BILE DUCT INJURIES:

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BILE DUCT INJURIES CAUSES, CLASSIFICATION, AND
PREVENTION
Michael G. House, PGY V Sinai Hospital
Resident/PA Conference 2 May 2006
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88 yo woman h/o HTN and Type II DM who developed
a minor episode of UGI bleeding in the setting of
microcytic anemia (Hb 9.3) P.E. no cervical
LAN, no abdominal/umbilical masses, normal rectal
exam, stool hemoccult positive EGD performed 3
cm fungating mass involving the distal
stomach/antrum, esophagus, duodenum normal,
pylorus free of disease Biopsies taken
adenocarcinoma Staging CT abd, pelvis thickening
distal stomach, omentum normal, no ascites, liver
with 2cm heterogeneous lesion in segment 4 of
liver
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4.12.06 Ex lap no distant disease, segment 4
lesion hamartoma (frozen section), gallstones,
chronic cholecystitis Resection en bloc subtotal
gastrectomy, omentectomy, D1 LNs,
cholecystectomy Reconstruction BII-type
antecolic gastrojejunostomy Path T2N0M0 mod diff
adenoca (intestinal type), LN 7, margins
- Post-op POD1 stable, no fever, WBC
57K POD6 no fevers, WBC down 18K, cellulitis
involving inferior portion of wound gt opened
frank pus (Strep viridans) POD9 no fevers, WBC
35K, TPN started, CT scan performed
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Collection drained, 10 Fr APD gt bilious fluid
(amylase lt4mg/dL) POD10 drain 200 cc/day,
increased cellulitis involving entire open wound,
fascia intact, ID consult vanc pip/tazo
started POD12 fever for first time, WBC 65K,
peripheral blood smear (reactive), Abx
linezolid, zosyn, flagyl, amphotericin POD13 PTC
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8 Fr PBD placed thru ampulla into
duodenum POD15 PBD 400 cc/day, collection
drain lt100cc/day, WBC 72K POD16 abdominal wall
debrided widely
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Bile duct injuries following laparoscopic
cholecystectomy Overall incidence 0.5 (4x gt
incidence for open cholecystectomy) Most injuries
(gt2/3) recognized after initial operation Risk
factors Chronic inflammation Obesity Periportal
fat Poor exposure Bleeding Failure to recognize
aberrant anatomy Misperceptions
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VARIATIONS IN CYSTIC AND HEPATIC DUCTS
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PATTERNS OF BILIARY TRACT INJURIES
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BISMUTH CLASSIFICATION BILIARY TRACT INJURIES
STEWART-WAY CLASSIFICATION BILIARY TRACT INJURIES
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LW Way, et al
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Presentation of bile duct injuries NON-SPECIFIC Va
gue abdominal pain Nausea/emesis Fever Diagnostic
Studies Labs cholestasis (ductal obstruction),
bile absorption U.S. CT HBS (occult leaks) MRCP
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Management of bile duct injuries
DEFINE THE ANATOMY ERCP PTC CONTROL
SEPSIS Abx Drain collections Bile drainage
(Endostent, PBD) REPAIR Immediate (lt30 injuries
detected at time of lap chole) Delayed OPTIONS
FOR REPAIR Stenting (cystic duct and lateral
duct injuries) Duct ligation (lt3mm, drains
lt2segments) Duct repair (lt180 degrees, lt1cm
length, no cautery Roux-en-Y HJ,
choledochoduodenostomy (Bismuth I injury of
CBD)