Chapter 13. Management of Bile Duct Injuries and Biliary Strictures

• 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.

Biliary Decompression

• 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

Absolute

• Active coagulopathy.

Relative

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

Endoscopic Retrograde Approach

Absolute

• Patients who cannot cooperate with the study.

Relative

• 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.

Biliary Reconstruction

Absolute

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

Relative

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

Biliary Stenting, Drainage, and Dilation

Expected Benefits

• 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.

Potential Risks

• 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.

Biliary Reconstruction

Expected Benefits

• Internal drainage of ...