Surgery (RMH) - Theses
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ItemBiliary tract injury( 2012)Aim - The aim of the thesis was to examine the causes, mechanisms, recognition and treatment of biliary injury. The hypothesis was that the management principles for biliary injury were similar regardless of the cause. Methods - Biliary injuries secondary to operative damage (iatrogenic), following transplantation or as a result of blunt or penetrating (traumatic) trauma were examined. The following databases were analyzed; A prospective database of biliary injuries in Victoria from 1997 - 1999, a database of iatrogenic biliary injuries from the Royal Infirmary of Edinburgh from 1984 - 2003, a prospective database for all liver transplants performed by the Scottish Liver Transplant Unit (SLTU) until September 2001 and the prospectively gathered trauma registry at The Royal Melbourne Hospital from 1999 - 2011. Retrospective case note review was performed for further data collection. Patient data was entered onto a Microsoft Access database and statistical analysis performed with SSPS versions using Cox regression for multivariate analysis, the Mann Whitney U test for independent variables and the Log rank test when appropriate. Not all data sets were of sufficient size to allow statistical analysis. Management of biliary injury included non-operative, percutaneous, endoscopic and surgical options. Results - Iatrogenic injuries were recorded in 33 patients from the Victorian audit and 123 patients from the Royal Infirmary of Edinburgh. Fifty five (14.6%) of 379 consecutive orthotopic liver transplants at the SLTU had biliary complications. Thirty three patients (0.1%) of 26,014 blunt and penetrating trauma patients had injuries to the biliary tree and gallbladder. Of the 123 iatrogenic injuries from the Royal Infirmary of Edinburgh, 55 (44.7%) had an attempted repair prior to referral, 59 (47.9%) were repaired after referral and 9 (7.3%) were managed without surgery. For the 59 patients repaired after referral a successful repair was possible in 22 (88%) of 25 patients repaired within the first two weeks compared with 20 (91%) of 22 repaired after 6 weeks (p=0.615). Nine patients were considered for hepatic resection. Five patients developed hepatic failure and were considered for liver transplantation with only two reaching transplantation. Of the 55 grafts from the SLTU with biliary complications, 28 biliary leaks occurred with 17 anastomotic leaks successfully treated non-operatively. Of the thirty anastomotic strictures, six (38%) of the 16 early anastomotic strictures required surgery for complete resolution, compared with 12 (86%) of the 14 late anastomotic strictures (p=0.0106). Of the blunt and penetrating biliary injuries there were 10 gallbladder and 23 biliary tree injuries. Fourteen patients had injuries to the intra-hepatic biliary tree and nine to the extra-hepatic biliary tree. Delay in the recognition of biliary injury following iatrogenic injury continues to be prevalent, with the delay often associated with sepsis, jaundice and peritonitis. Injury following liver transplantation is complicated by the association of hepatic arterial thrombosis and immunosuppression, whilst traumatic injury is frequently associated with intra-abdominal organ injury. The timing of repair and utilization of temporizing measures such as biliary drainage depends upon the associated injuries and presence of sepsis or jaundice. For all types of biliary injury, surgical reconstruction with Roux-en-Y hepaticojejunostomy remains the gold standard for repair. Successful long lasting repair is possible in the majority when managed by a specialist hepatobiliary team. Conclusion - The management of biliary injuries is multi-factorial and requires tailoring according to patient variables. However, common management pathways exist regardless of the cause.