Iatrogenic injury to the bile duct: a working classification for radiologists

Iatrogenic bile duct injuries after laparoscopic cholecystectomy: evaluation by MRCP before management

Background

Iatrogenic bile duct injuries are unusual but possibly associated with fatal complications with increased incidence since the introduction of laparoscopic cholecystectomy. Appropriate estimation of these injuries is essential for proper management. Imaging is vital for the initial diagnosis, extent assessment and consequently, treatment guidance of bile duct injury with an ideal outcome. In this study, MRCP was carried out in 37 cases (28 females and 9 males, age range from 19 to 58 years) with suspected BDI following laparoscopic cholecystectomy. MRCP images were assessed for bile duct transection injury, strictures, biliary leakage, and intrahepatic biliary radicles (IHBR) dilatation. In positive cases, Strasberg classification system was used with the definitive diagnosis was done regarding the surgical findings and/or findings on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC).

Results

Our study includes 37 cases with biliary injuries. On MRCP our cases were stratified regarding the Strasberg-Bismuth classification into five types (A to E). Most BDIs were type E2 (29.7%), followed by type E1 (18.9%), type A (16.2%), type E3 (10.8%), type E4 (8.2%), type C (5.4%), and type D and finally type E5 and B injuries with each one representing 2.7%. Twenty cases presented with biliary leakage and seventeen with bile duct obstruction, whether duct ligation or stricture.

Conclusion

MRCP is an essential imaging modality for assessment of iatrogenic BDIs enabling the radiologists to classify these injuries and helps to govern the management.

MR cholangiopancreatography of the pancreas and biliary system: a review of the current applications

MR cholangiopancreatography (MRCP) is still a rapidly evolving technique, but it has been already accepted as clinically useful and is widely used to evaluate biliary or pancreatic diseases. The advantages of this technique are that it does not use contrast media or ionizing radiation, it is noninvasive and complication free, and the examination is relatively short. MRCP has high sensitivity and specificity for diagnosing biliary dilatation and for determining the site and cause of stenosis. With further improvements of hardware and technique, MRCP is expected to replace diagnostic endoscopic retrograde cholangiopancreatography to examine the biliary and pancreatic ducts in the near future. The other applications include evaluation of primary sclerosing cholangitis, stenosis after liver transplantation, and bilioenteric anastomoses. This article reviews the current applications of MRCP in the evaluation of the pancreas and the biliary system.

Liver fibrosis secondary to bile duct injury: correlation of Smad7 with TGF-beta and extracellular matrix proteins

BACKGROUND

Liver fibrosis is the result of continuous liver injury stemming from different etiological factors. Bile duct injury induces an altered expression of TGF-beta, which has an important role in liver fibrosis because this cytokine induces the expression of target genes such as collagens, PAI-1, TIMPs, and others that lead to extracellular matrix deposition. Smad7 is the principal inhibitor that regulates the target gene transcription of the TGF-beta signaling. The aim of the study was to determine whether Smad7 mRNA expression correlates with the gene expression of TGF-beta, Col I, Col III, Col IV, or PAI-1 in liver fibrosis secondary to bile duct injury (BDI).

RESULTS

Serum TGF-beta concentration was higher in BDI patients (39 296 pg/ml) than in liver donors (9008 pg/ml). Morphometric analysis of liver sections showed 41.85% of tissue contained fibrotic deposits in BDI patients. mRNA expression of Smad7, Col I, and PAI-1 was also significantly higher (P < 0.05) in patients with BDI than in controls. Smad7 mRNA expression correlated significantly with TGF-beta concentration, Col I and Col III expression, and the amount of fibrosis.

CONCLUSION

We found augmented serum concentration of TGF-beta and an increase in the percentage of fibrotic tissue in the liver of BDI patients. Contrary to expected results, the 6-fold increase in Smad7 expression did not inhibit the expression of TGF-beta, collagens, and PAI-1. We also observed greater expression of Col I and Col III mRNA in BDI patients and significant correlations between their expression and TGF-beta concentration and Smad7 mRNA expression.

Should laparoscopic cholecystectomy be practiced in the developing world?: the experience of the first training program in Afghanistan

OBJECTIVE

We address the controversial issue of whether or not it is wise to perform and train laparoscopic cholecystectomy (LC) in a developing nation by reviewing the results of the first large series done in Afghanistan. Afghanistan has been devastated by 3 decades of war leaving it with deficiencies in training programs, medical technologies, and overall medical infrastructure that are among the worst in the developing world.

METHODS

We retrospectively reviewed 137 consecutive cholecystectomies, 102 laparoscopic and 35 open, performed by 4 senior and 3 junior surgeons trained at our hospital in Kabul from July 2005 until February 2008. Deaths, complications, conversion rate, operative time, and hospital length of stay were compared.

RESULTS

Unrecognized major operative injuries occurred in 4 LC patients, 3 bile leaks, and 1 duodenal perforation, although there were no such injuries in the open cholecystectomy group. Complication rates were much higher for patients operated on for acute cholecystitis for both surgeon groups. Even though junior surgeons converted to open cholecystectomy more frequently than senior surgeons, they had a higher major complication rate. Hospital length of stay was 28% shorter for the laparoscopic group.

CONCLUSIONS

The high rate of major unrecognized intraoperative complications during LC in our series underscores the difficulties inherent in performing and training LC in developing nations. Practical changes are suggested to make LC more efficient and safer in a developing world hospital.

[Anatomy of the liver: what you need to know]

A precise knowledge of arterial, portal, hepatic and biliary anatomical variations is mandatory when a liver intervention is planned. However, only certain variations must be searched when a precise intervention is planned. The basic liver anatomy as well as the most relevant malformations will be precised.

Chemotherapy-induced sclerosing cholangitis

AIM

To review the computed tomography (CT), magnetic resonance imaging (MRI) and cholangiographic findings of chemotherapy-induced sclerosing cholangitis (CISC).

METHODS

Between January 1995 and December 2004, 11 patients in the endoscopic retrograde cholangiography database were identified with CISC. Twelve CT, four MRI, 69 endoscopic and nine antegrade cholangiographic studies in these patients were reviewed. Serial change in appearance and response to endoscopic treatment were recorded.

RESULTS

CISC showed segmental irregular biliary dilatation with strictures of proximal extrahepatic bile ducts. The distal 5cm of common bile duct was not affected in any patient. CT and MRI findings included altered vascular perfusion of one or more liver segments, liver metastases or peritoneal carcinomatosis. Biliary strictures needed repeated stenting in 10 patients (mean: every 4.7 months). Cirrhosis (n=1) or confluent fibrosis (n=0) were uncommon findings.

CONCLUSION

CISC shares similar cholangiographic appearances to primary sclerosing cholangitis (PSC). Unlike PSC, biliary disease primarily involved ducts at the hepatic porta rather than intrahepatic ducts. Multiphasic contrast-enhanced CT or MRI may show evidence of perfusion abnormalities, cavitary liver lesions, or metastatic disease.

Using MR cholangiopancreatography to evaluate iatrogenic bile duct injury

OBJECTIVE

The purpose of this study was to assess the role of MR cholangiopancreatography (MRCP) in the evaluation of iatrogenic bile duct injuries.

SUBJECTS AND METHODS

In this prospective study, MRCP was performed in 10 postoperative patients (nine female and one male, ranging in age from 17 to 79 years) suspected of having bile duct injury as a result of surgery. Presence or absence of biliary dilatation, excision injury, stricture, fluid collection, and free fluid was noted. Excision injury was diagnosed if a segment of bile duct was not visible on any of the MRCP sequences. Positive cases were classified according to anatomic location and extent of injury. Results were compared with endoscopic retrograde cholangiopancreatography in five patients, percutaneous transhepatic cholangiography in one, surgery in four, and clinical follow-up in three.

RESULTS

Three patients had normal findings on MRCP and remained asymptomatic on clinical follow-up. Four patients had bile duct excision injury on MRCP that was surgically proven, and one had stricture, confirmed by percutaneous transhepatic cholangiography. Of these five patients, one had Bismuth type I injury, two had type II, one had type III, and one had type IV. Two patients had findings suggestive of cystic duct leak on MRCP that were confirmed on cholangiography.

CONCLUSION

MRCP can accurately diagnose postoperative biliary strictures and excision injuries and can characterize and anatomically classify these injuries for planning reparative surgery. It can also suggest the presence of cystic duct leaks in patients who have undergone cholecystectomy.