الفهرس 
Normal DevelopmentOnly 14 pages are availabe for public view
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Abstract
The management of patients following major bile duct injury is a surgical challenge often requiring the skills of experienced hepatobiliary surgeons at tertiary referral centers. Collaboration among surgeons, gastroenterologists and interventional radiologists is imperative in the care of such injuries.
Bile duct injuries can be traced to one of five errors: The wrong duct is ligated or transected.or The lumen of the bile duct is occluded during ”flush ligation” of the cystic duct.or The blood supply to the common duct is compromised by excessive dissection.or The lumen of the duct is traumatized by forceful ”dilatation”.or Application and control of an energy source are inappropriate.
Early presentation: within days to weeks of initial operation patients presented by jaundice with progressively abnormal liver function tests,While Late presentation: months to years after the initial operation patients presented with episodes of cholangitis.lastly Manifestations of complications: secondary biliary cirrhosis, Portal hypertension with bleeding varices and ascites may develop.
Advancement of early diagnosis represents the corner stone of management including: Laboratory Investigation,radiological diagnosis(Ultrasonography,Computarized Axial Tomography (CAT), fistulogram, Precutaneous Transhepatic Cholangiography (P.T.C),Endoscopic Retrograde Cholongiopancrea- tography (ERCP), Isotope scanning.and future investigation Intraoperative Near-Infrared Fluorescent Cholangiography (NIRFC).
Management plans could be summarized as:
(I) Detection during operation:
Firstly:injuries during laparoscopic choleycystectomy:
(A)If the injury is minor and lateral, it is sutured with one 5/0 atraumatic-interrupted suture. Cystic duct drainage canula is used to decompress the biliary tract for 7-10 days, and is then removed if the postoperative cholangiogram is satisfactory.
(b)If the injury is major, conversion to open surgery is essential.
Secondly: Injuries during open cholecystectomy or after conversion of laparoscopic cholecystectomy:
If injury to the extrahepatic biliary tree is recognized at the time of cholecystectomy,Or,If a segmental or accessory duct less than 3mm in size have been injured simple ligation of the injured duct is adequate,If the injured duct is 4mm or more in size, and this injury requires operative repair,Injury involves the common hepatic duct or the common bile duct, repair should be carried out at the time of injury,Initial repair may not be the final definitive reconstruction,Lateral injuries without loss of length are easy to repair by direct suture of the defect over a T-tube. Longer lateral injuries that are not circumferential, a vein patch, flaps of the cystic duct stump, or pedicled flaps of jejunum may be ,performed to cover such a defect Also a Roux-en-Y loop of jejunum can be prepared and used as serosal patch,If the bile duct has been transected and the ends can be opposed without tension, an end to end anastomosis may be feasible. The anastomosis is made over a T-tube brought out away from the anastomotic line.
(II) Injuries recognized in the early postoperative period:
Depends on the type and level of the lesion:
1) Minor bile duct leaks (type A lesion):
Initial treatment of minor biliary leakage is endoscopic sphincterotomy with or without insertion of a biliary endoprosthesis with elective stent removal after six weeks using ERCP,Percutaneous or surgical drainage of bile collections or both can be done before and after ERCP.
2) Major bile duct leaks (type B lesions):
Endoscopic treatment and insertion of biliary endoprosthesis should be attempted. After six weeks the lesion should be evaluated endoscopically. In the case of absence of leakage no ductal stenosis the endoprosthesis can be removed,If a stricture is present the patient enter the endoscopic treatment regimen for bengin ductal stenosis.
3) Complete transection of the bile ducts (type Dlesions):
All patients should be considered for reconstructive surgery as Roux-en-Y hepatico-jejunostomy, separate hepaticojejunostomies and end-to-end anastomosis of the common hepatic duct.
4) Bile duct strictures (type C lesions):
Initial treatment includes insertion of endoprosthesis attempted at ERCP. If it is successful the patient enter the endoscopic treatment regimens for benign ductal stenosis,If fails, because the stricture could not be passed by a guide wire surgery should be considered.
Future treatment which carry hope may be in tissue-engineered bioabsorbablepolymer patch(BAP)which had not yet proved any complication in animals, we hope so in humans,could that happen?,well we must wait and see….