Ekstrahepatik Safra Yolları İle İlgili Yaralanmalarda Tanı ve Tedavi Yaklaşımı
Özet
Ekstrahepatik safra yolları (EHSY) yaralanmaları, hastaların hayat kalitesini olumsuz etkileyen, yüksek mortalite ve ciddi morbiditeye yol açan önemli bir sağlık sorunudur. Bu yaralanmaların ana sebebi cerrahi girişimler olup, vakaların büyük çoğunluğu laparoskopik veya açık kolesistektomi ameliyatları sırasında, özellikle Calot üçgenindeki diseksiyon hataları veya anatomik varyasyonların yanlış tanımlanması nedeniyle gelişmektedir. Yaralanmaların anatomik ve mekanik özelliklerini tanımlamak için Bismuth, Strasberg ve ATOM gibi çeşitli sınıflama sistemleri kullanılmaktadır. Tanı aşamasında ultrasonografi, bilgisayarlı tomografi ve özellikle altın standart olarak kabul edilen Manyetik Rezonans Kolanjiyografi (MRCP) kritik rol oynarken; ERCP ve PTK hem tanı hem de minimal invaziv tedavi imkanı sunmaktadır. Tedavi stratejisi yaralanmanın ciddiyetine, tespit zamanına ve cerrahın deneyimine bağlı olarak değişmektedir; erken dönemde fark edilen majör yaralanmalarda deneyimli cerrahlarca yapılan Roux-en-Y hepatikojejunostomi en etkili rekonstrüksiyon yöntemidir. Ayrıca, akut kolesistit varlığında operasyon zamanlaması yaralanma riskini doğrudan etkilemekte ve semptomların ilk 72 saatinde yapılan müdahaleler daha güvenli sonuçlar vermektedir. Yaralanmaları önlemek için "eleştirel güvenlik görüşü" tekniğinin uygulanması ve riskli durumlarda subtotal kolesistektomiye geçilmesi hayati önem taşımaktadır.
Extrahepatic bile duct (EHBD) injuries are significant medical complications that adversely affect patients' quality of life, leading to high mortality and serious morbidity. The primary cause of these injuries is surgical interventions, with the vast majority occurring during laparoscopic or open cholecystectomy, often due to dissection errors in Calot's triangle or the misidentification of anatomical variations. Classification systems such as Bismuth, Strasberg, and ATOM are utilized to define the anatomical and mechanical characteristics of the injuries. While ultrasonography, computed tomography, and particularly Magnetic Resonance Cholangiopancreatography (MRCP)—considered the gold standard—play a critical role in diagnosis, ERCP and PTC offer both diagnostic and minimally invasive therapeutic options. The management strategy depends on the severity of the injury, the timing of detection, and the surgeon's expertise; for major injuries detected early, Roux-en-Y hepaticojejunostomy performed by experienced hepatopancreatobiliary surgeons is the most effective reconstruction method. Furthermore, the timing of surgery in acute cholecystitis directly correlates with injury risk, with interventions performed within the first 72 hours of symptom onset yielding safer outcomes. Applying the "critical view of safety" technique and switching to subtotal cholecystectomy in hostile gallbladders are vital strategies for prevention.
Referanslar
Schwaitzberg SD, Scott DJ, Jones DB, McKinley SK, Castrillion J, Hunter TD, Michael Brunt L. Threefold increased bile duct injury rate is associated with less surgeon experience in an insurance claims database: more rigorous training in biliary surgery may be needed. Surg Endosc. 2014 Nov;28(11):3068-73. doi: 10.1007/s00464-014-3580-0. Epub 2014 Jun 6. PMID: 24902815.
Törnqvist B, Strömberg C, Akre O, Enochsson L, Nilsson M. Selective intraoperative cholangiography and risk of bile duct injury during cholecystectomy. Br J Surg. 2015 Jul;102(8):952-8. doi: 10.1002/bjs.9832. Epub 2015 Apr 28. PMID: 25919401.
Fong ZV, Pitt HA, Strasberg SM, Loehrer AP, Sicklick JK, Talamini MA, Lillemoe KD, Chang DC; California Cholecystectomy Group. Diminished Survival in Patients with Bile Leak and Ductal Injury: Management Strategy and Outcomes. J Am Coll Surg. 2018 Apr;226(4):568-576.e1. doi: 10.1016/j.jamcollsurg.2017.12.023. Epub 2018 Jan 4. PMID: 29307612; PMCID: PMC6053912.
Misawa T, Saito R, Shiba H, Son K, Futagawa Y, Nojiri T, Kitajima K, Uwagawa T, Ishida Y, Ishii Y, Yanaga K. Analysis of bile duct injuries (Stewart-Way classification) during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2006;13(5):427-34. doi: 10.1007/s00534-006-1099-z. PMID: 17013718.
Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg. 2001 Oct;234(4):549-58; discussion 558-9. doi: 10.1097/00000658-200110000-00014. PMID: 11573048; PMCID: PMC1422078.
Krähenbühl L, Sclabas G, Wente MN, Schäfer M, Schlumpf R, Büchler MW. Incidence, risk factors, and prevention of biliary tract injuries during laparoscopic cholecystectomy in Switzerland. World J Surg. 2001 Oct;25(10):1325-30. doi: 10.1007/s00268-001-0118-0. PMID: 11596898.
Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2002;9(5):543-7. doi: 10.1007/s005340200071. PMID: 12541037.
Georgiades CP, Mavromatis TN, Kourlaba GC, Kapiris SA, Bairamides EG, Spyrou AM, Kokkinos CN, Spyratou CS, Ieronymou MI, Diamantopoulos GI. Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy? Surg Endosc. 2008 Sep;22(9):1959-64. doi: 10.1007/s00464-008-9943-7. Epub 2008 Apr 29. PMID: 18443865.
Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan;180(1):101-25. PMID: 8000648.
Bismuth H, Majno PE. Biliary strictures: classification based on the principles of surgical treatment. World J Surg. 2001 Oct;25(10):1241-4. doi: 10.1007/s00268-001-0102-8. PMID: 11596882.
Fingerhut A, Dziri C, Garden OJ, Gouma D, Millat B, Neugebauer E, Paganini A, Targarona E. ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy. Surg Endosc. 2013 Dec;27(12):4608-19. doi: 10.1007/s00464-013-3081-6. Epub 2013 Jul 27. PMID: 23892759.
Russell JC, Walsh SJ, Mattie AS, Lynch JT. Bile duct injuries, 1989-1993. A statewide experience. Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg. 1996 Apr;131(4):382-8. doi: 10.1001/archsurg.1996.01430160040007. PMID: 8615723.
Berry SM, Ose KJ, Bell RH, Fink AS. Thermal injury of the posterior duodenum during laparoscopic cholecystectomy. Surg Endosc. 1994 Mar;8(3):197-200. doi: 10.1007/BF00591829. PMID: 8191358.
Brooks DC, Becker JM, Connors PJ, Carr-Locke DL. Management of bile leaks following laparoscopic cholecystectomy. Surg Endosc. 1993 Jul-Aug;7(4):292-5. doi: 10.1007/BF00725942. PMID: 8351598.
Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 1991 Apr 18;324(16):1073-8. doi: 10.1056/NEJM199104183241601. Erratum in: N Engl J Med 1991 Nov 21;325(21):1517-8. PMID: 1826143.
Brunt LM, Deziel DJ, Telem DA, Strasberg SM, Aggarwal R, Asbun H, Bonjer J, McDonald M, Alseidi A, Ujiki M, Riall TS, Hammill C, Moulton CA, Pucher PH, Parks RW, Ansari MT, Connor S, Dirks RC, Anderson B, Altieri MS, Tsamalaidze L, Stefanidis D; and the Prevention of Bile Duct Injury Consensus Work Group. Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy. Ann Surg. 2020 Jul;272(1):3-23. doi: 10.1097/SLA.0000000000003791. PMID: 32404658.
Lidsky ME, Speicher PJ, Ezekian B, Holt EW, Nussbaum DP, Castleberry AW, et al. Subtotal cholecystectomy for the hostile gallbladder: failure to control the cystic duct results in significant morbidity. HPB (Oxford). 2017;19:547–56.
Arezzo A, Passera R, Forcignanò E, Rapetti L, Cirocchi R, Morino M. Single-incision laparoscopic cholecystectomy is responsible for increased adverse events: results of a meta-analysis of randomized controlled trials. Surg Endosc. 2018 Sep;32(9):3739-3753. doi: 10.1007/s00464-018-6143-y. Epub 2018 Mar 9. PMID: 29523982.
Sirinek KR, Schwesinger WH. Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography? J Am Coll Surg. 2015 Apr;220(4):522-8. doi: 10.1016/j.jamcollsurg.2014.12.043. Epub 2015 Jan 9. PMID: 25724609.
Buddingh KT, Hofker HS, ten Cate Hoedemaker HO, van Dam GM, Ploeg RJ, Nieuwenhuijs VB. Safety measures during cholecystectomy: results of a nationwide survey. World J Surg. 2011 Jun;35(6):1235-41; discussion 1242-3. doi: 10.1007/s00268-011-1061-3. PMID: 21445669; PMCID: PMC3092925.
Machi J, Tateishi T, Oishi AJ, Furumoto NL, Oishi RH, Uchida S, Sigel B. Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography. J Am Coll Surg. 1999 Apr;188(4):360-7. doi: 10.1016/s1072-7515(98)00313-5. PMID: 10195719.
Ding GQ, Cai W, Qin MF. Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis? World J Gastroenterol. 2015 Feb 21;21(7):2147-51. doi: 10.3748/wjg.v21.i7.2147. PMID: 25717250; PMCID: PMC4326152.
Ford JA, Soop M, Du J, Loveday BP, Rodgers M. Systematic review of intraoperative cholangiography in cholecystectomy. Br J Surg. 2012 Feb;99(2):160-7. doi: 10.1002/bjs.7809. Epub 2011 Dec 19. PMID: 22183717.
Dip F, LoMenzo E, Sarotto L, Phillips E, Todeschini H, Nahmod M, Alle L, Schneider S, Kaja L, Boni L, Ferraina P, Carus T, Kokudo N, Ishizawa T, Walsh M, Simpfendorfer C, Mayank R, White K, Rosenthal RJ. Randomized Trial of Near-infrared Incisionless Fluorescent Cholangiography. Ann Surg. 2019 Dec;270(6):992-999. doi: 10.1097/SLA.0000000000003178. PMID: 30614881.
Jabłońska B, Lampe P. Iatrogenic bile duct injuries: etiology, diagnosis and management. World J Gastroenterol. 2009 Sep 7;15(33):4097-104. doi: 10.3748/wjg.15.4097. PMID: 19725140; PMCID: PMC2738802.
Linhares BL, Magalhães Ada G, Cardoso PM, Linhares Filho JP, Pinho JE, Costa ML. Bile duct injury following cholecystectomy. Rev Col Bras Cir. 2011 Mar-Apr;38(2):95-9. English, Portuguese. doi: 10.1590/s0100-69912011000200005. PMID: 21710046.
Wigham A, Alexander Grant L. Radiologic assessment of hepatobiliary surgical complications. Semin Ultrasound CT MR. 2013 Feb;34(1):18-31. doi: 10.1053/j.sult.2012.11.002. PMID: 23395315.
Aduna M, Larena JA, Martín D, Martínez-Guereñu B, Aguirre I, Astigarraga E. Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP. Abdom Imaging. 2005 Jul-Aug;30(4):480-7. doi: 10.1007/s00261-004-0276-2. PMID: 15688109.
Fidelman N, Kerlan RK Jr, Laberge JM, Gordon RL. Accuracy of percutaneous transhepatic cholangiography in predicting the location and nature of major bile duct injuries. J Vasc Interv Radiol. 2011 Jun;22(6):884-92. doi: 10.1016/j.jvir.2011.02.007. Epub 2011 Apr 22. PMID: 21514840.
Lindemann J, Kloppers C, Burmeister S, Bernon M, Jonas E. Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series. Int J Surg Case Rep. 2019;60:340-344. doi: 10.1016/j.ijscr.2019.06.059. Epub 2019 Jun 28. PMID: 31279238; PMCID: PMC6612668.
Törnqvist B, Waage A, Zheng Z and al. Severity of Acute Cholecystitis and Risk of Iatrogenic Bile Duct Injury During Cholecystectomy, a Population-Based Case-Control Study. World J Surg. 2016 May;40(5):1060-7.
Brooks KR, Scarborough JE and al. No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database. J Trauma Acute Care Surg. 2013 Jan;74(1):167-73; 173-4.
Zafar SN, Obirieze A, Adesibikan B and al. Optimal time for early laparoscopic cholecystectomy for acute cholecystitis. JAMA Surg. 2015 Feb;150(2):129-36. doi: 10.1001/jamasurg.2014.2339. Erratum in: JAMA Surg. 2015 Feb;150(2):183.
Blohm M, Österberg J, Sandblom G and al. The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks. J Gastrointest Surg. 2017 Jan;21(1):33-40.
Pisano M, Allievi N, Gurusamy K and al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg. 2020 Nov 5;15(1):61.
de'Angelis N, Catena F, Memeo R and al. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg. 2021 Jun 10;16(1):30.
Fletcher R, Cortina CS, Kornfield H and al. Bile duct injuries: a contemporary survey of surgeon attitudes and experiences. Surg Endosc. 2020 Jul;34(7):3079-3084.
Sicklick JK, Camp MS, Lillemoe KD and al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005 May;241(5):786-92; discussion 793-5.
Pekolj J, Alvarez FA, Palavecino M and al. Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center. J Am Coll Surg. 2013 May;216(5):894-901.
Ray S, Sanyal S, Das S and al. Outcomes of surgery for post-cholecystectomy bile duct injuries: An audit from a tertiary referral center. J Visc Surg. 2020 Feb;157(1):3-11.
Wang X, Yu WL, Fu XH and al. Early Versus Delayed Surgical Repair and Referral for Patients With Bile Duct Injury: A Systematic Review and Meta-analysis. Ann Surg. 2020 Mar;271(3):449-459.
Mesleh MG, Asbun HJ. Management of common bile duct injury. In: Asbun HJ, et al., editors. The SAGES manual of biliary surgery. Switzerland: Springer; 2020. p. 213–31.
Kimura T, Suzuki K, Umehara Y and al. Features and management of bile leaks after laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2005;12(1):61-4.
ASGE Standards of Practice Committee, Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA and al. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc. 2015 Apr;81(4):795-803.
Maddah G, Rajabi Mashhadi MT, Parvizi Mashhadi M and al. Iatrogenic injuries of the extrahepatic biliary system. J Surg Res. 2017 Jun 1;213:215-221.
Walsh RM, Vogt DP, Ponsky JL and al. Management of failed biliary repairs for major bile duct injuries after laparoscopic cholecystectomy. J Am Coll Surg. 2004 Aug;199(2):192-7.
Flum DR, Cheadle A, Prela C and al. Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA. 2003 Oct 22;290(16):2168-73.
Dageforde LA, Landman MP, Feurer ID and al. A cost-effectiveness analysis of early vs late reconstruction of iatrogenic bile duct injuries. J Am Coll Surg. 2012 Jun;214(6):919-27.
Zerem E, Omerović S. Minimally invasive management of biliary complications after laparoscopic cholecystectomy. Eur J Intern Med. 2009 Nov;20(7):686-9.
Iannelli A, Paineau J, Hamy A and al. Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie. HPB (Oxford). 2013;15:611–6.
Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford). 2011;13:1 14.
Koffron A, Ferrario M, Parsons W and al. Failed primary management of iatrogenic biliary injury: incidence and significance of concomitant hepatic arterial disruption. Surgery. 2001 Oct;130(4):722-8; discussion 728-31.
Winslow ER, Fialkowski EA, Linehan DC and al. "Sideways": results of repair of biliary injuries using a policy of side-to-side hepatico-jejunostomy. Ann Surg. 2009 Mar;249(3):426-34.
Alves A, Farges O, Nicolet J and al. Incidence and consequence of an hepatic artery injury in patients with postcholecystectomy bile duct strictures. Ann Surg. 2003 Jul;238(1):93-6.
