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Questions and Answers
What percentage of interventional radiologist and/or surgeon patients did not improve clinically after tube placement?
What percentage of interventional radiologist and/or surgeon patients did not improve clinically after tube placement?
What is a possible complication of tube dislodgement or gallbladder wall necrosis?
What is a possible complication of tube dislodgement or gallbladder wall necrosis?
What should be suspected when a patient's leukocytosis worsens or does not improve after tube placement?
What should be suspected when a patient's leukocytosis worsens or does not improve after tube placement?
What is recommended by the TG18 regarding cholecystectomy after tube placement?
What is recommended by the TG18 regarding cholecystectomy after tube placement?
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What percentage of patients eventually undergo definitive cholecystectomy according to various studies?
What percentage of patients eventually undergo definitive cholecystectomy according to various studies?
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Why is it important to correct coagulopathy before tube placement?
Why is it important to correct coagulopathy before tube placement?
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What can occur if the bile leakage is contained and localized?
What can occur if the bile leakage is contained and localized?
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What is the long-term management of cholecystostomy tubes after initial treatment?
What is the long-term management of cholecystostomy tubes after initial treatment?
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What is the primary reason for placing closed-suction drains in the subhepatic space?
What is the primary reason for placing closed-suction drains in the subhepatic space?
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What is the most common ductal injury during laparoscopic cholecystectomy?
What is the most common ductal injury during laparoscopic cholecystectomy?
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Who typically achieves the best outcomes after iatrogenic biliary injuries?
Who typically achieves the best outcomes after iatrogenic biliary injuries?
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What is the recommended approach when a bile duct injury is recognized during laparoscopic cholecystectomy?
What is the recommended approach when a bile duct injury is recognized during laparoscopic cholecystectomy?
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What is the typical presentation of patients with an iatrogenic biliary injury?
What is the typical presentation of patients with an iatrogenic biliary injury?
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What is the primary goal of full disclosure to patients and their families in the context of iatrogenic biliary injuries?
What is the primary goal of full disclosure to patients and their families in the context of iatrogenic biliary injuries?
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What is the recommended approach for managing strictures that develop early or late postoperatively?
What is the recommended approach for managing strictures that develop early or late postoperatively?
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When repairing a bile duct injury, what is the role of a generous Kocher maneuver?
When repairing a bile duct injury, what is the role of a generous Kocher maneuver?
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What is the primary cause of biliary injuries?
What is the primary cause of biliary injuries?
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What is the significance of assessing the hepatic arteries during a biliary injury?
What is the significance of assessing the hepatic arteries during a biliary injury?
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What is the percentage of cases where vascular injury occurs concurrently with biliary injury?
What is the percentage of cases where vascular injury occurs concurrently with biliary injury?
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What is the most common structure involved in a vasculobiliary injury?
What is the most common structure involved in a vasculobiliary injury?
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What is the purpose of performing cholangiography and biliary drainage in the postoperative period?
What is the purpose of performing cholangiography and biliary drainage in the postoperative period?
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What type of imaging modality is usually used to assess the hepatic arteries in the postoperative period?
What type of imaging modality is usually used to assess the hepatic arteries in the postoperative period?
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What is the significance of Type E4 and E5 in the classification system of biliary injuries?
What is the significance of Type E4 and E5 in the classification system of biliary injuries?
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What is the challenge of performing cholangiography and biliary drainage in the postoperative period?
What is the challenge of performing cholangiography and biliary drainage in the postoperative period?
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Why is a Roux-en-Y jejunal limb preferred over an anastomosis to the duodenum?
Why is a Roux-en-Y jejunal limb preferred over an anastomosis to the duodenum?
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When should the definitive repair of a bile duct transection recognized in the postoperative period be planned?
When should the definitive repair of a bile duct transection recognized in the postoperative period be planned?
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What is the purpose of placing a transanastomotic stent across the anastomosis?
What is the purpose of placing a transanastomotic stent across the anastomosis?
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How are the catheters typically placed for external drainage?
How are the catheters typically placed for external drainage?
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What type of sutures are typically used to construct the anastomosis?
What type of sutures are typically used to construct the anastomosis?
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What is usually present in the right upper quadrant when the abdomen is explored through a midline incision?
What is usually present in the right upper quadrant when the abdomen is explored through a midline incision?
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Why is it important to monitor fluid, electrolytes, and hydration in patients with complete bile diversion?
Why is it important to monitor fluid, electrolytes, and hydration in patients with complete bile diversion?
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When can repair occur if there has been no bile leak?
When can repair occur if there has been no bile leak?
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What percentage of all choledochal cysts (CCs) are comprised of Type II cysts?
What percentage of all choledochal cysts (CCs) are comprised of Type II cysts?
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What is the most frequently used imaging modality to diagnose CC?
What is the most frequently used imaging modality to diagnose CC?
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What is a characteristic of Type IV cysts?
What is a characteristic of Type IV cysts?
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What should be suspected in an adult with a CBD diameter of >10 mm on any imaging modality?
What should be suspected in an adult with a CBD diameter of >10 mm on any imaging modality?
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What is a characteristic of Type III cysts?
What is a characteristic of Type III cysts?
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Why should caution be used when considering a CBD diameter of >10 mm in older patients?
Why should caution be used when considering a CBD diameter of >10 mm in older patients?
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What is a limitation of US and CT in diagnosing CC?
What is a limitation of US and CT in diagnosing CC?
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What is the approximate percentage of all CCs that are Type IV cysts?
What is the approximate percentage of all CCs that are Type IV cysts?
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What is the primary goal of full disclosure to patients and their families in the context of iatrogenic biliary injuries?
What is the primary goal of full disclosure to patients and their families in the context of iatrogenic biliary injuries?
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What is the benefit of near-infrared biliary imaging using indocyanine green or white light technology?
What is the benefit of near-infrared biliary imaging using indocyanine green or white light technology?
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What is the classification of biliary injuries based on the location of the injury with respect to the hepatic bifurcation?
What is the classification of biliary injuries based on the location of the injury with respect to the hepatic bifurcation?
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What type of biliary injury involves the transection of the aberrant right hepatic ducts?
What type of biliary injury involves the transection of the aberrant right hepatic ducts?
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What is the characteristic of Type E2 biliary injuries?
What is the characteristic of Type E2 biliary injuries?
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What is the purpose of laparoscopic ultrasonography or near-infrared biliary imaging using indocyanine green or white light technology?
What is the purpose of laparoscopic ultrasonography or near-infrared biliary imaging using indocyanine green or white light technology?
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What is the significance of assessing the hepatic arteries during a biliary injury?
What is the significance of assessing the hepatic arteries during a biliary injury?
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What is the primary goal of performing cholangiography and biliary drainage in the postoperative period?
What is the primary goal of performing cholangiography and biliary drainage in the postoperative period?
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What is the percentage of cases where vascular injury occurs concurrently with biliary injury?
What is the percentage of cases where vascular injury occurs concurrently with biliary injury?
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Which type of imaging modality is usually used to assess the hepatic arteries in the postoperative period?
Which type of imaging modality is usually used to assess the hepatic arteries in the postoperative period?
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What is the significance of assessing the hepatic arteries during a biliary injury?
What is the significance of assessing the hepatic arteries during a biliary injury?
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What is the purpose of performing cholangiography and biliary drainage in the postoperative period?
What is the purpose of performing cholangiography and biliary drainage in the postoperative period?
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What is the most common structure involved in a vasculobiliary injury?
What is the most common structure involved in a vasculobiliary injury?
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What is the significance of Type E4 and E5 in the classification system of biliary injuries?
What is the significance of Type E4 and E5 in the classification system of biliary injuries?
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What is the challenge of performing cholangiography and biliary drainage in the postoperative period?
What is the challenge of performing cholangiography and biliary drainage in the postoperative period?
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Why is it important to correct coagulopathy before performing any interventions for biliary injuries?
Why is it important to correct coagulopathy before performing any interventions for biliary injuries?
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What is the significance of mobilizing the superior portion of the cyst during type I CC surgery?
What is the significance of mobilizing the superior portion of the cyst during type I CC surgery?
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What is the recommended approach for transection of the duct during type I CC surgery?
What is the recommended approach for transection of the duct during type I CC surgery?
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What is the purpose of endoscopic sphincterotomy in the management of biliary dilation?
What is the purpose of endoscopic sphincterotomy in the management of biliary dilation?
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What is the importance of preoperative counseling in type I CC surgery?
What is the importance of preoperative counseling in type I CC surgery?
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What is the characteristic of Type IV cysts?
What is the characteristic of Type IV cysts?
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What is the recommended approach for managing strictures that develop early or late postoperatively?
What is the recommended approach for managing strictures that develop early or late postoperatively?
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What is the significance of assessing the hepatic arteries during a biliary injury?
What is the significance of assessing the hepatic arteries during a biliary injury?
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What is the purpose of performing cholangiography and biliary drainage in the postoperative period?
What is the purpose of performing cholangiography and biliary drainage in the postoperative period?
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Study Notes
Cholecystostomy Tubes
- 32% of interventional radiologists and/or surgeons should ensure that any critically ill patients who had a cholecystostomy tube placed did not improve or decline clinically after tube placement.
- Coagulopathy should be corrected before tube placement to avoid bile leakage.
- Bile leakage can occur if the tube is dislodged or the gallbladder wall is necrotic, leading to sepsis, diffuse biliary peritonitis, and/or a biloma/abscess in the right upper quadrant.
Long-term Management of Cholecystostomy Tubes
- The management of cholecystostomy tubes after initial treatment remains somewhat controversial.
- There are no broadly accepted guidelines regarding definitive tube management.
- 5% to 63% of patients eventually undergo definitive cholecystectomy, but this is not well defined.
Complications of Cholecystostomy Tubes
- Later complications, such as bile leakage, can occur if the tube is dislodged or the gallbladder wall is necrotic.
- Suspect leakage when a patient's leukocytosis worsens or does not improve after tube placement, or when symptoms initially improve but the patient subsequently develops sepsis, hemodynamic instability, fever, worsening leukocytosis, or worsening abdominal pain.
Classification of Biliary Injuries
- Strasberg and colleagues proposed a modified classification system (Fig. 3) to categorize biliary injuries.
- Involvement of aberrant right hepatic duct alone or with concomitant stricture of the common hepatic duct is important to consider.
Vascular Injury
- Vascular injury can occur concurrently with biliary injury in up to 15% of cases.
- Arterial injury can lead to biliary ischemia and propagate the injury to a higher level than the mechanical injury on the bile duct.
- It is imperative to assess the hepatic arteries when investigating any major biliary injury.
Management of Bile Duct Injuries
- Postoperative care involves cholangiography and biliary drainage.
- Closed-suction drains should be placed in the subhepatic space to control the bile leak and prevent peritonitis or biloma formation.
- Endoscopic dilation and stenting usually manage conditions successfully.
Transection of the Common Bile Duct
- The most common ductal injury involves complete transection of the common bile duct or common hepatic duct.
- Immediate repair should be performed if ductal length can be maintained without tension if recognized at the time of laparoscopic cholecystectomy with appropriate expertise available.
Delayed Presentation of Bile Duct Injuries
- The majority of patients with an iatrogenic biliary injury present in the early postoperative period with symptoms such as fever, jaundice, abdominal pain, or peritonitis.
- A Roux-en-Y jejunal limb is preferred over an anastomosis to the duodenum.
- A transanastomotic stent should be placed across the anastomosis and certainly in cases when two ducts have been transected.
General Approach to Repair of Bile Duct Injuries
- Recognized in the postoperative period, the definitive repair of a bile duct transection should not be planned until the patient has fully recovered from any sepsis or significant inflammation associated with a bile leak.
- A period of 6 to 8 weeks is allowed before repair.
- Complete bile diversion during this period is necessary, and fluid, electrolytes, and hydration must be monitored.
Choledochal Cysts
- Type II cysts comprise about 1% to 3% of all CCs and consist of a saccular diverticulum off of the extrahepatic biliary tree.
- Type III cysts (choledochoceles) consist of biliary ductal dilation within the duodenal wall and make up 1% to 3% of all CCs.
- Type IV cysts are the second most common type of cyst and make up 24% of all CCs.
- Type IV cysts are further subdivided into type IVa, consisting of multiple intrahepatic cysts and a single extrahepatic cyst, while type IVb consists of multiple intrahepatic and extrahepatic cysts.
Diagnosis of Choledochal Cysts
- US is the most frequently used imaging modality to diagnose CC and is the first imaging study recommended in the pediatric population.
- A CBD diameter of >10 mm in an adult on any imaging modality should alert practitioners to the possibility of CC; however, this guideline should be used with caution in older patients, as bile duct diameter increases with age.
Intraoperative Imaging Techniques
- Laparoscopic ultrasonography and near-infrared biliary imaging using indocyanine green or white light technology are alternative intraoperative techniques for imaging biliary anatomy, but are not commonly used due to limited familiarity and lack of high-level evidence.
Classification of Biliary Injuries
- The Bismuth classification system describes biliary injuries based on their location in the biliary tract with respect to the hepatic bifurcation.
- The Strasberg classification system is a modified classification system that includes five types of biliary injuries: A, B, C, D, and E.
- Type A injuries involve cystic duct leaks or leaks from small ducts in the liver bed.
- Type B injuries involve occlusion of part of the biliary tree, typically clipped and divided right hepatic ducts.
- Type C injuries involve transection (but not ligation) of the aberrant right hepatic ducts.
- Type D injuries involve lateral injuries to major bile ducts.
- Type E injuries are further classified into five subtypes: E1, E2, E3, E4, and E5.
Type E Injuries
- Type E1 injuries involve common hepatic duct division, more than 2 cm from bifurcation.
- Type E2 injuries involve common hepatic duct division, less than 2 cm from bifurcation.
- Type E3 injuries involve common bile duct division at bifurcation.
- Type E4 injuries involve hilar stricture, involvement of confluence and loss of communication between right and left hepatic duct.
- Type E5 injuries involve involvement of aberrant right hepatic duct alone or with concomitant stricture of the common hepatic duct.
Vascular Injuries
- Vascular injuries can occur concurrently with biliary injuries, with an incidence of up to 15% of cases.
- The right hepatic artery is the most commonly involved structure in a vasculobiliary injury due to its proximity to the bile duct.
- Arterial injury can lead to biliary ischemia and propagate the injury to a higher level than the mechanical injury on the bile duct.
- Assessment of the hepatic arteries is crucial when investigating major biliary injuries.
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Description
This quiz assesses the knowledge of interventional radiologists and surgeons on the proper placement of cholecystostomy tubes in critically ill patients, including the importance of correcting coagulopathy beforehand and avoiding bile leakage complications.
