cholangitis. 4. 2 of them were presented with jaundice without cholangitis. 5. Ten patients presented with biliary leakage through the previously inserted intra-peritoneal drain. 6. One patient was diagnosed with biliary leakage but with huge subcutaneous collection which was evacuated through removal of some stitches. This collection was composed of infected bile the operating surgeon have performed repeated dressing & follow up of the patient, but the general condition deteriorated & the patient came to ER unit by a disturbed conscious level, hypotention and tachycardia so admitted to the ICU & received antibiotics, I.V. fluids, correction of electrolyte disturbance, blood transfusion, U/S was done & revealed big 1326 collection in the right hypochondrium. These conservative measures failed to regain good general condition due to the presence of severe sepsis. The patient intubated & inotrope was started finally the patient died. 7. The remaining three patients were presented by abdominal pain especially at right hypochondrium which was associated with fever, anorexia and attacks of vomiting after removal of the drain. 8. Abdominal ultrasound guided aspiration revealed the presence of a collection in the right hypochondrium with biliary aspirate that mean the presence of biliary peritonitis.

Late postoperative:
There are three patients presented at variable intervals postoperatively (3 weeks-3 months). 1. One case presented with a rising levels of jaundice.
2. The other case presented with multiple attacks of abdominal pain, fever and vomiting this started to be present a month postoperatively. 3. The remaining case referred after 3 weeks of cholecystectomy with jaundice and the intra-operational tube drain that produces nearly 200 ml bile/day.

Patients' assessment:
The 21 patients that were presented postoperatively were assessed according to the following:

History taking and physical examination:
With special stress on: details of the previous operation; the location in which it was performed, the efficiency of the operating surgery and any investigations or interventional trials which were performed, symptoms such as jaundice, cholangitis, itching, dark urine, biliary leakage, and abdominal examination for: tenderness, rigidity or fixed dullness for biliary fistula.

Radiological investigations: Abdominal ultrasonography:
was done for all patients.

ERCP:
was done in sixteen cases; 15 cases who were presented postoperatively and 1 case who was diagnosed intraoperatively and ERCP were done at the same setting.

PTC:
It was done only in one case in which ERCP detected complete arrest of dye at the level of the cystic duct. It was done shortly before planned surgery.

MRCP:
was done in nine cases. 7. In 1 case ERCP diagnosed right hepatic duct injury just above the biliary confluence sphincterotomy was done with two plastic stents inserted (one in the right hepatic duct crossing the site of injury and the other in the left hepatic duct). 8. In 1 case ERCP diagnosed lacerated left hepatic duct, sphincterotomy with left hepatic duct stenting were done.
The surgical management Roux-en-Y hepatico jejunostomy : 1. Such procedure was done for ten cases. The operations were performed through a large right subcostal, right paramedian or bilateral subcostal incisions. Exploration at the triangle of calot to detect the possible site of the proximal stump through finding a suture on the course of the main bile duct was done. 2. Dissection at the area of Calot's triangle upwards towards porta-heptis to perform adequate exposure of a suitable caliber biliary duct with good blood supply was done. 3. About twenty five cm from the duodenojejunal junction resection of the jejunum done & the Roux jejunal limb brought retrocolic to be anastomosed with the biliary duct (end to side) by vicryl 4/0 single layer under vision. 4. The end to side jejuno-jejunal anastomosis was done 40 cm from the biliary-jejunal anastomosis. 5. Drainage of the abdomen was done by insertion of a large caliber tube drain (26Fr) at Morrison's pouch beside the anastomosis.
End-to-end anastomosis: 1. It was performed for two cases. We performed a tension-free mucosa-to-mucosa anastomosis in intact duct tissue using a single layer of vicryl 4/0 interrupted sutures.

2.
A T-tube is placed in the common bile duct, its vertical limb was located at a distance from the anastomosis then it was fixed to the anterior abdominal wall using a separate stab.
Results:-1. The twenty eight patients were: 17 females (60.7%) and 11 males (39.3%). There ages ranged from 24 -55 years old with a mean age 40.6. 2. PTC was performed in one case and revealed dilated intrahepatic biliary radical, dilated CHD and the dye was completely arrested at the level of cystic duct stump which denotes ligated CBD (Strasberg's type)  1328 Biliary leakage = leakage through the drain or the wound itself. 100% ERCP succeeded to be diagnostic & therapeutic modality in 10 cases (62.5%), while was diagnostic only in 5 cases (31%) that needed surgical intervention, and failed in one case (6.3%).        11.8 5.9 5.9 5.9 23.5

Hospital stay:
The cases that underwent diagnostic & therapeutic ERCP discharged after 1-2 days for follow up. But cases needed surgical intervention their period of hospitalization ranged from 15 to 30 days with an average of 20 days.

Mortality:
1. One patient died in ICU from severe sepsis before intervention. 2. No procedure related mortality.

Discussion:-
Iatrogenic bile duct injuries (IBDIs) have been found to be an important problem in gastrointestinal surgery. The early and accurate diagnosis of IBDIs is essential for both surgeons and gastroenterologists, as unrecognized IBDIs might lead to dangerous side effects such as biliary cirrhosis, hepatic failure and death (4) .
In the current study we have diagnosed six patients (21.4%) intra-operatively, while we diagnosed 22 patients in post-operatively.
The patients who were discovered intra-operatively complaining from the presence of persistent bile in the operative field without knowing its cause.
The bile stained towels during toilet of the field at open cholecystectomy or the irrigation-aspiration during laparoscopic cholecystectomy leads us to notice the injury.
Our results were similar to the study performed by Wu and Colleagues in (2007) (5) where (29%) of patients with BDI were discovered intra-operatively with the same finding in our study.

1330
The time interval between cholecystectomy and the patients' presentation in our study postoperatively were ranged from few days to 3 months, where, 86.4% of patients have been presented early postoperatively, while 13.6% of our patients were presented late postoperatively from 3 weeks to 3 months. Wu and Colleagues in (2007) (9) found that 71.1% of their patients were diagnosed in the early stage postoperatively, while 28.9% of patients presented in the late postoperative period.
Similarly, Wu and Colleagues in (2007) (9) where 44.3% of patients presented also with biliary leakage while patients presented with obstructive jaundice were 19.8% and those presented with biliary peritonitis were 35.9%.
ERCP have been found to succeed to be diagnostic & therapeutic tecnique in (62.5%) of patients underwent ERCP, while was diagnostic only in (31%) that needed surgical intervention but it failed in (6.3%). Similar results were proved by Karabulut and Colleagues in (2012) (10) where 62% of their cases successfully underwent diagnostic & therapeutic ERCP.
Ten patients (37%) underwent ERCP and stenting of the common bile duct, which offered a definite therapeutic measure for these patients as an alternative to surgical management. It was of success rate 90%. Similar results were seen in the study performed by Karabulut and Colleagues in (2012)6 ) where the success rate of performing therapeutic ERCP was 93%. While, Jablonska and Lampe, (2009) (4) proved different results where their success rate with therapeutic ERCP was 72%.
Complications of ERCP were cholangitis in 2 patients (20%) & mild pancreatitis in one patient (10%). They were managed conservatively untill became symptoms free. Gouma and Obertop, (2001) (7) commented that results after endoscopic treatment were excellent with a 94% success rate.
Blumgart and Matthews, (1997) (8) , and Lillemoe K, Melton G and Cameron J (2000) 9 : found that classic end-to-end bile duct repair over a T-tube have important features that are minimal loss of bile duct tissue and the presence of enough length of extrahepatic bile ducts to permit a tension-free mucosa-to-mucosa anastomosis in viable duct tissue. The segment of bile duct that has been clipped, ligated with a suture, or affected by thermal injury should be resected back to healthy viable tissue.
In our study End-to-End anastomosis over T-tube was the main surgical procedure in 29.4% of total patients managed surgically. While in Wu and Colleagues in (2007) (5) studt, End-to-End anastomosis with T-tube drainage was in (5%) and had been considered improper trimming of ductal end, incomplete scar removal and torsion of anastomosis stoma as technical errors in performing such approach.
In this study, the postoperative complications were; wound seroma & infection in 2 patients, subphrenic collection, DVT in only one patient, persistent vomiting in one patient, cholangitis in one patient and biliary leakage in four patients.
In the study performed by Sicklick and Colleagues in (2005) (10) there were three patients (1.5%) died after performing delayed referral before any attempts at repair due to uncontrolled sepsis.
All patients with BDI underwent surgical or endoscopic intervention in this study gave a good short term outcome with no mortality this is because their mean age was 40.6.
In the study performed by Wu and Colleagues in (2007) 5) there were no postoperative fatality while in the study performed by Karabulut and Colleagues in (2012) (6) 2 patients died in the postoperative period from total of 42 patients due to pulmonary embolism.