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Chapter 12
Box12.1 • Benign causes of biliary strictures
Strictures of the extrahepatic biliary tree
Iatrogenic biliary injury
Postcholecystectomy
Trauma
Other
Gallstone-related
Mirizzi's syndrome
Inflammatory
Recurrent pyogenic cholangitis
Parasitic infestation
Clonorchis sinensis
Opisthorchis viverrini
Echinococcus
Ascaris
HIV/AIDS cholangiopathy
Primary sclerosing cholangitis
Benign strictures imitating malignancy
Pancreatitis
IgG4-related disease
Autoimmune pancreatitis
IgG4-related cholangiopathy
Inflammatory pseudotumour
The incidence of choledochal cysts in Western
countries is around 1 in 200 000 live births but it is
much higher in Asia. There is frequent association with
other hepatobiliary disease such as hepatic fibrosis, as
well as an aberrant pancreatico-biliary duct junction.
Magnetic resonance cholangiopancreatography
(MRCP) is the non-invasive imaging investigation of
choice (Fig.12.1).
Classification
The modified Todani classification is employed
to describe the various forms of choledochal cyst
Fig. 12.2). Type I, the most common, represents a
(
solitary cyst characterised by fusiform dilatation
of the common bile duct. Type II comprises a
diverticulum of the common bile duct, whilst type
5
III cysts are choledochocoeles. Type IV is the second
most common, with extension of cysts into the
intrahepatic ducts. Lastly, type V involves intrahepatic
cystic disease with no choledochal cyst, which merges
into the syndrome of Caroli's disease.
Risk of malignancy
In the Western literature, the incidence of
cholangiocarcinoma (see Fig. 12.1) is reported to
be approximately 12%,
6
but is higher in Japanese
reports. Sastry etal. reported 434 cancers in 5780
patients with a choledochal cyst from 78 studies.
Cholangiocarcinoma occurred in 70.4%, gallbladder
cancer in 23.5% but cancer occurring before the age
of 18 years was rare.
7
Cyst drainage without cyst
excision does not prevent later malignant change,
and there is continuing debate regarding the precise
ongoing risk following cyst resection. In a report
of 180 patients who underwent primary surgery,
synchronous malignancy was found in 36 patients
(20%), with only one of the remaining patients
developing malignancy during follow-up.
8
Management
Surgical resection is required to prevent recurrent
episodes of sepsis and pain, to prevent the
risk of pancreatitis from passage of debris and
calculi, and because of the association with
cholangiocarcinoma. Complete cyst excision with
preservation of the pancreatic duct is required, with
hepatico-jejunostomy for reconstruction. Some
authors advocate liver resection for type IV cysts
with intrahepatic extension for complete removal
of the cyst, although the advantage is debatable. For
those patients with Caroli's disease, resection may
be feasible if the biliary involvement is localised to
one part of the liver. For other patients, endoscopic
or radiological techniques may be required to
address biliary sepsis by improving biliary drainage,
while others may need to be considered for hepatic
replacement if liver failure develops.
Cyst-enterostomy, or drainage of the cyst into
the duodenum, should no longer be performed
Figure12.1 • MRCP (a) and
macroscopic photograph
(b) demonstrating a type I choledochal
cyst with a distal cholangiocarcinoma
in a 42-year-old Caucasian woman
requiring a pancreatico-duodenectomy.
Gallbladder (GB), tumour (T), pancreatic
duct (single arrow) and aberrant
common channel (double arrow) are
shown.
Courtesy of Professor Prithi S. Bhathal,
Pathology Department, University of
a
b
Melbourne, Australia.
202
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Benign biliary tract diseases
(4 patients)
I
(9 patients)
IVa
Figure12.2 • Modified Todani classification for choledochal cysts.
Reproduced from Todani T, Watanabe Y, Narusue M etal. Congenital bile duct cysts: classification, operative procedures,
and review of thirty-seven cases including cancer arising from choledochal cyst. Am J Surg 1977;134:263–9. With
permission from Elsevier.
for extrahepatic cysts as the cyst epithelium
remains unstable and malignant potential exists. If
previous drainage has been performed, symptoms
of cholangitis generally persist and conversion to a
Roux-en-Y hepatico-jejunostomy is advisable.
II
(1 patient)
IVb V (Caroli’s disease)
9
III
the biliary confluence aids the surgeon in planning
the incorporation of any segmental duct into the
eventual hepatico-jejunal Roux-en-Y anastomosis.
Dissection into the head of the pancreas is made
easier by use of bipolar scissors and the CUSA™
(ultrasonic surgical aspiration system, ValleyLab,
Special operative techniques
During operative exposure, intraoperative
ultrasound is very useful to identify the biliary
confluence, the intrahepatic extension of the cyst
and the relationship to the right hepatic artery above
and to the pancreatic duct below (
aberrant hepatic ducts may enter the cyst below the
biliary confluence and these are missed frequently
on preoperative imaging. Such aberrant ducts are
usually identified once the cyst has been opened. The
uncomplicated cyst is normally best excised in its
entirety and this is facilitated by opening it along its
anterior length. This aids identification of the vessels
from which the cyst is freed. Early identification of
Fig.12.3). Small
Boulder, CO) if the plane of dissection is obscured
by fibrosis or inflammation. It may be necessary
to leave a small oversewn lower common bile
duct stump to avoid compromise to the pancreatic
duct lumen; however, recurrent pancreatitis
and possible malignant transformation remain
possible complications. Pancreatico-duodenectomy
is difficult to justify in the uncomplicated case
when dealing with the residual lower bile duct.
Laparoscopic resection and reconstruction has
been described; Senthinathan et al. reported 110
adults and children successfully managed, with
three adults requiring conversion, a re-exploration
rate of 1.8% and one death. Cholangitis occurred in
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203
Chapter 12
Figure12.3 • Operative ultrasound scan of a type I
choledochal cyst. The junction of the undilated proximal
biliary tree with the cyst (long dotted line) is demonstrated.
The right hepatic artery is posterior (two arrows), as is the
right branch of the portal vein (short dotted line).
three patients, with three requiring intervention for
anastomotic strictures on the short-term follow-up.9
(See recommended video at end of chapter.)
There is an accepted association between
choledochal cyst and cholangiocarcinoma. The cyst
should be excised and the biliary tree reconstructed
by means of a Roux-en-Y hepatico-jejunostomy.
Iatrogenic biliary injury
The commonest cause of an injury to the extrahepatic
biliary tree is as a result of an iatrogenic injury at the
time of cholecystectomy. Although it is recognised
that injury may also occur during other gastric or
pancreatic procedures, this is much less common
with the reduction in ulcer surgery and increasing
specialisation in pancreatico-biliary surgery. Rarely,
the injury may be related to abdominal trauma,10
injection of scolicidal agents in the management
of hydatid cyst, ablation of hepatic tumours or
radiotherapy. The true incidence of biliary injury
following laparoscopic cholecystectomy remains
obscure but there has been a slight increase since
its introduction, with a reported incidence of 0.3–
11
0.7%.
injury would decrease with experience, the Swedish
quality register reported a rate of 0.3% in 55 134
cholecystectomies performed from 2007 to 2011.12
Despite the expectation that the rate of
Recent variations in technique such as single-incision
laparoscopic surgery (SILS) cholecystectomy are
not immune to biliary injury, with a rate of 0.72%
reported in 2626 patients undergoing SILS.
13
Aetiology
Previous reports of injury during laparoscopic
cholecystectomy suggested that injury was more likely
to occur when performed for pancreatitis, cholangitis
or acute cholecystitis.
14
However, surgeons should
remain vigilant regardless of the indication. In the
majority of patients the problem is misinterpretation
of the biliary anatomy, with the common bile duct
being confused with the cystic duct. Associated
injury to the right hepatic artery often occurs as it
is mistaken for the cystic artery. Partial injury may
occur to the common bile duct after a diathermy
burn or due to rigorous traction on the cystic duct,
leading to its avulsion from the bile duct.
Techniques to avoid injury
Many techniques have been described to decrease
the risk of injury to the common bile duct during
cholecystectomy. The main risk factors are
thought to be inexperience, aberrant anatomy
and inflammation.
252 laparoscopic bile duct injuries, the authors
suggested that the primary cause of error was a
visual perceptual illusion in 97% of cases, whilst
faults in technical skill were thought to have been
present in only 3% of injuries.
Correct identification of the biliary anatomy is
essential in avoiding injury to the extrahepatic bile
duct. Dissection of Hartmann's pouch should start
at the junction of the gallbladder and cystic duct
and continue lateral to the cystic lymph node, thus
staying as close as possible to the gallbladder. The
biliary tree and hepatic arterial anatomy is highly
variable and therefore great care must be taken in
identifying all structures within Calot's triangle
before ligation. In Couinaud's published study
of biliary anatomy, 25% had drainage of a right
sectoral duct directly into the common hepatic
17
Sometimes this structure may follow a
duct.
prolonged extrahepatic course, where it can be
at greater risk from cholecystectomy. The right
hepatic artery may also course through this area.
All structures should be traced into the gallbladder
to minimise the risk of injury (
Calot's original description of gallbladder
anatomy described a triangle formed by the cystic
duct, common hepatic duct and superior border of
the cystic artery. For satisfactory visualisation of
the structures, dissection should also extend above
14,15
However, in an analysis of
16
Figs12.4 and 12.5).
204
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Benign biliary tract diseases
a b
Figure12.4 • Aberrant biliary anatomy. The normal biliary anatomy is a trifurcation of the right sectoral and left hepatic
ducts forming the common hepatic duct which receives the cystic duct after a variable distance. Operative photograph
(a) and a cholangiogram (b) of a short cystic duct (single arrow) draining into the right posterior sectoral duct (double
arrow), which has a long extrahepatic course.
Figure12.5 • Operative cholangiography of an aberrant right sectoral duct. The injury was recognised after division of
the duct following cholangiography. The cholangiogram catheter was used to obtain a cholangiogram of the aberrant
duct. The surgeon obtained advice by telephone and a decision was made to ligate the duct. The patient remains
asymptomatic.
the cystic artery to the liver. Extensive dissection
should be avoided in Calot's triangle as diathermy
injury may occur to the lateral wall of the common
hepatic duct. Furthermore, arterial bleeding in this
area should not be cauterised or clipped blindly.
Most bleeding can be controlled with several
minutes of direct pressure with a laparoscopic
forceps compressing Hartmann's pouch on to the
bleed point. During the era of open cholecystectomy
many advocated complete excision of the cystic duct
to its insertion into the common bile duct to avoid
a cystic duct stump syndrome. However, extensive
dissection around the common bile duct with or
without diathermy may cause an ischaemic stricture
due to damage to the intricate blood supply of the
common hepatic duct.
Strasberg described the ‘critical view of safety’
with complete dissection of Calot’s triangle by
mobilisation of the gallbladder neck from the
gallbladder bed of the liver before transecting the
cystic artery and duct.
15
More recently, Connor
et al. suggested a five-point checklist to limit
the occurrence of biliary injury at laparoscopic
cholecystectomy. The five steps are: ‘(i) confirm the
gallbladder lies in the hepatic principal plane and
is retracted to the 10 o'clock position; (ii) confirm
Hartmann's pouch is lifted up and toward the
segment IV pedicle; (iii) identify Rouvière's sulcus;
(iv) confirm the release of the posterior leaf of the
peritoneum covering the hepatobiliary triangle;
and (v) confirm the critical view with or without
intraoperative cholangiography’.
Many authors argue that operative cholangiography
is essential to avoid biliary injury.
18
11,14
Fletcher etal.
reported an overall twofold reduction in biliary
injuries with the use of operative cholangiography,
with an eightfold decrease in complex cases.
14
Flum
etal. analysed retrospectively the Medicare database
in the USA and identified 7911 common bile duct
injuries following cholecystectomy. After adjusting
for patient-level factors and surgeon-level factors,
the relative risk was 1.49 when intraoperative
cholangiography was not used.
11
When the use of
intraoperative cholangiography has undergone cost
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205
Chapter 12
analysis, routine cholangiography has been found to
be most cost-effective during high-risk operations
when employed by less experienced surgeons.
19
Unfortunately, many operative cholangiograms
are interpreted incorrectly and injuries are missed.
Although this event should be less frequent with
the use of modern C-arm imaging, in reported
series of biliary injuries only 6–33% of operative
cholangiograms are interpreted correctly. For
correct anatomical interpretation of the proximal
biliary tree, both right sectoral/sectional ducts and
the left hepatic duct should be visualised. In the
presence of an endoscopic sphincterotomy, contrast
will preferentially flow into the duodenum and
the patient may need to be placed in a head-down
position to fill the intrahepatic ducts. If the anatomy
is unclear no proximal clip should be placed on what
is presumed to be the cystic duct, to avoid a crush
injury to what may be the common hepatic duct.
Retrograde cholecystectomy has been described
previously as a safe technique when inflammation
around Calot's triangle makes identification of the
anatomy difficult. Nonetheless, care still needs to
be exercised during dissection to avoid injury to
the right hepatic artery and common hepatic duct,
which may be adherent to an inflamed gallbladder.
Eight such vasculobiliary injuries were described by
Strasberg and Gouma.
20
If identification remains
impossible then the gallbladder can be opened to
facilitate identification of the cystic duct. A subtotal
cholecystectomy should be considered if a safe plane
of dissection cannot be established, thus avoiding
injury to the common hepatic or left hepatic ducts.
Originally described for open cholecystectomy,
these techniques have now also been performed
laparoscopically.
Bile duct injury can be avoided by careful
identication of the biliary anatomy, dissection close
to the gallbladder and avoidance of diathermy in
Calot's triangle. The use of operative
cholangiography and its correct interpretation is
associated with a reduced incidence of bile duct
injury.
Classification
Injury to the distal biliary tree is less technically
demanding to repair than involvement of the biliary
confluence. The success of reconstruction depends
on the type of injury and the anatomical location.
Bismuth first described a classification system for
biliary strictures reflecting the relationship of the injury
to the biliary confluence (Table 12.1).
22
Strasberg
et al. further proposed a broader classification to
include a number of biliary complications, including
cystic stump leaks, biliary leaks and partial injuries
21
Table12.1 • Bismuth classification of biliary strictures
Bismuth
classification Definition
Bismuth 1 Low common hepatic duct stricture –
hepatic duct stump >
2 cm
Bismuth 2 Proximal common hepatic duct stricture –
hepatic duct stump <
2 cm
Bismuth 3 Hilar stricture with no residual common
hepatic duct – hepatic duct confluence
intact
Bismuth 4 Destruction of hepatic duct confluence –
right and left hepatic ducts separated
Bismuth 5 Involvement of aberrant right sectoral
hepatic duct alone or with concomitant
stricture of the common hepatic duct
to the biliary tree (Fig.12.6).23 Recently the European
Association for Endoscopic Surgery (EAES) has
proposed the ATOM (anatomic, time of detection,
mechanism) classification to facilitate epidemiologic
and comparative studies.
24
Presentation
It is preferable that injuries are recognised at the
time of surgery to allow the best chance of repair,
but this occurs in less than a third of patients.
An unrecognised injury may present early with a
postoperative biliary fistula, symptoms of biliary
peritonitis or jaundice. Early symptoms or signs may
be lacking but ductal injury should be suspected
in the patient whose recovery is not immediate
or is complicated by symptoms of peritoneal or
diaphragmatic irritation and/or associated with
deranged liver function tests in the first 24–48
hours of surgery. Signs may range from localised
abdominal tenderness through to generalised
peritonitis with overwhelming sepsis. Ligation
of the bile duct will present early with jaundice;
however, later presentation may occur as a result of
stricture formation from a partial injury, localised
inflammation or ischaemic insult.
Ligation of sectoral ducts may cause subsequent
or late atrophy of the drained liver segments, which
may become infected secondarily. Occasionally
liver resection or transplantation may be required
for unilobar hepatic necrosis or fulminant hepatic
failure secondary to combined biliary and vascular
injuries.
late with liver failure due to secondary biliary
cirrhosis as a result of the injury, and may require
liver transplantation.
suspicion or evidence of a biliary injury. In a report
25
More commonly, liver failure presents
25
In many patients there is a delay in referral, despite
206
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E5
A
>2 cm
E1
E3 E4
B
DC
<2 cm
E2
Benign biliary tract diseases
Management
Intraoperative recognition
In a review by Carroll etal., only 27% of patients
underwent a successful repair by the primary
surgeon responsible for the injury, whilst 79%
of repairs performed following referral had a
successful outcome.
hand, an attempt should not be made to remedy the
situation since this may compromise subsequent
successful management. Advice should be sought
immediately and a T-tube or similar drain should
be placed to the biliary injury and drains left in
the subhepatic space, followed by referral to a
specialist centre. Some specialist units may offer
a specialist surgeon who can travel to the site of
referral to expedite immediate repair. No attempt
should be made to repair a transection or excision
of the bile duct.
A partial injury to the bile duct may sometimes
be managed by direct closure with placement of
a T-tube through a separate choledochotomy.
Primary repair with or without a T-tube for
complete transection of the common bile duct is
nearly always unsuccessful. This may result from
unappreciated loss of common duct, an associated
arterial injury, or result from local diathermy injury
or devascularisation of the duct from overzealous
dissection of the common bile duct (
Successful endoscopic treatment is possible for
failed primary repair; however, as many as 32% will
require subsequent hepatico-jejunostomy.
27
If experienced help is not at
Fig. 12.7a,b).
28
Figure12.6 • Strasberg classification. Type A injuries
include leakage from the cystic duct or subvesical ducts.
Type B involves occlusion of part of the biliary tree, most
usually an aberrant right hepatic duct. If the former injury
involves transection without ligation this is termed a
type C injury. A lateral injury to the biliary tree is a type D
injury. Type E injuries are those described by Bismuth and
subdivided into his classification (Table12.1).
Adapted from Strasberg SM, Hertl M, Soper NJ, etal. An
analysis of the problem of biliary injury during laparoscopic
chole cystectomy. J Am Coll Surg 1995;180:102–25. With
permission from the American College of Surgeons.
by Mirza et al., the median interval until referral
was 26days.
26
This delay is not inconsequential as
the opportunity for an early repair is lost and may
result in the liver sustaining further damage.
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If an injury to the biliary tree is suspected
during cholecystectomy, help must be sought from an
experienced hepatobiliary surgeon. A successful
repair by the surgeon who has caused the injury is
far less likely than one performed by a surgeon
experienced in performing a biliary reconstruction.
Postoperative recognition: biliary fistula
Any patient who is not fit for discharge at 24 hours
due to ongoing abdominal pain, vomiting, fever or
bile in an abdominal drain should be considered to
have a biliary leak. The lack of bile in an abdominal
drain does not exclude the possibility of a biliary
leak, particularly if there is liver function test
derangement. Symptoms and signs vary widely, and
widespread soiling of the abdominal cavity may be
present with few signs in the early period following
cholecystectomy.
Initial investigation should include full blood
examination and determination of serum levels of
urea, electrolytes, creatinine and liver function tests.
Ultrasound is usually the initial investigation but
it cannot readily differentiate bile and blood from
207
Chapter 12
a
b
Figure12.7 • (a) Failure of primary repair with T-tube. Primary repair was performed for an injury to the common bile
duct presenting with biliary peritonitis. A T-tube was inserted through the anastomosis and this was removed at 4weeks.
An anastomotic stricture developed and the patient required a hepatico-jejunostomy 2months later. (b) Failure of primary
repair for ligation of the common bile duct. A complete transection of the common bile duct identified at postoperative
endoscopic retrograde cholangiopancreatography (ERCP). Immediate repair was performed with a direct duct-to-duct
repair. (c) A tight anastomotic stricture is demonstrated at a later ERCP.
a residual fluid collection following uneventful
cholecystectomy. It may provide important information about the presence of intra-abdominal or
pelvic fluid, biliary dilatation or retained stones
within the bile duct. CT is normally preferred since
it provides more objective information and allows
assessment of the liver vasculature.
c
If there is evidence of significant peritoneal
irritation from widespread biliary peritonitis, laparoscopy allows confirmation of this and provides
an opportunity for abdominal lavage. The porta
hepatis can be inspected to determine the cause of
the bile leak. Whilst dislodged clips from the cystic
duct can be managed by application of further clips
208
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Benign biliary tract diseases
or suture, any other form of bile leak should lead
to specialist referral. Drains can be placed to the
subhepatic space as well as the subdiaphragmatic
space and pelvis if required. No attempt should
be made to repair an injury at laparoscopy. If
laparotomy is required, this should be considered
in conjunction with specialist assistance if bile duct
injury is suspected.
Further assessment depends on the clinical situation.
The majority of biliary fistulas are due to leaks from the
cystic duct stump or subvesicle ducts, and endoscopic
retrograde cholangiopancreatography (ERCP) allows
anatomical definition, endoscopic sphincterotomy
or stent placement when abdominal contamination
has been controlled. As complete transection of the
bile duct precludes ERCP, computed tomography
intravenous cholangiography (CT-IVC) or MRCP
can determine continuity of the biliary tree prior to
endoscopy. Occasionally, persistent bile drainage
is associated with choledocholithiasis requiring
endoscopic sphincterotomy and stone extraction.
Most simple cystic duct stump leaks are resolved by
endoscopic stenting if cannulation is possible at ERCP
and occasionally side injury to the biliary tree can be
controlled with endoscopic stent placement.
If ERCP is unsuccessful or the bile duct is ligated
or occluded by clips, percutaneous transhepatic
cholangiography (PTC) may facilitate biliary
decompression but it is less frequently employed
for diagnosis or delineation of the biliary anatomy.
Occasionally, both sides of the liver may need to be
externally drained to gain control of a biliary fistula,
especially with Strasberg E4 injuries (Fig.12.6) to
the biliary confluence. However, injury to the biliary
tree detected in this way may allow surgical repair
to be considered within the first week of injury in
the stable non-septic patient, and again such further
investigation or management decisions should only
be considered following specialist referral.
Where the diagnosis of bile duct injury has been
delayed, the aim should be to control the biliary
fistula with external drainage using surgical or
radiologically placed drains. Further control may
be required with endoscopic stenting or external
biliary drainage. Delayed repair can be considered
subsequently once sepsis and intra-abdominal soiling
have resolved, as a planned elective procedure in a
specialist unit, usually 2–3months following injury.
Such an initial conservative approach renders a
potentially difficult operation into a repair that will
be considerably easier.
Diagnosis of a bile duct injury in the
postoperative period should lead to immediate
referral to a specialist centre since inappropriate
attempts to manage this outside a specialist centre
will compromise the outcome.
Postoperative recognition: biliary
obstruction
Ligation or inadvertent clipping of the biliary tree
presents early in the postoperative period with
jaundice. Later, stricture formation may occur
as a result of direct trauma during dissection,
clips placed inadvertently on the cystic duct but
compromising the bile duct, or from damage to
the intricate vascular supply of the bile duct
by extensive mobilisation or diathermy. Initial
investigation should include haematology,
assessment of coagulation by estimation of
prothrombin time, and liver function tests.
Ultrasound may indicate the level of obstruction
or exclude the presence of a correctable cause of
obstructive jaundice, such as a retained stone in
the common bile duct.
ERCP will identify a stricture or complete
transection of the bile duct; however, identification
of complete transection with MRCP will avoid
the risks of an unnecessary ERCP. CT IVC is not
indicated as the contrast agent (Biliscopin) will not
be excreted. Overzealous instillation of contrast at
ERCP should be avoided due to the potential to
introduce infection above the stricture. Placement
of an endoscopic stent should be considered only
after consultation with a specialist unit since this
may introduce sepsis into the biliary tree and
compromise further management. Furthermore,
an undrained biliary tree may allow proximal
biliary dilatation, thereby facilitating later
reconstruction.
Although some have reported satisfactory
resolution of biliary strictures with endoscopic
stenting alone, the follow-up has usually been
short and almost all patients require later surgery
in our experience. Partial occlusion of the duct by
a clip may be remedied by balloon dilatation with
or without placement of a stent; however, delay
in diagnosis may result in subsequent recurrent
stricture formation. Nonetheless, de Reuver etal.
reported 110 patients with bile duct strictures
following cholecystectomy that were treated
with endoscopic stenting, 48 (44%) of which had
already undergone attempted surgical repair. At
a mean follow-up of 7.6 years, 74% of patients
had a successful outcome.29 Parlak et al. recently
reported 156 partial biliary strictures following
cholecystectomy with only 11% requiring further
intervention at 7.5 years median follow-up post
stent removal.30 The technique of placing multiple,
increasing numbers of stents every 3–4 months
was associated with a better outcome than stent
replacement. The development of removable
endoscopic expandable metal stents has recently
been described,
large series are not yet available. Furthermore, stent
migration can complicate treatment.
31
although long-term results and
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209
Chapter 12
If the diagnosis of ductal obstruction is made
early within the rst week after surgery, the bilirubin
level is only moderately elevated and there is no
coexisting coagulopathy or sepsis, immediate repair
offers the best chance of a successful outcome.
If repair needs to be delayed, stent placement
may still be avoidable and a decision will generally be
made based on the individual patient circumstances.
Suspicion or evidence of arterial injury may inuence
the management decision.
For strictures that declare late, appropriate
indications for stent placement are the presence of
sepsis, severe itch resistant to medical therapy, or
signicant hepatic dysfunction.
The timing of repair
Early repair
When an injury is recognised in the early
postoperative period and there is minimal peritoneal
contamination or sepsis, a definitive repair by an
experienced surgeon can be successful (
our series of 123 patients referred with injury to the
biliary tree, 22 patients underwent primary biliary
repair in the first 2 weeks following injury and
three had revision of a failed biliary repair. Between
2 weeks and 6 months, a further 22 injuries were
repaired selectively. Successful repair was possible in
22 of 25 early repairs compared with 20 of 22 delayed
32
repairs.
(<
equivalent outcomes in 61 patients when managed
by an experienced team.
Kirks et al. compared immediate repair
48 hours) to delayed repair (>48 hours) and found
33
Dominguez-Rosado etal.
reviewed 614 bile duct injuries and found that the
intermediate group (repair between 8 days and
6 weeks) had a higher risk of complications when
compared to early or delayed repair.
Figure12.8 • Operative picture of an early repair of an
E4 injury. A right-angle forceps is placed in the opening of
the left hepatic duct whilst the open right hepatic duct is
visible below. The portal vein is skeletonised with ligation
and excision of both the extrahepatic biliary tree and right
hepatic artery (held by forceps).
Fig.12.8). In
34
Delayed repair
Many injuries continue to be unrecognised or
referral delayed, including patients with generalised
peritonitis. Controlling the biliary injury and
associated sepsis is the first treatment aim, which
may require endoscopic or percutaneous biliary
decompression, allowing jaundice to settle or biliary
sepsis to be drained. Intra-abdominal collections
may be drained percutaneously, or in the early
postoperative period this may be better achieved
by laparoscopic means. It is accepted, however, that
bile collections are frequently loculated and difficult
to eradicate in patients with intra-abdominal sepsis
or widespread biliary contamination or peritonitis.
The most effective treatment may be laparotomy
with extensive lavage and the placement of large
intra-abdominal drains. Definitive repair should not
be contemplated if there is severe peritoneal soiling
since injudicious attempts to repair the injury may
aggravate the injury and result in a poor outcome.
Once these objectives have been met, the patient
should be allowed to recover from the combined
insult of surgery and sepsis. A period of rehabilitation
at home is generally required before repair is
contemplated in these compromised patients.
Abdominal and biliary drainage can be managed on
an outpatient basis with community nursing support.
Nutritional supplementation may be required,
particularly in those who have required a prolonged
admission to the intensive care unit and hospital.
Attention should be paid to the consequences of
prolonged external biliary drainage and consideration
given to recycling of bile.
Associated vascular injury
In patients with a delayed diagnosis, abdominal CT
is required to ensure resolution of intra-abdominal
collections and before repair to exclude the presence
of liver atrophy. Atrophy can occur from prolonged
obstruction to the segmental, sectional or hepatic
ducts, but is generally associated with the presence
of a vascular injury, most usually of the right hepatic
artery. Liver resection may occasionally be needed
at the time of definitive repair to remove a source of
ongoing sepsis, or if satisfactory reconstruction to
the left or right duct is not possible.
Buell etal. identified associated vascular injury as
an independent predictor of mortality, with 38% of
patients dying compared to 3% (P <0.001) where
no arterial injury was present.
35
Some authors
advocate arteriography before repair to identify such
associated vascular injury as a repair is less likely to
be successful, or for consideration of hepatic arterial
reconstruction at the time of hepatico-jejunostomy.36
However, a recent review was unable to demonstrate
any difference in outcome between patients with and
without hepatic arterial injury.
37
Alves etal. described
55 patients with post-cholecystectomy strictures
210
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who underwent surgical reconstruction with a left
duct approach and preoperative coeliac axis and
superior mesenteric artery angiography.
38
Twentysix patients (47%) had an associated vascular
injury, of which 20 (36%) were of the right hepatic
artery. In this series, only one patient in each group
(vascular injury vs no injury) developed a recurrent
stricture after repair.
38
A proximal anastomosis may
offer a better blood supply, minimising the risk of
anastomotic stricturing (
Fig. 12.9). In support of
this theory, Mercado et al. demonstrated that an
anastomosis fashioned below the biliary confluence
was more likely to require revisional surgery (16%)
compared to an anastomosis performed at the biliary
confluence (0%; P <0.05).
39
Recent improvements
in magnetic resonance imaging (MRI) and spiral CT
provide impressive arterial and venous anatomical
reconstructions, which should negate the need for
invasive arteriography.
Injury to the hepatic arterial supply (usually
the right hepatic artery) may present with
haemobilia or intra-abdominal haemorrhage from
a false aneurysm, usually associated with ongoing
subhepatic sepsis. If suspected, urgent angiography
is required (
Fig. 12.10). Haemorrhage may be
controlled by embolisation of the feeding vessel,
although re-bleeding can occur and necessitate
further embolisation. However, in our experience,
further bleeding in the presence of ongoing sepsis
usually requires laparotomy for control of bleeding
and drainage of any subhepatic collection.
Benign biliary tract diseases
Figure12.9 • Anastomotic stricture following repair of
biliary injury. Percutaneous transjejunal cholangiogram
(PTJC) of a Bismuth 1 injury repaired by hepaticojejunostomy at the level of the transection of the common
bile duct (not to the left hepatic duct). Three months later
the patient required reconstruction of the anastomotic
stricture.
Rarely, combined injury to the hepatic artery and
portal vein can occur with resultant infarction of the
affected hepatic parenchyma, usually the right liver.
Such injuries may require urgent hepatic resection
or transplantation.
25
Figure12.10 • Digital subtraction angiogram demonstrating a false aneurysm of the common hepatic artery.
Embolisation was required for control. The patient has undergone a primary repair for a complete transection of the
common bile duct. FA, false aneurysm; GDA, gastroduodenal artery; HA, common hepatic artery; LHA, left hepatic artery;
RHA, right hepatic artery.
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