Bile Duct Injury (BDI) and timing of repair (Ιατπογενείρ κακώσειρ εξωηπατικών χοληυόπων)

Bile Duct Injury (BDI) and timing of repair (Ιατπογενείρ κακώσειρ εξωηπατικών χοληυόπων) Ε Φελέκουρας. Αν. Καθ Χειρουργικής, ΕΚΠΑ

ΧΕΙΡΟΤΡΓΟ ΜΕΣΑ ΑΠO ΣΡΑΤΜΑ ΧΟΛΗΦΟΡΩΝ 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 2

Pt. post BDI 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 3

Remember Sicklick JK et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005 May;241(5):786-92; discussion 793-5. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 4

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 5

critical window of safety and common error traps 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 6

7 Lessons 1. What is the steady state of BDI rate? 2. Why is the Lap Chole BDI rate higher? 3. Intraop danger cues (video)? 4. Role of IOC? 5. Best repair? 6. When to do the repair? 7. What to do when it happens? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 7

1. What is the steady state of BDI rate? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 8

What is the steady state of BDI rate? Roslyn JJ et al. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. 1993 Aug;218(2):129-37. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 9

What is the steady state of BDI rate? Wu YV, Linehan DC. Bile duct injuries in the era of laparoscopic cholecystectomies. Surg Clin North Am. 2010 Aug;90(4):787-802. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 10

What is the steady state of BDI rate? Björn Törnqvist et al. BMJ. 2012; 345: e6457 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 11

2. Why is the Lap Chole BDI rate higher? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 12

Why is the Lap Chole BDI rate higher? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 13

Why is the Lap Chole BDI rate higher? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 14

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 15

but this one you can not do it Felekouras E, et al. South Med J. 2007 Mar;100(3):317-20. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 16

5. Best repair? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 17

Which BDI repair is best? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 18

Which BDI repair is best? Sicklick JK et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005 May;241(5):786-92; discussion 793-5. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 19

Radiology *Misra S et al. Percutaneous management of bile duct strictures and injuries associated with laparoscopic cholecystectomy: a decade of experience. J Am Coll Surg. 2004 Feb;198(2):218-26. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 20

Radiology Sicklick JK et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005 May;241(5):786-92; discussion 793-5. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 21

ERCP?? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 22

What is the best timing for BDI repair? Sicklick JK et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005 May;241(5):786-92 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 23

What is the best timing for BDI repair? Injuries repaired in the intermediate period (between 72 hours and 6 weeks) were associated with a high rate of biliary strictures (9 of 34 [26%]) in 69 BDI injuries. compared with immediate ( < 72 hrs.) or late repairs (>6 weeks) Sahajpal et al Arch Surg. 2010;145(8):757-763 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 24

Key points (early or late or whenever) 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 25

Diagnosis 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 MRCP: sensitivity 85-100% gold standard before surgical repair 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 26

MRCP, MRI 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 27

PTC and PTCD 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 28

ERCP??? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 29

Fistulography 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 30

Vascular Injury The presence of hepatic arterial injury is a predictor of poor outcome of BDI repair Patients with biliary and vascular injuries may even require liver resection or transplantation 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 31

Classification 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 32

My Classification No classification system is universally The optimal management depends on 1. Leaks from cystic duct stump or small ducts in liver bed 2. Partial CBD/CHD wall injuries 3. Complete CBD/CHD transection 4. Right/left hepatic duct or sectoral duct injuries 5. Bile duct injuries associated with vascular injuries timing of recognition of injury the extent of bile duct injury the patient s condition the availability of experienced hepatobiliary surgeons. Complex bile duct injuries are defined as injuries of the common bile duct or its tributaries that require a circumferential anastomosis as a presumed definitive repair. According to the Strasberg classification, injuries of this type are included in groups E and D. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 33

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 34

INITIAL GOAL CONTROL OF SEPSIS CONTROL ONGOING BILE LEAK 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 35

Bile Leaks and Sepsis Drain Now, Fix Later (late repair) 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 36

PTCD 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 37

Any suspect of BDI? study the biliary anatomy COLANGIOGRAPHY (PTC / ERCP) YES successful repair in 96-98% NO unsuccessful repair in 98% Endoscopic treatment of post-surgical bile duct injuries: long term outcome and predictors of success Gut 2007;56:11 1599-1605 Wald, Surg Clin N Am 2008 Lillemoe, Br J Surg 2008 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 38

MANAGEMENT LONG-TERM GOAL RE-ESTABILISHMENT OF BILE FLOW INTO THE GI TRACT PREVENT STRICTURE PREVENT LIVER INJURY PREVENT CHOLANGITIS PREVENT STONE FORMATION 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 39

Early vs. Late repair No prospective, controlled, randomized trial (evidence level 1) and is not going to be conducted whether an early repair is better than a late one.. The timing of the operative repair should be individualized EAES guidelines for BDI. Surg Endosc (2012) 26:3003 3039

IMMEDIATE 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 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 41

Immediate vs early Is there a higher success rate for injuries identified at the index operation(lc)? No??? 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 42

But for expert surgeons The best chance injuries detected during surgery. Most surgeons unable to do the repair. call on a surgeon with the needed expertise for this type of operation. the patient should be referred to a capable unit with radiologists, endoscopists, and surgeons. A successful outcome.in a unit experienced in the management of biliary injury. In selected patients, early repair within the first 2 weeks resulted in a similar outcome to that of delayed repair. Thomson et al Br J Surg. 2006 Feb;93(2):216-20. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 43

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 44

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 45

Use It 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 46

112 (56%) patients were repaired by specialist hepatobiliary surgeons timing of repair: immediate, n = 28; early (<21 days), n = 43; and late (>21 days) n = 41 45 (22%) underwent repair by nonspecialist surgeons before specialist referral immediate, n = 16; early, n = 26 and late, n = 03. Outcomes after immediate and early repairs were comparable to late repairs when performed by specialists recurrent cholangitis:11%, 12%, and 10%; P = 0.96, NS; re-stricture:18%,5%, and 29%; P = 0.01; nonsurgical intervention: 14%, 5%, and 24%; P<0.03; redo surgery: 4%, 2%, and 5%; P = 0.81, NS; overall morbidity: 21%, 14%, and 39%; P<0.02]. CONCLUSIONS Early and immediate (< 21 days) repair have an equally good or better long-term outcome when performed at a specialist HBS center compared to On injuries multivariate that are analysis, repaired immediate late. and early repairs done by nonspecialist surgeons A delay in were referral independent to a specialist risk factors team (P < and 0.05) the for presence of associated vascular injuries contribute to adverse overall morbidity. Immediate assistance sought from HBS or early referral.that continues recurrent cholangitis [50% and 27%], re-stricturing (75% and 61%), to be redo the reconstructions drawback (31% of laparoscopic and 61%), and cholecystectomy. overall morbidity (75% and 84%). Perera et al Ann Surg 2011;253:553 560) 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 47

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 48

DELAYED SURGICAL REPAIR unstable patient with sepsis Water and electrolytic imbalance, it is wise to postpone the repair until a more stable condition is achieved. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 49

Median time to surgery 5,63 days in the early group 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 50

Early vs. Late repair No universal recommendations so far EAES guidelines for BDI. Surg Endosc (2012) 26:3003 3039 I prefer early if possible If not > 3 months 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 51

Survival in patients after cholecystectomy, in relation to no injury and early and delayed detection of bile duct injury 51.041 Chole BMJ. 2012; 345: e6457 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 52

Case report 48 yrs. Female 120 kg BW 8 kids Lap Chole Intraoperative bleeding Conversion Hemostasis finishing cholecystectomy Discharge on the 3 rd post op day, γgt 45 6 months later Jaundice Increased γgt 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 53

PTCD 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 54

PTC-ERCP (rendezvous), Sepsis 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 55

Angio-DSA, 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 56

PTCD, Dilatation 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 57

Surgery 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 58

Surgery 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 59

Surgery 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 60

Tips and Tricks 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 61

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 62

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 63

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 64

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 65

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 66

Hepatotomy S4 and 5 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 67

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 68

Σεχνική Δημιουργία της βλεννογόνο-βλεννογόνο εντερικής θέσης 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 69

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 70

Clockwise Hepaticojejunostomy combine with Kasai procedure (portoenterostomy) for vasculobiliary duct injury 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 71

Clockwise Hepaticojejunostomy combine with Kasai procedure (portoenterostomy) for vasculobiliary duct injury 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 72

Clockwise Hepaticojejunostomy combine with Kasai procedure (portoenterostomy) for vasculobiliary duct injury Follow up MRI MRCP 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 73

Follow up MRI MRCP 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 74

Felekouras E., Petrou A. et al. Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A dilemma looking for an answer. A single center 20 years experience (median follow-up of 93 months) Α' Βραβείο ζηο 10 o Σσνέδριο ηης EHPBA ζηο Belgrade, Servia 29-31 Μαΐοσ 2013 Submitted for publication in Hepatobiliary & Pancreatic Diseases International Patients (92) and BDI characteristics Age Mean( range) 53(33-83) Gender, n (%) Male 42(45.7) Female 50(54.3) LC performed to, n (%) Our unit 21(22.8) Others units 71(77.2) Presenting symptoms, n (%) Diagnosis during LC 22(23.9) Bile leak 20(21.7) Biloma 13(14.1) Biliary peritonitis 5(5.5) Cholangitis 11(12) Obstructive jaundice 21(22.8) Type of injury according to Strasberg classification, n (%) Type A 7(7.6) Type B 0(0) Type C 4(4.3) Type D 18(19.6) Type E 63(68.5) E1 10(10.9) E2 26(28.3) E3 22(23.9) E4 4(4.3) E5 1(1.1) 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 75

Definite management of BDI according to their type. Strasberg Classification of Bile Duct Injuries (n = 92) Type Description No. Patients (%) Type A Type B Type C Type D Type E E1 E2 E3 Bile leak from cystic duct stump or the gallbladder bed Right segmental duct division where both ends are clipped Right segmental duct division where the hepatic end remains open Lateral wall injury to Conservative (wait and see) Management Drainage PTC ERCP Bile duct repair Reconstruction (HJ) 7 2 1 1 3 0 0 0 0 0 0 0 0 0 4 1 1 2 0 0 0 the common bile duct 18 0 0 3 4 7 4 Major CBD division/stricture with 5 subdivisions Site of CBD division is > 2 cm from the bifurcation Site of CBD division is < 2 cm from the bifurcation Site of CBD division is 63 0 0 0 0 9 54 10 0 0 0 0 4 6 26 0 0 0 0 3 23 at the bifurcation 22 0 0 0 0 2 20 E4 Division or injury to the left, right or both 4 0 0 0 0 0 4 hepatic ducts E5 An injury of a right segmental duct along 1 0 0 0 0 0 1 10/12/2013 with a type E3/E4 injury Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 76 Total 92 3 2 6 7 16 58

Surgical Management of Bile Duct Injuries (n = 67) Patients operated by HBS(%) Total (74) Bile duct repair (16) HJ Reconstruction (58) Patients operated by non-hbs(%) Patients operated by HBS(%) Patients operated by non-hbs(%) Patients operated by HBS(%) Patients operated by non-hbs(%) Early (<2 weeks) Repair or Reconstruction 32(57.1) 7(38.9) 3(100) 6(46.2) 29(54.7) 1(20) Intermediate(2-12 weeks) Repair or Reconstruction 0(0) 11(61.1) 0(0) 7(53.8) 0(0) 4(80) Late (>12 weeks) Repair or Reconstruction 24(42.9) 0(0) 0(0) 0(0) 24(45.3) 0(0) Total 56(100) 18(100) 3(100) 13(100) 53(100) 5(100) HBS: specialized Hepatobiliary surgeons Non-HBS: non-specialized Hepatobiliary surgeons 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 77

Summary of Long-Term Outcomes After Surgical Intervention to BDI Results by Surgeon Group Non-HBS(18) HBS (56) Total(74) Significance Stricture, no (%) 11(61.1) 11(19.6%) 22(29.7) 0.001 Severe Recurrent Cholangitis, no (%) 4(22.2) 7(12.5%) 11(14.9) 0.445 Intervention/dilation, no (%) 10(55.6) 11(19.6%) (all t-tube and post 2 nd surgery) 21(28.4) 0.003 Redo reconstruction, no (%) 5(27.8) 0(0%) 5(6.8) 0.001 Overall long-term morbidity, No (%) 15(83.3) 15 (26.8%) 30(40.5) <0.001 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 78

Early or Late repair of BDI? Early repair after BDI results in equal long-term outcomes compared with late repair. When performed by specialists. Patients should be referred, as soon as possible after the diagnosis of BDI following laparoscopic cholecystectomy, to tertiary centers possessing the appropriate expertise and experience. HBP Unit 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 79

HBP Unit Pitt H et al. Ann Surg 2013;258:490 499 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 80

Non surgical Treatment in patients with bile duct injury Interventional GI In conclusion, ERCP can be considered a highly-effective therapy in patients with peripheral bile duct leakages bile duct strictures after cholecystectomy. Therefore, should be the first-line therapy (not for diagnosis) used in these patients. Although is less successful in patients suffering from central bile duct leakages Only in patients with a structural deficit of the hepatic duct or common bile duct we do recommend surgical management (which is the case) Weber A. et al. J Gastroenterol Hepatol. 2009;24(5):762-769. Interventional Radiologist PTCD allow definitive treatment of certain types of injuries and may be the only options for treating injuries in patients who are poor surgical candidates. Most major bile duct injuries ultimately require surgical biliary reconstruction, which provides excellent long-term outcomes overall, particularly when combined with percutaneous interventions to optimize the patient s condition preoperatively and to manage postoperative complications Thompson M. et al RadioGraphics 2013; 33:117 134 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 81

What to do when it happens? Do not panic Control sepsis Drainage of abscess/collections Control biliary leak Refer to tertiary center for early or late repair 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 82

Pay attention Melton GB et al. Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life. Ann Surg. 2002 Jun;235(6):888-95. 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 83

10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 84

So, everyone can to come to the Party

Survival in patients after cholecystectomy, with and without bile duct injury Björn Törnqvist et al. Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ. 2012; 345: e6457 51.041 Chole Björn Törnqvist et al. BMJ. 2012; 345: e6457 10/12/2013 Α ΧΕΙΡΟΤΡΓΙΚΗ ΚΛΙΝΙΚΗ ΕΚΠΑ, ΠΓΝΑ ΛΑΙΚΟ, Δ/ντής Καθ X. ΣΙΓΚΡΗ 86