iatrogenic bile duct injury
Introduction
Introduction to iatrogenic bile duct injury Iatrogenic bile duct injury refers to an accidental bile duct injury during surgery, usually an extrahepatic bile duct injury. Mainly seen in biliary tract surgery, especially cholecystectomy, in addition to major gastrectomy, liver rupture repair, liver resection can also occur, the occurrence of bile duct stricture after liver transplantation has also been reported. basic knowledge The proportion of illness: 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: biliary peritonitis abscess cholangitis sepsis
Cause
Etiology of iatrogenic bile duct injury
(1) Causes of the disease
Moorhead found from 958 cases of bile duct stenosis that 34% of patients with surgical injury were due to intraoperative bleeding and blind clamp ligation; 22% were due to triangulation of gallbladder or local inflammation; 21% were due to gallbladder The general canal was ligated; 5% occurred in the more difficult partial gastrectomy. Liang Lijian reported 20 cases of bile duct injury, except 1 case occurred in emergency surgery, and another case of local adhesion was unclear in LC, other bile duct injuries occurred. In the case of normal anatomy, the difficulty is not great, such as a case of hemorrhagic fluid drained by T-tube, laparotomy for common bile duct hemorrhage, postoperative T-tube angiography revealed a narrow distal stenosis, and another case of cholecystectomy When the fine needle was punctured through the common bile duct, there was no T-tube drainage leading to postoperative bile leakage. In 2 cases, due to intraoperative small blood vessel hemorrhage, the suture was sutured to stop the hepatic duct, and the right hepatic duct caused biliary peritonitis. Johnston The cause of bile duct injury is attributed to three points: dangerous pathology, dangerous anatomy, dangerous surgery, that is, anatomical factors, pathological factors and technical factors.
Anatomical factor
The trigeminal variation of the gallbladder is very common, mainly the appearance of the right accessory hepatic duct, the abnormality of the junction of the cystic duct and the extrahepatic bile duct, etc. If the incarceration of the stone increases the complexity of the anatomy, in addition to the variation of the bile duct, the hepatic artery and There are abnormal branches in the portal vein. It is easy to cause bleeding during the operation. The anatomy of the gallbladder triangle in the blood pool is easy to cause bile duct injury. Therefore, it is the key to successful bile duct mutation.
2. Pathological factors
Such as acute suppurative cholangitis, gangrenous cholecystitis, chronic atrophic cholecystitis, Mirizzi syndrome, gallbladder and surrounding tissue edema, congestion, inflammation, internal hemorrhoids make the normal anatomical relationship difficult to identify, increasing the difficulty of surgery, At the same time, it also increases the possibility of accidents. In addition, chronic duodenal ulcers are caused by inflammation of the surrounding tissues, anatomical variation of the liver and duodenum, shortening of the distance between the bile duct and the ulcer, and may damage the bile duct or even damage the portal vein during the major gastrectomy. .
3. Technical factors
The surgeon's experience and serious attitude are an important factor in the success of cholecystectomy. In addition, intraoperative anesthesia, intraoperative illumination, exposure, and patient obesity are factors that affect the success of the operation.
In addition to the above reasons, the technical conditions of the laparoscopic instrument itself are also potential risk factors. First, the surgeon is affected by the image of the two-dimensional camera system, and the visual field is not clear. The second operation is only done by the instrument, and cannot be used. Hand touch, lack of experience, in addition to the light source and lens from bottom to top, when the gallbladder is pulled to the right side of the head, the gallbladder neck will block the Calot triangle, so that the angle between the cystic duct and the common bile duct becomes smaller, and the common bile duct is easily mistaken. It is considered that the cystic duct is ligated, the cystic duct is thick or short, or it is more likely to occur in parallel with the common bile duct. In addition, delayed high bile duct stricture after LC is also common, and the electric heating of the extrahepatic bile duct is caused by the use of electrocautery and electrocoagulation. Damage related.
(two) pathogenesis
According to the time of injury
Divided into early bile duct injury, advanced bile duct stricture.
(1) Early bile duct injury: refers to a series of clinical manifestations related to bile duct injury occurred during or after discharge. The intraoperative findings of bile duct injury such as bile extravasation in the field, bile duct opening, and bile duct ligation are compared. Rarely, the vast majority of bile duct injuries are found during the post-operative return to the ward. Because of the early detection, it is generally easier to handle and the prognosis is better.
(2) Late biliary stricture: the general symptoms appear late, mostly bile duct stricture, most of the lesions are related to local biliary ischemia, or local tissue inflammatory changes after bile leakage, connective tissue hyperplasia, biliary stenosis gradually occurs, from bile duct Wall injury to local stenosis usually takes 3 months to 1 year, sometimes even 3 to 5 years, manifested as progressive jaundice, recurrent cholangitis, difficult diagnosis, more complications of repair surgery, high mortality, treatment The effect is not satisfactory.
2. According to the characteristics of the damage
Divided into bile leakage bile duct injury, obstructive bile duct injury, hypothalamic hypotube false injury.
(1) bile leakage bile duct injury: bile duct tear caused by various reasons, transverse, necrotic perforation and cystic duct stump leakage, if bile leakage is obvious, can be found during surgery, if the leakage is small or the surgeon Neglected, the patient was suspected of biliary peritonitis within a few days after surgery.
(2) obstructive bile duct injury: including miscarriage of extrahepatic bile duct and para-right hepatic duct, misfolding (transverse or partial transection), mechanical injury, electrical burns during LC can cause local ischemia and lead to secondary Sexual biliary stricture, most of the symptoms occurred several months after surgery, and the patient showed symptoms such as progressive jaundice and recurrent cholangitis.
(3) false common tract injury at the lower end of the common bile duct: due to the Bakes dilator in the common bile duct exploration, the common bile duct duodenal pseudo-traumatic injury caused by the lower end of the common bile duct is not easy to confirm during surgery. Local infection ruptures to form biliary duodenal fistula.
3. Classification by injury site
In order to better design the treatment plan and to evaluate the therapeutic effect, Bismuch made the following classifications for the patients with advanced biliary stricture according to the injury site: I was 2 cm away from the beginning of the common bile duct; II was from the beginning of the common bile duct. The distal end is less than 2cm; the left and right hepatic duct junctions; the IV left hepatic duct or the right hepatic duct; and the left and right hepatic duct branches.
The biliary system is the secretory and excretory passage of the liver. It has important physiological functions in connection with the normal communication of the intestine. It is of great significance for digestion and absorption and systemic metabolism. The iatrogenic bile duct injury can be roughly classified as timid and obstructive. Astragalus, 3 types of bile duct stricture after surgery:
1 In the cholecystectomy, the bile duct was partially or completely cut off. After the operation, the localized or diffuse biliary peritonitis was formed due to leakage of the gallbladder. After treatment, it eventually caused the formation of biliary fistula. At the beginning of the injury, the operator did not Attention to careful examination, most of which are not found. This is due to factors such as anesthesia, surgical trauma, etc. during the operation, which temporarily inhibits the excretion of bile from the liver, reduces the pressure of bile secretion, and has only a small amount or no obvious bile outflow at the time of surgery. Without causing the operator's attention, thus losing the opportunity for immediate treatment, when the liver's bile function gradually recovers after surgery, the clinical manifestations of peritonitis or bile overflow from the drainage port;
2 Obstructive jaundice is caused by acute or complicated biliary obstruction caused by clipping or suturing the common hepatic duct or common bile duct in the cholecystectomy. In the early postoperative period, it shows progressive yellowing of the whole body, and there are successive dark yellow urine and gray stool. Related signs such as itching;
3 biliary stricture after surgery, is the result of biliary tract injury in cholecystectomy, symptoms appear slowly, often a few weeks or months after surgery, abdominal pain, intermittent fever, jaundice, with the progression of the disease, in the episode of cholangitis, Astragalus can not be retired, which is often due to injury, leakage of the gallbladder, resulting in intrahepatic bile retention or postoperative drainage, the subhepatic area and the bile duct surrounding tissue due to strong chemical stimulation of bile acid, progressive fibrosis, hyperplasia, resulting in The wall of the bile duct is thickened, the lumen is narrowed, and it is gradually aggravated by the onset of cholangitis.
The hazards caused by these changes are:
1 destroys the connectivity between the gallbladder, leading to digestion, absorption disorders, and the consumption of the whole body;
2 systemic internal environment disorders caused by biliary peritonitis;
3 water and salt caused by the formation of biliary tract, acid-base balance disorder, and because it is a pathological channel that does not directly drain the bile duct, it is easy to cause uncontrollable suppurative cholangitis due to poor drainage, which are caused by patients after injury. The main cause of early death;
4 acute complete biliary obstruction, bile duct stricture after surgery and recurrent biliary tract infections, all lead to liver parenchymal damage, if not treated or treated in time, long-term development into biliary cirrhosis, portal hypertension, treatment is more difficult, The prognosis is also very serious.
Prevention
Iatrogenic bile duct injury prevention
The occurrence of iatrogenic biliary tract injury is often "accidental", caused by a variety of factors, and the important thing is prevention. Its occurrence is not only the deviation of "single time" in surgery, but actually the result of the comprehensive factors of the whole diagnosis and treatment process. In the prevention of biliary tract injury, it is always important to emphasize technical training, technical management and Lectra's rough style. Laparoscopic cholecystectomy (LC) provides a new technical means due to special energy (electrocoagulation, laser The application of microwaves, in addition to the pathological changes after injury, has increased the characteristics of occultity and prolongation, and put forward new requirements for clinical work. Prevention of biliary tract injury is also the primary issue. Safe cholecystectomy should be followed. The following principles:
1. Basic requirements
(1) Preoperative comprehensive diagnosis and full understanding of gallbladder pathology, and develop a more detailed surgical plan.
(2) Arrange the surgeons and assistants who are qualified for the operation.
(3) Choose a suitable surgical incision and have a good exposure.
(4) Always be alert to the possibility of injuring the bile duct, carefully identify the relationship between the gallbladder artery, the cystic duct and the common bile duct, flexibly use the antegrade, reverse the technical operation of the cholecystectomy, obey the rules of not arbitrarily clamping, ligation or cutting any structure. .
(5) Laparoscopic cholecystectomy should be carried out on the basis of certain conditions and training, and the indications should be strictly controlled.
2. In case of accidental bleeding or other events, calm down and properly handle the emergency
In the case of poor or unclear bile ducts, the disorderly hemostasis in the event of accidental bleeding is the two major causes of intraoperative biliary tract injury.
(1) Fully expose the cystic duct, carefully dissect the gallbladder triangle, should first free the cystic duct, lift it with silk thread without ligature and cut it, and finally confirm the anatomical relationship and then ligature and cut it. If the gallbladder triangle adhesion is serious, the cystic duct cannot be distinguished. When the gallbladder artery or common bile duct is used, the method of excision from the bottom of the gallbladder is used.
(2) Do not be busy when bleeding occurs during surgery, require good exposure, see the bleeding point, and properly stop bleeding, such as bleeding, can not see the bleeding site, can not blindly clamp, can pinch the small omentum hole with fingers The proper hepatic artery and portal vein control the bleeding, absorb the blood, and stop the bleeding by the surgeon. At this time, do not have the target clamp in the blood pool. It should be avoided that no one helps to reveal and absorb the blood at this time. Both the surgeon and the assistant went to the busy clamp.
(3) If laparoscopic cholecystectomy, it should be transferred to open surgery in time.
3. For difficult cholecystectomy
Sometimes due to chronic gallbladder inflammation, gallbladder atrophy into a mass, gallbladder triangle anatomical structure is difficult to distinguish, at this time can be cut at the bottom of the gallbladder, the finger in the gallbladder for guidance, downward separation, in order to prevent common bile duct injury, you can directly open the common bile duct, Insert the bake dilator, under its guidance, identify the relationship with the cystic duct, do not blindly separate and cut, if still can not treat the cystic duct, you should perform partial cholecystectomy or subserosal cholecystectomy for safety.
Intraoperative cholangiography or intraoperative B-ultrasound can help to understand the anatomical relationship of the biliary tract and prevent the damage of the bile duct, especially in cases of multiple biliary tract surgery, severe extrahepatic bile duct adhesions, and should be prepared before surgery. .
Complication
Iatrogenic bile duct injury complications Complications biliary peritonitis abscess cholangitis sepsis
If the bile leakage is not controlled, complications will soon appear, which can form biliary peritonitis and abscesses. Continuous cholangitis caused by stenosis can develop into multiple intrahepatic abscesses and sepsis.
Symptom
Symptoms of iatrogenic bile duct injury Common symptoms Abdominal discomfort Abdominal pain Biliary cirrhosis Peritonitis Intestinal paralysis sepsis secondary infection Ascites
Early bile duct injury
(1) bile leakage: more common in the common hepatic duct, hepatic duct, partial or complete severance of the common bile duct, or patients with common bile duct stump leakage, due to intraoperative anesthesia, surgical trauma, the patient's bile secretion is often affected Inhibition, so the incision is less likely to be discovered by the surgeon when the incision is small, and the chance of intraoperative repair is lost. The postoperative patient has biliary ascites, and the abdominal drainage tube has bile-like fluid outflow. If the infection is biliary peritonitis, the abdominal cavity The bile is drained from the drainage tube and needs to be differentiated from the small accessory hepatic duct injury from the gallbladder bed. The small parahepatic tube injury usually stops within 3 to 5 days of bile leakage, and the bile leakage of the bile duct injury is large and lasts for a long time. If the position of the drainage tube is improperly placed, the drainage fails, and the patient often has peritonitis, intestinal paralysis, and severe abdominal abscess.
(2) obstructive jaundice: early progressive progressive jaundice is more common in the common or complete ligation or suture of the common bile duct or common hepatic duct. Patients often feel discomfort in the upper abdomen and the urine is dark yellow.
(3) Common bile duct duodenal fistula: Generally, a large amount of odorous liquid flows out from the T-shaped tube on the 7th day after surgery, containing brownish yellow turbid floc, sometimes even food residue, T-tube drainage As many as 1000 ~ 1500ml, patients often have chills and high fever, but generally do not appear jaundice or only mild jaundice.
(4) Infection: Obstruction of bile duct, poor bile drainage, cholestasis, bacterial infection induces acute infection of biliary tract, abdominal pain, fever, jaundice and other symptoms. Patients with bile leakage also cause diffuse peritonitis and subgingival abscess after secondary infection. Pelvic abscess, etc., and symptoms of poisoning such as intestinal paralysis may occur.
2. Late biliary stricture
Symptoms often appear in the 3 months to 1 year after the first operation, often mistaken for residual stones in the liver, hepatitis, capillary cholangitis, etc., clinically have the following signs.
(1) recurrent biliary tract infection: the pathological basis of advanced biliary stricture is progressive bile duct stricture, resulting in poor drainage and residual bile, which can induce biliary tract infection, severe sepsis, even Charcot pentasis, antibiotics After treatment, it improved, but because the basic pathological basis still exists, often relapse, many patients were mistakenly diagnosed as residual stones in the liver.
(2) obstructive jaundice: bile duct stenosis is a progressive and persistent lesion, generally no jaundice in the early stage, but with the further narrowing of the stenosis, obstructive jaundice, accompanied by progressive aggravation, accompanied by stones, infection The symptoms are more pronounced.
(3) biliary cirrhosis: due to poor drainage for a long time, cholestasis, patients with high pressure in the bile duct, bile leakage into the liver cells after bile duct rupture, resulting in fibrous connective tissue hyperplasia, degeneration and necrosis of liver tissue, and finally Lead to biliary cirrhosis and portal hypertension, clinical manifestations of hepatosplenomegaly, ascites, jaundice, liver damage, coagulation disorders and malnutrition, sometimes patients may have upper digest caused by esophageal varices Big bleeding.
(4) bile duct stones: cholestasis caused by bile duct stenosis, recurrent biliary tract infections are high-risk factors inducing the formation of stones, and the formed stones often cause obstruction and infection, the three are causal, forming a vicious circle, resulting in Repeated episodes of bile duct stones.
Examine
Examination of iatrogenic bile duct injury
In patients with biliary stricture, serum alkaline phosphatase levels tend to increase, serum bilirubin fluctuates with symptoms, but usually stays below 10 mg/dl. When acute cholangitis occurs, blood cultures often show positive results.
For suspicious cases, necessary auxiliary examinations should be performed. Imaging examination plays an important role. Suspicious patients should undergo BUS, CT, percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography. Contrast-enhanced (ERCP), magnetic resonance cholangiopancreatography (MRCP), T-tube cholangiography, etc., to confirm the diagnosis, BUS, CT as a non-invasive examination, to understand the liver morphology, degree of hepatic bile duct expansion, scope and presence or absence The signs of stones, but limited application when there is scar formation around the bile duct, ERCP is a less invasive contrast method, the contrast agent is retrogradely injected into the biliary system through the Vater ampulla, which can clearly understand the internal biliary tract. Structure, the disadvantage is that only the area below the obstruction can be understood. In patients who have undergone major gastrectomy and biliary drainage, PTC is the best radiological examination for bile duct injury. The bile duct above the stenosis is fully displayed, fully understand the bile duct condition above the obstruction, and can reduce the yellowing of patients with jaundice by percutaneous transhepatic catheter drainage (PTCD), improve the patient's preoperative condition, but acute Cholangitis is contraindicated, and can cause bile leakage, bleeding, and small bile duct puncture is not easy to succeed. Some authors emphasize that patients with bile duct injury must undergo PTC examination before surgery. MRCP, ie, magnetic resonance cholangiopancreatography is a A new type of examination, which is a three-dimensional image, can show the location of bile duct stenosis, the degree of bile duct dilatation and whether or not stones are combined. Because of the simple operation, non-invasiveness has the tendency to replace PTC and ERCP. Dwerry-House et al believe that MRCP can be reduced by 3/ 4 patients with unnecessary ERCP examination, T-tube angiography using the T-tube or abdominal wall sinus sinus left after the previous surgery, can show bile duct lesions but not adequate display of intrahepatic bile duct, before reoperation of bile duct stricture Selective hepatic angiography can understand the blood supply of the bile duct and improve the success rate of reoperation.
Diagnosis
Diagnosis and diagnosis of iatrogenic bile duct injury
diagnosis
It is best to diagnose the bile duct injury immediately and to treat it in time, thus avoiding a series of complications involving biliary, liver, intra-abdominal and systemic. Czerniak reported that 49%-90% of the cases were not obtained at the time of injury. Intraoperative diagnosis, Shi Jingsen and other reports only 37.5% of cases were diagnosed during surgery, and most patients were still found in the back to the ward after surgery, so to improve the understanding of the risk of cholecystectomy, intraoperative gallbladder specimens After resection, it should be done regularly:
1 review the relationship between the common hepatic duct, cystic duct, and common bile duct;
2 check for bile extravasation;
3 Anatomical gallbladder specimens to determine whether there is bile duct injury. For patients with suspicious intraoperative, intraoperative cholangiography or intraoperative BUS should be performed to assist diagnosis. Although intraoperative cholangiography has certain risks, it can be obvious. To reduce the incidence of bile duct injury, LC patients should be transferred to open surgery in time, and there must be no luck.
Consideration should be given to the possibility of bile duct injury in the following situations:
1 In the operation, hepatic duodenal ligament was found to be yellow-stained, or after washing the gallbladder with clean gauze, there was yellow staining;
2 obstructive jaundice after upper abdominal surgery;
3 after cholecystectomy, repeated episodes of chills, high fever, jaundice and other symptoms of bile duct inflammation, exclude stones and other causes;
4 jaundice appeared 24 to 48 hours after cholecystectomy, or a large number of bile extravasation lasted for more than 1 week;
5 patients after biliary tract surgery, repeated biliary tract infection or obstructive jaundice, with the prolongation of the course of biliary cirrhosis, portal hypertension;
6LC intraoperative examination of the resected gallbladder specimen has a double tube structure.
Differential diagnosis
Common bile duct stones must first be differentiated from biliary stenosis because clinical and laboratory findings can be the same. The history of bile duct injury suggests that the most likely diagnosis is biliary stenosis, and the final identification must be determined by X-ray or surgery. , THC and ERCP examinations should be the means of diagnosis, and some patients should also rule out other causes of cholestatic jaundice.
