Bile Duct Injury (S+DT)

Bile Duct Injury [Speed]

Avoiding Biliary / Vasculobiliary injuries:

How to prevent Biliary injury?

• Strasberg
• Effective retraction with counter traction
• Clear calots of fat and connective tissue
• Only two structures should enter GB
• dissection of lower third of GB from Liver bed
• Both anterior and posterior views should be obtained.
• For persistent hemorrhage, achieving hemostasis primarily by compression and avoiding use of electrocautery or clipping

When to stop?

• Severe fibrosis and scarring in Calot’s triangle due to inflammation
• Impacted gall stone in the confluence of cystic, common hepatic, and common bile duct ( included in the expanded classification of mirizzi syndrome)

Bail out procedures, which include:

1. Subtotal cholecystectomy

   1. Reconstituting

   

   b. Fenestrating

   

2. Tube Cholecystostomy

3. Fundus First approach ( dome down)
4. Conversion to Open

5. Routine use of intraop cholangiogram before injury is not much of use. but technically it is more useful in identifying injury after it happened.

   • Detect injury;
   • Decrease severity of injury

6. Studies have suggested that misperception of anatomy is much more common factor in Iatrogenic injury than surgical skill

7. Confirmation bias
   • most bile duct injuries are identified in postoperative period. ( COGNITIVE ERROR)

Stewart - Way Classification of Laparoscopic Bile Duct Injuries:

• Class I Injury ( 7%)
  • Definition: Incomplete transection of the CBD with no loss of duct.
• Class II Injury (22%)
  • Definition: Lateral damage to the common hepatic duct.
  • Complications: Produces stricture or fistula.
  • Cause: Clips or cautery damage to the lateral aspect of the duct.
• Class III Injury 61% (most common)
  • Definition: Full transection of the CBD and a variable portion of the proximal duct.
• Class IV Injury (10%)
  • Definition: Transection or damage to the right hepatic duct.
  • Complications: Many cases also involve concurrent right hepatic artery injury.

Hannover Classification of Bile Duct Injuries:

• Type A: Peripheral Bile Leak
  • A1: Cystic duct leak
  • A2: Leak in the region of the gallbladder bed
• Type B: Stenosis of the Main Bile Duct
  • B1: Incomplete (e.g., caused by a clip)
  • B2: Complete
• Type C: Tangential Injury of the Common Bile Duct
  • C1: Small punctiform lesion (<5 mm)
  • C2: Extensive lesion (>5 mm) below the hepatic bifurcation
  • C3: Extensive lesion at the hepatic bifurcation
  • C4: Extensive lesion above the hepatic bifurcation
  • With vascular lesions: d (right hepatic artery), s (left hepatic artery), p (proper hepatic artery), com (common hepatic artery), c (cystic artery), pv (portal vein)
• Type D: Completely Transected Bile Duct
  • D1: Without defect below the hepatic bifurcation
  • D2: With defect below the hepatic bifurcation
  • D3: At hepatic bifurcation level (with or without defect)
  • D4: Above hepatic bifurcation (with or without defect)
  • With vascular lesions: d (right hepatic artery), s (left hepatic artery), p (proper hepatic artery), D2pv (portal vein)
• Type E: Structures of the Main Bile Duct
  • E1: Main bile duct circular (<5 mm)
  • E2: Main bile duct longitudinal (>5 mm)
  • E3: Hepatic bifurcation
  • E4: Right main bile duct/segmental bile duct

Strasberg Classification of Laparoscopic Biliary Injuries:

• doesnt deal with vascular injuries
• deals with CBD transection
• Types:
  • A = Cystic duct stump leak (or) Duct of Luschka leak
    • Present will Bile leak
    • MC cause of bile leak after LC
  • B = Ligation of aberrant duct not in continuity with biliary tree
    • DONOT Present with Bile leak
  • C = Division of aberrant duct not in continuity with biliary tree
    • Present with Bile leak
  • D = Lateral injury ( not complete transection)
    • Present with Bile leak
  • E = Bismuth Subtypes ( Complete Transection)
    • E1 = > 2cm
    • E2 = < 2cm
    • E3 = Patent Confluence
    • E4 = Separated Confluence
    • E5 = Aberrant + CBD

Strasberg = for biliary leak Bismuth = for Strictures

• Management Options: If injury identified in postop setting

  • Type A : Most of the time with just a PCD drain and without need of ERCP stenting this leak will settle down in 10-12 days if there is no distal obstruction. If required ERCP + Stenting can be done.
  • Type B : Cholangiogram Normal . ERCP is of No use. Wait and watch as the segment of liver gets atrophied.
  • Type C: Cholangiogram Normal .ERCP is of no use since it wont address the proximal portion of Aberrant duct which is cut. it will still leak.
  • Type D : Can be managed with ERCP stenting

Limitations of Strasberg:

• No mention of vascular injuries
• no mention of patient condition , severity

Management Options: If Injury Recognized at time of surgery:

• Stop further dissection
• Experience surgeon, tertiary care centre = Plan for repair if feasible
• Conversion to open, Cholangiogram, Rule out Vascular injury
  • Aberrant Duct < 3mm = can ligate the duct
  • Primary Repair =
    • If No thermal injury
    • <50% circumference
    • T tube through site of injury
  • End - End Repair:

    • 50% circumference

    • Defect < 1 cm
    • Away from hilum
    • T tube away from site of injury
  • Type E:
    • E1 / E2 = End - End (intraop) can be tried as stump is available here. RY HJ can be done as stump is available
    • E3/E4 = early repair not advised ,we can do RY HJ at a later setting

Early Repair of Bile Duct Injuries:

• 3 types :
  • Immediate repair = within 72 hrs
  • Early repair = within 6 weeks
  • Late repair = after 6 weeks
• Can be done in experienced centres
• Prerequisites of early repair: not frequently done
  • Absence of sepsis, Cholangitis
  • No intra abdominal collection
  • Complete cholangiogram
  • Experience surgeon
  • No Vascular injury

Standard algorithm for Management of Acute collection postop:

• Standard Mx:

  • IV fluids
  • IV antibiotics
  • USG & CECT abdomen
    • Collection; IHBRD
    • Vascular injury ; Pseudoaneurysm
    • Bowel Injury
  • Drain Collection
  • control of sepsis; hydration ; nutrition
  • then further workup and diagnose the type of leak and further management if required.

  

Factors Associated With Stricture Recurrence or Poor Outcome After Operative Reconstruction

46.) A 40-year-old female presents with obstructive jaundice. She had a laparoscopic cholecystectomy 2 months ago. MRCP shows a Type 4 biliary stricture. LFT results: Bilirubin 5.3/2.5, AST 55, ALT 60, Alk Phos 450. Hemoglobin 10.5, TLC 5500. CT angiogram shows right hepatic artery injury. What is not true?

A) Delay surgery due to vascular injury

B) Preoperative PTBD to aid in ductal visualization during surgery

C) Segment IV resection can be done

D) Lowering of hilar plate

Correct Answer: A. Delay surgery due to vascular injury

Explanation:

• A) Delay surgery due to vascular injury:
  • True. Presence of vascular injury is indeed a contraindication for immediate or early repair of bile duct injury. In such cases, delayed repair (greater than 6 weeks after injury) is recommended, especially once the stricture has already formed. This delay allows for better visualization of the anatomy and more effective management of the injury. Early surgery, in the presence of vascular injury, increases the risk of complications such as insufficient healing or re-stricture formation.
• Preoperative PTBD (Percutaneous Transhepatic Biliary Drainage) is often performed in complex ductal injuries. PTBD aids in visualization of the bile ducts during surgery by draining the bile and reducing inflammation, making the ducts easier to identify and operate on.
• In Type 3 and Type 4 biliary strictures, the complexity increases significantly. These strictures affect or encroach upon the confluence of the right and left hepatic ducts or extend proximally, isolating the ducts. The surgical outcomes in these cases are more challenging and have variable success rates.
• Adequate exposure of the bile ducts is crucial, and in these complex cases, it is often achieved by dissecting the left hepatic duct system. This dissection helps access and visualize the confluence, which is essential for proper surgical management.
• In Type 4 strictures, the confluence of the ducts is obliterated, requiring more extensive measures. In such cases, it is necessary to provide drainage to the right lobe of the liver as well. This is done through careful dissection across the stricture and, often, creation of a second anastomosis to the right ductal system.
• Segment IV mobilization or partial excision: In more severe cases of Type 4 strictures, mobilization or partial excision of Segment IV of the liver may be necessary to facilitate access to the ductal system. This allows the surgeon to create proper anastomoses and achieve bile flow restoration.
• Commonly, the surgical approach involves opening the umbilical fissure to gain access to the ducts, particularly in complex Type 4 strictures. Another approach is to extend the subhepatic dissection to expose the origin of the right hepatic duct. In this maneuver, the liver is opened in the line of the gallbladder fossa, and upward mobilization of Segment IV combined with opening the umbilical fissure helps expose and access the ducts, facilitating proper drainage and reconstruction.

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Bile Duct Injury Post-Cholecystectomy [DT]

Incidence and Epidemiology

• National Incidence Rates:
  • 0.2% to 0.6%: The incidence of bile duct injuries (BDIs) following cholecystectomy, making it the most common cause of iatrogenic biliary injuries.
  • Laparoscopic cholecystectomy is the standard treatment for symptomatic cholelithiasis, which contributes significantly to these statistics due to its widespread use.

Pathogenesis and Contributing Factors

• Technical Errors and Misinterpretation:
  • The most common cause of BDI during cholecystectomy is either a technical error or misinterpretation of the anatomy. These errors can lead to both major and minor injuries.
• Classification of Injuries:
  • Major Injuries: Include transection of the common bile duct (CBD), often requiring reoperation.
  • Minor Injuries: May include biliary leaks, which, while less severe, can still necessitate surgical intervention.

Anatomic Variations and Risk Factors

• Cystic Duct Variations:
  • High Insertion: The cystic duct may join the common hepatic duct very high, almost at the biliary confluence.
  • Low Insertion: In some cases, the cystic duct may run parallel to the common hepatic duct and join it very low, sometimes near the ampulla.
  • Absent Right Hepatic Duct: In up to 25% of patients, the right hepatic duct may be absent, with sectoral ducts joining the left hepatic duct independently. These variations significantly increase the risk of injury.
• Vascular Anomalies:
  • Aberrant Right Hepatic Artery: Commonly arises from the superior mesenteric artery and courses lateral and posterior to the CBD, making it prone to injury during cholecystectomy.
  • Combined Vascular Injuries:
    • Right Hepatic Artery: Injuries to this artery are associated with CBD injuries and occur in approximately 0.6% of laparoscopic cholecystectomies.
    • Right Portal Vein: Rarely, injuries may involve both the right hepatic artery and the right portal vein, which can be life-threatening.

Biliary Ischemia and Stricture Formation

• Blood Supply to Extrahepatic Bile Ducts:
  • 60% of the blood supply comes from below (retroduodenal and gastroduodenal arteries).
  • 40% of the blood supply comes from above (right hepatic artery).
• Risk of Biliary Stricture:
  • Extensive Periductal Dissection: Disrupts the arterial blood flow, potentially leading to delayed stricture formation.
  • Electrocautery Use: Can damage the ductal blood supply, further contributing to stricture development.

Risk Factors in Specific Conditions

• Acute Cholecystitis:
  • Increased Risk: The incidence of bile duct injury is 2 to 3 times higher during cholecystectomy for acute cholecystitis due to severe inflammation, distorted anatomy, and difficulty in dissection.
• Conversion to Open Surgery:
  • Complex Biliary Injuries: These are more likely to occur after conversion from laparoscopic to open surgery, especially in cases with severe inflammation or distorted anatomy.

Pathological Factors Leading to BDI

• Challenging Anatomy:
  • Patients with acute cholecystitis, cholangitis, or gallstone pancreatitis are at higher risk for biliary injuries due to challenging dissection fields.
• Chronic Inflammatory Conditions:
  • Chronic inflammation in the porta hepatis and Calot's triangle can obscure the surgical field and increase the likelihood of bile duct injuries.

MCQ 1

• Answer: c) CBD blood supply - from below 40% and from above 60%
• Explanation: The correct distribution of blood supply to the extrahepatic bile duct is 60% from below (retroduodenal and gastroduodenal arteries) and 40% from above (right hepatic artery). The other options are true: complex biliary injury is more likely after conversion to open surgery, and the incidence of post-cholecystectomy biliary stricture is 0.2-0.6%. Combined arterial injury involving the right hepatic artery can occur in 0.6% of cases.

Comparison of Management Strategies for Bile Duct Injury in Different Scenarios

Scenario	Immediate Postoperative Recognition	Interval (Late) Recognition	Intraoperative Recognition
Initial Approach	Avoid early reoperation; assess and stabilize the patient.	Delay definitive repair; focus on stabilizing the patient, particularly in high-risk cases.	Consider the surgeon's experience; seek assistance if needed.
Diagnostic and Management Steps	- Perform appropriate diagnostic studies (e.g., fistulography).	- Manage complications like infection, portal hypertension, and poor general condition.	- Immediate open conversion and repair by an experienced surgeon can reduce morbidity.
	- Assess continuity between the biliary system and the GI tract.	- Consider percutaneous biliary drainage for portal hypertension.	- In complex cases, consider placing drains to manage bile leakage and refer to specialists.
	- Prolonged drainage may allow spontaneous closure in certain cases.	- Establish external bile drainage and control sepsis.
	- Manage bile leakage from cystic duct, subvesical duct, or noncircumferential lacerations with drainage.
Repair Considerations	Avoid immediate repair in cases of severe laceration or complete transection; consider delayed repair.	Delay repair until patient stabilization; consider staged repair if there is infection or portal hypertension.	Immediate repair may be required for major injuries; surgeon experience is critical.
	Temporary internal fistulojejunostomy or stenting may be necessary in some cases.
Interventional Techniques	Endoscopic or percutaneous stenting may reduce fistula output and facilitate later surgical repair.	Use interventional radiology to place percutaneous biliary drainage catheters as a safer option for high-risk patients.
Risk of Complications	High risk of bile peritonitis, especially if bile is infected; manage with drainage and antibiotics.	Attempting repair in the presence of infection, acute portal hypertension, or severe illness may result in failure.	Avoid rushing into reoperation if the injury is recognized; stabilize the patient first.

Technical Approaches to Biliary Repair: Key Points for Revision

End-to-End Duct Repair

• Overview:
  • End-to-End Anastomosis: An early technique aimed at re-establishing normal anatomic continuity by excising the stricture and directly connecting the bile ducts.
  • Long-Term Success: Limited success with 50% to 60% incidence of long-term failure, particularly in high strictures.
  • Current Role: End-to-end repair has a limited role and is typically not favored for complex or benign biliary strictures.

Biliary-Enteric Repair

• Indication:
  • Preferred for Bile Duct Transection or Stricture: Particularly when the injury involves the retropancreatic or supraduodenal CBD.
  • Choledochoduodenostomy: Ideal for strictures of the retropancreatic or immediate supraduodenal portion of the CBD; requires a dilated bile duct.
  • Roux-en-Y Hepaticojejunostomy: Standard approach for strictures involving the common hepatic duct, particularly in high or complex strictures.
• Management of Proximal Hepatic Ducts:
  • Type 1 or 2 Strictures (Below the Confluence):
    • Direct anastomosis to the hepatic duct stump is usually straightforward.
  • Type 3 or 4 Strictures (Involving or Above the Confluence):
    • Complex cases requiring dissection across the stricture and possibly additional anastomoses to ensure drainage of both lobes of the liver.
    • May require mobilization or partial excision of segment IV of the liver for adequate exposure.

Liver Split and Liver Resection

• Hepatotomy:
  • Sometimes necessary to open liver tissue (hepatotomy) to expose bile ducts for repair, especially in type 4 strictures.
  • Umbilical Fissure Dissection: Used to access the segment III duct or the origin of the right hepatic duct.
• Liver Resection:
  • Indication: For patients with unsuccessful prior repairs, concomitant vascular injury, or significant intrahepatic complications (e.g., recurrent cholangitis).
  • Outcome: High success rate with 94% of patients achieving good or excellent results at 8 years follow-up.

Isolated Sectoral Hepatic Duct Injuries

• Challenges:
  • Injuries to aberrant or low entry right sectoral hepatic ducts are difficult to diagnose and manage.
  • Patients may remain asymptomatic for months or years, or present with cholangitis or abnormal liver function tests (LFTs).
• Management:
  • Surgical Intervention: Typically requires biliary drainage to a Roux-en-Y loop of jejunum.
  • Resection: May be necessary for patients with recurrent cholangitis or liver atrophy.
  • Nonoperative Management: Possible in asymptomatic patients or through interventional procedures like sclerotherapy.

Combined Modality Approaches

• Indication:
  • Used in complex cases, particularly with intrahepatic strictures and stones.
• Technique:
  • Hepaticojejunostomy: Performed over a transjejunal tube with the Roux limb brought to the exterior, allowing for future access for diagnostic or therapeutic procedures.
  • Long-Term Care: Provides an improved chance of excellent outcomes in difficult cases, potentially avoiding repeated major surgeries.

Liver Transplantation

• Indication:
  • Considered in cases of devastating combined vascular and biliary injury, or long-standing biliary obstruction leading to secondary biliary cirrhosis.
  • Alternative: Surgical reconstruction is preferred over transplantation in most cases with benign strictures.

Portal Hypertension and Biliary Stricture

• Challenges:
  • Co-existing portal hypertension complicates management, especially in patients with a history of GI bleeding or severe liver dysfunction.
• Management:
  • Nonoperative: Stenting or balloon dilation is preferred over immediate surgery.
  • Emergency Measures: Control hemorrhage and resuscitate the patient; consider shunting procedures if needed.
• Surgical Considerations:
  • Avoid bile duct repair during severe liver dysfunction; wait until patient stabilization.
  • Hepaticostomy Drainage: May be necessary in cases of hemorrhage during stricture repair.

Results of Biliary Reconstruction

• Morbidity and Mortality:
  • Significant morbidity associated with repair of benign strictures, including complications like abscesses, cholangitis, sepsis, biliary fistula, and hemorrhage.
  • Mortality is higher in patients with advanced age, comorbid conditions, and biliary sepsis.
• Success Factors:
  • Long-term outcomes are generally positive in experienced hands, with surgical reconstruction being relatively safe compared to nonoperative techniques. However, failed repairs complicate subsequent attempts and negatively impact outcomes.

Factors Associated With Stricture Recurrence or Poor Outcome After Operative Reconstruction

1. Proximal Stricture:
   • Bismuth Types 3 and 4: Strictures closer to or involving the biliary confluence are associated with higher rates of recurrence and poorer outcomes.
2. Multiple Prior Attempts at Repair:
   • Repeated surgical interventions increase the risk of complications and reduce the success rate of subsequent repairs.
3. Portal Hypertension:
   • Co-existing portal hypertension complicates the surgical procedure and is associated with a higher risk of recurrence and poorer overall outcomes.
4. Hepatic Parenchymal Disease:
   • Cirrhosis or Hepatic Fibrosis: Underlying liver disease negatively impacts healing and increases the likelihood of complications.
5. End-to-End Biliary Anastomosis:
   • This technique has a higher failure rate and is less favored in modern surgical practice.
6. Surgeon Inexperience:
   • Lack of experience in managing complex biliary injuries can lead to suboptimal outcomes and a higher risk of stricture recurrence.
7. Intrahepatic or Multiple Strictures:
   • The presence of strictures within the liver or multiple strictures complicates the repair and increases the risk of poor outcomes.
8. Concurrent Cholangitis or Hepatic Abscess:
   • Active infection at the time of surgery complicates the procedure and is associated with a higher risk of postoperative complications.
9. Intrahepatic Stones:
   • Stones within the liver increase the complexity of the repair and are associated with a higher risk of recurrent strictures.
10. External or Internal Biliary Fistula:
    • Fistulas complicate the surgical field and are associated with a higher likelihood of recurrent problems.
11. Intraabdominal Abscess or Bile Collection:
    • The presence of abscesses or bile collections indicates a complicated clinical course, which is associated with poorer outcomes.
12. Hepatic Lobar Atrophy:
    • Atrophy of liver segments due to prolonged obstruction or injury complicates the repair and is associated with poorer outcomes.
13. Advanced Age or Poor General Health:
    • Older patients or those with poor general health have a higher risk of complications and poorer overall outcomes following biliary reconstruction.

Sensitivity of Detecting CBD Calculi: Key Points

1. Ultrasound (USG):
   • Sensitivity: 20-75%
   • Note: The sensitivity of USG for detecting common bile duct (CBD) stones varies widely depending on the skill of the operator and the quality of the equipment.
2. Computed Tomography (CT):
   • Sensitivity: 25-90%
   • Note: CT has a broad range of sensitivity for detecting CBD stones, often dependent on the presence of calcification within the stones and the phase of imaging.
3. Magnetic Resonance Cholangiopancreatography (MRCP):
   • Sensitivity: 93% (Contrary to the statement)
   • Specificity: 96% for detection of choledocholithiasis.
   • Limitations: MRCP cannot differentiate stones from air bubbles, sludge, or blood clots. It also struggles with detecting stones smaller than 3 mm and impacted stones in the ampulla.
4. Endoscopic Ultrasound (EUS):
   • Sensitivity: Approaching 100%
   • Specificity: Greater than 90%
   • Overall Accuracy: 96%
   • Note: EUS offers high-resolution imaging, making it extremely accurate in detecting small CBD stones[<1mm] or other obstructive causes.
5. Intraductal Ultrasound (IDUS):
   • Diameter: 2 mm
   • Resolution: As fine as 0.07-0.018 cm
   • Frequency: High-frequency ultrasound at 12.3 MHz
   • Note: IDUS is used during endoscopy or percutaneously, offering exceptional resolution for detecting small lesions within the bile ducts.

MCQ

Not true regarding the sensitivity of detecting CBD calculi?

• a) USG- 20-75%
• b) CT- 25-90%
• c) MRCP- 100%
• d) EUS- 100%

Answer: c) MRCP- 100%

Explanation: MRCP is highly specific but not 100% sensitive for detecting CBD stones. It has limitations in detecting small stones, differentiating stones from other similar-appearing structures, and identifying impacted stones in the ampulla.

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Bile Duct Injury [Sabiston]

Overview

• More than 80% of bile duct injuries occur during cholecystectomy.
• Risk factors include:
  • Variable anatomy
  • Porta hepatis inflammation
  • Inappropriate exposure
  • Inadequate experience or skill
  • Aggressive hemostasis
• Misperception of anatomy is a common factor leading to iatrogenic injury.

Mechanism of Injury

• Without proper inferolateral traction of the gallbladder infundibulum, the cystic duct may be mistaken for the common hepatic duct, leading to injury.
• Cephalad retraction of the gallbladder fundus and opening the triangle of Calot help prevent misidentification.
• Use of a 30-degree laparoscope provides better visualization during laparoscopic cholecystectomy.
• Confirmation bias can cause surgeons to overlook signs of abnormal anatomy, leading to injury often recognized postoperatively.

Prevention

• Proper surgical techniques and awareness of anatomical variations are crucial.
• Cholangiography (routine or selective) may reduce the incidence and extent of injury by providing immediate recognition and management.
• Transanastomotic stents can improve anastomotic patency when used appropriately.

Classification of Bile Duct Injuries

Based on the Bismuth classification, modified by Strasberg:

• Type E1: Injury more than 2 cm below the biliary confluence.
• Type E2: Injury within 2 cm of the biliary confluence.
• Type E3: Injury at the confluence, preserving extrahepatic ducts.
• Type E4: Injury involving the entire extrahepatic biliary tree.
• Type E5: Injury involving aberrant right hepatic duct and common hepatic duct.

Presentation

• Bile leakage or stricture are common manifestations.
• Bile leakage leads to:
  • Early symptoms: Fever, increasing abdominal pain, jaundice, bile leakage from incision.
  • Peritonitis due to leakage into the peritoneal cavity.
• Strictures:
  • Less than 10% detected in the first week post-operation.
  • Over 70% diagnosed within 6 months.
  • May present with jaundice, with or without pain.

Treatment

Recognized at the Time of Cholecystectomy

• Immediate Actions:
  • Convert to an open operation.
  • Use cholangiography to delineate the injury.
• Goals:
  • Maintain ductal length.
  • Eliminate bile leakage.
  • Create a tension-free repair.
• Management Strategies:
  • Minor Injuries:
    • If the duct is larger than 3 mm, involves less than 50% of the circumference, and isn't caused by electrocautery, place a T-tube through the injury.
  • Thermal Injuries or Major Duct Damage:
    • Resection of the injured segment.
    • Biliary-enteric anastomosis to reestablish continuity.
  • Defects <1 cm and Away from Bifurcation:
    • End-to-end anastomosis with transanastomotic T-tube placement.
    • Ensure tension-free anastomosis using a Kocher maneuver.
  • Injuries Near Bifurcation or Large Defects:
    • Roux-en-Y hepaticojejunostomy is preferred.
    • Oversew the distal end and debride the proximal end to healthy tissue.

Identified After Cholecystectomy

• Suspect Injury in patients with:
  • New or worsening symptoms post-cholecystectomy.
  • Bilious drainage from drains or incision.
  • Signs of biliary obstruction or peritonitis.
• Diagnostic Steps:
  • Imaging:
    • Ultrasound (US) to detect fluid collections.
    • Computed Tomography (CT) for detailed anatomy and planning.
  • Cholangiography:
    • Endoscopic Retrograde Cholangiopancreatography (ERCP) if duct continuity exists.
    • Percutaneous Transhepatic Cholangiography (PTC) to visualize intrahepatic ducts and provide drainage.
• Management Goals:
  1. Control Infection:
     • Drain fluid collections (percutaneous or operative).
     • Administer broad-spectrum antibiotics.
     • Decompress the biliary tree.
  2. Anatomical Delineation:
     • Thorough cholangiography to map the biliary anatomy.

  3. Durable Biliary-Enteric Drainage:

     • Surgical reconstruction is preferred for long-term success.
     • Roux-en-Y hepaticojejunostomy with a tension-free, mucosa-to-mucosa anastomosis.
     • Use of transanastomotic stents may improve patency, especially near the hepatic duct bifurcation.

     

Surgical Reconstruction

• Preparation:
  • Separate adhesions between the duodenum, colon, and liver.
  • Encircle the porta hepatis with a Penrose drain for orientation.
• Identification of Bile Duct:
  • Use preoperative biliary catheters to aid dissection.
  • Employ needle aspiration to locate the bile duct while avoiding vascular injury.
• Anastomosis Techniques:
  • Limit dissection to less than 5 mm above the stricture to preserve vascular supply.
  • Create an end-to-side mucosa-to-mucosa anastomosis with the Roux-en-Y jejunal limb.
  • Consider anastomosis to the left hepatic duct if inflammation is substantial at the bifurcation.
  • Confirm patency of the biliary bifurcation with cholangiography before proceeding.

Interventional Radiologic and Endoscopic Techniques

• Percutaneous Balloon Dilation:
  • Suitable when duct continuity is preserved.
  • Success rate of up to 70%.
  • Complications: Cholangitis, hemobilia, bile leaks.
• Endoscopic Balloon Dilation:
  • Reserved for primary bile duct strictures or after choledochoduodenostomy.
  • Success rate of 88%.
  • Complications: Pancreatitis, cholangitis.

Outcomes

• High Success Rates:
  • Over 90% of patients are free of jaundice and cholangitis after reconstruction.
• Factors for Better Outcomes:
  • Early identification of injuries.
  • Immediate referral to experienced centers.
• Predictors of Stricture Formation:
  • Sepsis at the time of reconstruction.
  • Biliary cirrhosis.
• Influential Factors:
  • Use of transanastomotic stents may improve long-term patency.
  • Chronic liver disease and hepatic fibrosis increase operative risks.
• Quality of Life:
  • Proper management can restore health-related quality of life to pre-injury levels.