Objectives: Describing the pathological characteristics of biliary duct injury and evaluating the early results of surgical treatment. Subjects and methods: A retrospective and prospective study on 40 patients with biliary duct injury having bile duct reconstruction for iatrogenic injury at Viet Duc Hospital from 1 - 2005 to 10 - 2015.
Jourrnal of military pharmaco-medicine n09-2019 PATHOLOGICAL CHARACTERISTICS AND EARLY RESULTS OF SURGICAL TREATMENT IN 40 BILE DUCT INJURY CASES OF CHOLECYSTECTOMY AT VIET DUC HOSPITAL Dao Thanh Chuong1; Tran Bao Long2; Tran Binh Giang2 SUMMARY Objectives: Describing the pathological characteristics of biliary duct injury and evaluating the early results of surgical treatment Subjects and methods: A retrospective and prospective study on 40 patients with biliary duct injury having bile duct reconstruction for iatrogenic injury at Viet Duc Hospital from - 2005 to 10 - 2015 Results: Male/female = 23/17; average age: 55.05 ± 14.93; time to detect biliary duct injury: Intra-operative identification in 11 patients (25%); diagnosed postoperative in 29 patients Functional symptoms: Before cholecystectomy: Right lower quadrant abdominal pain in 10 patients, fever in patient After cholecystectomy: right quadrant pain in 27 patients; fever in 14 patients; jaundice in 13 patients Physical symptoms: Before cholecystectomy: patient had abdominal fluid; patients had abdominal wall reaction After cholecystectomy: 25 patients with free fluid in the abdomen; 15 patients had abdominal wall reaction; 13 patients with jaundice yellow eyes; patients leaked bile through drainage; peritonitis 11 patients Morphological form of bile duct injury including lateral wound in 15 patients; lost a part of biliary tract in patients Surgical repair including anatomosis intestinal biliary 18 patients Early complications after surgery (12 patients) undergoing medical treatment; removal of biliary tract stones patient; patient with severely ill pneumonia, pleural effusion and death case No reoperation Conclusion: Biliary duct injury in cholecystectomy accounted for a high proportion of late diagnosis after surgery Clinical characteristics of biliary duct injury included right quadrant abdominal pain, fever, jaundice yellow eyes, free fluid in the abdomen, reaction, leaked bile through drainage and peritonitis Side injuries and lost a part of biliary tract, interrupted were the most common The repairing of bile duct reconstruction for iatrogenic injury was one of the most applications of intestinal-biliary, biliary suture + biliary duct drainage, sutures of leakage of bile * Keywords: Bile duct injury; Pathological characteristics; Bile duct reconstruction; Early results INTRODUCTION The disease of stone gallbladder often has gallbladder cut Nowadays, laparoscopic cholecystectomy (LC) is used in many hospitals to bring good results [1] However, LC causes bile duct injury (BDI) [3, 8] from 0.3 - 0.6%, higher to times than open cholecystectomy Diagnosis and management of biliary tract injury caused by cholecystectomy have greatly difficulties Therefore, this study was conducted with aims: To describe the pathological characteristics and evaluate the results of surgical treatment of bile duct injuries caused by cholecystectomy in 40 cases at Viet Duc Hospital Vietnam Military Medical University Viet Duc Hospital Corresponding author: Dao Thanh Chuong (drdaothanhchuong@gmail.com) Date received: 15/10/2019 Date accepted: 06/12/2019 293 Jourrnal of military pharmaco-medicine n09-2019 Patients were studied on their diagnostic SUBJECTS AND METHODS Subjects circumstances (during and after surgeries), 40 patients were diagnosed and had surgery to treat BDI due to cholecystectomy characteristics of BDI and other lesions ; Methods A retrospective, prospective cohort descriptive study was conducted from - 2005 to 10 - 2015 at Viet Duc Hospital early results surgical methods, BDI treatments and The collected data were processed by statistical algorithms in the medicine RESULTS General characteristics of patients Gender: Male: 23 patients (57.5%); female: 17 patients (42.5%), average age: 55.05 ± 14.93 (the lowest 25, the highest 81); 39 patients were injured due to LC (24 patients at local hospitals, 15 patients at Viet Duc Hospital), patient had open cholecystectomy Detecting time of BDI: During operations of more than 10 patients (25%), detecting bile fluid in the surgery and/or witnessing bile ducts were damaged, post-operative diagnosis of BDI in 30 patients (diagnosed within the first 72 hours after surgeries of 17 patients, accounting for 42.5%) with days, max 88 days Clinical characteristics 100% 93,1% Before C After C 100 48,28% 44,83% 50 9,09% 0% fever Jaundice Abdominal pain Diagram 1: Functional symptoms before reconstruction * Functional symptoms: - Before cholecystectomy: Right lower quadrant abdominal pain (pebbles and symptomatic polyps): 10 patients, patient with fever, no patient had jaundice, yellow eyes - After cholecystectomy: Right lower quadrant abdominal pain: 27 patients; fever: 14 patients; jaundice: 13 patients 294 Jourrnal of military pharmaco-medicine n09-2019 * Physical symptoms: - Before cholecystectomy: patient had distended abdomen and abdominal fluid No patient had jaundice or peritonitis - After cholecystectomy: 25 patients had abdominal distention, abdominal fluid, 13 patients had jaundice, patients had bile leakage, 11 patients had peritonitis Subclinical characteristics * Diagnostic image of biliary tract before surgery: - Preoperative ultrasound: 10 patients were found BDI during operations: patients had cholecystitis, patients had acute cholecystitis, patients had stones, gallbladder polyps 24/29 patients underwent BDI ultra-sounded after surgeries and had abdominal fluid patient was found stenosis of the biliary tract, patients had biliary tract in the liver The rate of BDI found through intraoperative cholangiography: 1/3 patients; upstream scan: 7/8 patients; computed tomography: 3/9 patients and MRI: 4/9 patients * Indications for surgery: 30 patients diagnosed with BDI after surgeries, of which common bile duct lesions: patients, bile leakage: patients, abscess residue: patient, biliary peritonitis: 13 patients, biliary obstruction: patients * The morphology of BDI: BDI was common including 15 patients (37.5%), loss of biliary tract segment: patients (22.5%), cutting two-half of bile duct: patients, pair of clips and/or tying to the line bile: patients who had necrosis of the bile ducts caused bile discharge from the gallbladder duct: patients and patient had leak from the small bile duct in the gallbladder bed * Surgery to repair BDI: Biliary reconstruction: 18 patients (45%), of which biliary tract connection and jejunum on Y-lim (Roux-en-Y) 17 patients, patient had intestinal-biliary connection on omega straps Biliary tract drainage + bile duct drainage for 15 patients, biliary leak stitches: patients There was small BDI (Straberg D) patient with intestinalbiliary connection (because common bile duct was about mm, injury was about 10 mm of length, loss a part of common bile duct Surgery treatment followed by BDI level during surgery was reasonable The different was statistical sense with p < 0.05 (test χ2 = 29.33) * Complications after surgery (12 patients): Medical treatment for hospital discharge of patients who had surgical site infections, patients had bile leakages, patient had abscess treatment with aspiration and antibiotics; endoscopic treatment for retrograde lithotripsy in patient with a common bile duct stone severely ill patient requested for discharge due to pneumonia Taking bile duct before discharge: Good infiltration of biliary tract, good intestinal released drug: 21 patients, whether biliary medication was cleared without intervention - leakages in patients (22.5%) Average surgery time for repairment in patients with small BDI: 139.12 ± 67.89 minutes (range 50 - 300), in the large BDI 295 Jourrnal of military pharmaco-medicine n09-2019 group 172.67 ± 38.07 minutes (range 130 250 minutes) The average length of in-hospital treatment between the two groups was 15.84 ± 7.96 days (range 36 days) and 17.33 ± 8.86 days (range 42 days), the difference was not statistical * Early results of repairing BDI: Compared to the time of surgery: the corresponding good/average ratio: right in cholecystectomy surgery 9/1; in 72 hours after cholecystectomy 14/3; > 72 hours: 13/0 No bad results Good: 36 patients (90,0%) and average: patients (10,0%) The time of treatment after cholecystectomy, the number of patients of average ratio accounted for times higher than intraoperative and after cholecystectomy > days (3 patients = 75.0%) Intestinalbiliary connection had good early result in 100% of patients DISCUSSION Cholecystectomy is the most risk of BDI, especially when there is LC with many advantages compared to open surgery, but the rate of BDI accounted for 0.3 - 0.6%, - times higher than open surgery which remained a big concern to surgeons [4, 5] Many studies were found risk factors of BDI such as acute cholecystitis, Mirizzi syndrome and so on to limit the rate of BDI which has been seen as a disaster in cholecystectomy However, vulnerability detection, level of vulnerability, management, and outcome evaluation are also controversial The majority of patients, who had surgery after cholecystectomy (29/40) were met for study Detecting BDI 296 during surgery due to bile fluid, extra-hepatic biliary wounds during LC or moved to the open surgery due to suspicion of BDI and/or due to difficulty in cholecystectomy In our opinion, the bile duct X-ray was not used systematically in surgery, the rate of diagnosis of BDI in surgery was lower [6] 29 patients found after surgery, mainly based on signs after surgery such as fever, yellowing of the eyes and skin, abdominal distention, abdominal fluid, etc., and confirmed by imaging facilities such as magnetic resonance imaging bile duct or upstream bile duct scan similar to the literature announced [7] Bile duct upstream X-ray either to identify diagnosis, BDI morphology caused by cholecysctectomy also had effects on treatment [4] Diagnosis was usually - days later after surgery due to poor, non-specific symptoms Often thought of having biliary obstruction, peritonitis or septic syndrome, widespread pain, abdominal fluid [2] The most noticeable lesion pattern was the most frequent lateral injuries (15 patients), possibly due to unspeakable adhesion inflammation and/or by stretching the gallbladder along the outside of the liver without realizing it, especially in case of acute inflammation, cholecystitis atrophy Damages caused by bile leakage from the location of the neck of the gallbladder area in patients were probably due to unclear surgery limit, due to electric burn causing late necrosis and diagnosis Clamping, stitching and stitching cause obstruction in patients, bile leakage due to damage to the biliary tract in the gallbladder bed in patient The most common method of treatment Jourrnal of military pharmaco-medicine n09-2019 was intestinal biliary reconstruction in 18 patients (45%), suitable for broken or broken lesions, narrowing of the bile ducts due to clamping, forcing the common bile duct at the highest rate Surgery to connect the bile ducts with the jejunum on the Y loop after normal gallbladder cut which make difficult because the bile duct was small, the thin wall shrinked upward, obstructed by the liver In the case of hepatic artery damage, the risk of poor nutrition led to higher risk of junction and fibrosis causing a narrowing of the junction [8] Therefore, restoring circulation required surgeons who had experiences in biliary and digestive surgeries the cause was usually due to pneumonia, pulmonary thrombosis [9] According to Abdel Rafee A [10], early recovery of BDI would reduce the incidence of complications and complications Biliary suture + biliary duct drainage in 15 patients, biliary leak suture in patients who were indicated for small side wounds of extrahepatic biliary tract case of a fistula was diagnosed by retrograde cholangiography, when surgery was not found due to self-healing, only probes to clean the abdominal cavity and put drainage under the liver for repairing biliary tract lesions was Average surgery time to repair BDI and in-hospital treatment period after surgery in the small BDI group compared to the large BDI group (139.12 ± 67.89 minutes/172.67 ± 38.07 minutes and 15.84 ± 7.96 days/17.33 ± 8.86 days) medical treatment due to pneumonia As a result, early hospital discharge of 39/40 patients (97.5%) There were complications requiring medical treatment or procedure in 11 patients (27.5%), severe patient (2.5%) requested for home due to pneumonia This rate was similar to the literature of death, about 1.7%, CONCLUSION Biliary injuries due to gallbladder cut due to late diagnosis after surgery accounted for a high proportion (75%) The most common form of side wound injury and cut in half, missing or clamping, forced into the extrahepatic bile (each form accounted for 37.5%) The most common surgical procedure intestinal biliary obstruction (45%), bile duct injuries + biliary duct drainage (37.5%), biliary sutures (15%) Early hospital discharge was high (97.5%), the proportion of complications requiring medical treatment or procedures accounted for 27.5% and severely ill patient (2.5%) requested REFERENCES Tran Binh Giang, Ton That Bach Laparoscopy cholecystectomy Abdoment Laparoscopy Press II, Home Express Hanoi 2005, pp.309-327 Nguyen Tien Quyet, Tran Dinh Tho, Hoang Ngoc Ha Study characteristics injuries and results of surgical treatment bile peritonitis after laparoscopy cholecystectomy at Viet Duc Hospital Laparoscopy and Endoscopy Vietnam 2012, (2), pp.7-12 297 Jourrnal of military pharmaco-medicine n09-2019 Worth J.P, Kaur T, Diggs B et al Major bile duct injury requiring operative reconstruction after laparoscopic cholecystectomy: A follow-on study Surg Endose 2015, 30, pp.1839-1846 Fullum M.T, Downing R.S, Ortega G et al Is laparoscopy a risk factor for bile duct injury during cholecystectomy? 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