Laparoscopic cholecystectomy (LC) is complicated by bile duct injury in 0.3% to 0.6% of cases. These injuries range from simple leaks from the cystic duct stump that can almost always be managed by endoscopic stenting to complex strictures, transections, and even resections of the bile duct, often with concomitant vascular damage leading to ischemia. The management of LC-related biliary injuries requires a multidisciplinary approach involving an endoscopist experienced in the use of ERCP, a skilled interventional radiologist, and a surgeon with specific training in the management of hepatobiliary injuries.
Key points
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The majority of bile duct injuries are iatrogenic, and most commonly follow laparoscopic cholecystectomy (LC).
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Less than one-third of LC-related injuries are identified at the time of surgery.
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If an injury is observed during LC, a drain should be left and the patient urgently referred to a specialist hepatobiliary surgeon for management.
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Patients who develop symptoms suggestive of a bile leak following LC should undergo cross-sectional imaging to check for a contained or free bile collection (which should be drained).
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Complete transaction of the bile duct at LC cannot be managed solely by endoscopy; surgical reconstruction after percutaneous drain placement is almost always necessary.
Introduction
A variety of insults can result in injury to the biliary tree, including blunt and penetrating trauma, radiation, chronic pancreatitis, choledocholithiasis, autoimmune disorders (eg, cholangiopathy, primary sclerosing cholangitis, pancreatitis), interventional radiology, and surgery. This review focuses principally on by far the most common cause, gallbladder surgery (cholecystectomy), the vast majority of which are performed laparoscopically. Data from large population studies indicate that injuries to the biliary tree occur in 0.1% to 0.3% of open and 0.3% to 0.6% of laparoscopic cholecystectomies. Bile duct injuries can be classified according to mechanism and type of injury, location, effect on biliary continuity, and the timing of identification. Identification of the location of bile duct injury is critical to successful management. A length of healthy bile duct without ischemia, tension, or loss of length is necessary to ensure successful repair. Starting in 1982, Bismuth and colleagues classified biliary strictures based on their proximity to the biliary confluence ( Fig. 1 and Table 1 ). In 1995, Strasberg and colleagues expanded on this classification ( Table 2 ): they classified injuries by location, mechanism, and results, and separated leaks from strictures ( Fig. 2 ). The clinical presentation of bile duct injury is determined by its type and timing. Depending on the nature of the injury, endoscopic therapy alone, principally the placement of plastic biliary stents, may correct the problem. However, complex ductal injuries, especially duct clippings and transections causing vascular injury and arterial ischemia, almost always require surgery, usually after percutaneous drain placement.
| Type | Criteria |
|---|---|
| 1 | Low common hepatic duct stricture with a length of common hepatic duct stump of >2 cm |
| 2 | Proximal common hepatic duct stricture with hepatic duct stump <2 cm |
| 3 | Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved |
| 4 | Hilar stricture with involvement of confluence and loss of communication between right and left hepatic duct |
| 5 | Involvement of an aberrant right sectoral duct alone or with concomitant stricture of the common hepatic duct |
| Type | Criteria |
|---|---|
| A | Cystic duct leak or leak from small ducts in the liver bed |
| B | Occlusion of an aberrant right hepatic duct |
| C | Transection without ligation of an aberrant right hepatic duct |
| D | Lateral injury to a major bile duct |
| E1 | Transection >2 cm from the hilum |
| E2 | Transection <2 cm from the hilum |
| E3 | Transection in the hilum |
| E4 | Separation of major ducts in the hilum |
| E5 | Type C injury plus injury in the hilum |
Although this review concerns the endoscopic approach to bile duct injury, the endoscopist does not work in isolation when managing these problems: a multidisciplinary approach and a solid understanding of the biliary anatomy and surgical principles involved in managing bile leaks and strictures is essential to their successful resolution.
Introduction
A variety of insults can result in injury to the biliary tree, including blunt and penetrating trauma, radiation, chronic pancreatitis, choledocholithiasis, autoimmune disorders (eg, cholangiopathy, primary sclerosing cholangitis, pancreatitis), interventional radiology, and surgery. This review focuses principally on by far the most common cause, gallbladder surgery (cholecystectomy), the vast majority of which are performed laparoscopically. Data from large population studies indicate that injuries to the biliary tree occur in 0.1% to 0.3% of open and 0.3% to 0.6% of laparoscopic cholecystectomies. Bile duct injuries can be classified according to mechanism and type of injury, location, effect on biliary continuity, and the timing of identification. Identification of the location of bile duct injury is critical to successful management. A length of healthy bile duct without ischemia, tension, or loss of length is necessary to ensure successful repair. Starting in 1982, Bismuth and colleagues classified biliary strictures based on their proximity to the biliary confluence ( Fig. 1 and Table 1 ). In 1995, Strasberg and colleagues expanded on this classification ( Table 2 ): they classified injuries by location, mechanism, and results, and separated leaks from strictures ( Fig. 2 ). The clinical presentation of bile duct injury is determined by its type and timing. Depending on the nature of the injury, endoscopic therapy alone, principally the placement of plastic biliary stents, may correct the problem. However, complex ductal injuries, especially duct clippings and transections causing vascular injury and arterial ischemia, almost always require surgery, usually after percutaneous drain placement.
| Type | Criteria |
|---|---|
| 1 | Low common hepatic duct stricture with a length of common hepatic duct stump of >2 cm |
| 2 | Proximal common hepatic duct stricture with hepatic duct stump <2 cm |
| 3 | Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved |
| 4 | Hilar stricture with involvement of confluence and loss of communication between right and left hepatic duct |
| 5 | Involvement of an aberrant right sectoral duct alone or with concomitant stricture of the common hepatic duct |
| Type | Criteria |
|---|---|
| A | Cystic duct leak or leak from small ducts in the liver bed |
| B | Occlusion of an aberrant right hepatic duct |
| C | Transection without ligation of an aberrant right hepatic duct |
| D | Lateral injury to a major bile duct |
| E1 | Transection >2 cm from the hilum |
| E2 | Transection <2 cm from the hilum |
| E3 | Transection in the hilum |
| E4 | Separation of major ducts in the hilum |
| E5 | Type C injury plus injury in the hilum |
Although this review concerns the endoscopic approach to bile duct injury, the endoscopist does not work in isolation when managing these problems: a multidisciplinary approach and a solid understanding of the biliary anatomy and surgical principles involved in managing bile leaks and strictures is essential to their successful resolution.
Recognition of postoperative biliary injuries
Less than one-third of iatrogenic biliary injuries are detected at the time of LC. When a bile duct injury is identified at the time of the initial surgery, measures should be taken to try to define its extent. If the level of the injury is clearly defined and the surgeon is comfortable undertaking biliary reconstruction, immediate repair can be performed. However, if there is any question that the anatomy of the injury is unclear, the patient should have a drain placed in the gallbladder fossa and then be referred without delay to a center with an experienced hepatobiliary surgeon. Careful evaluation of the extent of the injury before attempted reconstruction optimizes the chances for favorable outcome. An obvious intraoperative sign of bile duct injury is sudden, unexpected leakage of bile from the liver or soft tissue adjacent to the porta hepatis. Encountering a second duct during cholecystectomy may lure the unsuspecting surgeon into clipping a right posterior duct, which has been wrongly assumed to be a benign accessory duct. If there is any question about the biliary anatomy, an intraoperative cholangiogram should be performed, although this does not always prevent injury. If an immediate repair is not going to be performed for a bile duct injury, immediate conversion to open laparotomy is not indicated; placement of a drain and immediate referral to an experienced hepatobiliary surgeon is appropriate, and may reduce liability.
An important part of the evaluation of any bile duct injury is the identifying the patency of vascular structures. Intraoperative Doppler ultrasonography should be performed to evaluate vascular integrity, because up to one-third of patients who have LC-associated bile duct injury have a concomitant arterial injury. Vascular injury significantly increases morbidity and mortality, and increases the likelihood of later stricture formation.
There is usually a delay in diagnosing biliary injuries that occur during LC. Affected patients often present with nonspecific symptoms, such as vague abdominal pain and low-grade fever, resulting from uncontrolled bile leakage into the peritoneal cavity. Some patients may present with established sepsis from severe bile peritonitis. Patients who have suffered bile duct ligation or stricture formation may present with jaundice with or without cholangitis. Patients with a significant postoperative bile duct leak may be recognized by bilious drainage from a drain placed during surgery. Leaking bile may form a walled-off collection (a biloma) ( Fig. 3 ) or bilious ascites, resulting in bile peritonitis.
Related posts:
Endoscopic Advances in Biliary Disease
Pre-ERCP Imaging of the Bile Duct and Gallbladder
Endoscopic Evaluation of Bile Duct Strictures
Endoscopic Management of Benign Bile Duct Strictures
Endoscopic Approach to the Patient with Motility Disorders of the Bile Duct and Sphincter of Oddi
Endoscopic Ultrasonographic Access and Drainage of the Common Bile Duct
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