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ABSTRACT
The results of surgical treatment of 103 patients with “fresh” IVS injuries were analyzed
. The main operation for
complete transection and excision of the IVS is HepEA according to Roux-en-Y, which was performed in 67 patients
with good long-term results in 97.01%. The formation of the BBA with complete intersection of the duct in all cases
resulted in a stricture. Restorative surgery is indicated only for partial damage to the duct. HepDA also had a negative
effect on treatment outcomes. Complications in the immediate postoperative period17.5%, in the remote
–
33.9%.
Repeated surgical interventions were performed in 32.03% of patients, mortality rate was 5.8%.
KEYWORDS
Bile ducts, iatrogenic damage, restorative and reconstructive operations.
INTRODUCTION
Over the past two decades, the incidence of biliary
tract diseases has increased in many countries of the
world, including Uzbekistan. Accordingly, the number
of operations on them. Thus, about 700,000
cholecystectomies (CE) are performed annually in the
Research Article
FEATURES OF SURGICAL TACTICS FOR “FRESH” DAMAGES OF THE MAIN
BILY DUCTS
Submission Date:
January 21, 2024,
Accepted Date:
January 26, 2024,
Published Date:
January 31, 2024
Crossref doi:
https://doi.org/10.37547/ajbspi/Volume04Issue01-12
Rakhmanov K.E.
Samarkand State Medical University, Uzbekistan, Samarkand
Nasimov A.M.
Samarkand State Medical University, Uzbekistan, Samarkand
Journal
Website:
https://theusajournals.
com/index.php/ajbspi
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
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USA, more than 100,000 in Russia, and about 10,000 in
Uzbekistan [5, 7, 13].
At the same time, the frequency and severity of bile
duct injuries have noticeably increased and amount to
0.2 - 1.9% [2, 4, 7, 8, 9, 11, 14, 16]. Authors dealing with
this problem note that the introduction of laparoscopic
cholecystectomy has led to a noticeable increase in the
frequency and severity of bile duct injuries. Taking the
average frequency of injuries to the main bile ducts
(MBD) as 0.5 - 1% in Uzbekistan, from 50 to 100 people
suffer from such a complication per year.
Treatment of bile duct injury is extremely difficult,
requires expensive therapeutic and diagnostic
procedures, and leads to serious disability in patients.
Mortality is 8-17%, complications during operations
occur in up to 47% of cases, the development of post-
traumatic strictures of the bile ducts - up to 35-55% [1,
3, 6, 10, 12, 15, 17].
The timing of detection of IVS damage is important in
the outcome of treatment. There are “fresh” injuries
and post-traumatic scar strictures of the bile ducts and
biliodigestive anastomoses. “Fresh” injuries are
divided into those diagnosed on the operating table
and those detected in the early postoperative period.
The results of studies, including in Uzbekistan, show
that only in 30% of cases iatrogenic damage to the bile
ducts is recognized during surgery, up to 50% of
damage is diagnosed in the postoperative period
against the background of the development of
peritonitis, rapidly increasing obstructive jaundice or
bile leakage through the drainage. More than 15% of
patients die from progressive peritonitis, increasing
jaundice or other postoperative complications that are
not recognized in a timely manner.
For the healthcare of our Republic, analysis of the
frequency and causes of unsatisfactory results of
surgical interventions on the biliary tract is extremely
relevant. In addition, it is extremely important for
practical surgeons to develop an algorithm of actions
for “fresh” injuries of the bile ducts.
Purpose of the study
: optimization of surgical
treatment of “fresh” injuries of the main bile ducts.
METHOD
An analysis of the results of surgical treatment of 103
patients with “fresh” IVS injuries in the period 2014 –
2023 was carried out. In our own observations, IVS
injuries were noted in 38 (0.58%) patients in 6521
cholecystectomies; 65 patients were admitted from
other hospitals with “fresh” IVS injuries.
In 78 patients there was intersection (9), excision (38)
and excision with ligation of the proximal stump of the
hepaticocholedochus (31), in 11 - a parietal edge wound,
in 14 - alipation or ligation without crossing the
duct.Localization of damage: common bile duct (CBD)
- in 14 patients, common hepatic duct (CHD) - in 48, AHF
and bifurcation area - in 31, AHF with destruction of
confluence - in 10. The nature and location of damage
are presented in Table. 1.
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Table 1.
Nature and location of damage
MZhP.
Character
Localization
Edge damage
Intersection
Excision
Excision and
ligation
Clipping or
ligation
without
crossing
Total
+2
8
5
1
4
6
24
+1
2
4
12
17
3
38
0
1
-
8
4
5
18
-1
-
-
10
3
-
13
-2
-
-
7
3
-
10
Total
eleven
9
38
31
14
103
In 28 (27.2%) patients, IVS damage was detected
intraoperatively. In the vast majority - 75 (72.8%)
patients, damage was detected in the early
postoperative period: increasing obstructive jaundice
was observed in 34 patients, biliary peritonitis - in 20,
bile leakage - in 10, and a combination of two or more
complications was observed in 11 patients.
When intraoperative damage to the IVS was detected,
out of 28 patients, 17 patients underwent restorative
surgery and 11 patients underwent reconstructive
surgery.
Crossing and excision of the bile ducts.
This type of damage was observed in 18 of 28 patients
(64.3%), with transection in 6 (21.4%) and excision in 12
(42.8%) patients. According to the terminology of bile
duct strictures, damage “+2” (the length of the
preserved proximal part of the AKI is more than 2 cm)
was in 3 patients, “+1” (the length of the AKI is 1 cm) –
in 6 patients, “0”
- bifurcation injury -
in 2 patients, “
-
1”
(preservation of the arch of AKI confluence)
–
in 3
patients and “
-
2” (AKI confluence is destroyed) –
in 4
patients. Thus, most patients had high damage.
Damage was identified intraoperatively by the
appearance of bile in the surgical wound and additional
tubular structures in the removed gallbladder.
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11 patients from this group underwent reconstructive
surgery: 9 of them had hepaticojejunostomy
(Hepaticojejunostomy) with a loop of small intestine
disconnected according to Roux, and 2 patients had
HepDA applied.
For injuries at the “+1”, “0” level, the site for
anastomosis was created by dissecting the left hepatic
duct, exposing it under the chiliary plate (Hepp-
Couinaud method).
In 4 cases, when the damage occurred with the
destruction of confluence (level “
-
2”)
, in order to form
a single anastomosis with the jejunum, the platform
was created by parallel suturing of the remnants of the
lobar ducts along their medial walls, cutting the
septum between them (Cattell method). After the
neoconfluence was formed, both lobar ducts were
additionally dissected, which significantly increased
the diameter of the future anastomosis.
Despite the small diameter of the ducts, it was possible
to create a platform for anastomosis ranging in size
from 10 to 25 mm (≤ 15 mm
- 3; 16-25 mm -
7; ≥25 mm
-
1). In 2 patients, HepEA was placed on transhepatic
frame drainage (TPCD) according to Seipol-Kurian due
to the narrow diameter of the duct.
Thus, the use of techniques developed during
operations for IVS strictures made it possible to
perform relatively wide precision anastomoses.
Reconstructive surgery (RBS) with transection
(4) and excision (3) of the CBD and AKI was performed
in 7 patients.
Regional wound of the hepaticocholedochus.
A marginal wound was observed in 10 (35.7%) patients.
In 2, the AKI was damaged and in 8, the CBD was
damaged. All patients underwent reconstructive
surgery: 2-3 sutures (Prolene 5/0) were placed on the
wall of the duct using a Kera drainage.
The types of operations for patients with “fresh” IVS
injuries detected intraoperatively are presented in
Table 2.
Table 2.
Types of operations for patients with IVS injuries identified intraoperatively.
Type of operation
Quantity
Suturing a duct defect on a Kera drainage
10
BBA
7
HepDA
2
HepEA
9
In the early postoperative period, IVS injuries were
detected in 75(72.8%)patients, with intersection and
excision in 60 (80%) patients, clipping or ligation
without intersection in 14 (18.7%) and marginal damage
in 1 (1.3%) pa
tient. Damage “+2” was in 13 patients, “+1”
–
in 31, “0” –
in 15, “
-
1” –
in 9 and “
-
2” –
in 7 patients.
When injuries were detected without inflammatory-
infiltrative changes in the subhepatic space and
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hepatorenal failure (HRF), 35 patients underwent one-
stage surgery.
Of the 14 patients with clipping or ligation of the duct,
12 patients had the clips or ligature removed and 2
patients had a BBA applied. During excision of HC,
HepEA was applied to 8 patients, HepDA was applied
to 2 patients, and BBA was applied to 10 patients
simultaneously. In case of a marginal wound, 1 patient
underwent suturing of the duct defect on the Kera
drainage.
In the presence of peritonitis, an inflammatory-
infiltrative process and PPN due to obstructive
jaundice and cholangitis, the bile ducts of 40 patients
were externally drained in the first stage,
reconstruction was performed in the second stage.
In this group, 3 patients died after the first operation
due to advanced peritonitis and multiple organ failure.
1 patient refused the second stage of the operation.
After correction of the inflammatory-infiltrative
process in the abdominal cavity and the clinic of PPN, 6
patients were given HepDA and 30 patients were given
HepEA, of which 27 anastomosis was applied to TPCD:
according to Praderi-Smith (2), Seipol-Kurian (21) and
Galperin (4 ). The indications for TPCD were high
damage to the bile ducts and a narrow diameter of the
duct. The types of operations for patients with “fresh”
IVS injuries identified in the early postoperative period
are presented in Table 3.
Table 3.
Types of operations for patients with IVS injuries identified in the early postoperative period.
Type of operation
Quantity
Removing ligatures or clips
12
BBA
12
Suturing a duct defect on a Kera drainage
1
HepDA
8
HepEA
38
External drainage of the bile duct
4
RESULTS
After correction of intraoperatively detected IVS
injuries, no specific complications were observed in the
immediate postoperative period. In the long-term
postoperative period, cicatricial strictures of the bile
ducts and BDA were detected in 35% (Table 4).
In 7 patients, after the application of a BBA, a cicatricial
stricture of the bile ducts was detected. In contrast to
the marginal wound, with complete transection and
excision of the bile duct, the axillary blood supply to
the bile duct is disrupted, which leads to a cicatricial
stricture, and the anastomosis in these cases is
performed with tension. These patients required
repeated interventions: HepEA was applied to 5
patients; 1
–
HepDA (had a history of gastric resection
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according to B-II); 1
–
bile duct stenting with a
satisfactory treatment result.
In patients after the application of HepDA, attacks of
cholangitis and BDA stricture were periodically
observed in the long-term postoperative period. 1
patient had HepEA applied and 1 patient periodically
received sessions of balloon dilatation and diathermic
expansion of the anastomotic area.
After applying HepEA, out of 9 patients, an
anastomotic stricture was observed in 1 patient. He
underwent antegrade bougienage with a satisfactory
treatment result.
Table 4.
Long-term results and types of re-interventions in the first group of patients.
Types of operations
Qty
Stricture of
the
gallbladder
and BDA
Repeated intervention
Suturing the defect on the Kera
drainage
10
-
-
BBA
7
7
5-HepEA, 1-HepDA, 1-duct
stenting
HepDA
2
2
1-HepEA, 1-REBV
HepEA
9
1
REBV
In patients with IVS injuries detected in the early
postoperative period after surgical interventions,
specific complications were observed in 8% and 33% of
cases, respectively, in the immediate and late
postoperative periods. Death was observed in 6 (8%)
cases: in 2 patients due to acute renal failure, 1 due to
acute cardiovascular failure, 3 due to advanced
peritonitis and multiple organ failure.
In the immediate postoperative period, in 5 patients
after the application of HepEA and HepDA, partial
failure of the BDA was observed, which in 4 cases was
manifested by bile leakage and 1 biloma of the
subhepatic
region.
Bile
leakage
stopped
spontaneously on days 11-15 after surgery, and the
biloma was drained under ultrasound guidance. In 1
patient, after the application of HepEA, hemobilia was
observed in the immediate postoperative period,
which was treated conservatively (Table 5).
Table 5.
Types of complications in the immediate postoperative period in the second group of patients.
Type of complication
Qty
%
Peritonitis
3 (3 deaths)
4
Liver failure
4 (2 deaths)
5.33
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Cardiovascular failure
1 (fatal)
1.33
Hemobilia
1
1.33
Wound suppuration
4
5.33
Partial failure of BDA
Of these, external bile leakage
biloma
5
4
1
6.67
Total
18
24
Of these, deaths
6
8
In 15 patients, after reconstructive operations in the
late postoperative period, a cicatricial stricture of the
bile duct developed and they required repeated
interventions: 12 patients were treated with HepEA; 1
patient with HepDA, 2 patients with bile duct stenting.
From this group, the patient, after applying HepDA,
periodically takes courses of X-ray endobiliary
intervention (REI) due to recurrent cholangitis and
HepDA stenosis.
All 7 patients with HepDA underwent repeated
interventions: 2 patients had HepDA uncoupled and
HepEA was applied, 5 patients received periodic REBV
sessions.
In 3 patients, after application of HepEA, stenosis of
the MDA was observed. 1 patient underwent repeated
HepEA and 2 patients periodically
received
conservative therapy (Table 6).
Table 6.
Long-term results and types of re-interventions in the second group of patients.
Types of operations
Qty
Stricture of the
gallbladder and
BDA
Repeated interventions
Removing ligatures or clips
12
5
HepEA
BBA
12
10
7-HepEA, 2 – stent, 1-HepDA
(REBV)
Suturing the defect on the Kera
drainage
1
-
-
HepDA
8
7
2 – HepEA, 5 – REBV
HepEA
38
3
1 – HepEA, 2 – conservative
therapy
External drainage of the bile duct
4
-
-
Total
75
25
15- HepEA, 2 – stent, 1-HepDA
(REBV), 5 – REBV, 2 –
conservative therapy
In total, complications developed in 18 (17.5%) patients
in the immediate postoperative period. In the long-
term period, an unsatisfactory result (development of
stenosis) was observed in 35 (33.9%) patients: in 13
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(37.14%) and 22 (62.86%), respectively, after
reconstructive and restorative operations. Repeated
surgical interventions were required in 33 (32.03%)
patients.
CONCLUSION
In recent years, the number of cholecystectomies has
increased markedly and most of them are performed
laparoscopically (according to our data - more than
80%). The number of IVS injuries has also increased, and
these injuries are particularly severe, since in addition
to the high bifurcation mechanical trauma, the thermal
effect on the duct wall is added.
The best results were obtained in patients where
operations were performed upon intraoperative
detection of IVS injuries (in 84.3% of patients). But
unfortunately, intraoperative detection of IVS injuries
occurred in 27.2% of cases. In a significant proportion of
patients, bile duct injuries are diagnosed late
(according to our data - in 72.8%), after the
development of bile peritonitis or obstructive jaundice.
Because of this, most patients had to undergo external
drainage of the bile ducts at the first stage, missing the
opportunity to normalize bile flow immediately after
injury.
We believe that if damage to the IVS is detected in the
immediate
postoperative
period
against
the
background of peritonitis, subhepatic abscess, or bile
leakage, at the first stage it is advisable to limit
ourselves to external drainage of the biliary tract. It is
advisable to perform reconstructive surgery after the
inflammatory-infiltrative process subsides in 2-3
months. This tactic was justified in 30 (73.1%) patients
in this group.
Our experience has shown that the main operation for
complete transection and excision of the IVS is HepEA
according to Roux-en-Y: a good long-term result was
obtained in 97.01% of patients. HepEA without frame
drainage significantly reduces the treatment time for
patients, however, we were able to use the Hepp
–
Couinaud method only in 11 patients in this group. The
peculiarity of this operation is the isolation of the left
hepatic duct at its confluence with the right duct under
the portal plate. This makes it possible to isolate the
ducts outside the scar tissue and apply an anastomosis
up to 2-3 cm wide, mainly due to the left hepatic duct,
avoiding long-term (up to 1.5-2 years) drainage of the
anastomosis zone, which is burdensome for the
patient.
Restorative surgery is indicated only for partial
marginal damage to the duct. In 11 patients of this
group, by suturing the duct defect on the Kera
drainage, we achieved a satisfactory result. When the
duct is injured, in contrast to its complete intersection,
good results are explained by the fact that the integrity
of the narrow posterior wall of the duct ensures
sufficient blood supply.
The formation of the BBA during the intersection and
excision of the duct in all 17 cases resulted in the
formation of a scar stricture: 14 patients underwent
reconstructive surgery, 3 - endoscopic stenting. Our,
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still small, experience with endobiliary stenting allows
us to positively evaluate this method.
Operations during which an anastomosis of the
damaged duct with the duodenum was formed had a
negative impact on the results of treatment. These
patients developed chronic cholangitis and stenosis of
the BDA, which required repeated reconstructive
operations in 2 cases and endoscopic intervention in 9
cases.
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