3. definition
A biliary stricture is an abnormal narrowing of
the bile duct, the tube that moves bile (A
substance that helps in digestion) from the
liver to the small intestine
5. Pathological effects of biliary
obstruction
Biliary
obstruction
High local
concentratio
n of bile salts
inflammatio
n
6. Pathological effects of biliary
obstruction
Fibrosis
and
scarring
Biliary fistula
Biliary
stasis
Liver
atrophy
Repeated
cholangitis
Biliary cirrhosis and
PHTN
7. Causes of benign stricture
I. Congenital strictures
Biliary atresia
II. Bile duct injuries
A. Postoperative strictures
(1) Cholecystectomy or common bile duct
exploration (accounting 80% of nonmalignant stricture)
(2) Biliary-enteric anastomosis
(3) Hepatic resection
(4) Portocaval shunt
(5) Pancreatic surgery
(6) Gastrectomy
(7) Liver transplantation
B. Stricture after blunt or penetrating trauma
8. Causes of benign stricture
C. Strictures after endoscopic or percutaneous
biliary intubation
III. Inflammatory strictures
A. Cholelithiasis or choledocholithiasis
B. Chronic pancreatitis
C. Chronic duodenal ulceration
D. Abscess or inflammation of liver or subhepatic
space
E. Parasitic infection
F. Recurrent pyogenic cholangitis (Oriental
cholangiohepatitis)
IV. Primary sclerosing cholangitis
V. Radiation-induced stricture
9. Causes of malignant stricture
Primary tumors
1. Cholangiocarcinoma
2. GB Cancer
3. Pancreatic
adenocarcinoma
4. Ampullary carcinoma
5. Hepatoma
6. Gastric carcinoma
Metastatic tumors
1. pancreatic
adenocarcinoma
2. Colon cancer
3. Breast cancer
4. Lung cancer
5. Melanoma
6. Ovarian cancer
10. Bile duct injury at
cholecystectomy
Incidence
1.open cholecystectomy 0.1 -0.2%
2.lap cholecystectomy 0.4 -1.3%
80% of benign strictures occurs following
injury during a cholecystectomy.
A major factor is surgeons inexperience-
learning curve effect
13. Technical factors
Experience of surgeon
Improper assistance
Extensive dissection
Excess use of cautery
Misplacement of clips
Excess traction on gall bladder
Subvesical duct of luschka in 1-2 % patients
CBD Exploration-use of metal bougies
Attempts to achieve hemostasis
14. Pathologic factors
Acute cholecystitis
inflammation leads to edema in the porta
hepatis and calots triangle—distortion of
anatomy
Chronic cholecystitis
chronic inflammation leads to fibrosis,
adherence, contracted fibrotic gall bladder,
cholecystocholedochal fistula
(partial cholecystectomy, cholecystostomy, and
cholecystocholedochoduodenostomy are
options)
15. Laparoscopicspecific
- Classification of Causes of Laparoscopic Biliary
Injuries
1. Misidentification of the bile ducts as the cystic duct
a. Misidentification of the common bile duct as the cystic
duct
b. Misidentification of an aberrant right sectoral hepatic
duct as the cystic duct
2.Technical causes
a. Failure to occlude the cystic duct securely
b. Plane of dissection away from gallbladder wall into the
liver bed
c. Injudicious use of electrocautery for dissection or
bleeding control
d. Excessive traction on cystic duct with tenting upward of
common hepatic duct
e. Injudicious use of clips to control bleeding
f. Improper techniques of ductal exploration
39. Surgical treatment of BDI
Recognized at operation
Immediate open conversion and repair by an
experienced surgeon
If competent help unavailable, put a drain &
should be referred to a specialist center
End to end repair overT- tube
Roux –en –Y hepaticojejunostomy
(silk sutures should be avoided for all biliary
reconstructions, because they can act as
nidus for stone formation)
40. Surgical treatment of BDI
Recognized in immediate postoperative period
Avoid early reoperation
Bile leak from cystic duct, subvesical duct of
luschka or from noncircumferential laceration
with no distal obstruction to bile flow may
close spontaneously (1to 3 weeks)
Endoscopic sphincterotomy with stenting-
hasten closure
For severe lacerations and complete
transactions –delayed approach is best
(timing of surgical intervention 4-10 weeks)
41. Surgical treatment of BDI
injury presenting at an interval
Presented as late bile duct stenosis and
stricture
Consider nonoperative biliary drainage
procedures
Consider surgery if no resolution in 12 -24
months
Almost always requires Roux –en –Y
hepaticojejunostomy
47. Roux-en-Y Hepaticojejunostomy
Common method of repair of bile duct injury
Proper exposure of healthy ,well vascularised
proximal bile duct
Roux- en –Y Limb of jejunum >60 cm
Mucosa to mucosa tension free anastomosis
Side to side or end to side
hepaticojejunostomy using left hepatic duct
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65. •Factors associated with poor outcome
after surgery
Proximal stricture (Bismuth type 3 and 4)
Multiple prior attempts at repair
Portal hypertension
Hepatic parenchymal disease (cirrhosis or hepatic fibrosis)
End-to-end biliary anastomosis
Surgeon inexperience
Intrahepatic or multiple strictures
Concurrent cholangitis or hepatic abscess
Intrahepatic stones
External or internal biliary fistula
Intra-abdominal abscess or bile collection
Hepatic lobar atrophy
Advanced age or poor general health
Many authors have advocated the use of anasto
Triad –pain, jaundice, fever……….pentad –shock, altered mental status
Symptoms of obstructive jaundice---itchy skin,clay coloured stool,anorexia,yellowish discolouration of eyes and skin,dark coloured urine,easy bruising,fever
Curv law –nontender enlarged gb with mild jaundice ,cause is unlikely to be gall stones,usually pancreatic or gb ca
Signs of HCF—ascites,encephalopathy,variceal bleed
Lpj id calculi.ERCP dilated duct cut off due to caluli