Clinical Diagnosis And Treatment Of Iatrogenic Bile Duct Injury

Background:Iatrogenic bile duct injury (IBDI) is regarded as one of the common and serious complications of upper abdominal operation, especially in the department of hepatobiliary surgery operation. According to reports in the literature, open cholecystectomy bile duct injury incidence rate was0.15%-0.5%in the foreign, and it was0.27%-0.78%in the domestic, LC induced IBDI occurred rate was2to7times of the traditional cholecystectomy operation; Some reports was even as high as5.9%, The mortality rate was1%～7.2%. Once the biliary injury is happened, it gives the patient great pain on health side and economic side. The cause, type, site, especially the processing mode of injury will directly affect the prognosis. According to reports in the literature, today incidence of IBDI is less than0.1% in some specialized centers, meanwhile the treatment success rate can reach more than90%. But with the laparoscopic radical gastrectomy for gastric cancer, minimally invasive operation to carry out extensive and sustained rise in certain level, In the long-term effect of IBDI repairing operation is good only20%-27% in the non specialist centers. It is thus obvious that surgical scholars has been attached great importance to iatrogenic bile duct injury all the time, today, how to avoid, how to find early, which will adopt to the reasonable way of treatment about bile duct injury and so on must be still an important issue to every general surgeons.Objective: To explore how to reduce the occurrence of iatrogenic bile duct injury and to investigate its etiology, classification, diagnosis, prevention and management. Further it will be provided countermeasures and reference for the prevention of IBDI and reduce its incidence.Method:Through the consult massive literature material and a retrospective analysis was undertaken of21patients with iatrogenic bile duct injury who presented to the general surgery department of general surgery department of First Hospital Affiliated to Lanzhou University from February2010to October2013, This paper will reviewed the cause of iatrogenic bile duct injury, type of injury, diagnosis, treatment and prevention strategies.Result: The related risk factors of IBDI include man-made factors (divided into subjective and objective two aspects), the local anatomy variation (vascular, biliary) factor, pathological factors (congestion, edema, adhesion, scar contracture twisted). Easy to damage the parts includes hepatocystic duct, common hepatic duct, common hepatic duct and common bile duct junction, the right hepatic duct wall, accessory right hepatic tube and other parts during operation by mistake. According to the damage diagnosis time and local pathological state to select repair operation such as bile duct suture repair, biliary tract end to end anastomosis, bile duct jejunum Roux-en-Y anastomosis, bile duct jejunum Roux-en-Y anastomosis and jejunal artificial valve forming etc. Moreover, it is also available in ERCP biliary stent or balloon dilation for the simple complication with biliary stricture.21cases in this group were treated in our department, they were all discovered after the operation, every patient appears abdominal discomfort, or ascites, or jaundice and other symptoms in varying time after operation end and then confirmed by CT, MRCP and other imaging examination. The mode of surgery:15patients were biliary jejunal Roux-en-Y anastomosis;5cases who there are obvious jaundice and abnormal liver function were given PTCD drainage jaundice and were protected liver function treatment, then underwent biliary intestinal anastomosis.1patient of common bile duct ligation were removed ligation line and placed T-tube drainage.3patients with the clinical symptoms of biliary fistula were improved and gradually disappeared by abdominal cavity drainage.1case was cured by common bile duct exploration and the left and right hepatic duct stricture dilatation and T-tube drainage.1patient was ERCP and EPBD in the1years after initial operation. All the patients who were followed from3month to3years and the processing results are excellent by far.Conclusion: Iatrogenic bile duct injury is an inevitable problem to every biliary surgeon, It is critical for prevention of iatrogenic bile duct injury. Careful intraoperative identification of cystic duct, common hepatic duct, common bile duct three anatomical relationship is the key. Once IBDI is happened, If the finding in operation and one stage repair can obtain satisfactory effect, but more than half of the patients was discovered and confirmed until the patients postoperative had already had bile leakage or jaundice. So it needs more exploration and research that the reasonable processing and one stage repair operation was given to the patients who is found postoperative. Operator and the repair operation mode and repair time were considered the three main factors to determine the repair operation success or not, but the specific operation should be treated on the basis of bile duct injury time, location, extent and type. Biliary jejunum Roux-en-Y anastomosis is generally accepted the repair operation mode of certainty up to present. But it is still high which caused by the incidence of postoperative complications. Overall treatment effect of IBDI depends on the correct timing of operation, the right repair way, accurate operation technology and experienced experts in biliary surgery.