MANAGEMENT OF NOM FAILURE IN IATROGENIC BILE DUCT INJURY AFTER
LAPAROSCOPIC CHOLECYSTECTOMY and ERCP STENTING
EAES Academy. Doria E. 07/05/22; 363036; P080
LAPAROSCOPIC CHOLECYSTECTOMY and ERCP STENTING
Dr. Emanuele Doria
Contributions
Contributions
Abstract
S. Carini MD∗∗, I D’Addea MD∗∗, E. Doria MD∗∗, RM Lauro. MD, FACS, FRCS∗∗, F Masci
MD∗∗, GS Necchi MD∗∗, E Pastore MD∗∗, V Raveglia MD∗∗, A Scorza MD∗∗, PG Traini MD∗∗,
M Paganelli MD PhD∗, F Cipriani MD PhD∗ & Prof. L Aldrighetti MD, PhD∗
∗Hepato-Biliary Surgery Unit – University “Vita e Salute” San Raffaele Hospital – Milan - Italy
∗∗General Surgery Unit – ASST Settelaghi – L. Confalonieri Hospital – University of Insubria –
Luino - Varese
Background:
In the event of Minor Bile Duct Injuries (BDI) detected during laparoscopic Cholecystectomy,
surgeons must promptly analyse the injury and choose between an intraoperative repair or "drain
now and fix later" strategy. In case of failure of NOM for worsening of symptoms of the patient
may be indicated an ERCP with sphincterotomy +/- stent placement.
Case Report
A 54-year-old male patient with severe acute-chronic cholecystitis came to our attention. An
emergency laparoscopic cholecystectomy was carried out. The gallbladder pouch was attached to
the CBD. A minimal bile leak was detected over the dissection of the Calot Triangle (Gost Calot).
After the Cholecystectomy, the gallbladder bed was drained with an 18F drain. Given the increase
of drainage output, we chose non-operative management (NOM) since a Cholangio-MRI showed a
suspected minimal biliary leakage from the CBD. According to Strasberg's classification, the bile
leak and injury of the CBD were supposed to be Type D. Since the bile output from the drain was
still consistent, the patient underwent two attempts of ERCP, with unsuccessful cannulation of the
CBD. Two days later, a biliary stent was inserted through ERCP in another institution in Milan with
high-volume ERCP. After the procedure, the patient's general condition worsened for a progressive
increase of drainage output associated with fever. The CT abdominal scan showed a suspected stent
dislocation through the right bile duct injury. The patient was moved to a High-volume
Hepatobiliary Surgery Unit in Milan. A diagnostic laparoscopy was carried out, and the stent
dislocation along with Strasberg's Type E4 injury instead was detected. The stent was removed, and
two "Bracci" biliary catheters were inserted in the right and left hepatic duct. Multiple drains were
positioned. Eighteen days later, the CBD was reconstructed with 4B liver segment resection end an
end-to-side anastomosis of the biliary sheath and jejunostomy tailoring according to Delaney's
procedure.
The post-operative course had no severe surgical complications. The patient was discharged on day
14th.
MD∗∗, GS Necchi MD∗∗, E Pastore MD∗∗, V Raveglia MD∗∗, A Scorza MD∗∗, PG Traini MD∗∗,
M Paganelli MD PhD∗, F Cipriani MD PhD∗ & Prof. L Aldrighetti MD, PhD∗
∗Hepato-Biliary Surgery Unit – University “Vita e Salute” San Raffaele Hospital – Milan - Italy
∗∗General Surgery Unit – ASST Settelaghi – L. Confalonieri Hospital – University of Insubria –
Luino - Varese
Background:
In the event of Minor Bile Duct Injuries (BDI) detected during laparoscopic Cholecystectomy,
surgeons must promptly analyse the injury and choose between an intraoperative repair or "drain
now and fix later" strategy. In case of failure of NOM for worsening of symptoms of the patient
may be indicated an ERCP with sphincterotomy +/- stent placement.
Case Report
A 54-year-old male patient with severe acute-chronic cholecystitis came to our attention. An
emergency laparoscopic cholecystectomy was carried out. The gallbladder pouch was attached to
the CBD. A minimal bile leak was detected over the dissection of the Calot Triangle (Gost Calot).
After the Cholecystectomy, the gallbladder bed was drained with an 18F drain. Given the increase
of drainage output, we chose non-operative management (NOM) since a Cholangio-MRI showed a
suspected minimal biliary leakage from the CBD. According to Strasberg's classification, the bile
leak and injury of the CBD were supposed to be Type D. Since the bile output from the drain was
still consistent, the patient underwent two attempts of ERCP, with unsuccessful cannulation of the
CBD. Two days later, a biliary stent was inserted through ERCP in another institution in Milan with
high-volume ERCP. After the procedure, the patient's general condition worsened for a progressive
increase of drainage output associated with fever. The CT abdominal scan showed a suspected stent
dislocation through the right bile duct injury. The patient was moved to a High-volume
Hepatobiliary Surgery Unit in Milan. A diagnostic laparoscopy was carried out, and the stent
dislocation along with Strasberg's Type E4 injury instead was detected. The stent was removed, and
two "Bracci" biliary catheters were inserted in the right and left hepatic duct. Multiple drains were
positioned. Eighteen days later, the CBD was reconstructed with 4B liver segment resection end an
end-to-side anastomosis of the biliary sheath and jejunostomy tailoring according to Delaney's
procedure.
The post-operative course had no severe surgical complications. The patient was discharged on day
14th.
S. Carini MD∗∗, I D’Addea MD∗∗, E. Doria MD∗∗, RM Lauro. MD, FACS, FRCS∗∗, F Masci
MD∗∗, GS Necchi MD∗∗, E Pastore MD∗∗, V Raveglia MD∗∗, A Scorza MD∗∗, PG Traini MD∗∗,
M Paganelli MD PhD∗, F Cipriani MD PhD∗ & Prof. L Aldrighetti MD, PhD∗
∗Hepato-Biliary Surgery Unit – University “Vita e Salute” San Raffaele Hospital – Milan - Italy
∗∗General Surgery Unit – ASST Settelaghi – L. Confalonieri Hospital – University of Insubria –
Luino - Varese
Background:
In the event of Minor Bile Duct Injuries (BDI) detected during laparoscopic Cholecystectomy,
surgeons must promptly analyse the injury and choose between an intraoperative repair or "drain
now and fix later" strategy. In case of failure of NOM for worsening of symptoms of the patient
may be indicated an ERCP with sphincterotomy +/- stent placement.
Case Report
A 54-year-old male patient with severe acute-chronic cholecystitis came to our attention. An
emergency laparoscopic cholecystectomy was carried out. The gallbladder pouch was attached to
the CBD. A minimal bile leak was detected over the dissection of the Calot Triangle (Gost Calot).
After the Cholecystectomy, the gallbladder bed was drained with an 18F drain. Given the increase
of drainage output, we chose non-operative management (NOM) since a Cholangio-MRI showed a
suspected minimal biliary leakage from the CBD. According to Strasberg's classification, the bile
leak and injury of the CBD were supposed to be Type D. Since the bile output from the drain was
still consistent, the patient underwent two attempts of ERCP, with unsuccessful cannulation of the
CBD. Two days later, a biliary stent was inserted through ERCP in another institution in Milan with
high-volume ERCP. After the procedure, the patient's general condition worsened for a progressive
increase of drainage output associated with fever. The CT abdominal scan showed a suspected stent
dislocation through the right bile duct injury. The patient was moved to a High-volume
Hepatobiliary Surgery Unit in Milan. A diagnostic laparoscopy was carried out, and the stent
dislocation along with Strasberg's Type E4 injury instead was detected. The stent was removed, and
two "Bracci" biliary catheters were inserted in the right and left hepatic duct. Multiple drains were
positioned. Eighteen days later, the CBD was reconstructed with 4B liver segment resection end an
end-to-side anastomosis of the biliary sheath and jejunostomy tailoring according to Delaney's
procedure.
The post-operative course had no severe surgical complications. The patient was discharged on day
14th.
MD∗∗, GS Necchi MD∗∗, E Pastore MD∗∗, V Raveglia MD∗∗, A Scorza MD∗∗, PG Traini MD∗∗,
M Paganelli MD PhD∗, F Cipriani MD PhD∗ & Prof. L Aldrighetti MD, PhD∗
∗Hepato-Biliary Surgery Unit – University “Vita e Salute” San Raffaele Hospital – Milan - Italy
∗∗General Surgery Unit – ASST Settelaghi – L. Confalonieri Hospital – University of Insubria –
Luino - Varese
Background:
In the event of Minor Bile Duct Injuries (BDI) detected during laparoscopic Cholecystectomy,
surgeons must promptly analyse the injury and choose between an intraoperative repair or "drain
now and fix later" strategy. In case of failure of NOM for worsening of symptoms of the patient
may be indicated an ERCP with sphincterotomy +/- stent placement.
Case Report
A 54-year-old male patient with severe acute-chronic cholecystitis came to our attention. An
emergency laparoscopic cholecystectomy was carried out. The gallbladder pouch was attached to
the CBD. A minimal bile leak was detected over the dissection of the Calot Triangle (Gost Calot).
After the Cholecystectomy, the gallbladder bed was drained with an 18F drain. Given the increase
of drainage output, we chose non-operative management (NOM) since a Cholangio-MRI showed a
suspected minimal biliary leakage from the CBD. According to Strasberg's classification, the bile
leak and injury of the CBD were supposed to be Type D. Since the bile output from the drain was
still consistent, the patient underwent two attempts of ERCP, with unsuccessful cannulation of the
CBD. Two days later, a biliary stent was inserted through ERCP in another institution in Milan with
high-volume ERCP. After the procedure, the patient's general condition worsened for a progressive
increase of drainage output associated with fever. The CT abdominal scan showed a suspected stent
dislocation through the right bile duct injury. The patient was moved to a High-volume
Hepatobiliary Surgery Unit in Milan. A diagnostic laparoscopy was carried out, and the stent
dislocation along with Strasberg's Type E4 injury instead was detected. The stent was removed, and
two "Bracci" biliary catheters were inserted in the right and left hepatic duct. Multiple drains were
positioned. Eighteen days later, the CBD was reconstructed with 4B liver segment resection end an
end-to-side anastomosis of the biliary sheath and jejunostomy tailoring according to Delaney's
procedure.
The post-operative course had no severe surgical complications. The patient was discharged on day
14th.
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