Biliary Stricture y265v

BENIGN BILIARY STRICTURES

: Dr Chaitanya Krishna Kondabala Senior Resident , Department of Surgery CRH , Gangtok Presenter : Dr Md Nazar Imam DNB Resident , Department of Surgery CRH , Gangtok

INTRODUCTION  A biliary stricture is an abnormal narrowing of the common bile duct.  A feared complication of many surgical and endoscopic procedures.  If improperly treated, it may lead to cholangitis, portal hypertension & cirrhosis.  Treatment of this disease is challenging as well as rewarding, as most of the patients are in younger age group.

CAUSES I. Congenital strictures (a) Biliary atresia II. Bile duct injuries (a) Postoperative strictures (i) Cholecystectomy or common bile duct exploration (ii) Biliary-enteric anastomosis (iii) Hepatic resection (iv) Portocaval shunt (v) Pancreatic surgery (vi) Gastrectomy (vii) Liver transplantation (b) Strictures after blunt or penetrating trauma (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

IV. Primary sclerosing cholangitis V. Radiation-induced stricture VI. Papillary stenosis

Incidence: Bile duct injuries are reported in 0.2 to 0.3 % of open cholecystectomy and 0.4 to 1.3% of laparoscopic cholecystectomy in larger studies. Actual incidence may be higher.

AUTHOR

BDI incidence following OC

BDI incidence following LC

McMahon, 1995

0.2

0.81

Strasberg, 1995

0.7

0.5

0.19-0.29

0.36-0.47

Targaroma, 1998

0.6

0.95

Lillemoe, 2000

0.3

0.4-0.6

0.0-0.5

0.07-0.95

Savar, 2004

0.18

0.21

Moore, 2004

0.2

0.4

Misra,2004

0.1-0.3

0.4-0.6

Gentileschi, 2004

0.0-0.7

0.1-1.1

0.3

0.6

Shea, 1996

Gazzaniga, 2001

Kaman, 2006

Jablonska, World J Gastroenterol 2009

Classification BISMUTH CLASSIFICATION IS BASED ON THE MOST DISTAL LEVEL AT WHICH HEALTHY BILIARY MUCOSA IS AVAILABLE FOR ANASTOMOSIS DURING REPAIR OF BILIARY INJURY

TYPE 1

2

CRITERIA Low common hepatic duct stricture with a length of common hepatic duct stump of > 2 cm Proximal common hepatic duct stricture with hepatic duct stump < 2 cm

3

Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved

4

Hilar stricture with involvement of confluence and loss of communication between right and left hepatic duct

5

Involvement of an aberrant right sectorial duct alone or with concomitant stricture of the common hepatic duct

STRASBERG CLASSIFICATION STRATIFIES INJURIES FROM TYPE “A” TO “E”, WITH TYPE “E” INJURIES BEING FURTHER SUBDIVIDED INTO E1 THROUGH E5 ACCORDING TO THE BISMUTH CLASSIFICATION SYSTEM

TYPE CRITERIA A

Cystic duct leak or leak from small ducts in the liver bed

B

Occlusion of an aberrant right hepatic duct

C

Transection without ligation of an aberrant right hepatic duct

D

Lateral injury to a major bile duct

E1

Transection > 2 cm from the hilum

E2

Transection < 2 cm from the hilum

E3

Transection in the hilum

E4

Separation of major ducts in the hilum

E5

Type C injury plus injury in the hilum

STEWART-WAY CLASSIFICATION IS BASED PRIMARILY ON THE ANATOMIC PATTERN AND MECHANISM OF A PARTICULAR INJURY, INCLUDING THE PRESENCE OF ASSOCIATED VASCULAR INJURY

Pathological effects of biliary obstruction

Biliary obstruction

High local concentration of bile salts

inflammation

Pathological effects of biliary obstruction (Contd.) Fibrosis and scarring

Biliary stasis

Liver atrophy

Biliary fistula

Repeated cholangitis

Secondary Biliary cirrhosis and PHTN

Clinical Presentation Biliary colic Obstructive Jaundice Features of ascending cholangitis - Charcot’s triad, Reynold’s pentad Past history of cholecystectomy. History suggestive of pancreatitis , trauma , radiation , alcohol abuse. Overall only 10% of post-op. bile duct strictures are recognized within 1st week and approx. 70% are diagnosed within 6 months of original operation.

Laboratory Tests  Liver function tests usually show evidence of cholestasis with fluctuating serum bilirubin level.  When elevated, serum bilirubin is usually below 10 mg/dL, unless secondary biliary cirrhosis has developed, or there is complete cut off.

 Serum alkaline phosphatase is usually elevated.  Serum aminotransferase levels can be normal or minimally elevated except during episodes of cholangitis.  If advanced liver disease exists, hepatic synthetic function can be impaired, with lowered serum albumin and a prolongation of prothrombin time.

Imaging Studies

Ultrasound  Study of choice for the initial evaluation of jaundice or symptoms of biliary disease  Will show dilated bile ducts proximal to the stricture  Information about level of stenosis

CBD

PV

Contrast enhanced CT abdomen CT helps in assessing any intra abdominal collection.  Definite level of bile duct stricture, dilated intrahepatic radicals with cholangitic abscess.  Vascular injury with liver atrophy-hypertrophy complex. Limited in evaluation of the type and extent of biliary stricture.

Magnetic Resonance Cholangiopancreatography Non-invasive method Only diagnostic Provides anatomic information about location and degree of dilatation Delineate the intrahepatic and extrahepatic biliary tree and pancreas

CBD

PD

Endoscopic Retrograde Cholangiopancreatography  Diagnostic and therapeutic  Invasive test using endoscopy and fluoroscopy to inject contrast through the ampulla and image the biliary tree  Used for dilatation of the biliary stricture

Percutaneous transhepatic cholangiography  Useful in intrahepatic biliary disease

 In whom ER is not technically feasible  It will outline proximal biliary tree, define stricture and its location, allow decompression of the biliary tree

Hepatobiliary iminodiacetic acid scan  Helps in diagnosing biliary leaks.  Provides functional assessment of biliary stricture and anastomosis leak.  Suggests complete biliary obstruction if small intestine is not visualized in 60 minutes.  Insensitive for detection of biliary dilatation or cause of bile duct obstruction.

Operative Procedure  The first surgical reconstruction (“end-to-side” Choledochoduodenostomy) of iatrogenic bile duct injury was performed by Mayoin 1905.

 The first Roux-en-Y hepaticojejunostomy (HJ) was described by Monprofit in 1908.  Dahl noted Roux en-Y HJ for surgical treatment of bile duct injury in 1909. In1969, Smith created a mucosal graft anastomosis in the repair of the damaged proximal bile duct.  In 1954, Hepp and Couinaud described the hilar plate and long extrahepatic course of the left hepatic duct.  Restoration of bile flow is achieved by a bilio-enteric anastomosis. Rarely, when the stricture is in pancreatic or immediate supra-duodenal CBD, a choledochoduodenostomy can also be constructed.  Most often the reconstruction is by a Roux loop with hepaticojejunostomy.

Surgery (Biliary enteric anastomosis)  Choledochoduodenostomy Choledochojejunostomy Roux-en-Y Hepaticojejunostomy (ideal)

 Successful bile duct enteric reconstruction is dependent on several factors: 1. Adequate preoperative assessment of biliary anatomy 2. Exposure of proximal, healthy bile ducts with adequate blood supply 3. The repair must include all injured/strictured ducts to ensure adequate drainage of the entire liver, and control of bile leakage. 4. Use of a healthy segment of intestine that can be brought to the anastomosis without tension (most often a Roux-en-Y jejunal limb) 5. Creation of a tension-free biliary mucosa-to-bowel mucosa anastomosis

Choledochoduodenostomy  Commonly used for repair of the benign strictures in the retropancreatic portion.  Most successful in presence of dilated CBD (>15 mm).  For strictures in distal most part of CBD  Maintains endoscopic access to the biliary tree.  The distal common bile duct is opened longitudinally, as is the duodenum. Interrupted sutures are placed between the common bile duct and the duodenum.    

Concerns : bile reflux ascending cholangitis sump syndrome

Choledochojejunostomy

Roux-en-Y Hepaticojejunostomy (ideal)  It is the preferred method of surgical biliary drainage in most instances, and is the standard method of biliary reconstruction following bile duct resection.  Proper exposure of healthy well vascularised proximal bile duct. 

Roux- en –Y Limb of jejunum >60 cm.

 The entire extrahepatic biliary tree has been resected and the reconstruction done with a Roux-en-Y limb of jejunum.  This is an end-to-side anastomosis of the common hepatic duct onto the jejunum.  HEPP- COUINAUD APPROACH: Hilar plate is dissected , left hepatic duct is anastomosed to Roux jejunal loop with creation of proximal ‘access loop’ for future endoscopic approach.

THANKS