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limb maximum mobility. Division of the first vascular arcade
of the small bowel mesentery can usually be done safely,
though the end of the Roux limb should always be
inspected for sufficient perfusion. A retrocolic Roux-en-Y
hepatico-jejunostomy, brought to the right upper quadrant
through a defect made in the mesocolon to the right of the
middle colic vessels and above the duodenum, provides
the most direct route to the porta and can avoid any undue
tension created by draping the Roux limb over the colon. In
patients with previous abdominal surgery, time should be
taken to meticulously lyse any adhesions that tether the
small bowel mesentery. In cases where patients have a
foreshortened mesentery, due to previous surgery,
radiation, or other conditions, a medial visceral rotation of
the right colon will expose the root of the small bowel
mesentery that can be mobilized up to the level of the
duodenum and neck of the pancreas.
A few important principles apply to the dissection of the
porta in the setting of a biliary injury. The mechanism of bile
duct injury in these cases often arises from unintentional
dissection of a long segment of the bile duct, which can
strip the duct of its blood supply that runs through the
periductal adventitial tissue. In early repair cases, it is
therefore important to identify a portion of the duct that has
not been completely dissected, and carefully expose or
shorten the hepatic duct in a location that is amenable to
construction of the biliary anastomosis. In E1 or E2 injuries,
it may be possible therefore to stay below the true hepatic
duct bifurcation, but care should be taken not to sew to a
traumatized end of the hepatic duct. Opening the duct on its
anterior surface, with a ductotomy extended toward the long
extrahepatic portion of the left hepatic duct can expose
healthy tissue and avoid further dissection behind the duct
which can further compromise ductal blood supply. In later
repair cases, avoiding dissection behind the hepatic duct
is really essential, as this allows preservation of any
collateralized blood supply that has been created at the site
of the injury. This principle of “anterior-only” dissection also
avoids creating additional vascular injury, as the right
hepatic artery is often directly behind the hepatic duct at
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this level and can be obscured or difficult to identify in a
chronically inflamed or scarred field.
All biliary anastomoses should be performed under
loupe magnification, using fine monofilament absorbable
suture, typically in an interrupted fashion. Placement of
subhepatic drains to monitor for biliary leak is typically
performed. After completion of the biliary anastomosis, the
Roux limb can be further anchored to relieve tension by
taking seromuscular bites of the jejunum and tacking it to
the former gallbladder fossa, portal plate, or umbilical
fissure.
Special Intraoperative Considerations
For E3 injuries or higher, the hepatic duct bifurcation needs
to be exposed by lowering the portal plate. This involves
incising into the liver parenchyma to get above the hepatic
duct bifurcation, beginning above the long extrahepatic
course of the left hepatic duct. This can often be done with
a blunt technique and judicious use of electrocautery but
can be facilitated in difficult cases by the use of an
ultrasonic or hydrojet dissector. Bleeding may be
encountered during this technique, but can be stopped by
packing gauze or other hemostatic material into the
hepatotomy for a period of time. Returning to this area after
completing other tasks, such as creating the
enteroenterostomy of the Roux limb, allows performance of
the biliary anastomosis in a dry and controlled field.
Controversy exists over the need for transhepatic biliary
catheters to serve as a stent across a fresh biliary-enteric
anastomosis. In the case of early repairs, many surgeons
will go to the operating room without transhepatic catheters.
Intraoperative placement of retrograde transhepatic biliary
catheters is difficult and potentially adds additional trauma
to the liver. Therefore in these cases, routine postoperative
stenting is not possible or advised. In the case of delayed
repairs, a transhepatic biliary catheter is typically in place
at the time of repair, and may be passed across the new
biliary–enteric anastomosis. These tubes typically can be
capped off (“internalized”) in the immediate postoperative
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period if no evidence of anastomotic leak, used for
postoperative cholangiography to interrogate the new
anastomosis, and removed 3 to 6 weeks after repair.
Associated vascular injury is not uncommon in bile duct
injury and may be associated with both acute liver injury
and delayed biliary stricture due to ischemia. Significant
vascular injury associated with a measurable rise in liver
enzymes and systemic inflammatory response is a relative
contraindication to early repair of bile duct injury, as the
patient may not be optimized for a complex operation.
Delayed repair also allows for collateral blood flow to
involved biliary segments to mature over time. Fortunately,
segmental hepatic vascular injuries do not typically require
reconstruction due to the redundant blood flow to the liver.
Exceptions to this general rule would include ligation or
severe stenotic injury to the main portal vein or proper
hepatic artery.
Postoperative Management
The postoperative period in patients undergoing a biliaryenteric anastomosis is typical of other major upper
abdominal operations. Appropriate analgesia, early
mobilization, and sequential advancement in diet should
occur in all patients. Wounds should be monitored for signs
of infection, especially in patients with indwelling
percutaneous biliary drains, which predispose to surgical
site infection. Patients should be monitored for biliary leak
or other signs of intra-abdominal infection. In cases where
a closed suction drain is left at the time of operation, the
output should be monitored for bilious fluid. Typically the
drain(s) can be removed in 3 to 4 days once the patient has
resumed a diet if the output is nonbilious. In the case of a
low-volume biliary leak, observation with continued external
drainage may be the only necessary intervention, as such
leaks will resolve. In the case of a more significant leak, or
a leak associated with signs of sepsis, percutaneous
biliary drainage may be necessary if not already in place.
Reoperation is typically not necessary for management of a
biliary leak.
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In the intermediate and long term, biliary stricture is the
most significant potential postoperative event. As many as
15% of patients undergoing biliary reconstruction may
develop an anastomotic stricture, with the vast majority able
to be managed by percutaneous transhepatic dilatation
and stenting without the need for operative revision. As
most biliary strictures may present indolently, a liver profile
should be followed for signs of cholestasis. Often an
isolated rise in the alkaline phosphatase is the initial sign of
a biliary stricture. A liver profile should be checked every 3
to 6 months for the first 2 years, and then annually
thereafter. The majority of anastomotic strictures will
present i n the first 2 years postoperatively, though rarely
may present even in a markedly delayed fashion.
Case Conclusion
With percutaneous biliary drainage and antibiotics, the
patient improves and is sent home. After an 8-week
delay, biliary reconstruction is performed with a Rouxen-Y hepaticojejunostomy. The biliary catheter is
passed across the new biliary enteric anastomosis and
removed after a follow-up cholangiogram at 3 weeks
postoperatively reveals a widely patent anastomosis
(Figure 2, panel D). At 3-year follow-up, the patient is
clinically well with a normal liver profile.
TAKE HOME POINTS
Patients who present following cholecystectomy with
unusual pain or signs of infection should be
considered to have a bile duct injury until proven
otherwise.
Ini tial diagnostic imaging of a patient with a
suspected bile duct injury should include ultrasound
and/or CT to assess for perihepatic fluid collections.
Ini tial management of bile duct injury should include
control of sepsis, drainage of all bilomas, and
establishment of secure internal or external biliary
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drainage.
Patients who present beyond 48 to 72 hours from the
time of their injury, and/or who show signs of intraabdominal sepsis, are best managed with a delayed
operative repair.
A broad, tension-free anastomosis using absorbable
suture is the preferred method for reestablishing
biliary–enteric continuity.
Biliary stricture is the primary significant long-term
complication of hepaticojejunostomy; serial liver
profile monitoring may detect an indolent stricture
before clinically apparent.
SUGGESTED READINGS
Couinaud C. Exposure of the left hepatic duct through the hilum or in the
umbilical of the liver: anatomic limitations. Surgery. 1989;105(1):21–27.
Melton GB, et al. Major bile duct injuries associated with laparoscopic
cholecystectomy: effect of surgical repair on quality of life. Ann Surg.
2002;235(6):888–895.
Sicklick JK, et al. Surgical management of bile duct injuries sustained
during laparoscopic cholecystectomy: perioperative results in 200
patients. Ann Surg. 2005;241(5): 786–792; discussion 793–795.
Winslow ER, et al. “Sideways”: results of repair of biliary injuries using a
policy of side-to-side hepatico-jejunostomy. Ann Surg. 2009;249(3):426–
434.
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25
Cholangitis
WILLIAM C. BECK and BENJAMIN K. POULOSE
Presentation
A 68-year-old man with a history of adult-onset
diabetes, obesity, and tobacco use presents to the
emergency department. He is febrile on arrival with a
temperature of 102.7, a blood pressure of 95/50, and a
heart rate of 106. His primary complaint is of right
upper-quadrant pain of 24-hour duration. He notes that
he has had similar pain on occasion before but always
had complete resolution of pain within a couple of
hours. He reports his urine has been very dark for the
last 12 hours. On exam, he has tenderness of his right
upper quadrant with voluntary guarding. The sclerae are
mildly icteric. No jaundice is present.
Differential Diagnosis
The typical presentation of cholangitis involves the
combination of right upper-quadrant pain, fever, and
jaundice, commonly known as Charcot’s triad. Only 50% to
70% of patients, however, present with all three elements.
The addition of mental status changes and hypotension
comprise Reynold’s pentad, which is indicative of systemic
sepsis. Although biliary colic may be elicited, patients with
cholangitis usually also manifest with fever and jaundice. In
a patient presenting with a history of gallstones or right
upper-quadrant pain, the presence of jaundice,
hypotension, or altered mental status should alert the
provider to the diagnosis of cholangitis. Peritonitis is
uncommon and should prompt the examiner to look for
other causes of abdominal pain such as diverticulitis,
perforated ulcer, or pancreatitis. Careful consideration
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should be given to acute cholecystitis in the differential
diagnosis, as the immediate treatment would differ
considerably. A previous history of biliary interventions
should prompt providers to consider the diagnosis of acute
cholangitis. Those patients with prior biliary operations,
endoscopically or radiologically placed biliary stents, and
history of chronic biliary conditions (i.e., primary sclerosing
cholangitis) are at increased risk of developing cholangitis.
Presentation Continued
This patient undergoes further evaluation of his
abdominal pain, fevers, and jaundice with a complete
blood count (CBC), comprehensive metabolic panel
(CMP), amylase, lipase, coagulation profile, and two
sets of blood cultures. He has a leukocytosis of
13,300/mL with a left shift, a bilirubin of 4.4 mg/dL, and
alkaline phosphatase of 500 IU/L. Both the AST and the
ALT are elevated at 210 and 334 IU/L, respectively.
Workup
An abdominal ultrasound (US) is the preferred initial
imaging study. In the above patient, it reveals cholelithiasis
with mild intra- and extrahepatic biliary duct dilation.
Computed tomography (CT) scan and magnetic resonance
cholangiopancreatography (MRCP) are not needed for the
diagnosis of cholangitis but may prove helpful to identify the
underlying etiology of the biliary obstruction that
predisposed the patient to cholangitis, such as benign or
malignant biliary strictures, or periampullary mass. In the
case of malignant causes of biliary obstruction, pain is
usually less of a component of presentation and the onset
is more insidious. In general, a single, good-quality
noninvasive study (US, CT, or MRCP) can suffice to
establish biliary ductal dilation and provide clues to the
etiology of biliary obstruction. A high suspicion for common
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bile duct stones is present with clinical ascending
cholangitis without other obvious etiology, or total bilirubin
>4 mg/dL. Other strong predictors of common bile duct
stones include a dilated common bile duct (>6 mm) on US
with gallbladder
in situ
and bilirubin between 1.8 and 4
mg/dL.
Many patients do not present with Charcot’s triad, and
in 2006 an international consensus meeting was held in
Tokyo, Japan, with the goal of developing guidelines useful
in establishing the diagnosis of acute cholangitis. The
consensus was reached that Charcot’s triad was sufficient
to diagnose acute cholangitis. Additionally, the Tokyo
guidelines suggest that if two of the three elements of
Charcot’s triad are present, along with (1) laboratory
evidence of inflammatory response, (2) abnormal liver
function tests, and (3) abnormal imaging studies
demonstrating biliary dilatation, inflammatory findings, or
the presence of an etiology such as a biliary stricture,
calculus, stent, or mass that the diagnosis of cholangitis
can be made (Figure 1).
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FIGURE 1 • Diagnosis of cholangitis may be made using either the
traditional Charcot’s triad, or Tokyo criteria.
Blood test results can vary in patients with acute
cholangitis, and must be taken in the context of the history
and physical exam of the individual patient. The white blood
cell count is elevated above 10,000/mL in 60% to 80% of
patients that present with acute cholangitis and is the most
often noted abnormal result. The absence of an elevated
total bilirubin should question the diagnosis of cholangitis.
Liver tests (AST, ALT, GGT) are usually elevated, but no
specific pattern has been demonstrated. Alkaline
phosphatase is also usually elevated and is typically more
elevated in biliary obstruction due to malignant etiologies
as compared to choledocholithiasis.
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Diagnosis and Treatment
In this patient presenting with two elements of Charcot’s
triad (fever, abdominal pain, and jaundice), biliary disease
should be at the top of the differential diagnosis. In the
setting of altered mental status and relative hypotension in
a normally hypertensive man, the provider should strongly
suspect cholangitis as the diagnosis. Many patients have a
history of prior calculous biliary disease or biliary operation.
In Western countries, choledocholithiasis is the most
common etiology, followed by benign and malignant biliary
strictures. Other etiologies include autoimmune cholangitis,
parasitic infections, prior biliary operations, indwelling
stents, and chronic pancreatitis.
When cholangitis is suspected, the patient should be
admitted to the hospital for intravenous fluid resuscitation,
initiation of appropriate antibiotics, hemodynamic
monitoring, and prompt biliary decompression if indicated.
Blood cultures should be sent prior to the initiation of
antibiotics to allow for the tailoring of antibiotic therapy after
the causative organism is identified. Timely initiation of
empiric intravenous antibiotic therapy is crucial to
successful treatment. Therapy should target gram-negative
bacteria and anaerobes. A fluoroquinolone with added
metronidazole or extended-spectrum beta lactam
(piperacillintazobactam) can provide adequate empiric
coverage. Occasionally, coagulopathy is present, which
needs to be corrected prior to undergoing any intervention.
If the patient responds well to antibiotic therapy, and there
is no hemodynamic instability, further imaging (CT or
MRCP) may be performed to better elucidate the
underlying cause of the cholangitis. However, if the patient
appears septic, urgent biliary decompression is required
either by endoscopic, percutaneous, or surgical means.
Those patients who respond well to initial resuscitation
and antibiotic therapy without biliary drainage are deemed
as having mild cholangitis. Continued clinical improvement
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