Biliary stricture

Dr N SURENDRA BABU jr resident dept. of gen surgeryTIRUMALA HOSPITALS

Biliary stricture

definition

A biliary stricture is an abnormal narrowing of the bile duct, the tube that moves bile (A substance that helps in digestion) from the liver to the small intestine

Anatomy of biliary tree

Pathological effects of biliary obstruction

Biliary obstructionHigh local

concentration of bile salts

inflammation

Pathological effects of biliary obstruction

Fibrosis and

scarring

Biliary fistula

Biliary stasis

Liver atrophy

Repeated cholangiti

s

Biliary cirrhosis

and PHTN

Causes of benign stricture

I. Congenital strictures Biliary atresia II. Bile duct injuries A. Postoperative strictures (1) Cholecystectomy or common bile duct exploration (accounting 80% of nonmalignant stricture) (2) Biliary-enteric anastomosis (3) Hepatic resection (4) Portocaval shunt (5) Pancreatic surgery (6) Gastrectomy (7) Liver transplantation B. Stricture after blunt or penetrating trauma

Causes of benign stricture

C. Strictures after endoscopic or percutaneous biliary intubation III. Inflammatory strictures A. Cholelithiasis or choledocholithiasis B. Chronic pancreatitis C. Chronic duodenal ulceration D. Abscess or inflammation of liver or subhepatic space E. Parasitic infection F. Recurrent pyogenic cholangitis (Oriental cholangiohepatitis)IV. Primary sclerosing cholangitis

V. Radiation-induced stricture

Causes of malignant stricture

Primary tumors1. Cholangiocarcinoma2. GB Cancer3. Pancreatic

adenocarcinoma4. Ampullary

carcinoma5. Hepatoma6. Gastric carcinoma

Metastatic tumors

1. pancreatic adenocarcinoma

2. Colon cancer3. Breast cancer4. Lung cancer5. Melanoma6. Ovarian cancer

Bile duct injury at cholecystectomy

Incidence 1.open cholecystectomy

0.1 -0.2% 2.lap cholecystectomy

0.4 -1.3% 80% of benign strictures occurs

following injury during a cholecystectomy.

A major factor is surgeons inexperience-learning curve effect

causes Anatomic variations Technical factors Pathologic factors

Anatomic variations(failure to recognize abnormal anatomy &anomalies)

Technical factors Experience of surgeon Improper assistance Extensive dissection Excess use of cautery Misplacement of clips Excess traction on gall bladder Subvesical duct of luschka in 1-2 % patients CBD Exploration-use of metal bougies Attempts to achieve hemostasis

Pathologic factorsAcute cholecystitis inflammation leads to edema in the

porta hepatis and calots triangle—distortion of anatomy

Chronic cholecystitis chronic inflammation leads to

fibrosis, adherence, contracted fibrotic gall bladder, cholecystocholedochal fistula

(partial cholecystectomy, cholecystostomy, and cholecystocholedochoduodenostomy are options)

Laparoscopic specific- Classification of Causes of Laparoscopic Biliary Injuries 1. Misidentification of the bile ducts as the cystic duct a. Misidentification of the common bile duct as the cystic duct b. Misidentification of an aberrant right sectoral hepatic duct as the cystic duct 2. Technical causes a. Failure to occlude the cystic duct securely b. Plane of dissection away from gallbladder wall into the liver bed c. Injudicious use of electrocautery for dissection or bleeding control d. Excessive traction on cystic duct with tenting upward of common hepatic duct e. Injudicious use of clips to control bleeding f. Improper techniques of ductal exploration

Laparoscopic specificProper exposure –maximum cephalad traction on fundus with concomitant lateral traction on infundibulum

Location &classification

1. Bismuth`s classification—based on location of biliary stricture with respect to the hepatic duct confluence

2. Strasberg`s classification—is of laparoscopic biliary injuries, is applicable for acute injuries with bile leak, lateral injuries and transection.

3. Hannover classification—combine Bismuth and Strasberg classification and has also addressed the vascular injuries—most refined

Bismuth`s classification

Strasberg`s classification

Strasberg`s classification

Hannover`s classification

Clinical presentation

Clinical presentation

investigations

investigations

cholangioscopy

Benign Malignant Benign

Surgical treatment of BDI Recognized at operation

Immediate open conversion and repair by an experienced surgeon

If competent help unavailable, put a drain & should be referred to a specialist center

End to end repair over T- tubeRoux –en –Y hepaticojejunostomy(silk sutures should be avoided for all

biliary reconstructions, because they can act as nidus for stone formation)

Surgical treatment of BDI Recognized in immediate postoperative period

Avoid early reoperationBile leak from cystic duct, subvesical duct of

luschka or from noncircumferential laceration with no distal obstruction to bile flow may close spontaneously (1to 3 weeks)

Endoscopic sphincterotomy with stenting-hasten closure

For severe lacerations and complete transactions –delayed approach is best (timing of surgical intervention 4-10 weeks)

Surgical treatment of BDI injury presenting at an intervalPresented as late bile duct stenosis

and strictureConsider nonoperative biliary

drainage proceduresConsider surgery if no resolution in

12 -24 monthsAlmost always requires Roux –en –Y

hepaticojejunostomy

end t

Roux-en-Y HepaticojejunostomyCommon method of repair of bile duct

injuryProper exposure of healthy ,well

vascularised proximal bile ductRoux- en –Y Limb of jejunum >60 cmMucosa to mucosa tension free

anastomosisSide to side or end to side

hepaticojejunostomy using left hepatic duct

• Factors associated with poor outcome after surgery

Proximal stricture (Bismuth type 3 and 4) Multiple prior attempts at repair Portal hypertension Hepatic parenchymal disease (cirrhosis or hepatic fibrosis) End-to-end biliary anastomosis Surgeon inexperience Intrahepatic or multiple strictures Concurrent cholangitis or hepatic abscess Intrahepatic stones External or internal biliary fistula Intra-abdominal abscess or bile collection Hepatic lobar atrophy Advanced age or poor general health Many authors have advocated the use of anasto

Prevention is the best treatment of biliary strictures.