Management of Bile Duct Injuries and Biliary Strictures

Indications Iatrogenic biliary injuries associated with laparoscopic cholecystectomy (most common), or other foregut operations. Operative approach depends on the time the injury is diagnosed (eg, immediately, early [ 4 weeks after injury], or late [> 4 weeks after injury]). If the patient is hemodynamically stable, immediate biliary reconstruction is indicated when an injury is identified intraoperatively during a laparoscopic cholecystectomy or other operation and a hepatobiliary surgeon is available to perform the repair. For patients with early or late injuries, operative management typically requires delayed biliary reconstruction with a biliary-enteric anastomosis. The aim of operative intervention is definitive treatment of patients with iatrogenic common bile duct or more proximal biliary injuries after the residual inflammation from the acute injury has resolved. If the injury has been thoroughly evaluated and the biliary system has been sufficiently decompressed and drained for 6 weeks or more, reconstruction is required if a biliary stricture persists or if biliary-enteric discontinuity remains.

Contraindications Biliary Decompression Few contraindications exist for biliary decompression. This may be achieved using a percutaneous transhepatic approach or endoscopic retrograde-guided stent placement. Rarely, operative decompression may be required. Percutaneous Transhepatic Approach Absolute Active coagulopathy. Relative Hepatic malignancy. Hydatid disease. Ascites. Contrast-related anaphylaxis. Endoscopic Retrograde Approach Absolute Patients who cannot cooperate with the study. Relative Active or recent acute pancreatitis. Recent myocardial infarction. Severe cardiopulmonary disease. Biliary Stricture Dilation Contraindications depend on approach (transhepatic or endoscopic retrograde), as outlined earlier. Biliary Reconstruction Absolute Incomplete preoperative evaluation. Inability to tolerate general anesthesia. Surgeon's lack of expertise in performing complex biliary reconstruction. Relative Acute cholangitis. Early biliary injury without adequate biliary drainage (< 6 weeks).

Informed Consent Biliary Stenting, Drainage, and Dilation Expected Benefits Treatment of life-threatening cholangitis. Treatment of biliary stricture. In patients with short strictures (< 2 cm), biliary stenting with successive dilation may successfully resolve the stricture without operative reconstruction. Prevention of cholestatic liver injury in situations where cholestasis cannot be definitively relieved within 2–4 weeks. In patients with bilirubin > 20 mg/dL, biliary decompression allows recovery of liver function prior to operative therapy. Assists in identification of hilar bile ducts at the time of operative biliary reconstruction. Potential Risks Bleeding. Biliary sepsis. Pancreatitis. Damage to liver or adjacent structures. Failure of drainage. Need for periodic stent changes until reconstruction. Need for additional interventions or procedures. Biliary Reconstruction Expected Benefits Internal drainage of obstructed bile flow by providing enteric drainage of the biliary tree. Correction of biliary strictures results in decreased risk of biliary cirrhosis, cholangitis, intrahepatic gallstones, hepatic abscesses, portal hypertension, and resulting progressive liver failure. Alleviation of strictures also lessens the risk of future development of cholangiocarcinoma. Potential Risks Late failure of reconstruction resulting in biliary cirrhosis, cholangitis, intrahepatic gallstones, hepatic abscesses, portal hypertension, and resulting progressive liver failure. Need for additional invasive or operative procedures. Usual postoperative complications (eg, infection, injury to adjacent structures, cardiopulmonary complications).

Equipment Biliary Injury Evaluation Access to CT, percutaneous transhepatic cholangiogram (PTC), diagnostic and therapeutic endoscopic retrograde cholangiopancreatogram (ERCP), magnetic resonance cholangiopancreatogram (MRCP), and intraoperative cholangiogram are imperative. Biliary Reconstruction General instrumentation set. Vascular instrumentation should be available. Intraoperative ultrasound. Gastrointestinal anastomosis (GIA) stapler. Self-retaining retractor. Intraoperative cholangiogram capability (C-arm, contrast, cholangiogram catheters). Device to divide liver parenchyma. Choledochoscope should be available.

Patient Preparation Preoperative Evaluation Figure 13–1: Management algorithm for patients with suspected biliary injury, based on timing of diagnosis. Management of iatrogenic injuries depends on the time at which they are diagnosed. A combination of imaging studies may be required to properly understand the anatomy of the injury. Complete diagnostic evaluation is necessary for successful reconstruction. The goal of preoperative therapeutic interventions is to relieve biliary obstruction, drain bilomas, and assist in identification of hilar bile ducts for a future reconstructive operation. External or internal biliary drainage, as warranted by type of injury. Treatment of sepsis and recurrent cholangitis is the goal of therapy. Common duct strictures may be stented via an endoscopic retrograde approach. Patients with more proximal strictures may benefit from both external and internal biliary drainage with interval dilation over time and delayed reconstruction. A transected common duct requires external biliary drainage. All bilomas and bile leaks should be drained. Concomitant injuries to the hepatic vasculature may also be present, and may require preoperative angiographic evaluation. Review of operative reports from the index operation and direct discussion with the initial surgeon may improve understanding of the injury. Patients presenting with a stricture late after biliary surgery should be evaluated for other potential stricturing processes (Table 13–1), which should be ruled out before proceeding with operative intervention. Figure 13–1 Management algorithm for patients with suspected biliary injury, based on timing of diagnosis. Table 13–1. Causes of extrahepatic biliary stricture. Ampullary adenoma Infectious: viral, Clonorchis sinensis  Ampullary carcinoma Mirizzi syndrome Biliary adenoma Pancreatic adenocarcinoma Blunt or penetrating trauma Postoperative stricture Cholangiocarcinoma Primary sclerosing cholangitis Cholangiohepatitis Radiation therapy-related Choledocholithiasis Retroperitoneal fibrosis Chronic pancreatitis Stenosis at sphincter of Oddi Crohn disease Toxic drugs Duodenal adenocarcinoma   Duodenal ulcers   Source: Based on information in Lillemoe KD. Biliary Injuries and Strictures and Sclerosing Cholangitis. In: Mulholland MW, Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific Principles & Practice, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:999–1014. At the Time of Elective Biliary Reconstruction Preoperative nutritional supplementation, if necessary. Intraoperative placement of a Foley catheter. Intraoperative placement of nasogastric suction. External or internal biliary drains in the right ductal system often exit very far laterally and do not necessarily need to be included in preparation of the operative field. Left-sided external or internal biliary drains should be included in preparation of the operative field. Care should be taken not to manipulate these tubes while positioning the patient. The skin sutures anchoring the left-sided catheter should be loosened to maintain catheter position during the operation, as elevation of the anterior abdominal wall can dislodge left-sided catheters during the dissection. Prophylactic antibiotics. Pharmacologic deep vein thrombosis prophylaxis.

Patient Positioning The patient should be supine with biliary drainage catheters positioned as outlined earlier.

Procedure Classification of Biliary Injuries Postoperative strictures are related to multiple direct causes, including cautery-related burn injury to the biliary tree, transection or sharp injury to the common bile duct or the right or left hepatic ducts, stapling of the bile duct, ischemia-related injury due to vessel ligation, or a combination of these injury types. Complex injuries may or may not be surgically reconstructible. Figure 13–2A–H: Strasberg classification of biliary injuries. Type A injuries (Figure 13–2A) are reserved for cystic duct stump leaks, which are usually managed with very good results via a combination of sphincterotomy and endoscopically placed plastic stents. Interval ERCP is conducted after 4–6 weeks. Stents may be removed if the leak has resolved, as outlined in Figure 13–1. Type B (Figure 13–2B) and C (Figure 13–2C) injuries involve the division of an aberrant right hepatic duct. Type B injuries involve ligation of the aberrant proximal duct, but type C injuries involve persistent biliary leak through the aberrant duct from the right hepatic lobe. Most laparoscopic cholecystectomy-related biliary injuries involve division of the bile duct going to the right anterior liver, which aberrantly inserts onto the common duct instead of inserting as the first radical of the right hepatic duct. Operative strategies for these types of injury are dictated by the amount of liver dependent on biliary drainage through that duct. If the biliary flow through the transected duct is low, this duct may be electively ligated. The patient should subsequently be followed for the development of cholangitis. Large hepatic segments with significant flow through this duct may need biliary reconstruction or hepatic resection. Reconstruction can be considered if the bile duct is at least 1 cm in length and > 3 mm in diameter. If reconstruction is not feasible, the liver segments at risk should not be salvaged. Type D (Figure 13–2D) injuries represent a lateral injury to the common hepatic duct. These may resolve with stenting and dilation, depending on the anatomy of the injury and the size of the defect in the duct. Large defects usually require reconstruction. Type E injuries are subclassified into five injury types, according to the Bismuth classification. E1 and E2 (Figure 13–2E) injuries involve common hepatic duct transection. E3 (Figure 13–2F) and E4 (Figure 13–2G) injuries are complex hilar injuries, and may also be associated with hepatic artery injuries. E5 (Figure 13–2H) injuries involve strictures of the common hepatic duct with an associated stricture or injury to an aberrant right sectorial duct. Biliary reconstruction, depending on the exact anatomy of the injury and viability of the remaining bile ducts, may involve a single biliary-enteric anastomosis or multiple anastomoses. Figure 13–2 A–H Injuries Identified at the Index Operation If an injury is suspected during a laparoscopic cholecystectomy, an intraoperative cholangiogram should be performed to identify the exact nature and extent of the injury. Consideration of immediate reconstruction should only be entertained by surgeons with sufficient training and experience in managing complex operative and nonoperative hepatobiliary problems. The area should be widely drained with Jackson-Pratt or Blake drains. Proximal bile ducts should be marked, if possible, with careful attention to avoid worsening the injury. Retrograde external biliary drainage catheters should be avoided. A hepatobiliary surgeon or a tertiary referral center should be contacted and the patient transferred as quickly as possible. Reconstructions performed for even complex injuries within 72 hours have been successful in our experience. The relevant workup (as outlined in Figure 13–1) should be performed expeditiously to enable the patient to proceed to a well-planned reconstruction within 72 hours. For biliary reconstruction, a retrocolic Roux-en-Y biliary-enteric anastomosis is our preferred method, and is described later. Delayed Reconstruction The right upper quadrant and the liver hilum can be accessed through a variety of incisions. We attempt to use a previous incision, otherwise a Kocher incision or upper midline offers adequate exposure. Right upper quadrant and upper abdominal adhesions may be present and should be taken down sharply. Careful dissection of the hepatoduodenal ligament is necessary. Palpation of the porta hepatis for the biliary catheters assists in identification of the injured bile ducts in a scarred field. Intraoperative ultrasound may be helpful in identifying the hepatic artery and portal vein. The bile duct should be dissected sharply in a distal to proximal direction. Large lymphatics should be ligated. Careful attention must be paid to avoid injuring or ligating hepatic artery branches, which often run anterior to the right and left bile ducts. In particular, the left hepatic artery travels anterior to the left hepatic duct. Right hepatic arteries may also run anterior to the right duct but may have been ligated at the index operation due to misidentification. The Roux limb is constructed by dividing the jejunum and its mesentery approximately 15–20 cm from the ligament of Treitz. A GIA stapler is used to divide the bowel, and the crossing mesenteric vessels are ligated with silk sutures. The hepatic flexure of the colon is mobilized in the usual fashion. A window is opened behind the hepatic flexure of the colon, anterior to the duodenum, between the middle colic and right colic arteries. The Roux limb is delivered to the liver hilum through this window, with careful attention to avoid twisting the mesentery. Figure 13–3: Dissection of the biliary tree at the liver hilum. The injured bile ducts are visible and have been dissected with the assistance of preoperatively placed biliary catheters. The distal common bile duct is suture-ligated or oversewn. The Roux limb is also pictured, and is placed without tension near the hilum of the liver against the transected bile duct. Depending on the type of injury, exploration of the distal common bile duct prior to ligation may be warranted. The goal is to identify and treat choledocholithiasis in the distal duct. This may be achieved by incising the duct and inserting a choledochoscope, visually inspecting the duct, and removing the stones. The duct may then be closed. Splitting the liver may be necessary if adequate length or exposure of the bile duct is not achieved. This division is very helpful in accessing the right anterior bile duct. Dissection proceeds proximally along the interlobar plane anterior to the hilum. A short distance of liver dissection may yield sufficient bile duct length and exposure for reconstruction. Preoperatively placed external or internal biliary drains can be helpful if maintained postoperatively in several situations. Postoperative edema may cause poor bile drainage, and external drainage may be warranted. Anastomotic leaks or strictures may develop, requiring external biliary drainage and stenting. Technically difficult biliary-enteric anastomosis may lead to these situations. Interrogation of the anastomosis may be clinically warranted postoperatively, and catheter access to the biliary tree is extremely helpful. The preoperative external or internal biliary drain is transected approximately 1–2 cm proximal to the intended anastomosis or may be retained through the anastomosis. Bile cultures should be obtained upon entering the proximal biliary tree. Figure 13–4A: The biliary-enteric anastomosis. Creation of the anastomosis involves a few key points: Bile duct spatulation. Biliary-enteric alignment. Tension-free approximation. Every attempt should be made to maximize the circumference of the biliary-enteric anastomosis by spatulating the bile duct. This may be accomplished by incising the bile duct longitudinally on the anterior aspect of the bile duct. Careful attention should be paid to avoid shortening the length of the duct. The bowel is aligned with the spatulated duct and sharply incised in the diameter of the duct on its antimesenteric surface. We do not recommend spatulating the right and left ducts and syndactylizing them for long distances (> 1 cm) proximal to the anastomosis. Syndactylizing the right and left hepatic ducts only at the point where they are closest will allow a single large anastomosis, rather than two small ones. The anastomosis is performed in an interrupted fashion using 4-0 PDS sutures. The anterior sutures should be placed on the bile duct first, with the needles left on. These sutures may act as a handle to expose the posterior wall. The posterior wall is then completed, and the knots are tied in the lumen after all the back row stitches are placed. Figure 13–4B: Front wall of the biliary-enteric anastomosis. Once the back wall is complete, the front wall is closed in a similar fashion. The knots are tied on the outside. Figure 13–5: Roux-en-Y hepaticojejunostomy. The use of tacking sutures from the Roux limb to the liver capsule anteriorly reduces tension on the bowel. The mesocolon should also be tacked to the serosa of the Roux limb to prevent internal hernias. The enteroenterostomy is constructed 40 cm from the anastomosis, which may be performed using a hand-sewn or stapled technique. A 10-mm Jackson-Pratt drain is typically used, and is placed in Morrison's pouch. The drain is not placed against the anastomosis. If internal or external biliary drains have been removed in the operating room, and the exit tracts from the liver are exposed, drains are placed near these holes. These tracts drain bile until they heal, and drains placed in the operating room control these leaks well. Figure 13–3 Figure 13–4A Figure 13–4B Figure 13–5

Postoperative Care Antibiotics Systemic antibiotics are administered and tailored according to the bile culture from the operating room sample. Deep Vein Thrombosis Prophylaxis Pharmacologic deep vein thrombosis prophylaxis is routine with subcutaneous unfractionated or low-molecular-weight heparin. Early ambulation should be encouraged. Drain Management Drains are monitored for bilious output and are removed if bilious drainage is not present following advancement to a regular diet. Persistent bilious drain output (drain fluid bilirubin level > 3.0 mg/dL) should warrant cholangiography on or after postoperative day 4. If an anastomotic leak is detected, the external or internal biliary drains can be exchanged if needed, and advanced past the anastomosis. Percutaneous drains control the ongoing peritoneal contamination. After 6 weeks, cholangiography should be repeated. If the leak has resolved, the drains can be removed. Biliary Duct Catheters External or internal biliary drain catheters should be removed 6 weeks after surgery if there is no evidence of an anastomotic leak. If a leak is suspected, cholangiography should be performed through the biliary drain catheter. If a leak is present, the drain catheter should be exchanged for an appropriately sized catheter, and it should be advanced through the anastomosis. After 6 more weeks, a repeat cholangiogram should be performed. If the leak has resolved, the catheters can be removed.

Potential Complications Early Superficial or deep surgical site infection. Bleeding. Bile leak. Cholangitis. Biliary anastomotic edema. Biliary anastomotic leak. Enteric anastomotic leak or enterocutaneous fistula. Pancreatitis. Sepsis. Multiple organ failure. Death. Late Stricture. Cholangitis. Intrahepatic bile duct stones. Liver abscess. Varices. Biliary cirrhosis. Portal hypertension. Further biliary injury related to ischemia or technical issues from repeated attempts at reconstruction, resulting in nonreconstructible anatomy. These patients should be referred for liver transplant evaluation.

Pearls and Tips Reconstruction of iatrogenic biliary injuries that are diagnosed during the index operation should only be undertaken by hepatobiliary surgeons, or those who have training or expertise in the operative and nonoperative management of complex hepatobiliary problems. Wide drainage and expedient contact of a referral center or appropriately trained or experienced surgeon is warranted and optimally done while in the operating room with the patient on the table. Clear communication with receiving surgeons is imperative. Nonoperative management of the iatrogenic biliary injuries aims to identify the extent of the injury anatomically, followed by biliary decompression with drainage to prevent ongoing cholestatic liver injury and provide relief of cholangitis. Some short segment strictures may be managed nonoperatively with PTC tube or ERCP-placed stents and interval dilation, with reasonable rates of resolution. Metal wall stents should not be used in the biliary tree for benign strictures. Identification of the injured bile duct is difficult in an inflamed or scarred liver hilum; preoperative PTC or endobiliary drain placement facilitates this maneuver. Appropriate biliary drainage and delayed operation lead to the best results from biliary reconstruction. Retrocolic Roux-en-Y biliary-enteric anastomosis is the preferred approach for reconstruction. Anastomotic tension can be relieved by securing the Roux limb to the liver capsule. Spatulation of the bile duct decreases the risk of postoperative anastomotic strictures. Maintenance of the external or internal biliary drain is useful for potential evaluation of bile leaks.

References Cameron JL, Sandone C. Atlas of Gastrointestinal Surgery, 2nd ed, vol 1. Hamilton, ON: BC Decker; 2007. Colletti LM. Complications of Biliary Injury. In: Mulholland MW, Doherty GM, eds. Complications in Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:999–1014. Lillemoe KD. Biliary Injuries and Strictures and Sclerosing Cholangitis. In: Mulholland MW, Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific Principles & Practice, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1310–1334. Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2002;9:543–547.