Websurg, e-Surgery 關於腹腔鏡手術

Clinical Case

COMMON BILE DUCT (CBD) INJURY

F Jamali, MD, J Marescaux, MD, PhD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Summary

CBD injuries represent the most serious complication of laparoscopic cholecystectomy. This case illustrates a delayed recognition of a CBD injury. It discusses and illustrates the diagnostic and therapeutic approaches to this problem.

2. Patient

74-year-old man

3. Past medical and surgical history

- partial thyroidectomy for hyperactive thyroid nodule;
- atrial arrhythmias treated medically;
- known cholelithiasis.

4. History of present illness

The patient presents with a history of several attacks of typical biliary colic over the course of the preceding months. One such attack was associated with mild jaundice and a slight elevation of total and direct bilirubin levels as well as elevation of liver enzymes and alkaline phosphatase, in the absence of fever or hyperleukocytosis.
The patient recovered uneventfully with simple medical therapy. Notably, no ERCP was performed at the time. Ultrasonography had confirmed thickening of the gallbladder wall and cholelithiasis with a normal biliary tract.

5. Clinical progression

The patient undergoes an "uneventful" laparoscopic cholecystectomy at an outside hospital.
The operative report describes intraoperative findings of mild cholecystitis. An intraoperative cholangiogram is performed and interpreted as normal.
Pathologic examination of the gallbladder confirms chronic cholecystitis.

The immediate postoperative period is marked by:
1. Urinary retention requiring placement of an in-dwelling urinary catheter;
2. Supraventricular tachy-arrhythmias requiring medical therapy;
3. Progressive jaundice, starting on the first postoperative day.

6. Laboratory values

AST: 111 UI/l (9-38)
ALT: 162 UI/l (12-50)
Bilirubin: 262.8 mmol/l (3.4-20.5)
Conj. bilirubin: 183.1 mmol/l (1.7-6.8)
Alk. phosphatase: 201 UI/l (41-117)
Gamma GT: 166 UI/l (11-85)

7. Workup

Ultrasonography: no intrahepatic biliary ductal dilatation, no subhepatic collections.
MRCP: interpreted as showing 2 points of obstruction in the CBD, compatible with retained stones.

8. Chest X-Ray and flat abdominal plate

These radiographs present findings pathognomonic of a CBD injury.

Figure 8.a

Figure 8.b

Figure 8.c

Figure 8.d

QUIZ: What is this classic finding?
1) Free air under the diaphragm
2) Ileus
3) Left lower lobe atelectasis
4) Excess clips in the right upper quadrant
Correct answer:
4) Excess clips in the right upper quadrant

9. ERCP

The patient was referred for an ERCP because of a suspicion of retained stones.
The ERCP pictures below demonstrate the guide wire reaching an obstruction at the level of the lowermost clip, which appears to be placed on the CBD.

Figure 9

10. MRCP

Upon further review, the MRCP images reveal classic findings of a CBD injury with a missing segment of CBD.

Figure 10.a

Figure 10.b

11. Clinical progression

The patient is referred to our center on the 7th postoperative day for further treatment. He is medically stable. After proper ressuscitation, a decision to proceed with an immediate operative exploration is made.
Intraoperative findings confirm the injury to the CBD with a missing 2 cm segment of common bile duct. The proximal hepatic duct is slightly dilated at 7 mm. A Roux-en-Y hepatico-jejunostomy is performed over a T-tube.
The patient recovers uneventfully.

Figure 11.a

Figure 11.b

Figure 11.c

12. Discussion

Bile duct injury represents the gravest complication of laparoscopic cholecystectomy. Risk factors for CBD injuries include the surgeon's learning curve, acute cholecystitis, misidentified anatomy, misinterpreted or incomplete cholangiography, anatomical abnormalities and excessive bleeding.
The most common mechanism for CBD injury is the misidentification of the CBD for the cystic duct during the dissection. This injury is associated with a loss of substance of a portion of the CBD and is often associated with a right hepatic artery injury. It accounts for 67% of cases of CBD injury following laparoscopic cholecystectomy.
Several variations of this injury along with other mechanisms have also been described. (Please refer to the biliary tract injury chapter of the World Virtual University for further details on these injuries and their mechanisms.)
Intraoperative cholangiography has been credited with a decrease in the severity of CBD injuries as it may allow early detection of such an injury before the CBD is completely transected. The case at hand illustrates the classic CBD injury. Rapid recognition and proper operative planning resulted in a good outcome, at least in the short-term, in this case.

13. References

Asbun HJ, Rossi RL, Lowell JA, Munson JL. Bile duct injury during laparoscopic cholecystectomy: mechanism of injury, prevention, and management. World J Surg 1993;4:547-51.
Bismuth H, Lazorthes F. 83rd Congress of the French Surgical Society (Paris, Sept 21-24, 1981). Second report. Operative injuries of the common biliary duct. J Chir 1981;10:601-9.
Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ et al. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiographie: a population-based study. Ann Surg 1999;4:449-57.
Kum CK, Chua TE. Management of acute cholecystitis in the era of laparoscopic surgery. Ann Acad Med Singapore 1996;5:640-2.
Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 1995;10:1123-8.
Strasberg SM, Hertl M, Soper NJ. An anlysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;1:101-25.
Woods MS, Traverso LW, Kozarek RA, Donohue JH, Fletcher DR, Hunter JG et al. Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiographie. Surg Endosc 1995;10:1076-80.

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