La calcolosi della VPB oggi TRATTAMENTO DELLE COMPLICANZE DELLA CHIRURGIA MININVASIVA

1. La calcolosi della VPB oggiTRATTAMENTO DELLE COMPLICANZE DELLA CHIRURGIA MININVASIVA UNIVERSITÀ DI PADOVA DIPARTIMENTO DI SCIENZE ONCOLOGICHE E CHIRURGICHE CLINICA CHIRURGICA II^ Direttore: Prof. Donato Nitti Donato Nitti

2. LAPAROSCOPIC CHOLECYSTECTOMY IATROGENIC INJURIES Catarci, Surg Endosc 2001 Shamiyeh, Langenbecks Arch Surg 2004 Bleeding from the liver bed: 8% Bile duct injuries: 0.4 - 0.6% Minor vascular injuries (branches of the epigastric vessels, mesenteric and omental vessels): 0.1 - 0.2% Major vascular injuries (aorta, iliac vessels, vena cava, inferior mesenteric arteries and lumbar arteries): 0.07 - 0.4% Bowel lesions: 0.07 - 0.7% Abdominal wall hematoma: case reports

3. IATROGENIC BILIARY INJURIES

4. IATROGENIC BILIARY INJURIES Biliary injuries that occur during LC tend to be more severe than those encountered with OC LC is generally performed in a retrograde fashion, the level of injury can be proximal and enter into the second- and third-order bile ducts within the liver parenchyma McPartland, Surg Clin N Am 2008 A bile duct injury or stricture is the most serious complication of laparoscopic cholecystectomy (LC) This incidence appears to be 2-4 times higher than that of open cholecystectomy (OC) (0.1-0.2%)

5. IATROGENIC BILIARY INJURIES Jablonska, World J Gastroenterol 2009

6. IATROGENIC BILIARY INJURIESMECHANISM Factors associated with an increased risk of BDI • Anatomical anomalies of the bile ducts and hepatic arteries • Chronic inflammation around the gallbladder • Obesity • Poor exposure • Bleeding in the surgical area McPartland, Surg Clin N Am 2008 Jablonska, World J Gastroenterol 2009

7. IATROGENIC BILIARY INJURIESMECHANISM inflammation in the area of the triangle of Calot can result in close approximation of the cystic duct and common bile ducts excessive cepahalad retraction on the gallbladder fundus or insufficient lateral retraction on the gallbladder infundibulum Nuzzo, Am J Surg 2008 70-80% of all IBDI are a consequent of misidentification of biliary anatomy before clipping, dividing and ligating structures The most common type of BDI during LC is the so-called “classical” laparoscopic BDIthat occurs when a portion of the common bile duct is resected with the gallbladder

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

9. IATROGENIC BILIARY INJURIESCLASSIFICATION 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

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

11. IATROGENIC BILIARY INJURIESINTRAOPERATIVEIDENTIFICATION OF BDI • INTRAOPERATIVE IDENTIFICATION OF BDI: • Sudden unexpected leakage of bile from the liver or soft tissue adjacent to the porta hepatis • Persistent bile leakage after transection of an apparent cystic duct < 15-20% OF BDI ARE DETECTED DURING LC Gouma, Dig Surg 2002 Lillemoe,

12. IATROGENIC BILIARY INJURIESPOSTOPERATIVEIDENTIFICATION OF BDI SYMPTOMS: LABORATORY: • Indicators of cholestasis and liver funcion: bilirubin, ALP, AST, ALT, gGT Sicklick, Ann Surg 2005 Jablonska, World J Gastroenterol 2009

13. IATROGENIC BILIARY INJURIESPOSTOPERATIVEIDENTIFICATION OF BDI IMAGING: • US-doppler • Abdominal CT: free-fluid  BILE LEAK hepatic artery and portal vein injuries • ERCP: confirm BDI • Percutaneous transhepatic cholangiography (PTC): confirm BDI define biliary antomy • ColangioMRI: sensitivity 85-100% gold standard before surgical repair

14. IATROGENIC BILIARY INJURIESPOSTOPERATIVEIDENTIFICATION OF BDI IMAGING: • US-doppler • Abdominal CT: free-fluid  BILE LEAK hepatic artery and portal vein injuries • ERCP: confirm BDI • Percutaneous transhepatic cholangiography (PTC): confirm BDI define biliary antomy • ColangioMRI: sensitivity 85-100% gold standard before surgical repair

15. IATROGENIC BILIARY INJURIESPOSTOPERATIVEIDENTIFICATION OF BDI IMAGING: • US-doppler • Abdominal CT: free-fluid  BILE LEAK hepatic artery and portal vein injuries • ERCP: confirm BDI • Percutaneous transhepatic cholangiography (PTC): confirm BDI define biliary antomy • ColangioMRI: sensitivity 85-100% gold standard before surgical repair

16. IATROGENIC BILIARY INJURIESPOSTOPERATIVEIDENTIFICATION OF BDI IMAGING: • US-doppler • Abdominal CT: free-fluid  BILE LEAK hepatic artery and portal vein injuries • ERCP: confirm BDI • Percutaneous transhepatic cholangiography (PTC): confirm BDI define biliary antomy • ColangioMRI: sensitivity 85-100% gold standard before surgical repair

17. IATROGENIC BILIARY INJURIES Any suspect of BDI? study the biliary anatomy: COLANGIOGRAPHY (PTC / ERCP) YES successful repair in 96-98% NO unsuccessful repair in 98% Wald, Surg Clin N Am 2008 Lillemoe, Br J Surg 2008

18. IATROGENIC BILIARY INJURIESMANAGEMENT INITIAL GOAL CONTROL OF SEPSIS  CONTROL ONGOING BILE LEAK

19. IATROGENIC BILIARY INJURIESENDOSCOPIC AND RADIOLOGIC TREATMENT ERCP: confirm BDI temporary internal stent Percutaneus transhepatic cholangiography (PTC): • define the biliary anatomy • decompress the biliary • system Sicklick, Ann Surg 2005 McPartland, Surg Clin N Am 2008

20. IATROGENIC BILIARY INJURIESMANAGEMENT LONG-TERM GOAL RE-ESTABILISHMENT OF BILE FLOW INTO THE GI TRACT PREVENT STRICTURE PREVENT LIVER INJURY PREVENT CHOLANGITIS PREVENT STONE FORMATION

21. IATROGENIC BILIARY INJURIESMANAGEMENT SURGICAL TREATMENT IMMEDIATE DELAYED

22. IATROGENIC BILIARY INJURIESIMMEDIATE SURGICAL REPAIR LESS THAN 1/3 OF BDI ARE DETECTED DURING LC try to define the extent of the injury if the level of injury is clearly defined and the surgeon is comfortable with biliary reconstruction, immediate repair can be performed

23. IATROGENIC BILIARY INJURIESIMMEDIATE SURGICAL REPAIR • Simple leak from the cystic duct stump found during LC  placement of an additional clip or a suture ligature loop videolaparoscopy / laparotomy • Complex biliary injuries CONVERT TO LAPAROTOMY STRASBERG CLASSIFICATION

24. IATROGENIC BILIARY INJURIESMANAGEMENT SURGICAL TREATMENT IMMEDIATE DELAYED

25. IATROGENIC BILIARY INJURIESDALAYED SURGICAL REPAIR Who? • 75% of primary surgeon attempt to repair the injury themselves  17% are successful • If first repair performed in a hepatobiliary third level center 94% are successful When? • Some surgeons suggest waiting 4-6 weeks to stabilize patient • Other surgeons suggest to repair the injury as soon as possible to avoid formation of adeshions Schmidt, Br J Surg 2005 Flum, JAMA 2003 McPartland, Surg Clin N Am 2008

26. IATROGENIC BILIARY INJURIESDALAYED SURGICAL REPAIR • How? • Lateral ductal injuries (Strasberg type D) without a complete transaction  repaired primarly over anadjacently place T-tube as long as there is no evidence of significant ischemia or cautery damage • More extensive Strasberg type D and E  biliary enteric anastomosis for reconstruction Schmidt, Br J Surg 2005 McPartland, Surg Clin N Am 2008

27. IATROGENIC BILIARY INJURIESSURGICAL REPAIR END-TO-END ANASTOMOSIS: • feasible if injured segment is 1-2 cm and the 2 ends can be opposed without tension • Kocher maneuver allows tension-free anastomosis Connor, Br J Surg 2006 Jablonska, World J Gastroenterol 2009

28. IATROGENIC BILIARY INJURIESSURGICAL REPAIR ROUX HEPATICOJEJUNOSTOMY: (most performed anastomosis) - preferable choice in lesions between the hepatic duct and the lobar ducts (less tension of the anastomosis) • lower number of strictures Sicklick, Ann Surg 2005 McPartland, Surg Clin N Am 2008

29. IATROGENIC BILIARY INJURIESSURGICAL REPAIR HEPATICO-DUODENOSTOMY: • PRO: • normal physiology → less ulcers and malabsorbtion • only one anastomosis: easier and faster to perform • post-operatory control through endoscope • no secondary biliary cirrhosis reported • CONTRA: • difficult to perform for proximal bile duct lesions • (75% of lesions) • need to an experienced surgeon • risk of cholangitis Moraca, Arch Surg 2002 Sicklick, Ann Surg 2005

30. IATROGENIC BILIARY INJURIESCLINICA CHIRURGICA 2 EXPERIENCE 1993-2008: 850 laparoscopic cholecystectomy • 1 aortic lesion (0.11%) • 1 jejunal perforation (0.11%) • 1 hepatic hematoma (0.11%) • 3 bile duct injuries (BDI) (0.35%) 1993-2008: 6 bile duct injuries refferred from other hospital

31. IATROGENIC BILIARY INJURIESCLINICA CHIRURGICA 2 EXPERIENCE STEWART-WAY CLASSIFICATION

32. IATROGENIC BILIARY INJURIESCLINICA CHIRURGICA 2 EXPERIENCE OUTCOME

33. IATROGENIC BILIARY INJURIESSTEWART-WAY II

34. IATROGENIC BILIARY INJURIESSTEWART-WAY II

35. IATROGENIC BILIARY INJURIES P.O. CHOLANGIOGRAPHY (+10 D) AFTER HEPATICOJEJUNOSTOMY

36. IATROGENIC BILIARY INJURIESSTEWART-WAY III

37. IATROGENIC BILIARY INJURIESSTRATEGIES TO PREVENT BDI DURING LC • CAREFUL DISSECTION AND IDENTIFICATION OF STRUCTURES BEFORE TRANSECTION IS THE BEST MEANS OF A FAVORABLE OUTCOME Meticulus dissection of the triangle of Calot to estabilish the “critical view of safety” before the division of any structures: when the cystic duct and cystic artery are clearly seen, safe clipping and division can be performed Dissection of the cystic duct–common duct junction The role of intraoperative colangiography during cholecystecomy is controversial, but is an effective means to delineate the biliary anatomy.

38. IATROGENIC BILIARY INJURIES McPartland, Surg Clin N Am 2008 "...whenever the anatomy of the triangle of Calot cannot be clearly defined, conversion to an open procedure is indicated and should not be viewed as a failure or a complication."