Bismuth Classification of Bile Duct Injury and Its Association with Increasing 30 Days Mortality after Revision Surgery

Background: The incidence rate of bile duct injury has not been changed for many years for both open or laparoscopic technique. Open cholecystectomy has risen from 0.5% to 1.4% when gallbladder removal is performed laparoscopically. Injuries of the bile duct system after laparoscopic cholecystectomy are more complex than that after an open approach, causing significant morbidity and even death. From initial classification published by Bismuth, there have been many classifications of common bile duct injury. We would reported the 30 days mortality rate following reconstruction after bile duct injury according to type of Bismuth classification. Case Report: 7 cases of common bile duct injury were reported from 2016 until 2018 following cholecystectomy (both open and laparoscopic), all cases were diagnosed as early complication and without intra operative cholangiography performed. The most common bile duct injury was Bismuth type II and IV (2 patients in each type). Reconstruction has been done by hepatico jejunostomy for type III and IV. Choledoco Duodenostomy bypass was done for type I and II. 2 patients with bismuth type IV have long standing cholangitis and cannot survive during 30 days of follow up. 4 others patients could survive with no intra abdominal complication nor other morbidity. Conclusion: Bismuth classification was the simpliest type to described the bile duct injury, Bismuth type IV was associated with the high risk of 30 days mortality rate. Keywords: bismuth classification, bile duct injury, cholecystectomy, mortality

RIGHT HEPATIC DUCT STENOSIS DUE TO MULTIPLE METALLIC CLIPS AFTER CHOLECYSTECTOMY. IS THERE A WAY OUT? RE-LAPAROSCOPY AND ERCP STENTING

Bile duct lesions with leakage and stenosis can occur after open or laparoscopic cholecystectomy. Multiple factors are involved either related to the patient or external due to technical equipment or surgeon. Bismuth classification is generally accepted. The aim is to restore the bile duct and to prevent short-term and long-term complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis, and secondary biliary cirrhosis. Endoscopic therapy with biliary sphincterotomy alone or with the additional placement of a biliary/nasobiliary stent drainage is recommended. Stenting should be avoided if complete strictures exist or a circumferential resection of the duct. Endotherapy can be considered a sensible option and should be the main-stay treatment in these patients but one must keep in mind it is costly and is usually practiced by experienced teams in tertiary centers. The purpose of our paper is to exemplify this complication which is inherently rare, to highlight the diagnostic and treatment tools with minimal long-term sequelae.

KOLANGITIS AKUT PADA PENDERITA TUMOR KLATSKIN

Tumor Klatskin merupakan suatu kolangiokarsinoma tipe ekstrahepatik yang bersifat ganas dan timbul dari epitel duktus koledokus dan kedua percabangannya. Seorang wanita usia 47 tahun mengalami keluhanbadan panas sejak 1 hari sebelum masuk rumah sakit. Satu hari sebelum masuk rumah sakit, pasien mengalami demam tinggi terus- menerus, tidak disertai dengan menggigil. Keluhan disertai nyeri hebat di perut kanan atas sampai ke ulu hati, nafsu makan menurun, mual setiap hendak makan, BAK berwarna seperti teh, BAB biasa, dan mata terlihat kuning. Satu minggu sebelum masuk rumah sakit, keluhan nyeriperut makin sering timbul disertai demam, mual, kadang-kadang muntah bila makan, dan nafsu makan makin turun. Hasil MRI menunjukkan kesan lesi hipointens dengan tepi yang irreguler di distal CBD sepanjang ±2 cm dengan dilatasi sedang CBD di bagian proksimalnya dan dilatasi ringan IHBD serta tak tampak dilatasi pada duktus pankreatikus, mengesankan massa di distal CBD yang menyebabkan obstruksi, curiga Klatskin Tumor Type 1 (berdasarkan Bismuth Classification). Pasien menolak dilakukan tindakan pembedahan maupun kemoterapi. Pasien mengaku merasa dalam kondisi baik, keluhan nyeri perut sangat jarang, nafsu makan sudah meningkat. Kata kunci: kolangitis akut, TumorKlatskin, kolangitis