The treatment of common biliary duct injuries after surgery is a permanent challenge for physicians, and management by a multidisciplinary team is often required. The endoscopic approach is a valuable tool because it is able to assess the problem and also provide a therapeutic option for both fistulas and stenosis of the biliary tree. This article discusses the endoscopic management of postsurgical injuries of the common bile duct and discusses the application of practical tools.
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The treatment of common biliary duct injuries after surgery remains a challenge for physicians.
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The management of biliary tract injuries will depend on the nature and extent of the injury, the presence or absence of biloma, and time to diagnosis of the injury. It should be performed in referral centers.
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The lesions of the bile ducts are divided into fistulas and stenosis.
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In biliary fistulas, the goal of endoscopic therapy is to reduce the pressure of the sphincter of Oddi with nasobiliary drainage, biliary sphincterotomy, or placement of prosthesis with or without sphincterotomy.
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For biliary strictures the objectives are to relieve the obstruction, prevent restenosis, and prevent hepatocellular damage.
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The treatment of biliary injuries after surgery needs a multidisciplinary team.
Endoscopic treatment of bile duct injury is a permanent challenge for endoscopists, and endoscopic retrograde cholangiopancreatography (ERCP) is a valuable tool in this field.
This article discusses the endoscopic management of biliary fistulas and postsurgical stenosis including liver transplantation. It also aims to provide tools to determine when and how endoscopic management may be the treatment of choice in a patient with a surgical complication of the biliary tract. Practical information on the management of these complications is also given.
Classification
There are multiple classifications, of which the Strasberg classification remains the most widespread and widely used. Strasberg classifies the biliary tract injuries according to anatomic considerations and therapeutic alternatives. The authors recommend Strasberg because it identifies potential endoscopically treatable lesions and also because it is widely accepted by surgical teams ( Fig. 1 ).
There are no management algorithms based on evidence that allow determination of which lesions of the biliary tract improve with ERCP. At present the indications and contraindications for endoscopic management are based primarily on recommendations from experts, supported by facts such as the extent of the injury, fistula flow, the time when the lesion is diagnosed in the intraoperative or postoperative period, the presence of sterile or infected biloma, and the risk associated with surgical repair ( Table 1 ).
| Factor | ECRP | Surgery | |
|---|---|---|---|
| Nature and magnitude of the lesion | Cystic duct (Strasberg A) | X | |
| Luschka duct (Strasberg A) | X | ||
| Ligated sectorial duct (Strasberg B) | X a | ||
| Nonligated sectorial duct (Strasberg C) | X b | X | |
| CBD small tearing/burning (Strasberg D) | X | ||
| CBD transection (Strasberg E) | X c | X | |
| CBD resection (Strasberg E) | X | ||
| Flow through the leak | Low-grade leak | X | |
| High-grade leak | X d | X | |
| Time to set the diagnosis | Intraoperative | X | |
| Early postoperative | X | ||
| Late postoperative (strictures) | X d | X | |
| Associated collections | No associated or small collection | X | |
| Aseptic, no septated collection | X | ||
| Infected or septated collection | X e | X | |
| Surgical risk | High risk | X | |
| No high risk | X d | X | |
a Absent communication to CBD branches lead to late liver resection.
b Only if aberrant system is communicated to CBD branches.
c Only if continuity can be established can stenting be considered.
d ERCP seems as effective as surgery; other factors should be considered.
e Drainage is priority; after completion, endoscopic therapy should be used.
Endoscopic management considerations
Nature and Extent of Injury
The presence of continuity of the bile duct is the most important factor in determining the ability to manage the injury by endoscopy. If there is continuity of the bile duct (lesion types Strasberg A, C, and D), ERCP is considered the primary therapy. On the other hand, the endoscopic management is often not possible in the presence of injuries that completely transect the bile duct, when there are clips on the distal stump and when there is no continuity between the injured segments (injury types Strasberg B or E).
Although the authors have successfully treated complete transection of the bile duct by ERCP, without requiring a simultaneous transhepatic percutaneous access, these cases should be considered anecdotal. Complete transection of the bile duct is a strong indication for surgery. Exclusive use of endoscopic treatment is to be considered only if one can successfully cross the lesion and completely decompress the bile duct using prosthesis.
Aberrant bile ducts usually drain bile from liver segments directly to the gallbladder bed or common bile duct, and rarely to the right or left bile duct. If an inadvertent injury of an aberrant duct occurs during surgery, an ERCP is likely to be required. If the contrast displays an aberrant duct, this means that the latter is connected to the biliary tract, so ERCP would be therapeutic if a sphincterotomy is performed, a biliary stent placed, and/or cyanoacrylate is injected. If the injury is not visible during ERCP, other studies such as scintigraphy or cholangioresonance will be required, and the resolution will likely be surgical resection.
Flow Through the Fistula
A clinically significant biliary fistula is a potentially serious complication that is reported in 0.1% to 0.5% of classic cholecystectomies and goes up to 2% in cases of laparoscopic cholecystectomies.
The cystic duct is the most common leak site (78%), followed by an aberrant right hepatic duct of Luschka (13%) and other sites (9%) such as the common hepatic bile duct and the point of insertion of the Kehr tube. High-flow fistulas were traditionally considered for surgical resolution, but there are now several reports of successful endoscopic treatment ( Table 2 ).
| Series | n | Stones (%) | ES | Stent | ES and Stent | NT | Efficacy (%) |
|---|---|---|---|---|---|---|---|
| Kozarek et al | 11 | 18 | 2 | 7 | — | 1 | 82 |
| Foutch et al | 23 | 30 | 4 | 6 | 12 | 1 | 100 |
| Barkum et al | 52 | 22 | 27 | 1 | 27 | 8 | 88 |
| Ryan et al | 50 | 22 | 6 | 13 | 31 | — | 88 |
| Davids et al | 48 | 31 | 20 | — | 25 | 3 | 90 |
| Prat et al | 26 | 31 | 15 | — | 3 | 8 | 70 |
| De Palma et al | 64 | 33 | 25 | 18 | — | 21 | 96.9 |
| Sandha et al | 204 | 20 | 75 | — | — | — | 99 |
Shanda and colleagues defined the low-flow fistula as one that appears only after contrasting the intrahepatic bile duct and the high-flow fistula as one that is recognized before contrasting the intrahepatic bile duct. ERCP is generally used as a diagnostic method in suspected biliary fistula, and endoscopic management should be attempted even in the case of a high-flow fistula.
The most common biliary fistulas originate within the cystic duct, either by failure of the clip, drop of the clip, or thermal injury of the cystic remnant. Injury to the Luschka duct may occur during cholecystectomy because it originates in the common bile duct or right hepatic duct, and ends in the gallbladder bed of the right lobe of the liver.
Instead, the main bile duct fistulas are usually considered as part of a more extensive injury, and the cause is usually a thermal injury.
Time to Diagnosis
If a patient is diagnosed with a bile duct injury in the postoperative period (early or late), the treatment of choice is endoscopic. If the injury is diagnosed intraoperatively, it should be resolved during the same surgical procedure. However, a stent may be used to ensure biliary drainage after a choledochorrhaphy.
Management of the Lesions of the Biliary Tract
As already mentioned, the management of biliary tract injuries will depend on the nature and extent of the injury, the presence or absence of biloma, and time to diagnosis of the injury. Most injuries are recognized in the period after cholecystectomy, and only 25% to 36% are recognized during laparoscopic cholecystectomy.
It is important to make a thorough evaluation of the patient to ensure early recognition of injury and prevent a deterioration that might end in peritonitis, sepsis, or even death.
Successful treatment of these complications requires a multidisciplinary group that includes biliary endoscopists, interventional radiologists, and hepatobiliary surgeons. It is important to refer patients to tertiary centers with experience in the management of these lesions, which has been proved to reduce related morbidity and mortality rates.
To address this issue, according to the Strasberg classification the authors divided the lesions of the bile ducts into those presenting fistulas and those for which the main manifestation is biliary stenosis.
Endoscopic management considerations
Nature and Extent of Injury
The presence of continuity of the bile duct is the most important factor in determining the ability to manage the injury by endoscopy. If there is continuity of the bile duct (lesion types Strasberg A, C, and D), ERCP is considered the primary therapy. On the other hand, the endoscopic management is often not possible in the presence of injuries that completely transect the bile duct, when there are clips on the distal stump and when there is no continuity between the injured segments (injury types Strasberg B or E).
Although the authors have successfully treated complete transection of the bile duct by ERCP, without requiring a simultaneous transhepatic percutaneous access, these cases should be considered anecdotal. Complete transection of the bile duct is a strong indication for surgery. Exclusive use of endoscopic treatment is to be considered only if one can successfully cross the lesion and completely decompress the bile duct using prosthesis.
Aberrant bile ducts usually drain bile from liver segments directly to the gallbladder bed or common bile duct, and rarely to the right or left bile duct. If an inadvertent injury of an aberrant duct occurs during surgery, an ERCP is likely to be required. If the contrast displays an aberrant duct, this means that the latter is connected to the biliary tract, so ERCP would be therapeutic if a sphincterotomy is performed, a biliary stent placed, and/or cyanoacrylate is injected. If the injury is not visible during ERCP, other studies such as scintigraphy or cholangioresonance will be required, and the resolution will likely be surgical resection.
Flow Through the Fistula
A clinically significant biliary fistula is a potentially serious complication that is reported in 0.1% to 0.5% of classic cholecystectomies and goes up to 2% in cases of laparoscopic cholecystectomies.
The cystic duct is the most common leak site (78%), followed by an aberrant right hepatic duct of Luschka (13%) and other sites (9%) such as the common hepatic bile duct and the point of insertion of the Kehr tube. High-flow fistulas were traditionally considered for surgical resolution, but there are now several reports of successful endoscopic treatment ( Table 2 ).
| Series | n | Stones (%) | ES | Stent | ES and Stent | NT | Efficacy (%) |
|---|---|---|---|---|---|---|---|
| Kozarek et al | 11 | 18 | 2 | 7 | — | 1 | 82 |
| Foutch et al | 23 | 30 | 4 | 6 | 12 | 1 | 100 |
| Barkum et al | 52 | 22 | 27 | 1 | 27 | 8 | 88 |
| Ryan et al | 50 | 22 | 6 | 13 | 31 | — | 88 |
| Davids et al | 48 | 31 | 20 | — | 25 | 3 | 90 |
| Prat et al | 26 | 31 | 15 | — | 3 | 8 | 70 |
| De Palma et al | 64 | 33 | 25 | 18 | — | 21 | 96.9 |
| Sandha et al | 204 | 20 | 75 | — | — | — | 99 |
Shanda and colleagues defined the low-flow fistula as one that appears only after contrasting the intrahepatic bile duct and the high-flow fistula as one that is recognized before contrasting the intrahepatic bile duct. ERCP is generally used as a diagnostic method in suspected biliary fistula, and endoscopic management should be attempted even in the case of a high-flow fistula.
The most common biliary fistulas originate within the cystic duct, either by failure of the clip, drop of the clip, or thermal injury of the cystic remnant. Injury to the Luschka duct may occur during cholecystectomy because it originates in the common bile duct or right hepatic duct, and ends in the gallbladder bed of the right lobe of the liver.
Instead, the main bile duct fistulas are usually considered as part of a more extensive injury, and the cause is usually a thermal injury.
Time to Diagnosis
If a patient is diagnosed with a bile duct injury in the postoperative period (early or late), the treatment of choice is endoscopic. If the injury is diagnosed intraoperatively, it should be resolved during the same surgical procedure. However, a stent may be used to ensure biliary drainage after a choledochorrhaphy.
Management of the Lesions of the Biliary Tract
As already mentioned, the management of biliary tract injuries will depend on the nature and extent of the injury, the presence or absence of biloma, and time to diagnosis of the injury. Most injuries are recognized in the period after cholecystectomy, and only 25% to 36% are recognized during laparoscopic cholecystectomy.
It is important to make a thorough evaluation of the patient to ensure early recognition of injury and prevent a deterioration that might end in peritonitis, sepsis, or even death.
Successful treatment of these complications requires a multidisciplinary group that includes biliary endoscopists, interventional radiologists, and hepatobiliary surgeons. It is important to refer patients to tertiary centers with experience in the management of these lesions, which has been proved to reduce related morbidity and mortality rates.
To address this issue, according to the Strasberg classification the authors divided the lesions of the bile ducts into those presenting fistulas and those for which the main manifestation is biliary stenosis.
Related posts:
Therapeutic and Advanced ERCP Is Rapidly Progressing
Endoscopic Retrograde Cholangiopancreatography for Stone Burden in the Bile and Pancreatic Ducts
Sampling at ERCP for Cyto- and Histopathologicical Examination
Endoscopic Retrograde Cholangiopancreatography for Distal Malignant Biliary Stricture
Complications of Endoscopic Retrograde Cholangiopancreatography
Endoscopic Retrograde Cholangiopancreatography
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