29 Bile Leak and Bile Duct Injury

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Chapter 28 / Minimally Invasive Biliary Surgery 351

h. The 12 o’clock stay suture should be removed now to prevent

confusion.

i. Stenting the biliary–enteric anastomosis would occur either now or

midway through completing the anterior row.

j. e anterior row is completed by suturing outside-in on the bowel

then inside out on the bile duct.

k. e anastomosis is completed by tying the two sutures on the outside

at the 9 o’clock position.

l. After completion of the anastomosis, the redundant Roux limb is

pulled back through the mesocolon defect toward the jejunojejunos-

tomy. Furthermore, the limb is secured directly to the peritoneum

at the mesenteric defect with 3-0 nonabsorbable suture to prevent

herniation.

m. Surgical drainage of the anastomosis is by surgeon preference.

POSTOPERATIVE MANAGEMENT, INCLUDING COMPLICATIONS

e majority of the postoperative management centers on bowel function

and the advancement of the patient’s diet. e previously established overall

complication rate for open hepaticojejunostomy is 10% to 20% and mortal-

ity of 1% (Table 28.2). e principal complication for hepaticojejunostomy is

the development of a biliary stula (early) or stricture (late). e number of

laparoscopic hepaticojejunostomy reports is so low that a true incidence of

these complications is undetermined. A recent systematic review reported

19 studies to date describing a collective experience with true laparo-

scopic choledochoduodenostomy, cholecystojejunostomy, or hepaticojeju-

nostomy for benign or malignant biliary disease (Table 28.2); the authors

reported a biliary stula or early stricture rate that appears to be greater

than that of the open approach. e corresponding question that presently

has no answer is whether a biliary stula in the laparoscopic approach

has worse outcomes as compared to the open approach. When comparing

laparoscopic and open reconstruction, it is important to note that many

surgeons with open biliary reconstruction currently do not internally stent

or externally drain this anastomosis. Routine drainage of laparoscopic

iliary–enteric anastomosis may be prudent as the incidence of early biliary

stula may be slightly higher using the laparoscopic approach. Although

not common, it is possible to see bile in the surgical drain on postoperative

day 1. Nevertheless, in limited experience with these biliary stulas, they

resolve in 2 to 3 days later and the majority prior to the date of discharge.

Laparoscopic Open

Patients Review

(N=89) Historical Comparison

Conversion to open 2 (2%) N/A

Early patency rate (90 d) 85 (96%) >90%

Mortality 5 (6 %) 1%

Morbidity 11 (12%) 15%

Biliary stula 2 (2%) 1%

Early biliary stricture (1 y) 2 (2%) 1%

Long-term patency rate (>20 y) N/A 70%–90%

Toumi Z, Aljarabah M, Ammori B. Role of laparoscopic approach to biliary bypass for benign and

malignant disease: a systematic review. Surg Endosc 2011;25:2105–2116.

Comparison of Laparoscopic and Open Biliary–Enteric

Reconstruction

TABLE

28.2

Section III / Biliary352

If a prolonged stula is seen, then the surgical drain is left in place at the

time of discharge, and the suction bulb is changed to a gravity drainage

bile bag. Prolonged stulas are managed as an outpatient as long as the

patient is asymptomatic, and at each clinic visit, the drain is retracted a

short distance (2 to 3cm) away from the stula and secured to the skin.

As long as the surgical drain is in place, rarely does a biliary stula require

intervention or lead to biliary sepsis. A high-volume (i.e., >100 to 200mL)

biliary stula demands more thorough interrogation and more aggressive

treatment.

Further complications include a jejunojejunostomy leak (<1%), which

is exceedingly rare and does not typically require external drainage. e

likely cause of this complication is due to ischemia of the bowel by inat-

tentive division of the arterial supply with the tissue-sealing device within

the mesentery while creating the Roux limb. If the bowel appears dusky or

blue, it is best to repeat the anastomosis instead of hoping it improves. Some

surgeons routinely create BP and Roux limbs 50cm each, which gives extra

length of bowel in case one needs to repeat anastomosis either at the time of

the index procedure or during a take-back/revision. Internal hernia is more

likely in larger patients and those where the mesocolon and jejunojejunos-

tomy mesenteric defects were not closed. In spite of suture closure of defects,

patients still likely have a 5% to 10% lifetime risk of developing a symptom-

atic internal hernia. ese hernias present as a bowel obstruction, and any

patient with a Roux limb should have an increased suspicion for internal

hernia and a low threshold for operative exploration especially considering

nonoperative management rarely resolves this type of bowel obstruction.

e development of port site hernia is rare for 5-mm port sites and less than

1% for 12-mm port sites. Port sites do not require fascial closure if they are

5mm; some surgeons do not close 12-mm port sites above the umbilicus

since they are “protected” by the liver and stomach. A prudent approach is

to close all fascial defects at 12-mm port sites either conventionally in thin

patients or laparoscopically with the suture passer in obese patients.

OUTCOMES/FOLLOW-UP

e primary long-term outcome of interest following biliary–enteric recon-

struction is patency rate. Open series report a 70% to 90% patency rate

two decades following Roux-en-Y hepaticojejunostomy (Table 28.2). Data

for laparoscopic biliary reconstruction are scant; no long-term data exist

documenting true patency rates.

Follow-up varies widely, yet most surgeons see their patients 3 to 4

weeks postoperatively with a history and physical exam and laboratory

studies (CBC, CMP) to determine if the patient has any signs of biliary s-

tula or stricture and to ensure adequate biliary drainage. A more thorough

approach is to obtain a right upper quadrant ultrasound at 12 weeks to

determine the presence of any dilated intrahepatic ducts or postoperative

uid collection in the gallbladder fossa, followed by a 99mTc choletech scan

in nuclear medicine at 24 weeks to document lling of the Roux limb with

radiotracer from the liver. In cases where a biliary stula or stricture is iden-

tied in the postoperative period, cholangiography is indicated; the percu-

taneous approach is favored over double-balloon enteroscopy via the Roux

limb since intervention is more accessible via the percutaneous approach.

CONCLUSION

Minimally invasive biliary surgery has not progressed as rapidly as mini-

mally invasive liver or pancreatic surgery. e principal hurdle is the tech-

nical challenge and paramount reliance of intracorporeal suture at dicult

Chapter 28 / Minimally Invasive Biliary Surgery 353

angles in the “faraway” porta hepatis where retraction and exposure are

technically challenging. Optimal outcomes are achieved by proper patient

selection as well as surgeon experience both with biliary pathology and

with complex laparoscopic skills.

Bile Leak and Bile Duct Injury

Jordan P. Bloom and Keith D. Lillemoe

Chapter 29 / Bile Leak and Bile Duct Injury 355

Biliary leaks can also be classied as either a minor bile leak or a major

biliary ductal injury. Minor bile leaks are typically a result of cystic duct

stump leak (60% to 75%) or duct of Luschka injuries (10% to 20%). Ducts of

Luschka are accessory bile ducts located in the gallbladder bed that do not

communicate with the lumen of the gallbladder. While they do not drain

any liver parenchyma, they are a common source of minor bile leak after

cholecystectomy. Major biliary ductal injury is most often an injury to the

common bile duct (CBD) or common hepatic duct and includes avulsion,

ligation, and transection. A bile leak can also be classied based on the vol-

ume of drainage. Low-output drainage is considered less than 300mL of

bile per day with high-output drainage being greater than 300mL/day.

While cholecystectomy is the commonest cause of bile leak, it is

important to remember that bile leakage can complicate any procedure

that has a bilioenteric anastomosis. e exact incidence of biliary leak after

these procedures is dicult to determine due to the wide variety of possible

procedures; however, it is likely in the range of 2% to 5%. One of the great-

est challenges in the diagnosis of leak after a bilioenteric reconstruction is

that typically a jejunal Roux-en-Y limb is involved, which creates an access

problem for traditional endoscopic diagnostic techniques.

In the last 15 years, there has been a marked increase in the complex-

ity of liver surgery with a concomitant increase in the bile leak rate. e

incidence of bile leak after hepatic resection is between 2% and 10% with

most of the leaks being minor. A recent prospective analysis of 2,628 hepatic

resections found that while liver-related complication rates remained sta-

ble since 1997, bile leak rates increased (5.9% from 3.7%). ese authors

reported that independent predictors of bile leak included bile duct resec-

tion, extended hepatectomy, repeat hepatectomy, en bloc diaphragmatic

resection, and intraoperative transfusion. Since it is known that bile leak

is associated with both increased hospital stay and mortality, novel tech-

niques to minimize leak after hepatic resection have been introduced with

numerous ongoing trials of new methodologies to accomplish this goal.

Bile leaks continue to be an uncommon complication of liver trans-

plantation. Despite great improvements in surgical technique, biliary

Etiology of Bile Leak

TABLE

29.1

Abdominal operations

• Cholecystectomy

∞

Major BDI

∞

Minor bile leak (cystic duct, duct of Luschka)

• Pancreaticobiliary resection

• Biliary reconstruction

• Hepatic resection

• Hepatic transplantation

• Gastroduodenal surgery

Percutaneous interventions

• Transhepatic cholangiography/drainage (PTC)

• Stricture dilation

• Radiofrequency tumor ablation

• Embolization

• Liver biopsy

Endoscopic retrograde cholangiography perforation

Trauma (blunt and penetrating)

FIGURE 29.1 Strasberg classication. Type A: Injury to the cystic duct or from minor hepatic

ducts draining the liver bed. Type B: Occlusion of biliary tree, commonly aberrant right hepatic

duct(s). Type C: Transectionwithout ligationof aberrant right hepatic duct(s). Type D: Lateral

injury to a major bile duct. Type E (1–5): Injury to the main hepatic duct; classied according

to level of injury (i.e., below). E1 (Bismuth type 1): Injury more than 2 cm from conuence;

E2 (Bismuth type 2): Injury less than 2 cm from conuence; E3 (Bismuth type 3): Injuryat

the conuence; conuence intact; E4 (Bismuth type 4): Destruction of the biliary conuence;

(Bismuth type 5): Injury to aberrant right hepatic duct. (Reproduced from Winslow ER,

Fialkowski EA, Linehan DC, 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, with permission.)

Chapter 29 / Bile Leak and Bile Duct Injury 357

complications are a common source of morbidity, which result in the need

for intervention including percutaneous, endoscopic, or even surgical

procedures. e incidence of biliary complications currently ranges from

5% to 25% with biliary strictures (9% to 12%) and leaks (5% to 10%) being

the most common complications. Bile leak after liver transplant is almost

always related to the biliary reconstruction and is complicated by the need

for immunosuppression in the patient population.

A bile leak after blunt and penetrating abdominal trauma involving

the liver is seen in 5% to 10% of reported cases and can occur after either

operative or nonoperative management.

ETIOLOGY OF BILE DUCT INJURY

In the United States, BDIs are most commonly the result of injury during

laparoscopic cholecystectomy. CBD injury during cholecystectomy can

occur due to either a technical error or more commonly misidentication

of the ductal anatomy. e Stewart-Way classication is a clear and con-

cise method of classifying for the type of CBD injury based on the specic

mechanism of injury (Table 29.2). e most common mechanism is a class

III injury where the CBD is mistaken for the cystic duct with the error being

unrecognized at the time of injury (Fig. 29.2). e duct is then transected

and a segment usually resected. In the case series used to generate the

Stewart-Way classication scheme, class III injuries were observed in 60%

of the cases.

Contributing factors to BDI include acute or chronic inammation in

the triangle of Calot, a short cystic duct, excessive cephalad retraction on

the gallbladder fundus, and insucient or excessive lateral retraction of the

gallbladder infundibulum. Other factors that can increase the likelihood of

injury include use of an end-viewing scope, excessive use of cautery, physi-

cian inexperience, and aberrant biliary anatomy.

e “critical view of safety” (CVS) was rst described in 1995 by

Strasberg et al. is method has been adopted increasingly by surgeons

around the world for performance of laparoscopic cholecystectomy

(Fig. 29.3). e CVS has three requirements. First, the triangle of Calot must

be cleared of fat and brous tissue. e second requirement is that the low-

est part of the gallbladder be separated from the cystic plate, the at brous

surface to which the nonperitonealized side of the gallbladder is attached.

e third requirement is that two structures, and only two, should be seen

entering the gallbladder. Once these three criteria have been fullled, CVS

Mechanism of Common Bile Duct Injury (Stewart-Way

Classication)

TABLE

29.2

Class I CBD mistaken for cystic duct but recognized

Cholangiogram incision in cystic duct extended into CBD

Class II Lateral damage to the CHD from cautery or clips placed on duct

Associated bleeding, poor visibility

Class III CBD mistaken for cystic duct, not recognized

CBD, CHD, R, L. hepatic ducts transected and/or resected

Class IV RHD mistaken for cystic duct, RHA mistaken for cystic artery,

RHD and RHA transected

Lateral damage to the RHD from cautery or clips placed on duct

CBD, common bile duct; CHD, common hepatic duct; L, left; R, right; RHA, right hepatic artery; RHD,

right hepatic duct.

Reprinted from Way LW, et al. Causes and prevention of laparoscopic bile duct injuries. Ann Surg

2003;237(4):460, with permission.

Section III / Biliary358

FIGURE 29.3 Operative photo demonstrating the CVS with extensive separation of the

lower gallbladder from the cystic plate. The cystic duct and cystic artery are clearly dened.

Accidentally

divided

hepatic

ducts

Cystic duct

Common

bile duct

Common hepatic duct

FIGURE 29.2 Classic laparoscopic BDI. The CBD is mistaken for the cystic duct and tran-

sected. A variable extent of the extrahepatic biliary tree is resected with the gallbladder.

The right hepatic artery, in background, is also often injured. (Adapted from Branum G,

Schmidt C, Baillie J, et al. Management of major biliary complications after laparoscopic

cholecystectomy. Ann Surg 1993;217:532.)

Chapter 29 / Bile Leak and Bile Duct Injury 359

has been attained. ere is no level I evidence that CVS reduces BDI, and

there likely never will be as the incidence of injury is so low that it would

be dicult to adequately power a prospective randomized trial. ere are

numerous case series, however, which show a reduction in the incidence

of BDI when the CVS is attained, such that it is widely considered to be the

“safest” technique for performing laparoscopic cholecystectomy.

e role of intraoperative cholangiography (IOC) in preventing BDI

during laparoscopic cholecystectomy is controversial. Individual insti-

tutional series have failed to demonstrate that either routine or selective

cholangiography aects the incidence of BDI. Furthermore, large databases

have provided mixed results as to whether IOC is an eective strategy to

reduce the incidence of BDI.

CLINICAL PRESENTATION

e clinical presentation of postoperative bile leak is variable. If surgical

drains are in place, a leak is obvious and easily detectable. Assuming there

are not drains in place or the drains do not communicate with the area of

leakage, bile can leak freely into the peritoneal cavity or it can loculate as a

collection. e presentation can be subtle ranging from nonspecic com-

plaints such as abdominal discomfort, nausea, and low-grade temperate to

severe abdominal pain and/or a “septic” appearance due to bile peritonitis.

erefore, clinicians should have a high index of suspicion for bile leak in

patients who have undergone right upp er quadrant surgical procedures and

who have any postoperative deviation from the projected clinical course.

DIAGNOSIS

ere are numerous diagnostic modalities to consider in the evaluation of

a potential bile leak. After history and physical exam, the rst step in the

workup of suspected bile leak should be basic laboratory studies. While

laboratory values may be totally normal, a mild elevation in the serum

total bilirubin, often due to bile absorption from the peritoneum, may be

seen. Other liver function tests are often normal. Leukocytosis representing

inammation or infection is common.

Following laboratory evaluation, there are numerous imaging modali-

ties to consider.

Ultrasonography is an inexpensive and noninvasive imaging tech-

nique that may be a useful rst step in identifying an intra-abdominal uid

collection; however, numerous studies have concluded that the sensitiv-

ity of ultrasound for detection of bile leak is signicantly inferior to other

modalities. Abdominal axial imaging with CT provides a more detailed

view of the pertinent structures as well as uid collections or bile ascites

(Fig. 29.4). Although the exact nature of the uid as being bile may be uncon-

rmed, such collections certainly warrant suspicion and further workup.

e gold standard for diagnosis of biliary leakage is cholangiography.

ere are numerous ways that a cholangiogram can be achieved in the

postoperative patient. If the patient has operative drains in place, contrast

can be injected in a retrograde fashion that may demonstrate the point of

leakage and biliary anatomy. Operatively placed T tubes or transhepatic

stents also provide direct access to the biliary tree. In patients who have

no access to the biliary tree, cholangiography can be performed either

antegrade via percutaneous transhepatic puncture (PTC) or, more com-

monly, retrograde via endoscopic retrograde cholangiopancreatography

(ERCP). Both of these techniques require skilled operators and confer some

degree of risk. Assuming the patient has native anatomy, the rst option

would be ERCP. Although ERCP is generally well tolerated by patients and

Section III / Biliary360

allows therapeutic intervention (stent placement and/or sphincterotomy)

at the time of diagnosis, a recent large European study reported an overall

complication rate of 10%. Post-ERCP pancreatitis occurred in 4.2%, bleed-

ing in 3.6% (0.4% clinically relevant), cholangitis in 1.4%, cardiopulmonary

complications in 1.2%, perforation in 0.6%, and procedure-related deaths in

0.1% of procedures. e limitation of ERCP is that in cases with disruption

of the normal biliary anatomy, either through biliary transection or anasto-

mosis, an ERCP will not demonstrate the proximal biliary tree and therefore

not dene the location of the leak or the anatomy necessary for reconstruc-

tion (Fig. 29.5). PTC may therefore be the only access to the biliary tree in

certain situations (Fig. 29.6). PTC is another safe technique with a major

complication rate of 2% to 10% (sepsis, cholangitis, bile leak, hemorrhage,

or pneumothorax). After gaining access to the biliary tree, PTC also oers

the potential for therapeutic intervention.

A noninvasive modality for imaging the biliary tree that might be

useful in patients who are clinically stable is magnetic resonance cholan-

giopancreatography (MRCP). Recent developments in imaging technology

have enabled MRCP to replace invasive alternatives for the pre- and post-

operative assessment of biliary disease. MRCP enables rapid, noninvasive

evaluation of both the biliary tree and pancreatic duct without the use of

intravenous contrast media. Attention has recently focused on the utility in

evaluation of the biliary system in suspected biliary injuries to help select

the most appropriate next step if any (Fig. 29.7). e major limitation to

MR-based biliary imaging is that there is no potential for therapeutic inter-

vention. Other limitations include high cost, patient size restrictions, and

the requirement of lying still for a prolonged period of time, which might be

dicult in the acutely ill patient.

Finally, technetium-99m–labeled hydroxy iminodiacetic acid (HIDA)

is commonly used as initial, noninvasive imaging modality for a sus-

pected biliary leak. HIDA scintigraphy is a dynamic study in which an

ongoing bile leak may be detected. However, it provides suboptimal

anatomic detail. A biliary leak will be demonstrated by extravasation

FIGURE 29.4 Large bile duct collection (biloma) occurring after BDI.

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