Benign Biliary Strictures Flashcards
What is the rate of CBD injury during laparoscopic cholecystectomy?
0.4-0.6% following lap chole and 0.2-0.3% following open cholecystectomy
What is the most common cause of lap chole-induced bile duct injury?
Exaggerated cephalad retraction of the gallbladder fundus
True/False. Routine IOC has been proven to prevent bile duct injury during laparoscopic cholecystectomy.
FALSE
What is a Bismuth level I CBD injury?
transection of CBD with a common hepatic duct stump >2cm
What is a Bismuth level II CBD injury?
transection of CBD with a common hepatic duct stump <2cm
What is a Bismuth level III Bile Duct injury?
hepatic duct stricture with preserved ductal continuity
What is a Bismuth level IV Bile duct injury?
Disruption of the hepatic duct confluence
What is a Bismuth level V Bile duct Injury?
transection of the right sectoral duct
What changes occur to the liver parenchyma with chronic biliary obstruction?
segmental atrophy and fibrosis; rotation of hepatic parencyma and ductal structures toward the injured lobe.
If a CBD injury is identified intraoperatively, what is the first step to repair?
Define the anatomy - IOC
What is the appropriate treatment for partial laceration of the CBD?
Primary repair over T-tube
What is the appropriate treatement for CBD transection?
Primary repair UNLESS cautery or clip was used to transect
What is the appropriate treatment for CBD transection if primary repair is contraindicated?
Kocher maneuver, end-to-end single layer interrupted fine caliber absorable suture repair + T-tube OR Roux-en-y hepaticojejunostomy
What are the contraindications to primary CBD repair after transection?
Tension on repair, high biliary duct injuries, duct excision
True/False. Early post-operative bile leaks where ERCP confirms gastrointestinal continuity of the biliary tree can be treated with ERCP and stent placement alone.
TRUE
What causes prothrombin time abnormalities in patients with bile duct injuries?
Biliary fistulas result in inability to absorb fat-soluble vitamins leading to vitamin insufficiency
What is the typical electrolyte abnormality seen in patients with biliary fistulas?
Hypovolemic hyponatremia
For a bile leak treated with percutaneous drainage and stent placement, how long does the stent remain in place after drainage?
4-6 weeks
What percentage of patients treated for benign biliary stricture with stent placement will have recurrent strictures?
20%
What percentage of patients treated for benign biliary stricture with stent placement have complications?
10-15%
What are some of the complications of treating benign biliary strictures with stents?
bleeding, cholangitis, pancreatitis, stent migration
Where is the blood supply of the bile ducts located in cross sectional orientation?
3 and 9 o’clock, therfore dissection should be anterior with minimal circumferential dissection
When performing dissection to inspect the ductal confluence, in what direction should dissection proceed?
left-to-right
What is the significance of finding the posterior remnant joining the left and right lobar ducts if there is a bile duct injury at the level of the confluence?
It identifies the right lobar duct and allows for singular reconstruction of both ducts
Which lobar duct has the shortest extrahepatic course?
right lobar duct
Which factors portend a favorable outcome after repair of biliary injuries?
younger patient age, Roux-en-Y biliary-enteric reconstruction, absence of infection & hepatic fibrosis, transhepatic stents, and lower number of previous reconstructions
What are the indications for surgical management of benign biliary strictures?
elevated alkaline phosphatase (prevents development of biliary cirrhosis from chronic obstruction), jaundice, hyperbilirubinemia
What are the advantages and disadvantages of performing choledochoduodenostomy for biliary drainage as opposed to choledocho-/hepaticojejunostomy?
advantages - biliary flow continues through duodenum, jejunum left intact; disadvantages -previous inflammation may leave duodenum fibrotic making mobilization difficult
What is the treatment of choice in a patient with suspicious distal CBD stricture, abdominal pain due to chronic pancreatitis?
Pancreaticoduodenectomy
What is Mirizzi syndrome?
gallstones impacting the neck of the gallbladder inducing narrowing of the common hepatic duct by mechanical compression, inflammation, scarring, necrosis, then fistual formation
True/False. Mirizzi syndrome is a relative contraindication to laparoscopic cholecystectomy.
TRUE
How should a small fistula in a patient with Mirizzi syndrome be treated technically?
open cholecystectomy, open the gallbladder - leave wall of GB on CHD, close small fistula along its horizontal axis
How should a large fistula in a patient with Mirizzi syndrome be treated technically?
open cholecystectomy, Roux-en-Y hepaticojejunostomy reconstruction
