- Iatrogenic biliary injuries associated with laparoscopic cholecystectomy (most common), or other foregut operations.
- Operative approach depends on the time the injury is diagnosed (eg, immediately, early [≤ 4 weeks after injury], or late [> 4 weeks after injury]).
- If the patient is hemodynamically stable, immediate biliary reconstruction is indicated when an injury is identified intraoperatively during a laparoscopic cholecystectomy or other operation and a hepatobiliary surgeon is available to perform the repair.
- For patients with early or late injuries, operative management typically requires delayed biliary reconstruction with a biliary-enteric anastomosis.
- The aim of operative intervention is definitive treatment of patients with iatrogenic common bile duct or more proximal biliary injuries after the residual inflammation from the acute injury has resolved.
- If the injury has been thoroughly evaluated and the biliary system has been sufficiently decompressed and drained for 6 weeks or more, reconstruction is required if a biliary stricture persists or if biliary-enteric discontinuity remains.
- Few contraindications exist for biliary decompression. This may be achieved using a percutaneous transhepatic approach or endoscopic retrograde-guided stent placement. Rarely, operative decompression may be required.
Percutaneous Transhepatic Approach
- Hepatic malignancy.
- Hydatid disease.
- Contrast-related anaphylaxis.
Endoscopic Retrograde Approach
- Patients who cannot cooperate with the study.
- Active or recent acute pancreatitis.
- Recent myocardial infarction.
- Severe cardiopulmonary disease.
Biliary Stricture Dilation
- Contraindications depend on approach (transhepatic or endoscopic retrograde), as outlined earlier.
- Incomplete preoperative evaluation.
- Inability to tolerate general anesthesia.
- Surgeon's lack of expertise in performing complex biliary reconstruction.
- Acute cholangitis.
- Early biliary injury without adequate biliary drainage (< 6 weeks).
Biliary Stenting, Drainage, and Dilation
- Treatment of life-threatening cholangitis.
- Treatment of biliary stricture.
- In patients with short strictures (< 2 cm), biliary stenting with successive dilation may successfully resolve the stricture without operative reconstruction.
- Prevention of cholestatic liver injury in situations where cholestasis cannot be definitively relieved within 2–4 weeks.
- In patients with bilirubin > 20 mg/dL, biliary decompression allows recovery of liver function prior to operative therapy.
- Assists in identification of hilar bile ducts at the time of operative biliary reconstruction.
- Biliary sepsis.
- Damage to liver or adjacent structures.
- Failure of drainage.
- Need for periodic stent changes until reconstruction.
- Need for additional interventions or procedures.
- Internal drainage of obstructed bile flow by providing enteric drainage of the biliary tree.
- Correction of biliary strictures results in decreased risk of biliary cirrhosis, cholangitis, intrahepatic gallstones, hepatic abscesses, portal hypertension, and resulting progressive liver ...
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