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Managing bile duct injuries sustained during cholecystectomies

Bile duct injuries always have been a problem to understand. Anatomical variation, aberrant duct, abnormal and deformed anatomy, misidentification proved to be the reason to this tragedy. Laparoscopy introduction has raised the hope of providing a better solution, unfortunately the incidence of bile duct injuries proved to be more in laparoscopic cholecystectomy than in open cholecystectomy, an observation accepted globally.


INTRODUCTION
Bile duct injuries always have been a problem to understand. Anatomical variation, aberrant duct, abnormal and deformed anatomy, misidentification proved to be the reason to this tragedy. Laparoscopy introduction has raised the hope of providing a better solution, unfortunately the incidence of bile duct injuries proved to be more in laparoscopic cholecystectomy than in open cholecystectomy, an observation accepted globally. 1 Injuries caused are both major and minor in nature. 2 Clip slip, clip application in confusion, laparoscopic environment, inadequate biliary defaults, video view illusion added to the causation. 3 The bile duct injuries in laparoscopic cholecystectomy are more active than passive in nature. 4 In absence of fixed algorithms to define the injuries as major or minor, active or passive, development of biliary leak and bilioma with or without jaundice and symptoms of fever, pain, sepsis, peritonitis, it is difficult to manage bile duct injuries even though USG, MRCP, CV-ITC are available investigation, but it is the Endoscopic retrograde cholangio pancreoticography has been the most dependable diagnostic and therapeutic has proved. [5][6][7][8] Management included endoscopic and surgical or both either singularly or in combination. The endoscopic stenting and sphincteroplasty cure the majority of cases; it is only in major cases which fails to respond needed surgery. 9 The surgical procedure hepatic jejunostomy provides the best answer so far. 10 11 Bilioma, biliary leak, combination of bilioma and leak were the presenting signs. In our series in laparoscopic group, 3/12 cases presented as bilioma, 7/12 bilioma and leak, 2/12 only leak. In OC group bilioma in 2 cases, leak in 6 cases, bilioma with leak 2 cases. On the basis of amount of leak and duration we tried to divide the injuries as minor or major. Wherever the leak was <300 ml per day and duration was 7-8 days we labeled it as a case of minor injuries. Whereas the leak >300ml persisting for long periods, it is labelled as major injuries. Clinically developments of pain, fever, nausea, vomiting, distention were the main symptoms developing during 1-7 days in both groups. Raised value of WBC alkaline phosphates, hyper bilirubinaemia noted in most of the patients. 3/12 cases of LC, 3/10 OC cases were also having jaundice too. [12][13] Two patients developed nausea, anorexia till one month with raised alkaline phosphates and serum bilirubin. 14 Results of ERCP detailed in table 5 and 6. The reason assigned for these injuries are aberrant ducts, distorted anatomy due to intense fibrosis and misidentification of CBD as cystic duct, thermal burn, causing clip slip due to cautery use. [15][16] RESULT Patients who develop sign and symptoms after surgery underwent investigation and endoscopic study. The lesion identified and response of stenting only or with sphincterotomy are analysed. Changes in WBC, bilirubin, ALT, ALP was mildly increased in 9 out of 12 cases which resolved by stenting and sphincterotomy classified as minor injury cases. 3/12 cases where WBC count rise of bilirubin was marked, not responding to stenting and sphincterotomy were classified as major injury cases operated by laparoscopic procedure (Table 1).   Clinical presentation along with relative pathological changes, reflected in WBC and LFT changes. It revealed that in bilioma cases (3-LC), 2 OC. WBC and LFT value were raised more than cases developed in bilioma with leak and leak only cases (Table 3). Cases not improved with stenting and sphincterotomy 3/12 cases revealing major duct injuries whereas 9/12 cases improved with stenting and Sphincterotomy classified as major duct injuries (Table 4).

METHODS
ERCP based analysis revealing the injuries not improved with stenting and Sphincterotomy 3/10 cases termed as major injuries whereas 7/10 cases improved with stenting and Sphincterotomy classified as minor injuries cases in Open cholecystectomy ( Table 4).
Nature of injuries caused to biliary tract and result of stenting and sphincterotomy. There may be overlapping of causes of injuries in some of the cases. Nature of injuries in caused to biliary tract and result of stenting and sphincterotomy during laparoscopic cholecystectomies. It is appreciated that the cautery inflicted injuries in both minor in 3 cases and major cases two, too. There may be overlapping of causes of injuries in some of the cases (Table 5).  Causation of the injuries based on ERCP procedure, response of stenting and sphincterotomy in bile duct injuries during open cholecystectomies. Thermal burn 5 cases liver bed leak as a result of excessive dissection and cauterization stands the maximum number of injuries in open cholecystectomies. Some of the cases were having more than one factor responsible for injury seen ( Table  6).

DISCUSSION
Laparoscopic surgery considered to be latest and safe technique in hepatobiliary surgeries, but reports are confirming the fact that incidence of bile duct injuries has increased from pre-lap period. 17 80 injuries in LC were noted in cholecystitis than in cholelithiasis or in other condition.
The development of fever paid sepsis distention and tenderness with raised WBC, alkaline phosphates and bilirubin in serum noted in 70% of cases but clinical presence of jaundice noted only in 30%, 3/12 cases. Obvious more in cases operated by laparoscopy than by open method, our observation matches with others. 18 Development of biliary fistula 10/12 LC cases and 8/10 in OC is a most common feature whereas bilioma 3/12 LC and 2/10 in OC is signified the major injuries. 19 Author relied more on ERCP than cholangiography. Cholangiography, for not only being accepted universally but technically difficult procedure also, hence it is avoided. ERCP followed by stenting and sphincteroplasty were done and results analysed. We have seen that low output fistula where leak was <300ml/day 7-10, has improved with procedure hence they are classified as cases of minor injuries. 20 The cases who have not improved by the procedure were having leak >500ml/day and more than 10 days, they were classified as cases of major injuries and undergone surgery i.e. R-Y anastomosis.
ERCP study revealed leak from cystic duct in 41% cases, leak from liver bed in 33% cases and leak from slip of clip 26% of cases. Cystic duct leak is caused by mainly as a result of cautery burn at dissection sight. In 2 cases where the leak was caused by back pressure due to stone in CBD not detected before operation. 21 Leak from liver bed resulted in patients who underwent deep dissection and excessive use of cautery, because of fibrosis, adhesion and to stop bleeding. ERCP showed the presence of aberrant duct, accessory or sectoral duct as noted elsewhere by Strasberg et al, and depicted as type ABC injuries. 22 These types of injuries were not recognized under bismuth classification. 23 Clamp application was another big factor in causing the incidence of injuries. The complexity such as mirrizi syndrome, fibrosis adhesions, vascular bleeding which distorted anatomy so much that it leads to clamp application on CBD in disguise of cystic duct. 24 This has happened more in cases of simple cholecystitis than in cholelithiasis. 25 Finally, we can say that it's not only oblivious but distorted anatomy are responsible for bile duct injuries and also the laparoscopic environment fixed restricted view of laparoscope and excess cautery use are the causes of increasing number of injuries in laparoscopic era than pre-laparoscopic era.

CONCLUSION
We tried to establish the stepwise proceedings to reach conclusively as the injury is minor or major in nature and how best it can be managed without much complication. We go with opinion expressed by Roslyn et al, that number of series shown in the past the excellent longterm results in the management of the bile duct injuries before laparoscopy, but the result will be transferred to lap cholecystectomies has to be seen (Kei-D. Lille Moe).