CC BY
16
III. SURGERY
IATROGENIC BILE DUCT STRICTURES AFTER CHOLECYSTECTOMY
МРНТИ 76.29.39
УДК 616, 366-089.87 617-089
Asadova A.A.
Azerbaijan Medical University,Baku, Azerbaijan
Asadova A.A. -
orcid.org/0000-0001-8459-3509
Abstract
Benign biliary strictures can occur as a result of large variety of causes, but approximately more than 80% are iatrogenic after direct or vascular injury during laparoscopic or open cholecystectomy. Especiallyy after widespread application of laparoscopic cholecystectomy the incidence of iatrogenic bile duct injuries has increased two-four times higher than recorded in open cholecystectomy. Iatrogenic bile duct strictures (IBDS) can present with heteregenous clinical signs. The severity of clinical symptoms depends on stricture localization, the time of injury and septic condition. There are broad spectrum non- invasive (US, CT, MRI) and invasive (ERCP, IDUS) imaging techniques for confirming diagnosis and clarifying the etiologies of biliary strictures. At the moment MRCP is the "gold standart" for the complete evaluation of the biliary tree. Successful treatment requires a correct assessment of current patients condition with iatrogenic biliary strictures because, most of patients have a history of multiple interventions and complication. Despite different treatment tactics available for iatrogenic bile duct strictures the gold standard method is still not defined. The management of iatrogenic bile duct strictures after cholecystectomy are challenging and requires multidisciplinary approach comprising hepatobiliary surgeons, endosopists and interventional radiologists. Endoscopic stenting with multiple plastic stents should be chosen as first-line therapy for most cases of iatrogenic bile duct strictures. Fully covered self-expandable metal stents may be a good alternative to plastic stents, in some cases. Surgery is indicated in patients with complicated biliary and anastomotic strictures and in whom non-surgical treatments have failed. Patients with complex injuries (vasculo-biliar injuries), secondary biliary cirrhosis and portal hypertension are good candidat to the liver transplantation. Implementation of novel technologies increases expectations for improved treatment options in future.
Keywords
iatrogenic bile duct strictures, cholecystectomy, endoscopic treatment, Roux-en Y hepaticojeju-nostomy, novel technologies
Холецистэктомиядан кешнп ет жолдарыньщ ятрогендi стриктуралары
Асадова А.А.
Азербайджанский Медицинский Университет, Баку, Азербайджан
Ацдатпа
вт жолдарыньщ катерсз структуралары эр турл! себептермен болуы мумюн, б'рак жащайлардын, шамамен 80% -ы лапароскопиялык немесе ашык холецистэктомия кезШде ятрогендi жаракатка бай-ланысты. Лапароскопиялык холецистэктомияны кещнен колданганнан кейн, вт жолдарыныщ ятрогенд закымдану жилю ашык холецистэктомиямен салыстырганда ею-тврт есе артты. Холецистэктомиядан кеШн ятрогенд билиарлы стрикураны емдеу киынжэне мультидисциплинарлы эдст кажет етедi, соныщ шнде гепатобилиарлы хирургтар, эндоскопистер жэне интервенциялык рентгенологтар. Квптеген пластикалык стенттердi колданатын эндоскопиялык стенттеу вт жолдарыныщ струстык ятрогенд стриктураларыныщ квпшшпнде бiрiншi кезектеп терапия ретде тащдалуы керек. Хирургиялык емдеу хирургиялык емес емдеу сэтсiздiкке yшыраfан курдел'1 билиарлы жэне анастомозды стриктуралары бар наукастарга кврсетлген. Бауыр трансплантациясы ушн курдел'1 жаракаттармен (васкуло-билиар-лы жаракат), екiншi дэрежелi билиарлы цирроз жэне портальды гипертензиямен ауыратын наукастар жаксы ум'тткерлер болып табылады. Жаща технологияларды енпзу болашакта емдеу эдстертщ жаксаруына ум'т артады.
Туйш сездер
ет жолдарыныц ятрогендi стриктуралары, холоцистэктомия, эндоскопиялык емдеу, гепатикоежуностомия, жаца технологиялар
Ятрогенные стриктуры желчных протоков после холецистэктомии
Асадова А.А.
Азербайджанский Медицинский Университет, Баку, Азербайджан
Ключевые слова
ятрогенные стриктуры желчных протоков, холоцистэктомия, эндоскопическая лечение, гепатикоеюноанастомоз, новые технологии
Аннотация
Доброкачественные стриктуры желчевыводяших протоков могут возникать в результате разных причин, но примерно 80% случаев возникают вследствии ятрогенных повреждений во время лапароскопической или открытой холецистэктомии. Особенно после широкого приминение лапароскопической холецистэктомии частото ятрогенных поврождений желчных протоков увеличилась в два-четыре раза выше чем при открытой холецистэктомии. Выраженность клинических симптомов зависит от локализации стриктуры, времени травмы и септического состояния. Для потверждение диагноза и уточнение этиологии билиарных стриктур, существуют широкого спектра неинвазивные (УЗИ, компьютерная томография, магнитно-резонансная холангиопанкреатикография (МРХПГ),), и инвазивные методы исследования (внутрипротоковая УЗИ, ретроградная холангиопанкреатография). МРХПГ является «золотым стандартом» для полной оценки желчного дерево. Несмотря на различные тактики лечения, метод золотого стандарта до сих пор не определен. Лечение ятрогенных стриктур желчных путей после холецистэктомии является сложной задачей и требует мултидисциплинарного подхода, включающего гепатобилиарных хирургов, эндоскопистов и интервенционных радиологов. Эндоскопическое стентирование с использованием нескольких пластиковых стентов следует выбирать в качестве терапии первой линии для большинства случаев ятрогенных стриктур желчных протоков. В некоторых случаях покрытые саморасширяющиие металлические стенты могут быть хорошей альтернативой пластиковым стентам. Хирургическое лечение показана пациентам со сложными билиарнымы и анастомозными стриктурами, у которых нехирургическое лечение не принесло результатов. Пациенты с сложными травмами (васкуло-билиарными повреждениями), вторичным билиарным циррозом и портальной гипертензией являются хорошими кандидатами для трансплантации печени. Внедрение новых технологий повышает ожидания в отношении улучшенных вариантов лечения в будущем.
Introduction
Generally, bile duct strictures can be classified as malign or benign. Nearly two- third of biliary strictures have malign nature [1]. The most common causes of malignant biliary strictures are the cholangiocarcinoma, pancreatic adenocarcinoma (>90%), gallbladder cancer and he-patocellularcarcinoma (10%) [1,2]. Up to 30% of patients have non-malignant-benign biliary strictures. Benign causes of biliary strictures (BBS) include primary sclerosing cholangitis, chronic pancreatitis, autoimmun diseases such as Ig-4 related sclerosing cholangitis and some abdominal operations (gastroectomy, liver transplantations, pancreatic resection etc.) [3,4]. (table 1) But approximately more than 80% BBS occur, during cholecystectomy as result of direct surgical trauma from partial or comple transection by clipping or ligation of the bile duct, thermal injury or vascular damage [5,6]. After widespread application of laparoscopic cholecystectomy the incidence of iatrogenic bile duct injuries has increased two-four times higher than recorded in open cholecystectomy [2,5,6]. The main reason
of increased incidence during LC, is the acute or chronic inflammation around gallbladder, blind or excessive use of electrocautery, bleedings and due it inaccurate placement of clips, sutures and ligations [6,7]. The most of strictures after laparoscopic cholecystectomy occur near the confluence zone, more commonly in the common hepatic duct [8,9].
Clinical presentation
Iatrogenic bile duct strictures (IBDS) can present with heteregenous clinical signs,from abdominal pain with mild elevation of liver enzymes to jaundice, recurrent cholangitis, portal hypertension and due it biliary cirrhosis [2,10]. The severity of clinical symptoms depends on stricture localization, the time of injury and septic condition [11]. The most common location of IBDS include the junction of the cystic duct with the common hepatic duct (CHD) and the confluence of right and left hepatic ducts (Strasberg E4 type). Unfortunately in contrast acute transection or cutting injury, most of benign strictures go unrecognized at the time of surgery (>75% cases) [11,12].
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 4-2020
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Diagnosis
Labaratory tests. Abnormal liver function tests including conjugated hyperbilirubinemia, serum alkaline phosphatase levels and gamma glutamyltransferase levels are elevated in the majority (65%) of patients with IBDS [3,13]. For distinguishing between malignant and benign strictures can be used tumor markers such as serum Ca 19,9 and carcinoembryonic antigen (CEA) level [14,16.16].
Imagine techniques
There are broad spectrum non- invasive and invasive (ERCP, IDUS. CLE) imaging techniques for confirming diagnosis and clarifying the etiologies of biliary strictures. The non- invasive tests include ultrasonography- US, computed tomography (CT) and magnetic resonance (MR)5. The abdominal US is the simpliest imaging way which can detect intrahepatic and extrahepatic bile duct dilatations and any associatedhni vascular lesions. The main advantages of US is its low cost, avaliability , safety and high sensivity (nearly 100%) in detecting the level of obstruction [17]. But it is a poor imaging tool for diagnosing the cause of strictures or any masses.
Abdominal cross-sectional imaging tests ( MRCP, CT) are very useful for initial evaluation of patients. Recently the development of multi-detector CT scanners allows to define the biliary obstruction with upstream dilatation, the results of long-standing strictures such as lobar atrophy or biliary cirrhosis. It also helps to identify vascular lesions and gives some information about etiology of lesions based on rate of the contrast uptake and clearce by focal lesions [5,17,18]. The majority of recent studies has shown a sensitivity of 75-80% and specificity 60-80% for predicting the nature of biliary strictures using CT images [3,17,19].
At the moment MRCP is the "gold standart " for the complete evaluation of the biliary tree. The main advantages of this diagnostic tool are the lack of ionizing, providing high quality cholangiograms which can correctly determine the level, length and morphology of biliary strictures [20,21]. These information helps to make a "road map" for futher preprocedure plan(endoscopic and/or percutaneous interventions) [2,22]. A meta-analysis including 4711 patients with biliary strictures demonstrated that MRCP has sensitivity and specificity 98% in determining level of obstruction, also 38-90% sensitivity and 70-85% specificity for 8distinguishing benign from malignant strictures [23]. Also MRCP is useful for the patients with anastomotic strictures than endoscopic retrograde cholangiopancreatog-raphy (ERCP) due to altered post-surgical anatomy.
In nowdays, the role of ERCP as a diagnostic technicque is llimited, but it has great advantages over MRCP because of ERCP allows for tissue sampling using biliary brushings or endoscopic intraductal biopsies and fine needle aspiration (FNA) [24]. Despite this advantage the biliary brushings and biopsies which obtained during ERCP has poor sensitivity (41.6%) and negative predictive value (58%) [25]. Therefore, for increasing diagnostic value can be used endoscopic ultrasound fine needle aspiration (EUS-FNA), intraductal ultrasound (IDUS) flurescent in-situ hybridization (FISH) and confo-cal laser endomicroscopy (CLE) [26,27,28,29]. In patients with distal biliary strictures EUS-FNA can help to identify benign and also malign lesions because up to 40% of malign masses may be missed on CT scan [30]. IDUS may be recommended in patient with proximal and mid-bile duct strictures for differentiating benign from malign masses [31]. With collobration of these newer techniques can be achieved higher diagnostic results in patients with indeterminate biliary strictures.
Malign Benign
Iatrogenic Inflammotory Other
pancreatic adenocarcinoma cholecystectomy (open or laparoscopic) acute or chronic pancreatitis Mirizzi syndrome
cholangiocarcinoma liver transplantation primary or secondary sclerosing cholangitis ischemia
hepatocellularcarci-noma gastroectomy IgG4-related cholangiopathy vasculitis
gallbladder cancer Pancreatic resection eosinophilic cholangiopathy papillary stenosis
metastatic disease with external compression bilioenteric anastomosis etc. 3ffectiv infections (HIV, tuberculosis, viral, parasitis) blunt abdominal trauma
radiation therapy
transarterial chemoembo-lization
Table 1.
Etiology of biliary strictures
Management tactics
Perioperative assesment
Successful treatment requires a correct assessment of current patients condition with IBDS. Because, most of patients with IBDS have a history of multiple interventions and complications, even life-threatening conditions such as cholangitis, liver abscesses or bile peritonitis which can leads to malnutrition [32]. Complicated IBDS may be associated with portal hypertension and secondary biliary cirrhosis which can caused gastrointestinal bleedings from esophageal varices [33]. In cases with recurrent variceal bleeding transjugular intrahepatic portosystemic shunting (TIPS) can be better choice , because of it is associated with a high success rate ( nearly 90-100 % ) [34]. For achivement better results it is very important to find and treat all complications on time.
Endoscopic treatment
Recently endoscopic biliary stenting is feasible approach for IBDS despite surgery is considered method for these patients. Endoscopic options can be performed in patients in whom the bile duct has not transected or ligated and it is carried out by placement of multiple large-bore plastic stents with trimonthly exchange for a one year [35]. Severe fibrotic strictures require firstly 4ffecti or bougie dilatation, following placement of multiple large plastic stents or FCSEMS [36,37]. Studies indicate the rate of stricture recurrence is around 20% all of occuried in 2 years after stent removal [38]. In the study of Parlak et al. stricture reccurrence was seen in 18 patients (11%) out of 156 patients [39]. However, in the study of Costomagna et all.with the longest follow-up (13 year) reported no cases of recurrence with the use of a more aggressive approach (up to 6 stents) [40]. By the same group of authors in a cohort extended study of 164 patients with IBDS were reported 9.3% stricture rate after a mean follow-up 7 year (over 22 year- period) [41]. The utility of a fully covered self-expandable metal stents (FCSEMS) in patients with post- cholecystectomy strictures are limited due high stent migration rate [42,43].
The role of endoscopic treatment in patients with recurrent strictures after hepaticojejunos-tomy is very challenging due to altered anatomy. Despite this, in the small series of Monkomuller and Fry had been achived nearly 90% of diagnostic and 60% of therapeutic success [44]. Later , other studies showed similar results [45,46]. The comparision study of 66 patients treated by endoscopic stenting and 35 patients treated by surgical therapy for IBDS, showed similar long- term success rate, with stricture recurrence occurring in 17% in both groups [47]. In the retrospective
study of Tocci et.al. which compared endoscopic and surgical treatment of patients after IBDS showed similar long-term outcomes but with highest morbidity rate in patients treated endo-scopically.(9 vs 2) [48].
Percutaneous intervention
Percutaneous transhepatic baloon dilatation (PTBD) is avaliable procedure when ERCP failed and in cases when anatomy surgically altered (such as R&Y hepaticojejunostomy) or patient has severe comorbidities. This modality requires 1-4 repeat dilatation with a period of biliary drainage nearly 3 months [48,49]. The main advantage of PTBD is its low procedural morbidity which prevalence about 11-13% and overall success rate is about 6676% [50,51]. In a novel pilot study of Huszar et al. demonstrated percutaneous transhepatic balloon dilatation combined with targeted intramucosal corticosteroid injection in patients with IBDS . They achived 100% success rate with this terapy without any side-effect of corticosteroids [52]. Also, using PTBD as a step-up approach before surgical treatment of IBDS can give advisable results with high success rates of 98% [53].
Surgical treatment
Definitive management of postcholecystectomy or iatrogenic biliary strictures is the surgical reconstruction - hepaticojejunostomy with Roux en Y limb [52,54]. Surgical treatment involves anastomosing an isolated loop of jejunum to the healthy, vascularized and unscarred part of the bile duct [54,55,56]. For the strictures on or below the confluence the most preferrable method is Hepp-Couinaud approach because of rich vascular supply of this area [57,58]. This tecnique allows to approach the left duct by the dissection of hilar plate. When biliary strictures located deep in the liver it becomes impossible draining with single anastomosis as in the Hepp- Couinaud approach [59,60]. These cases require creating double-barrel anastomosis. On the other hand in selected cases - when strictures with an associated lobar atrophy, cholangitis or if it is located too far inside liver it is recommended to perform an ipsilateral liver hepatectomy and create a hepaticojejunostomy with the opposite duct [61,62]. Patients with complex injuries ( vasculo-biliar injuries), secondary biliary cirrhosis and portal hypertension are good candidat to the liver transplantation [63].
Novel management strategies
Novel technologies including biodegradable stents, intraductal radiofrequency ablation, and magnetic decompression anastomosis may provide a valuable addition to the treatment options for IBDS patients, especially for the selected cases refractory to endoscopic or percutaneous methods [64]. In the study of Siiki et al. with 21 month follow-
up reported 83% stricture resolution after treatment endoscopically placed biodegradable stents [65]. In the other study treated by a percutaneously placed biodegradable stent stricture resolution rate was 100% [66]. Intraductal radiofrequency ablation also, may be useful in some cases after IBDS. The results of pilot study Hu et.al. showed 55% success rate in treatment of BBS with the intraductal radiofrequency ablation followed by baloon dilatation [67]. The other promising new technique in the treatment of IBDS is magnetic decompression anastomosis (MDA). In the study of Jang et al. using MDA biliary recanalization was achived in 89,7% of patients [68].
Summary
In the past 3 decades laparoscopic cholecys-tectomy become "gold standart" as a treatment of gallstone diseases. Despite all advantages of LC the rate of biliary injury has increased also 7,8,9]. Studies suggest that about 30-60% patients with iatrogenic bile duct injury can develop IBDS [69]. The management of IBDS after cholecystectomy is challenging and requires multidisciplinary approach comprising hepatobiliary surgeons, endoscopists and interventional radiologists[49,69]. There are several treatment options for post-cholecystectomy strictures.
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