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  • 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.

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Biliary Decompression

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  • 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.

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Percutaneous Transhepatic Approach

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Absolute

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  • Active coagulopathy.

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Relative

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  • Hepatic malignancy.
  • Hydatid disease.
  • Ascites.
  • Contrast-related anaphylaxis.

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Endoscopic Retrograde Approach

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Absolute

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  • Patients who cannot cooperate with the study.

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Relative

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  • Active or recent acute pancreatitis.
  • Recent myocardial infarction.
  • Severe cardiopulmonary disease.

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Biliary Stricture Dilation

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  • Contraindications depend on approach (transhepatic or endoscopic retrograde), as outlined earlier.

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Biliary Reconstruction

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Absolute

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  • Incomplete preoperative evaluation.
  • Inability to tolerate general anesthesia.
  • Surgeon's lack of expertise in performing complex biliary reconstruction.

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Relative

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  • Acute cholangitis.
  • Early biliary injury without adequate biliary drainage (< 6 weeks).

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Biliary Stenting, Drainage, and Dilation

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Expected Benefits

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  • 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.

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Potential Risks

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  • Bleeding.
  • Biliary sepsis.
  • Pancreatitis.
  • Damage to liver or adjacent structures.
  • Failure of drainage.
  • Need for periodic stent changes until reconstruction.
  • Need for additional interventions or procedures.

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Biliary Reconstruction

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Expected Benefits

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  • 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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