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Acute bile duct injury
The need for a high repair
M. A. Mercado, C. Chan, H. Orozco, M. Tielve, C. A. Hinojosa
Department of Surgery, National Institute of Medical Sciences and Nutrition, Salvador Zubira
´
n, Vasco de Quiroga 15, Mexico City 14000, Mexico
Received: 13 February 2003/Accepted: 21 February 2003/Online publication: 19 June 2003
Abstract
Background: An immediate repair is considered optimal
in acute biliary duct injuries; however, it may prove to
be a challenge, because such repairs are usually per-
formed on small ducts whose viability cannot always be
determined.
Methods: We performed a retrospective review of the
charts of patients with acute bile duct injury who un-
derwent repair at a tertiary care academic university
hospital. A total of 204 patients with acute bile duct
injury were seen between 1989 and 2002. Of these, 30
were repaired within minutes to hours after the injury.
These patients were divided into two groups. Group I
patients had a Roux-en-Y hepatojejunostomy below the
hepatic junction; Group II patients had a Roux-en-Y
hepatojejunostomy at the junction level. We then per-
formed a long-term evaluation of anastomosis function
in these patients, using clinical, radiological, and labo-
ratory.
Results: Twenty-eight injuries were secondary to a la-
paroscopy; the other two resulted from open cholecys-
tectomies. All of the patients suffered complex injuries
with complete section of the duct and substance loss
(Strasberg E). There were 12 patients in group I and 18
in group II. Three cases in group I (25%) and one in
group II (5%) developed anastomosis dysfunction.
Mean follow-up was 56 months (range, 12–80) in group
I and 52 months (range, 10–76) in group II. Two cases in
group I (16%) and none in group II (0) required reop-
eration (p < 0.05).
Conclusions: In the acute setting, complex lesions should
be treated with a high bilioenteric anastomosis (at the
junction level) in the first attempt at repair. Lower-level
anastomoses are associated with a higher dysfunction
rate and the need for radiological manipulation and
reoperation. Also, stenosis of the anastomosis secondary
to undetected duct ischemia in the acute repair is more
frequent in low bilioenteric anastomoses.
Key words:
Bile duct injury — Cholecystectomy com-
plications — Roux-en-Y hepatojejunostomy — Bilio-
enteric anastomosis — Iatrogenic injuries
Biliary injury is a demanding challenge for patient and
surgeon alike. It is a complex condition induced by the
surgeon in an otherwise healthy (and usually young)
patient that is associated with significant morbidity
and—although the mortality rule is low—can cause
death in the long term. It is generally accepted that the
incidence of injuries has increased because of the wide-
spread use—and probable overuse—of laparoscopic
cholecystectomy; the incidence of known injury now
ranges from 0.3% to 0.6% in most hospitals worldwide
[1]. Several causal factors have been implicated in the
occurrence of such lesions [12], but it is very difficult to
prevent them completely. They continue to occur even
after the learning curve has been surpassed and even at
the hands of the most experienced surgeons. Strasberg et
al. have developed a classification that describes the
entire spectrum of lesions produced by laparoscopy [13]
and includes all the possibilities that may be observed.
Within the Strasberg classification, type A refers to ex-
ternal biliary fistula, type B to the section of accessory
ducts, type C to leakage secondary to injury of the ac-
cessory ducts, type D to lateral lesion of the duct, and
type E (and subtypes) complete lesion of the duct at
different levels.
Most lesions are recognized in the early postopera-
tive period (torpid postoperative evolution with ileus,
biliary ascites, and/or jaundice). Less frequently
(<50%), the injuries are recognized intraoperatively. In
the remaining cases, the lesions are detected in the late
postoperative period; patients present mainly with
symptoms of cholangitis and biliary obstruction [2].
Early repair is considered optimal, and a better
outcome for the patient can to be expected when the
injury is recognized intraoperatively. Immediate con-
Correspondence to: M. A. Mercado
Original articles
Surg Endosc (2003) 17: 1351–1355
DOI: 10.1007/s00464-002-8705-1
Ó Springer-Verlag New York Inc. 2003
version to an open procedure is indicated after detection
of the injury and repair according to its type. Most
surgeons would agree that a biliodigestive (Roux-en-Y
hepatojejunostomy) is the treatment of choice for com-
plex injuries that include complete duct section and loss
of substance (Strasberg E) [7].
Other options, such as duct-to-duct or hepatoduo-
denum anastomosis, have not had good long-term re-
sults. The repair should be performed only if the
surgeon feels confident; otherwise, a surgeon with ample
experience in biliary tract surgery should be called in. If
an expert is not available, the patient should be referred
to a tertiary care center for the repair.
Herein we review our experience with biliary-in-
jured patients who were reconstructed in an acute set-
ting (within minutes to hours after the injury). We
compare two groups of patients: those with a high
bilioenteric anastomosis vs those with a low bilioenteric
anastomosis.
Patients and methods
Between April 1989 and April 2002, 204 patients were referred to our
surgical team for biliary tract reconstruction after bile duct injury. A
total of 30 cases were operated on in an acute setting, which was
defined as an operation performed minutes to hours (<24 h) after the
injury. Six cases were repaired during the same operation in which the
injury occurred, and 22 cases were referred from other hospitals within
hours of the injury. Patients were operated on after stabilization.
The charts of these patients were analyzed, and they were divided
into the following two groups: group I, patients with Roux-en-Y he-
patojejunostomy with a low anastomosis (below the hepatic junction),
and group II, patients with Roux-en-Y hepatojejunostomy with a high
anastomosis (at the level of the hepatic junction). All patients had
complex injuries with complete section of the duct and substance loss
(Strasberg E).
Anastomosis dysfunction was diagnosed when the patients
showed clinical or laboratory evidence of obstruction: obstructive
jaundice, cholangitis, and/or abnormalities of liver function tests (in-
creased bilirubin and alkaline phosphatase). Percutaneous cholangi-
ography was initially performed in these cases to evaluate the patients’
anastomosis status, after which they were reoperated.
Groups were compared using Fisher’s exact test.
Results
General data for the 30 cases are shown in Table 1.
Twenty-eight injuries resulted from a laparoscopy, six
were created after conversion to an open procedure
(according to the referring surgeon’s report), and two
were secondary to an open procedure. All of the patients
had complex injuries at different levels with complete
duct section.
There were 12 patients in group I and 18 in group II.
All cases were repaired by our team. Six were repaired
during the operation in which the injury occurred.
Twenty-four were referred from other hospitals; a
drainage system had been placed in the subhepatic area
in 17 patients, and seven arrived packed with gauze in
the upper abdominal quadrant. Electrolyte abnormali-
ties were corrected after arrival.
All of the patients had varying amounts of free bile
(200–2000 ml) disseminated in the peritoneal cavity. The
hepatic hilus was explored after profuse peritoneal la-
vage. Careful dissection under magnification was carried
out, preserving the small arterial branches as much as
possible. The duct had a bile leak in all but two cases,
where partially occluding clips were identified. Packed
patients also had vascular injuries and/or bleeding at
different levels—three from the gallbladder bed and at
the level of Calot’s triangle, two with small injuries to
the right portal vein, and one in the left portal vein. This
last case required a concomitant left hepatectomy; the
others underwent primary repair of the vessels using
standard vascular techniques.
After we had identified the ligament of Treitz, a 40–
50-cm Roux-en-Y loop was constructed, and the anas-
tomosis was performed under magnification using sep-
arate 5-0 polyglycolic acid stitches. A transhepatic stent
was used in all cases. The anastomosis level depended on
finding a healthy duct, as determined by the operating
surgeon and team. In cases with a high repair, the an-
astomosis was done at the junction level (Fig. 1). The
confluence of the ducts was identified intraluminally,
and a longitudinal anterior section of the left hepatic
duct was performed. Cases treated with a low repair
were those in which a longitudinal anterior section of
the common hepatic duct was performed without
reaching the duct confluence. Subhepatic and suprahe-
patic drains were placed and extracted through separate
incisions. There were no operative deaths.
Three cases developed small supra- and infrahepatic
collections that required CT-guided percutaneous
drainage. Patients were discharged when their general
condition improved and oral intake with intestinal
transit was demonstrated.
Mean hospital stay was 7.3 days (range, 5–16). In the
2nd postoperative week, a cholangiography was ob-
tained, and the transhepatic stents were closed if ade-
quate bile passage and no leaks were seen. Patients were
instructed to flush the stents two to three times a week.
Stents were removed between the 5
th
and 7
th
postoper-
ative months, based on cholangiographic findings. Ra-
diological intervention was carried out if there was
evidence of stenosis and/or obstruction with or without
lithiasis. The cases that failed to dilate after radiological
manipulation were reoperated, and a new hepatojeju-
Table 1. Patient data
Group I Group II p value
No. of patients 12 18
Mean age (yr) 34 32
Lesion
Laparoscopic 11 17
Open 1 1
Type
Strasberg E-2 12 11
Strasberg E-3 0 7
Roux-en-Y hepatojejunostomy 12 18
Transhepatic stent 12 18
Postoperative adominal collection 1 2 NS
Lost to follow-up 1 2 NS
Radiological instrumentation 3 1 NS
Anastomotic stenosis 3 0 p < 0.05
Reoperation 2 0 p < 0.05
Good long-term results 11 16 NS
NS, not significant
1352
nostomy was performed. Three patients (25%) in group
I needed radiological instrumentation; the technique
was unsuccessful in two cases, which were reoperated
(Fig. 2). In the high repair group, only one patient
needed radiological instrumentation. There was evi-
dence only of bile sludge; no stenosis was seen at the
anastomosis level.
All but three patients were available for follow-up.
These three were lost after the 1st postoperative year
(one in group I, two in goup II). Mean follow-up was 56
months (range, 12–80) for group I and 52 months
(range, 10–76) for group II. The lost patients were
asymptomatic at the time of their last visit after removal
of the transhepatic stent.
All dysfunctions were detected in the 1st postoper-
ative year, early after removal of the stent (between the
6
th
and 12
th
postoperative months). Eleven patients
(89%) in group I are currently doing well; all 11 have
achieved complete clinical rehabilitation, including the
two reoperated patients. One patient has persistently
elevated alkaline phosphatase but no other symptoms.
In group II, 16 patients (87%) were available for follow-
up, and all have had good long-term results.
Significant differences were found when reoperations
and anastomosis stenoses were compared; both com-
parisons favored the group with a high repair, where
there were no reoperations and no anastomotic dys-
function.
Discussion
There is no doubt that the increase in indications for
cholecystectomy and the introduction of the laparo-
scopic approach are directly responsible for the dra-
matic growth in the number of biliary duct lesions. The
data presented in this report show a higher failure rate
for patients in whom a repair was done at the level of the
common hepatic duct and a better outcome for patients
in whom the reconstruction was done at the level of the
biliary junction, where better-quality ducts can be
found. Anastomotic dysfunction occurred early in the
postoperative period (within the 1st postoperative year).
Due to the nature of their mechanisms, laparoscopic
injuries have unique features that produce a wide spec-
trum of lesions, ranging from small orifices and bile duct
leaks (main and accessories) to complete ablation of the
duct. Strasberg’s classification describes a spectrum of
lesions produced by laparoscopy [13], in which all the
possibilities that might be observed are included.
In some cases, there are concomitant complex vas-
cular injuries [15]. Dissection of the misidentified main
duct under scope magnification enables the ligature to
be done with clips and/or the electrocoagulation of small
branches of the hepatic artery, which are important for
duct viability. Biliary leaks produced in the presence of
duct continuity (Strasberg A) can be resolved by means
of an endoscopic and/or a radiological approach. There
are several ways to resolve injured ducts that drain
isolated segments that are not in continuity with the
main duct, including drainage with late spontaneous
occlusion (with late atrophy of the drained segments);
surgical occlusion, if the duct is very small; or a bilio-
digestive anastomosis, if the duct has a diameter of >2–
3 mm [11]. Liver resection is seldom necessary; it is
needed only in patients with refractory cholangitis and/
or persistent fistula. For Strasberg E lesions, surgical
reconstruction is the only option and is mandatory.
Surgeons called on to repair these lesions may be
confronted with several scenarios:
1. Acute setting (minutes to hours after the injury)
2. Late acute setting (days after the injury)
3. Late setting (weeks after the injury). These cases are
characterized by external biliary fistulas or biliary
obstruction, with or without cholangitis. Many of
Fig. 1. Patent bilioenteric anastomosis done at the junction level.
Fig. 2. Late stenosis at the level of the hepatic common duct. Failed
radiological instrumentation led to the need for reoperation.
1353
them cases have undergone previous attempts at re-
pair. Most reported series of iatrogenic injuries in-
volve this type of patient.
In the acute setting, patients are generally in good
status and/or can be rapidly corrected. Most of the
severed ducts can be identified. The flow of bile can be
seen through the hilar components, without inflamma-
tory reaction. Clips or sutures occluding the branches of
the hepatic artery or the right hepatic artery can usually
be identified. After the duct is identified, instrumenta-
tion of the duct with dilators is done to identify the right
and left ducts. When the duct is completely severed, it is
difficult to obtain a cholangiogram, so the ducts have to
be identified via careful instrumentation.
Reconstruction should always be attempted. We do
not support a policy of waiting for spontaneous occlu-
sion of the duct and dilation after an external fistula [4].
In our experience, bile produces an inflammatory reac-
tion, leading to localized and generalized peritonitis with
systemic repercussions for the patient. Adequate drain-
age of the cavity can diminish, but not always preclude,
this situation.
Bile duct ligation can produce hepatic dysfunction, as
well as cholangitis. For this reason, we do not recommend
ligating the duct and waiting for dilation if, as in most
cases, the repair can be completed. An acutely ligated duct
is not comparable to malignant obstruction of the duct
(intrinsic or extrinsic), in which a slow increase of bile
pressure produces dilation of the duct without acute
consequences. This is why immediate attempt of repair is
always recommended, except in cases where the patient is
in a poor general state with hydroelectrolitic abnormali-
ties and/or septic conditions. Percutaneous drainage and/
or limited surgical drainage is the treatment of choice for
these cases. In some cases, surgery must be deferred for
weeks until the inflammatory reaction diminishes [8].
We favor the reconstruction of complex cases
(Strasberg E) with a Roux-en-Y hepatojejunostomy.
Loss of substance and ischemic compromise of the duct
are the rule in these lesions, making an end-to-end (duct-
to-duct) anastomosis risky, because tension generated at
the anastomosis level subsequently produces leakage,
ischemia, and stenosis.
In patients who were operated on for a late repair, the
stricture was one level higher than the level of the original
injury, as described by Bismuth and Manjo [4]. This was
probably due to a late ischemic event. In the acute set-
ting, the evaluation of the duct can be deceptive because
the relatively fresh end is seen with a minimal inflam-
matory reaction, making it difficult to assess the stump’s
circulatory status. The surgeon tends to preserve a duct
as long as possible; and in some instances, an ischemic
stump that is preserved will produce a stricture in the late
postoperative period. A late biliary fistula (4
th
to 10
th
postoperative day) can also result from an ischemic duct
rather than a technically deficient anastomosis.
In Strasberg E injuries, by definition, ablation of the
duct deprives it from the arterial circulation provided by
the gastroduodenal and pancreaticoduodenal arteries.
In these lesions, blood to the duct is totally dependent
on the hepatic artery, a situation that closely resembles
that of liver transplantation, in which patency and
preservation of the hepatic artery and their branches are
critical for the viability of the duct [16].
Thus, we routinely favor a high dissection of the duct,
at the level of the junction where no inflammatory reaction
is found and no evidence of the first surgery can be seen.
This technique also results in adequate microcirculatory
status of the ducts, assuring the successful results of a
carefully executed anastomosis. When performing this
dissection, it is advisable to prevent damage to the arterial
branches close to the ducts so as to avoid circulatory
compromise. Circulation can be preserved if only the an-
terior aspect of the ducts is dissected at the junction level.
In some instances, partial liver resection of segments
IV and V [9, 14] can be done. This maneuver allows
identification and exposure of the anterior aspect of the
ducts. In the acute setting, it is usually not possible to find
a dilated duct. On the contrary, in most—if not all—cases,
small-diameter ducts are found. Thus, the repairing sur-
geon has two options: a terminolateral anastomosis of the
duct at the level at which he or she believes a healthy duct
is found, and second, a longitudinal incision of the ante-
rior aspect so as to obtain a wider anastomosis (Hepp-
Couinaud) [5]. Even with the latter approach, the devel-
opment of a late stenosis due to ischemia is possible if the
circulatory status of the duct is altered.
Koffron et al. studied vascular biliar injury in patients
with a failed primary surgery of the injured duct. In an
angiographic study of 18 patients with failure of recon-
struction, vascular injury was seen in 61%. A high injury
increased the probability of finding concomitant arterial
damage. They also concluded that arterial disruption
might affect the outcome of the first repair attempt [6].
Bachellier et al. advocate the reconstruction of sev-
ered arteries, in an attempt to reestablish the arterial
flow to the hepatic lobe [3]. This reconstruction proba-
bly does not reestablish duct circulation, although cir-
culation to the hepatic lobe can be restored. The use of a
stent is advisable for these high, small-duct anastomoses
[10]. Although the anastomosis is performed on a heal-
thy duct, it usually has a small diameter. The mainte-
nance of low bile pressure in the ducts is advisable to
prevent leakage and subsequent fistula with a perianas-
tomotic inflammatory reaction that can produce ische-
mia and late scarring.
We recommend that all complex injuries (Strasberg
E) in the acute setting be treated from the beginning
with a high bilioenteric (junction level) anastomosis.
Arguably, the failure of a high repair can be disastrous,
because there is no further chance to perform another
anastomosis. In our experience, however, a carefully
performed anastomosis with healthy ducts has a low
probability of failure.
We began to treat these lesions with a high repair
because we had the impression that a low reconstruction
was associated with a higher rate of stenosis. In this
retrospective comparative study, better results were
achieved in patients in whom the lesion had been treated
with a high repair, although the long-term results for the
two groups were comparable. We consider that it is
virtually impossible to conduct a prospective controlled
randomized study comparing high with low repairs be-
1354
cause of the shortage of cases (30 cases in 10 years) and
the almost individual anatomical and functional nature
of each lesion.
Although we are in no way against a low repair, we
believe that a higher repair has a more favorable out-
come with a lower probability of reoperation. We are
certain that if an adequate duct is found (one with no
ischemia and no inflammatory process), a good result
can be obtained even with a low repair. However, in the
acute setting, the status of the duct is difficult to evalu-
ate; thus, a high repair is a better choice.
Our proposal of a high repair de principe is intended
for acute lesions in which the common duct diameter is
normal or even smaller than normal (which is almost the
rule in injured ducts). It is not recommended for a di-
lated duct, found in some cases of elective repairs. Di-
lated ducts are easily anastomosed; although scarring
occurs, the final diameter of the anastomosis is sufficient
for long-term patency. Patients with dilated ducts are
usually not referred to tertiary care centers because they
can be treated in most large hospitals and specific ex-
perience in bile duct injury repairs is not necessarily
required.
A high repair is recommended for acute cases with
normal or subnormal diameter in which the circulatory
status of the duct cannot be assessed because of the fresh
nature of the injury. The high repair generally requires
greater surgical expertise and experience in dissection of
the liver hilus, making it a technically more challenging
operation. The decision to perform a lower anastomosis
is perhaps easier, but the higher probability of failure
should be weighed carefully against the difficulty of the
high anastomosis and its greater likelihood of success.
Acknowledgments. We thank Dr. Carla Archer-Dubon for reviewing
the manuscript.
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