Dit

Figure 4.8. Leak from cystic duct remnant with CBD stone. (A) Postoperative ERCP film from a recent cholecystectomy showing extraluminal contrast medium extending from the cystic duct remnant. A stone is present with CBD. (B) Same patient showing contrast medium accumulating in the drain.
Figure 4.9. Leak from cystic duct remnant with choledocholithiasis and CBD stricture. Cholangiogram performed via an external biliary drainage catheter shows leakage of contrast medium from the cystic duct remnant, a stone in the CBD, and a stricture of the distal CBD due to pancreatitis.

Biliary leakage may also be secondary to inadvertent transection of the common duct or an accessory bile duct. Transection of the common duct can occur if a segment of the common hepatic duct is mistaken for the cystic duct and is excised along with the gallbladder (Fig. 4.10). Under this circumstance, the proximal duct lies free and the distal portion is clipped. ERCP will demonstrate only the distal portion of the distal system (Fig. 4.11) Percutaneous transhepatic cholangiography

Figure 4.10. Common duct injury. The common duct was mistaken for the cystic duct and excised along with the gallbladder.

FIGURE 4.11. Common duct injury. (A) Film from an ERCP shows the common duct to be clipped. (B, C) CT scan on the same patient demonstrates fluid due to bile leak from the proximal duct in the gallbladder fossa and subhepatic and right subphrenic spaces. (D) Sonogram in the same patient showing the fluid collection in the gallbladder bed. (E) Filling of the collection with communication to the biliary tree in the same patient upon injection of contrast medium via and drainage catheter.

FIGURE 4.11. Common duct injury. (A) Film from an ERCP shows the common duct to be clipped. (B, C) CT scan on the same patient demonstrates fluid due to bile leak from the proximal duct in the gallbladder fossa and subhepatic and right subphrenic spaces. (D) Sonogram in the same patient showing the fluid collection in the gallbladder bed. (E) Filling of the collection with communication to the biliary tree in the same patient upon injection of contrast medium via and drainage catheter.

Figure 4.11. (Continued)
Figure 4.11. (Continued)
Figure 4.12. Biliary injury. Film from a cholangiogram via an external biliary drainage catheter reveals obstruction at the level of the bifurcation of the left and right intrahepatic ducts due to bile duct injury during cholecystectomy.

(PTC) is generally necessary to identify the proximal ducts and to provide important information for planning therapy (Fig. 4.12). Inadequate identification of the junction of the cystic duct and common duct may lead to tenting, ligation, or partial excision of a segment of common duct when the gallbladder is removed [31]. Simple lacerations can be successfully repaired after conversion to open technique. These injuries to the common duct occur more frequently with LC than with conventional cholecystectomy because visualization of the portal triad is more limited with LC. Deziel and others state that bile duct injuries during LC are best avoided by maintaining a low threshold for conversion to open cholecystectomy in cases where the anatomy cannot be precisely delineated [24]. Unrecognized Mirizzi syndrome can also lead to inadvertent ligation of the common bile duct.

Moossa et al. [25] identified four ways in which the bile duct may be injured at the time of cholecystectomy:

Ligating or transecting the wrong duct

Occluding the lumen of the common duct during "flush ligation" of the cystic duct

Excessive dissection to "expose" the common duct, with compromise of the blood supply and subsequent ischemic stricture Trauma to the common duct during common duct exploration by forceful manipulation or "dilatation"

Common duct perforation may occur secondary to technical problems during T-tube placement. Blind clamping of bleeding vessels may lead to common duct injury as well.

Anatomic variants are commonly found in the biliary tree, some of which predispose patients to bile duct injury. An accessory right hepatic duct, coursing along the gallbladder fossa draining into the extrahepatic biliary tree or cystic duct, is present in approximately 2 to 3% of the population. Anomalous ducts may be ligated, transected, or torn during extraction of the gallbladder, and subsequent bile leakage may ensue. Such anomalies may not be appreciated at the time of surgery, particularly if inflammatory changes are present. Since there is less exposure of the common duct with LC than with open cholecystectomy, there is an increased risk of this type of injury. For this reason, as well as others, some advocate preoperative ERCP, magnetic resonance cholangiopancreatography (MRCP), or intraoperative cholangiography to identify any unusual anatomical features.

Clinically, bile leaks usually present with shoulder pain, abdominal pain, bloating, leukocytosis, and fever with mildly elevated bilirubin and transaminase levels, or bilious drainage from a drain, if present. Bile collections usually accumulate in the gallbladder fossa and in the subhepatic and right subphrenic spaces, but bile can accumulate in other locations as well, such as the cul-de-sac.

"Biloma" is the term used to describe an encapsulated bile collection. Biloma may be treated with percutaneous drainage. Bile peritonitis, which may result when bile leakage is rapid and not contained by peritoneal adhesions, can be a cause of postoperative mortality [20]. Bile increases the permeability of the peritoneum and causes exudation of fluid, which if not recognized and treated may lead to fluid and electrolyte imbalance, hypotension, and oliguria. Bile peritonitis may be identified on CT imaging by ascites associated with engorged mesen-teric vessels and diffuse inflammatory changes [32]. CT imaging and sonography are sensitive for identification of fluid collections; however they cannot usually differentiate between a postoperative seroma, lym-phocele, hematoma, abscess, or bile leak, and CT and sonography are unable to determine the precise site of leakage in most cases (Fig. 4.13). Hepatobiliary scintigraphy is specific for bile leak, demonstrating the so-called choleperitoneum unless the leak has sealed at the time of the study, but owing to poor anatomic resolution it is not precise in determining the site of leakage (Fig. 4.14). ERCP is generally necessary for this purpose.

Figure 4.13. Biliary leak. CT scan of the upper abdomen shows fluid around the liver from biliary leak. The exact etiology cannot be determined on CT imaging.
Figure 4.14. Biliary leak on DISIDA scan: "choleperitoneum." Radiotracer is seen to accumulate in the peritoneal cavity in this patient with a biliary leak.

Biliary obstruction may develop if the common duct is ligated but not transected (Fig. 4.15). These patients will present with progressive obstructive jaundice. Postoperative jaundice may be secondary to ligated ducts, retained stones, or biliary leak with peritoneal absorption of bile. Differentiation of these conditions can be made by ERCP, or ERCP in combination with CT or radionuclide scintigraphy. The consequences of ligation of an aberrant duct will depend on the volume of liver parenchyma drained by the duct. An aberrant right hepatic duct is the most common biliary anomaly [33]. If the segment is small and there is normal liver function, jaundice is unlikely but cholangitis may occur, and isolated dilatation of the posterior segment of the right lobe (usually segment VI) may be identified. In chronic obstruction, segmental biliary cirrhosis may develop along with segmental atrophy. Recognition of a ligated aberrant right hepatic duct can be difficult on cholangiography on account of underfilling.

Figure 4.15. Ligated CBD during cholecystectomy. Film from an ERCP demonstrates abrupt termination of the common duct at the level of the clips due to inadvertent ligation of the duct during cholecystectomy.

Was this article helpful?

0 0

Post a comment