Benign Biliary Strictures

Question 1

What is the rate of CBD injury during laparoscopic cholecystectomy?

Answer 1

0.4-0.6% following lap chole and 0.2-0.3% following open cholecystectomy

Question 2

What is the most common cause of lap chole-induced bile duct injury?

Answer 2

Exaggerated cephalad retraction of the gallbladder fundus

Question 3

True/False. Routine IOC has been proven to prevent bile duct injury during laparoscopic cholecystectomy.

Answer 3

FALSE

Question 4

What is a Bismuth level I CBD injury?

Answer 4

transection of CBD with a common hepatic duct stump >2cm

Question 5

What is a Bismuth level II CBD injury?

Answer 5

transection of CBD with a common hepatic duct stump <2cm

Question 6

What is a Bismuth level III Bile Duct injury?

Answer 6

hepatic duct stricture with preserved ductal continuity

Question 7

What is a Bismuth level IV Bile duct injury?

Answer 7

Disruption of the hepatic duct confluence

Question 8

What is a Bismuth level V Bile duct Injury?

Answer 8

transection of the right sectoral duct

Question 9

What changes occur to the liver parenchyma with chronic biliary obstruction?

Answer 9

segmental atrophy and fibrosis; rotation of hepatic parencyma and ductal structures toward the injured lobe.

Question 10

If a CBD injury is identified intraoperatively, what is the first step to repair?

Answer 10

Define the anatomy - IOC

Question 11

What is the appropriate treatment for partial laceration of the CBD?

Answer 11

Primary repair over T-tube

Question 12

What is the appropriate treatement for CBD transection?

Answer 12

Primary repair UNLESS cautery or clip was used to transect

Question 13

What is the appropriate treatment for CBD transection if primary repair is contraindicated?

Answer 13

Kocher maneuver, end-to-end single layer interrupted fine caliber absorable suture repair + T-tube OR Roux-en-y hepaticojejunostomy

Question 14

What are the contraindications to primary CBD repair after transection?

Answer 14

Tension on repair, high biliary duct injuries, duct excision

Question 15

True/False. Early post-operative bile leaks where ERCP confirms gastrointestinal continuity of the biliary tree can be treated with ERCP and stent placement alone.

Answer 15

TRUE

Question 16

What causes prothrombin time abnormalities in patients with bile duct injuries?

Answer 16

Biliary fistulas result in inability to absorb fat-soluble vitamins leading to vitamin insufficiency

Question 17

What is the typical electrolyte abnormality seen in patients with biliary fistulas?

Answer 17

Hypovolemic hyponatremia

Question 18

For a bile leak treated with percutaneous drainage and stent placement, how long does the stent remain in place after drainage?

Answer 18

4-6 weeks

Question 19

What percentage of patients treated for benign biliary stricture with stent placement will have recurrent strictures?

Answer 19

20%

Question 20

What percentage of patients treated for benign biliary stricture with stent placement have complications?

Answer 20

10-15%

Question 21

What are some of the complications of treating benign biliary strictures with stents?

Answer 21

bleeding, cholangitis, pancreatitis, stent migration

Question 22

Where is the blood supply of the bile ducts located in cross sectional orientation?

Answer 22

3 and 9 o’clock, therfore dissection should be anterior with minimal circumferential dissection

Question 23

When performing dissection to inspect the ductal confluence, in what direction should dissection proceed?

Answer 23

left-to-right

Question 24

What is the significance of finding the posterior remnant joining the left and right lobar ducts if there is a bile duct injury at the level of the confluence?

Answer 24

It identifies the right lobar duct and allows for singular reconstruction of both ducts

Question 25

Which lobar duct has the shortest extrahepatic course?

Answer 25

right lobar duct

Question 26

Which factors portend a favorable outcome after repair of biliary injuries?

Answer 26

younger patient age, Roux-en-Y biliary-enteric reconstruction, absence of infection & hepatic fibrosis, transhepatic stents, and lower number of previous reconstructions

Question 27

What are the indications for surgical management of benign biliary strictures?

Answer 27

elevated alkaline phosphatase (prevents development of biliary cirrhosis from chronic obstruction), jaundice, hyperbilirubinemia

Question 28

What are the advantages and disadvantages of performing choledochoduodenostomy for biliary drainage as opposed to choledocho-/hepaticojejunostomy?

Answer 28

advantages - biliary flow continues through duodenum, jejunum left intact; disadvantages -previous inflammation may leave duodenum fibrotic making mobilization difficult

Question 29

What is the treatment of choice in a patient with suspicious distal CBD stricture, abdominal pain due to chronic pancreatitis?

Answer 29

Pancreaticoduodenectomy

Question 30

What is Mirizzi syndrome?

Answer 30

gallstones impacting the neck of the gallbladder inducing narrowing of the common hepatic duct by mechanical compression, inflammation, scarring, necrosis, then fistual formation

Question 31

True/False. Mirizzi syndrome is a relative contraindication to laparoscopic cholecystectomy.

Answer 31

TRUE

Question 32

How should a small fistula in a patient with Mirizzi syndrome be treated technically?

Answer 32

open cholecystectomy, open the gallbladder - leave wall of GB on CHD, close small fistula along its horizontal axis

Question 33

How should a large fistula in a patient with Mirizzi syndrome be treated technically?

Answer 33

open cholecystectomy, Roux-en-Y hepaticojejunostomy reconstruction