lesion de via biliar

lesiones de vías biliares

DiagnosticHumberto Juárez Rosario

medico residente cirugía general

IntroducciónAnatomía

Juicio, técnica y atención a los detalles

Incidencia:

• Abierta 0.1 a 0.2 %

• Laparoscopica 0.4 a 0.6 %

• 750 000 Colecistectomias laparoscopicas

• Trauma hepatico 0.5% Iatrogenic Biliary Injuries: Classification, Identification, and Management Kenneth J. McPartland, MDa,b, James J. Pomposelli, MD, PhD Clin N Am 88 (2008) 1329–1343

Anatomía

Lesiones de vias Biliares. Miguel Mercado 2005

Anatomía

Lesiones de vias Biliares. Miguel Mercado. 2005

Anatomía

Lesiones de vias Biliares. Miguel Mercado. 2005

ANATOMÍA%20Liver_fichiers/loadBinaryCA6XK5IZ.jpg

Anatomia

Impacto

Iatrogenic bile duct injury-a cost analysis ROLAND ANDERSSON, KARIN ERIKSSON, PER-JONAS BLIND &BOBBY TINGSTEDT HPB, 2008; 10: 416-419

Costos segun el tipo de lesión

Transplante Hepático10 a 12%

fugas biliares

estrecheses en la anastomosis y fuera de ella

mas prevalencia en receptores pediatricos

Fisiopatología

Factores de riesgo

colecistitis

Adherencias del cistico y coledoco

hemorragia

Variantes anatomicas

Factores de Riesgo

Factor OR

sexo masculino 1.92

hospital escuela 2.16

Pancreatitis 2.5

Colangiografia 0.5

Fletcher et al. annals of surgery 1999

MecanismosMala interpretacion de las estructuras anatomicas (97%)

errores tecnicos (3%)

Incapacidad o resistencia de realizar colangiografia

excesiva retraccion cefalica del fondo

Poca retraccion lateral del infindubuloPrevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469

Mecanismos

Uso excesivo del cauterio

excesiva retraccion lateral del infindibulo

radical derecho de insercion baja

Prevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469

Esquema mental

Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469

Visiones heuristica

Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469

■ Si no consigues entender un problema, dibuja un esquema.

■ Si no encuentras la solución, haz como si ya la tuvieras y mira qué puedes deducir de ella (razonando a la inversa).

■ Si el problema es abstracto, prueba a examinar un ejemplo concreto.

Mecanismos - Trasplante

Trombosis de la arteria hepatica

lesion durante la preservacion

barro biliar

Prevencion

PrevencionManiobra critica

uso de lente angulado

mantenerse cerca a la vesicula

Minimizar el uso del cauterio

Ver las puntas de los clips

colangiografia transoperatoria?¿

Prevencion

diseccion del tejido sobre el cistico y el infindibulo

uso de mas de ocho clips

Maniobra critica

Prevencion

Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?Chandika A. H. Liyanage Æ Yoshihiko

colangiografia por el dreanje nasobiliar

tecnicas visualizar estructuras

Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs Surgical Endoscopy 2011

colangiografia fluorescenia infra-roja

Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs Surgical Endoscopy 2011

Clasificaciones

Clasificacion de Bismuth

Clasificación de Strasberg

Clasificacion de Stewart-way

Class I refersto the incompletesection of bile duct with

no loss of tissue. It has a prevalence rate of 7%. The first mechanism of injury is a misleading recognition of the common hepatic duct with the cystic duct but is rectified and results in only a small loss of tissue with no complete section of the bile duct. The second mecha- nism refers to the lateral injury of the common hepatic duct which results from the cystic duct opening extension during cholangiography. The former represents 72% and the latter 28% of class I cases.

Class I refersto the incompletesection of bile duct with

no loss of tissue. It has a prevalence rate of 7%. The first mechanism of injury is a misleading recognition of the common hepatic duct with the cystic duct but is rectified and results in only a small loss of tissue with no complete section of the bile duct. The second mecha- nism refers to the lateral injury of the common hepatic duct which results from the cystic duct opening extension during cholangiography. The former represents 72% and the latter 28% of class I cases.

Class II is a lateral injury of the common hepatic duct that leads to stenosis or bile leak. It is the consequence of thermal damage and clamping the duct with surgicalstaples. It has a prevalence of 2% with a concomitant he- patic artery injury in 18% of cases. T-tube related injuries are included within this class.

Class II is a lateral injury of the common hepatic duct that leads to stenosis or bile leak. It is the consequence of thermal damage and clamping the duct with surgicalstaples. It has a prevalence of 2% with a concomitant he- patic artery injury in 18% of cases. T-tube related injuries are included within this class.

Class III is the most common (61% of cases) and rep- resents the complete section of the common hepatic duct. It is subdivided in to type IIIa, remnant common hepatic duct; type IIIb, section at the confluence; type IIIc, loss of confluence; and type IIId, injuries higher than confluence with section of secondary bile ducts. It occurs when the common hepatic duct is confounded with the cystic duct, leading to a complete section of the common hepatic duct when resecting the gallbladder. A concomitant injury of right hepatic artery occurs in 27% of cases

Class III is the most common (61% of cases) and rep- resents the complete section of the common hepatic duct. It is subdivided in to type IIIa, remnant common hepatic duct; type IIIb, section at the confluence; type IIIc, loss of confluence; and type IIId, injuries higher than confluence with section of secondary bile ducts. It occurs when the common hepatic duct is confounded with the cystic duct, leading to a complete section of the common hepatic duct when resecting the gallbladder. A concomitant injury of right hepatic artery occurs in 27% of cases

Class IV describes the right (68%) and accessory right (28%) hepatic duct injuries with concomitant injury of the right hepatic artery (60%). Occasionally it includes the common hepatic duct injury at the confluence (4%) besides the accessory right hepatic duct lesion. Class IV has a prevalence of 10%[11,12].

Class IV describes the right (68%) and accessory right (28%) hepatic duct injuries with concomitant injury of the right hepatic artery (60%). Occasionally it includes the common hepatic duct injury at the confluence (4%) besides the accessory right hepatic duct lesion. Class IV has a prevalence of 10%[11,12].

Diagnostico

Diagnostico Transoperatorio

salida de bilis del higado o porta hepatis

observar un segundo conducto o arteria cistica

USG Doppler estrechez de la via biliar

Salida de bilis de una estructura tubular u otro sitio distinto a la vesicula

ecause 12% to 32% of patients who have laparoscopic cholecystectomy– associated bile duct injury have a concomitant arterial injury and vascular injury significantly increases morbidity and mortality and may increase the incidence of later stricture formation

However, bile duct injuries are recognized intraoperatively in only 20%– 30% of laparoscopic cholecystectomie

ecause 12% to 32% of patients who have laparoscopic cholecystectomy– associated bile duct injury have a concomitant arterial injury and vascular injury significantly increases morbidity and mortality and may increase the incidence of later stricture formation

However, bile duct injuries are recognized intraoperatively in only 20%– 30% of laparoscopic cholecystectomie

Diagnostico Trans-operatorioTejido fibroso en la el lecho vesicular

linfaticos rodeando al conducto cistico

conducto cistico que no se puede ligar

un cistico que se va sin interrupcion hasta el duodeno

75% inadvertidas

22% tuvieron protocolos que expusieron la dificultad

Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469

Porcentaje de deteccion intraoperatoria

Bile Duct Injury during Laparoscopic Cholecystectomy : Risk Factors, Mechanisms, Type, Severity and Immediate Detection J.-Fr. Gigot Acta chir belg, 2003, 103, 154-160

Diagnostico Post-Operatorio

Fuga BiliarObstruccion

biliar

CuadroClinico

Nauseas, vomitos,

peritonitisColangitis

Patron bilirrubina

Mixto Directo

errores en diagnosticoIleo, distension y dolor abdominal

Falla en reconocer el drenaje bilioso persistente

Regreso al cuarto de urgencia

No realizar colangiografia previo a la LPE

no encontrar el sitio de lesionSurgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition

diagnostico y fines

conocer la anatomia

reestablecer la comunicacion bilio-enterica

CPREFuga del muñon del cistico vs lesion intra/extrehepatica

Coledocolitiasis

Limitacion en oclusiones y ligaduras

e missed on ERCP (6). Aberrant right posterior segmental duct injuries are often suspected in the setting of clinical or imaging evidence of a bile leak (perihepatic fluid collection on postcholecystectomy cross-sectional imaging or copious bil- ious output from surgical drains) but “normal” ERCP

e missed on ERCP (6). Aberrant right posterior segmental duct injuries are often suspected in the setting of clinical or imaging evidence of a bile leak (perihepatic fluid collection on postcholecystectomy cross-sectional imaging or copious bil- ious output from surgical drains) but “normal” ERCP

Colangiografía Transhepática

identifacion de la anatomia

busqueda de fugas, estrecheces

tutor y drenaje

Cholangiography is used to distinguish between a transected duct, a completely occluded duct, and a duct that has been partially obstructed.

Cholangiography is used to distinguish between a transected duct, a completely occluded duct, and a duct that has been partially obstructed.

Accuracy of Percutaneous Transhepatic Cholangiography in Predicting the Location and Nature of Major Bile Duct Injuries Nicholas Fidelman, MD, Robert K. Kerlan, Jr., MD, Jeanne M. LaBerge, MD, and Roy L. Gordon, MDJ Vasc Interv Radiol 2011;10.1016/j.jvir.2011.02.007

Colangiografía Transhepática

Deteccion del punto lesion 85%

100% 92% 55% 83% 82%

Resonancia magnetica

Se ve todo el arbol biliar

desventaja costo

no terapeutica

Ultrasonido

busqueda de colecciones

dilatacion de via biliar

Tomografía Computada

deteccion de Colecciones

patencia de la circulación

Planeamiento de Drenaje de Colecciones

HIDA

Sospecha de fuga

No detecta el sitio

algoritmo Diagnostico

Sospecha de Lesión

CPRE

FugaLesión Parcial

Seccion

CPTHProtesis

Centelleo Hepatobiliar

negativa

Tratamiento

Tratamiento

Reduccion de la presion distal

Endoscopico o Tubo en T

fuga de alto y bajo grado

Strasberg A

Evaluation and Treatment of Biliary Leaks after Gastrointestinal SurgeryGary C. Vitale & Brian R. DavisJ Gastrointest Surg DOI 10.1007/s11605-011-1513

Tratamiento

Manejo Conservador

Casos refractarios: drenaje percutaneo resecciones segmentarios

Strasberg b

Segmentary bile duct occlusion is the etiological factor in this type of injury. If mild pain and elevation of liver function tests are present with no clinical impairment, conservative management is followed. The presence of moderate and severe cholangitis makes the drainage of the occluded liver segment necessary.

Segmentary bile duct occlusion is the etiological factor in this type of injury. If mild pain and elevation of liver function tests are present with no clinical impairment, conservative management is followed. The presence of moderate and severe cholangitis makes the drainage of the occluded liver segment necessary.

Tratamiento de fugas

Postoperative Bile Duct Injuries Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech Gastrointest Endosc 8:81-91 2006

Seguimientos estenosis

Postoperative Bile Duct Injuries Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech Gastrointest Endosc 8:81-91 2006

Tratamiento

Manejo Conservador

Drenajes externos

Hepatectomia

Derivacion biliodigestiva/ Drenaje percutaneo

Strasberg c

As in Strasberg B injury, an accessory right duct is sec- tioned but the proximal stump is not detected and oc- cluded, with an unnoticed bile leak as a consequence. No continuity exists with the rest of the bile duct system, leaving endoscopy out of the therapeutic options.Subhepatic collections are frequent in the postopera- tive setting. These must be drained in order to avoid bili- ary peritonitis and septic shock.It is common that the bile leak is occluded spontane- ously with no other intervention maintaining a controlled bile leak through external drains. If this does not happen, therapeutic options are the same that Strasberg B injury, biliodigestive derivation to segmentary ducts (also with poor long term prognosis), percutaneous drainage and hepatectomy.

As in Strasberg B injury, an accessory right duct is sec- tioned but the proximal stump is not detected and oc- cluded, with an unnoticed bile leak as a consequence. No continuity exists with the rest of the bile duct system, leaving endoscopy out of the therapeutic options.Subhepatic collections are frequent in the postopera- tive setting. These must be drained in order to avoid bili- ary peritonitis and septic shock.It is common that the bile leak is occluded spontane- ously with no other intervention maintaining a controlled bile leak through external drains. If this does not happen, therapeutic options are the same that Strasberg B injury, biliodigestive derivation to segmentary ducts (also with poor long term prognosis), percutaneous drainage and hepatectomy.

TratamientoRafia Primaria - Drenaje percutanea - endoscopia con Esfinterotomia/Protesis

Desvacularización

Tratamiento quirúrgico ultima opción

Strasberg D

In the setting of a devascularized duct, even if small5-0 absorbable stitches are used, a bile leak will develop during the first postoperative week with concomitant bile collections. Management of these cases requires a mul- tidisciplinary approach with endoscopy and radiological- guided drainage as the first therapeutic options. Surgery is the last resource of treatment when a loss of bile duct tissue is present and migration of a Strasberg D to E in- jury has taken place.

In the setting of a devascularized duct, even if small5-0 absorbable stitches are used, a bile leak will develop during the first postoperative week with concomitant bile collections. Management of these cases requires a mul- tidisciplinary approach with endoscopy and radiological- guided drainage as the first therapeutic options. Surgery is the last resource of treatment when a loss of bile duct tissue is present and migration of a Strasberg D to E in- jury has taken place.

Tratamiento

Hepato-yeyunostomia

Strasberg e

dilataciones/Protesis vs Cirugia

cirugia Promedio (Rango)

Dilataciones Promedio (Rango)

Exitos temprano ( 0 a 4 años) % 89 (81-98) 74 (27-95)

Exitos Tardio( > 4 años)% 85 (74-99) 55

Dias de Tratamiento (dias) 14 (7-27)

365 ( 146-550)

Hospitalización (dias) 14 (7-27) 24 (10-38)

Morbilidad % 19 ( 4-39) 28 (5-72)

Mortalidad % 1.6 (0-9) 1.3 (0-22)

Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition

Cirugía

Hepato-yeyunostomia en y de roux

•parte anterior de la placa•extension al radical izquierdo•resecciones parciales segmento IV

Segmento IV

Hepp-couinaud

Hepp-couinaud

Hepp-couinaud

Hepp-couinaud

Hepp-couinaud

The Hepp-Couinaud Approachto StricturesoftheBileDucts AlbertusMyburgh. Annals of Surgery Vol 218 No 5 1993

Claves anatomicasCirculacion 3 y 9 horas

60% de la circulacion tiene una direccion cefalocaudal

las anastomosis altas no dependen de la arteria hepatica derecha

Perlas del exitoerradicar la sepsis e inflamacion

usar tejido viable

una capa mucosa-mucosa

monofilamento absorbible

sin tension

protesis no son mandatarias

cirujano con experiencia

Resumen del Cohorte de los tres periodos

Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April 27; 3(4): 43-48

RecomendacionesLesion de via biliar laparoscopica

No convertir

dejar drenajes y referir

Hacer hemostasia

anastomosis Amplias

diferir procedimientos en casos de sepsis o falla organica multiple

Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April 27; 3(4): 43-48

recomendaciones

Centro terceriario

buscar ayuda

convertir

establecer el daño

Colangiografia

¿cuando operamos?

Durante el evento, si la realiza un cirujano experimentado

Estabilizar, drenajes y Referir

Reparacion temprana vs Tardia

No hay estudios aleatorizados

strasberg recomienda esperar 12 semanas*

Mercado no hubo diferencias entre el manejo temprano y tardio (75 pacientes)

*Strasberg SM, Picus DD, Drebin JA (2001) Results of a new strategy for reconstruction of biliary injuries having an isolated right-sided component. J Gastrointest Surg 5: 266–274

Cirugía

Hepatectomía

Daño irreversible del radical

Daño de la arteria Hepatica

Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April 27; 3(4): 43-48

Trasplante

cirrosis biliar secundaria

no se puede reconstruir

Pronostico

Contribución de los tratamientos al periodo de enfermedad

Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition

Pronostico43 % de morbilidad luego de una reconstruccion

6 a 22% desarrollan enfermedad hepatica cronica

1.7 a 9% de mortalidad

Dilataciones y Stents

33% de las lesiones proximales a confluencia desarrollan estrecheces

90% de éxito

The Good Surgeon believes what he sees, The Bad Surgeon sees what he believes.Richard I Cook Cognitive Technologies Laboratory Chicago

Bibliografia1. Iatrogenic bile duct injury-a cost analysis ROLAND ANDERSSON, KARIN ERIKSSON, PER-JONAS BLIND

&BOBBY TINGSTEDT HPB, 2008; 10: 416-419

2. Prevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006r

3. Accuracy of Percutaneous Transhepatic Cholangiography in Predicting the Location and Nature of Major Bile Duct Injuries Nicholas Fidelman, MD, Robert K. Kerlan, Jr., MD, Jeanne M. LaBerge, MD, and Roy L. Gordon, MDJ Vasc Interv Radiol 2011;10.1016/j.jvir.2011.02.00

4. Evaluation and Treatment of Biliary Leaks after Gastrointestinal SurgeryGary C. Vitale & Brian R. DavisJ Gastrointest Surg DOI 10.1007/s11605-011-1513

5. Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April 27; 3(4): 43-4

6. Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd editio

7. Strasberg SM, Picus DD, Drebin JA (2001) Results of a new strategy for reconstruction of biliary injuries having an isolated right-sided component. J Gastrointest Surg 5: 266–274

8. Early versus late repair of bile duct injuries Miguel Angel MercadoSurg Endosc (2006) 20: 1644–1647

Bibliografia9. Bile Duct Injuries in the Era of Laparoscopic Cholecystectomies Yuhsin V. Wu, MDa, David C. Linehan, MDb,* Clin N Am 90 (2010) 787–802

• Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469

• Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?

• Chandika A. H. Liyanage Æ Yoshihiko J Hepatobiliary Pancreat Surg (2009) 16:458–462 Postoperative Bile Duct Injuries Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech Gastrointest Endosc 8:81-91 2006

• Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs Surgical Endoscopy 2011

• The Hepp-Couinaud Approachto StricturesoftheBileDucts AlbertusMyburgh. Annals of Surgery Vol 218 No 5 1993

• Lesiones de vias Biliares. Miguel Mercado. 2005

• Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition