Bile duct injury is common. Management is complicated. Mismanagement leads to life long disability.

1. Bile duct injury and Post
Cholecystectomy biliary stricture
Dr. Md. Arifuzzaman Shehab
Resident.
Department of Hepatobiliary Pancreatic and Liver Transplant Surgery
Bangabandhu Sheikh Mujib Medical University,
Dhaka, Bangladesh

2. 2
INTRODUCTION
In the era of laparoscopy, the
incidence of bile duct injury is more.
It is a devastating condition both
surgeons and patients. The effect of
bile duct injury both on surgeon and
patient is tremendous both
physically and mentally.
INTRODUCTION

4. A Post operative biliary
stricture is defined as an abnormal
narrowing of the bile duct
that may lead to obstruction and / or
fistula due to any surgical procedures
Definition

5. 6
INCIDENCE
0.6% 0.4% 0.6% .42%
National survey
of 77,604 cases
in US1
A population
Based Study of
152,776 in
Sweden2
an audit of 5913
cases in West of
Scotland3
National survey
on 56,591 cases
in
Italy4
?
World Wide
1. Deziel ,Milliken,et al Am J Surg January 1993. 2. Anne Waage MD,Magnus Nilson MD.,Arch Surg.2006. 3. MC Richardson,G Bell,Mr. G. M.
Fullarton, BMJ. 4. Gennaro Nuzzo,MD;Felice Giueliante, MD et al,Arch Surg.2005

6. In BSMMU
July 2015 to June 2016 (12 months)
Total patients : 33 (1.5 patients/mon)
Male: Female : 12:21 (4:7)
Age (yrs) : 39±13 (18-62)
Average -2 to 3 per month
Incidenced placed in
Upa-zila private clinic : 08 (24.2%)
District private clinic : 22 (66.6%)
Medical College Hospital : 03 (9.2%)

7. Incidence
Overall incidence of 1.1 -4%1.
1. Kim KH, Kim TN: Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years, Clin
Endosc47(3):248–253, 2014

8. Patient Factor
Acute or chronic
inflammation.
Empyema
Fibrosed and
contracted GB
Anomaly of the BT
Excessive Bleeding
Previous surgery
Obese patient
Accident
8
CAUSES OF BILE DUCT
INJURY
Surgeon Factor
Over-Confident Surgeon
Fatigue
Inexperience Surgeon
Instrument
Factor
Improper Light
Lacking of appropriate
instrument
Improper Instrument

9. Etiopathological Classification
Classification of Causes of Laparoscopic Biliary Injuries
1. Misidentification of the bile ducts as the cystic duct.
2. Misidentification of the common bile duct as the cystic duct.
3. Misidentification of an aberrant right sectoral hepatic duct as the cystic duct.
4. Technical causes.
5. Improper techniques of ductal exploration.
6. Failure to occlude the cystic duct securely.
7. Plane of dissection away from gallbladder wall into the liver bed.
8. Excessive traction on cystic duct with tenting upward of common hepatic duct.
9. Injudicious use of electrocautery for dissection or bleeding control.
10.Injudicious use of clips to control bleeding.

10. Delay leakage
• Usually a result of thermal
or vascular injury during
dissection.
• Suture failure due to high
biliary pressure secondary to
retained choledocholithiasis.
Early Leakage
• Inaccurate cystic duct closure
or clip displacement.
• Leakage of Luschka duct
(direct communication from
the gallbladder to the right
hepatic ductal system
through the gallbladder bed)
• Partial or complete
transection of BT
1
0
CAUSES OF EARLY &
DELAYED BILE LEAK

11. Strasberg’s classification
• It is a modification of the Bismuth classification.
• But allows differentiation between small biliary channel (bile leakage from
the cystic duct or aberrant right sectoral branch).
• serious injuries performed during laparoscopic cholecystectomy.
Based on
• acute injuries
• bile leak,
• lateral injuries,
• and transection.
• The transection subgroup (type E) incorporates the Bismuth’s classification.
• Limitation
• it does not describe additional vascular involvement at all.

12. A
B
C
D
Bile leak from cystic duct stump or a minor biliary
radical in gallbladder fossa.
Occluded right posterior sectoral duct.
Bile leak from divided right posterior sectoral duct..
Bile leak from main bile duct without major tissue loss

13. Bismuth classification
• First classification of bile duct injury is reported by H. Bismuth in
1982.
• Based on the location of the injury in the biliary tract.
• Established biliary stricture.
• Important determinant of outcome.
Limitation of this classification
• does not include the wide spectrum of possible biliary injuries.

14. Bismuth classification
E1: Transected main bile duct with a stricture
more than 2 cm from the hilus. E2: <2 cm from
the hilus
E1 & E2
E6: Complete excision of the extrahepatic
ducts involving the confluence
E6
E5: Stricture of the main bile duct and the
right posterior sectoral duct.
E5
E3: Stricture of the hilus with right and
left ducts in communication.
E3
E4: Stricture of the hilus with separation
of right and left hepatic ducts.
E4

16. Classification of
bile duct injury
McMahon Classification of bile duct Injury
• These classification based on the width of bile duct injury.
• McMahon classification,
• Minor Injury
• lacerations < 25% of the common bile duct (CBD) diameter or
• Cystic-CBD junction
• Major Injury
• transection or laceration > 25% of CBD diameter.
• postoperative bile duct stricture.

17. Stewart-Way classification system
Partial CBD Injury
Class I
Lateral Injury to
CHD
Class II
Excision of CBD/
CHD
Class III
Isolated injury to
RHD
Class IV

18. Stewart-Way classification system
Injury occurs when
CBD is mistaken for the
cystic duct, but the
error is recognized
before CBD is divided.
Class I
Partial CBD Injury
7 %

19. Stewart-Way classification system
Injuries involve damage to CHD from
clips or cautery used too close to the
duct. This often occurs in cases where
visibility is limited due to inflammation or
bleeding.
Class II
Lateral injury to CHD
22%

20. Stewart-Way classification system
The most common type, occurs when
CBD is mistaken for the cystic duct.
The common duct is transected and a
variable portion including the junction of
the cystic and common duct is excised
or removed.
Class III injury
Excision of CBD/CHD
61 %

21. Stewart-Way classification system
injuries involve damage to the
right hepatic duct (RHD), either
because this structure is mistaken
for the cystic duct, or because
it is injured during dissection.
Class IV
Isolated injury to RHD
10%

22. Early Recognition of bile duct injury
Sign
Mild abdominal
discomfort/ tenderness.
If drain tube - contained
bile
Present within 48-72 hours
from surgery.
Biochemical Investigation
Imaging
USG of WA
CT Scan of WA
MRCP
ERCP
Symptoms
Abdominal pain,
Nausea,
Anorexia,
Fatigue
10-20%
patients are
diagnosed in
early period

23. Advantage of Early Repair
Sahajpal AK, Chow SC, Dixon E, Greig PD, Gallinger S, Wei AC. Bile duct injuries associatedwith laparoscopic cholecystectomy: timing of repair and long-term outcomes. Arch Surg.2010;145:757–63.
Inflammation is low
Within 72 hoursContents
↓chance of septic
complication and other
new complication. Contents
Successful long-term
resultsContents
Minimize the
morbidity. Contents
Of bile duct injury

24. Clinical
Presentation
• Excessive, abnormal biliary
drainage from a drain site or
wound,
• localized or generalized peritonitis.
• Sub-hepatic or sub-phrenic abscess.
• Features of cholangitis.
• Septicemia.

25. Fever
Jaundice
Abdominal
Tenderness,
distention,
Bile comes from
wound or drain
tube.
2
5
PHYSICAL
EXAMINATION

26. Investigation
CBC –
Hb- May be Reduced
Leukocytosis.
LFT
Liver function tests usually show evidence of cholestasis.
The serum bilirubin may fluctuate; it may occasionally even be normal.
bile leakage, the bilirubin may be normal or minimally elevated because of absorption from
the peritoneal cavity.
Serum alkaline phosphatase is usually elevated.
Serum transaminase levels may be normal or minimally.
serum albumin level – lower – Advanced Stage
Prothombine Time- Prolonged – Advantaged stage
USG of Abdomen
Localized collection of bile.
Late case – dilatation of the bile duct.
Vascular injury

27. 2
7
ERC
1. Contrast is noted to
extravagate from the blind
end at the site of
transection
2. ERCP with contrast
extravasation. Note
several surgical clips
adjacent to the injury.
3. CBD transection 
normal-sized distal CBD
upto site of transection

28. Imaging
a) CT shows fluid around the liver
after laparoscopic cholecystectomy.
b) HIDA scan performed after CT
clearly demonstrates that the fluid is
due to bile leak
c) MRCP image showing filling defect
(arrow) in CBD suggestive of
choledocholithiasis and thin rim of
perihepatic fluid (dashed arrows)
due to leakage from the cystic duct
stump (Type A injury)
d) MRCP image showing Type E1
ductal injury 2 cm beyond the
confluence with collection/biloma
(arrow)

29. Bile
leak
Delayed diagnosisImmediate intra operative
diagnosis
Minor Injury Major injury
Repair over
T-tube
No experienced
hepato-Biliary surgeon
Clip open duct
Drain
IV antibiotics
Experienced
hepatobiliary
surgeon available
Call second surgeon
Roux-en-Y hepatico-
jejunostomy
Drainage
Low -output High-output
Observe
Resolve < 5-7 daysContinued
ERCP
Transfer to tertiary
centre
Duct of Luschka
Cystic duct stumpleak
Sphinctrectomy
Stent± sphincterectomy
Suspected CHD
injury
PTC to deliniate anatomy
Control drainage
Repair by experienced
hepatobiliary surgeon
Plan of management of Bile Leak

30. Immediate repair of Per-operative bile duct injury
• Initial repair of bile duct can reduce
post operative stricture formation.
• In minor duct injury - ligation of the
duct.
• If the injured duct is > 4 mm -requires
operative repair.
• If the injured segment of the bile duct
is short (less than 1 cm)
- end-to-end anastomosis can be
performed.

31. • End-to-end repair, however, should be
avoided if the ductal injury is near the
hepatic duct bifurcation.
• For proximal injuries or if the injured
segment of bile duct is greater than 1
cm in length, Roux en Y
hepaticojejunostomy
Immediate repair of Per-operative bile duct injury Continue

32. Initial management
Of early biliary Leak
After proper evaluation
Resuscitate the patient with
Adequate fluid
Broad Spectrum antibiotic.
Intra-abdominal collection drainage
Percutaneously - USG or CT guided
Sealed the biliary leakage
Endoscopically
Percutaneously
Laparotomy
Surgically Toileting of the abdominal cavity.
Establishment a drain tube.
No definite repair at this time.

33. Strasburg classification
TypeA
Type B & C
Potentialy serious injuries
More common since
introduction of LC
No reconstruction
Treated
endoscopicaly
Type B
Silent
Asymptomatic atrophy
of involved liver
Hepatectomy of
atrophied segment.
Pain or cholangitis
many yrs. after
injury
Type C
Biliary fistula
Uncontrolled
fisturla
Converted to
controlled fistula
Persistence
Type D
25% - 50% or
 Caused by diathermy or
Small bile duct
Type E (>50%)
<25
%
Repaired primarily
Over T-tube
Reconstruction by
hepaticojejunostomy
B,C and E1 to E5 are
major
biliary injuries
Reconstruction

34. Endoscopic Management of post operative bile leak
• Depressurize the biliary tree by lowering the pressure gradient
between the bile ducts and the duodenum at the level of the
sphincter of Oddi.
• Establisehment of bilioenteric bile flow to duodenum.
• Maintain the patency of bile duct as well as the sphincter of Oddi.
Principle

35. Main Goal
Depressurize the
biliary tree by lowering
the pressure gradient
between the bile ducts
and the duodenum at
the level of the
sphincter of Oddi.
How It Achieved
Biliary sphincterotomy
Placement of a
nasobiliary drain
Placement of a plastic
stent
Goal of Endoscopic Management In Bile leak

36. For Successful Endoscopic management
A lot of patience Skills
Good Quality of
fluoroscopic
imaging
should be gentle
To
avoid
false
routes

37. Disadvantage0
02
01
04
Hospital stay or follow up
more
Patient discomfort
damage to the
papilla is
minimal
Nasobiliary Drainage
01
Single setting
Endoscopic
procedure
Follow up
cholangiogram
done easily
Healing of the
leak Faster -7-14
days
Advantage
03 04
02

38. Less.
7-14 days
2-11 days
1.0+/-0 .
Nasobiliary
Drain
More
2-3 days
14-53 days
2-3 times
Endoscopic
Stent
number of ERCPs required
Patient Compliance
Stay of the hospital
Closure of the leak
Comparison of Nasobiliary Drain and endoscopic Stent
Pinkas H1, Brady PG. Biliary leaks after laparoscopic cholecystectomy : time to stent or time to drain. Hepatobiliary Pancreat Dis Int. 2008 Dec;7(6):628-32.

39. Made by poly-dioxanone which is similar as PDS
suture
Self-expanding Stent
Biodegraded within 3-6 months
Biocompatibility of biliary BDBS is reportedly good
Overall cost effective
Biodegradable Stent
No need of stent remove endoscopically
Biliary drainage is good

40. Biliary drainage better, Hospital stay is less and overall cost is less in biodegradable stent than
plastic or metallic stent.
More Advantage is Re-endoscopy can be avoided in biodegradable Stent.
Clinical outcome Between Biodegradable and
Plastic Stent in Bile Leak

41. Post cholecystectomy
Biliary stricture

42. Operative Causes of bile duct strictures
1. Cholecystectomy or common bile duct exploration – 90-95%.
2. Biliary-enteric anastomosis
3. Hepatic resection
4. Portocaval shunt
5. Pancreatic surgery
6. Gastrectomy
7. Liver transplantation
8. Biliary anastomoses.(excessive skeletonization of the duct in preparation for the anastomosis )

43. Other causes
• Strictures after blunt or penetrating trauma.
• Strictures after endoscopic or percutaneous biliary intubation.

44. Etiopathological causes of stricture
• Attempts to flush ligation the cystic duct
causes CBD injury and stricture formation.
• Ischemia of the bile duct due to
Unnecessary dissection around the bile duct
During bile duct anastomosis.
Injure the major arteries of the bile duct that
run in the 3- and 9-O’clock positions.
Excessive cephalad retraction of the GB
fundus
• Intense connective tissue response with
fibrosis and scarring

45. Mode of Presentation bile duct stricture
• H/O leakage of bile from the injured bile duct. - from
operatively placed drains or through the wound .
• H/O biliary ascites or bile peritonitis. – If drain is not
kept is situ.
• progressive elevation of LFT,
particularly total bilirubin and
alkaline phosphatase levels.
• Repeated cholangitis.
• Painless jaundice and no evidence of sepsis.
• Biliary cirrhosis and its complications.

46. Percentage of patients developing symptoms

47. Complication of bile duct stricture
• Cholangitis.
• biliary cirrhosis.
• Portal hypertension.
• Malignant transformation.

48. Management of bile duct Stricture
1.Endoscopic balloon dilatation and stenting
2.Percutaneous balloon dilatation and stenting
3.Surgery

49. Goal Of The Operative Management
Tension-free
anastomosis
between
healthy tissues
Establishment of
bile flow
To prevent
 cholangitis,
 sludge or stone
formation,
 re-stricture and
 biliary cirrhosis.

50. Elective repair of established strictures
• The choice of procedure is dictated by
• The location of the stricture,
• A history of previous unsuccessful attempts at repair,
• The surgeon’s personal preference.

51. Option of Surgical management
• End-to-end repair,
• Roux-en-Y hepaticojejunostomy,
• Roux-en-Y choledochojejunostomy,
• Choledocho- duodenostomy.
• Hepatectomy

52. End to end Anastomosis
• rarely be accomplished
• invariable loss of duct length as a result
of fibrosis associated with the injury.
Choledochoduodenostomy
• adequate length of bile duct for creating
a tension-free anastomosis to the
duodenum cannot usually be obtained.

53. Hepaticojejunostomy
• Porta hepatis is dissected,
• The bile duct is then divided at the
lowest extent of the stricture and
dissected proximally.
• Excessive dissection should be avoided
to prevent vascular compromise.
• The distal duct is then oversewn.
• Portion of the Roux-en-Y jejunal limb
used for the biliary anastomosis.

54. Results of surgical management of bile duct
strictures.

55. Post operative complication
• Post-operative morbidity approaches 10-20%.
• post-operative complications, such as
• haemorrhage,
• cardiopulmonary problems,
• urinary tract infection and
• wound infection.
• anastomotic leaks at the site of the biliary-enteric anastomosis,
• cholangitis

56. NON-OPERATIVE MANAGEMENT
• Percutaneous balloon dilatation
• Endoscopic dilatation

57. Percutaneous balloon dilatation
• Access to the proximal biliary tree is
gained.
• The stricture is transversed with a
guide- wire under fluoroscopic
guidance.
• At this point, dilatation of the stricture
is performed using angioplasty-type
balloon catheters,
• Chosen on the basis of the location of
the stricture and the diameter of the
normal duct.
• After the procedure, a transhepatic
stent is left in place across the
stricture to allow access to the biliary
tree for follow-up cholangiography,

58. Results of transhepatic balloon dilatation of
bile duct strictures.

59. Complication of balloon dilation
• Cholangitis,
• haemobilia and
• bile leaks
• Sepsis
• Vascular injury
• High recurrence rate.

60. Endoscopic
management of
stricture
• Endoscopic therapy consists of balloon dilation followed
by placement of plastic biliary stents.
• It is now accepted that, placement of multiple side-by-side
large-bore plastic stents over the course of several
endoscopic sessions.
• Stents remaining in place for up to one year.
• The use of a large-diameter (10-mm) covered SEMS may be
an alternative to multiple plastic stents.
• The SEMS leads to dilation of the stricture over time and
is removed after 3 to 6 months.
• Results using this approach have been encouraging,
although the SEMS is not yet approved for use in benign
diseases.
• Endoscopic treatment with stents of major bile duct injuries
and strictures is at least effective.

61. Endoscopic
management of
stricture
• The advantages of endoscopic treatment are its
• simplicity,
• reversibility, and
• minimal invasiveness.
• Endoscopic treatment with stents of major bile duct injuries and strictures is
at least as effective as surgical treatment.
• It is less responsive of strictures located at the hepatic ductal confluence.
• Success rate at bismuth type I & II is 80% but type III is 25%.1
1. Draganov P, Hoffman B, Marsh W, Cotton P, Cunningham J. Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple
stents. Gastrointest Endosc2002; 55: 680-686

62. Endoscopy Vs Surgery
Recurrence of
stenosis
Recurrence of
stenosis
Procedure-
related
complications
Procedure-
related
complications
Successful drainageSuccessful drainage
Surgically
managed
Overall Success -
73%
Death
6
00
%
01
100%
02
23%
03
5%
01
72%
02
31%
03
8-
10%
Endoscopically
managed
Overall Success –
54%
G.D. De Palma et al / The American Journal of Surgery 185 (2003) 532–535

63. Prevention
 30 laparoscope, high quality imaging equipment.
 Firm cephalic traction on fundus & lateral traction on
infundibulum, so cystic duct perpendicular to CBD.
 Dissect infundibulo-cystic junction very carefully.
 Expose “Critical view of safety” before dividing cystic duct
 Convert to open, if unable to mobilise inf bleeding or
inflammation in Calot’s triangle
 Routine intra-op cholangiogram.
 Intraoperative laparoscopic ultrasound.
Mastery of Surgery 6th ed.

64. Critical View of
Safety (CVS)
• Three criteria are required to achieve
the CVS:
– The hepatocystic triangle is
cleared of fat and fibrous
tissue. .
– The lower one third of the
gallbladder is separated from
the liver to expose the cystic
plate.
– Two and only two structures
should be seen entering the
gallbladder.
• CVS is good practice
• It is easy in easy case
• Impossible in very
difficult cases
• Methods of
achieving CVS is very
important.
• It is important to
recognize difficult
cases and
instrument selection
and dissection
techniques are also
important.

65. 6
5
Treatment
Summery
Strasberg
 Type A - ERCP + sphincterotomy + stent
 Type B & C - Hepaticojejunostomy.
 Type D – Primary repair over an
adjacently placed T-tube (if no evidence
of significant ischemia or cautery damage
at site of injury)
 More extensive type D & E injuries – Roux
an- Y hepaticojejunostomy.

66. Conclusion
• Multidisciplinary management including
radiologist, gastroenterologist and
surgeon should be needed for successful
management.
• Mismanagement can leads to lifelong disability &
chronic liver disease.
• Repair of the bile duct injury during it’s
occurrence result is excellent.
• Surgical management is the best management
option in the post operative bile duct stricture

67. 1. BLUMGART’S Surgery of the Liver, Biliary Tract, and Pancreas.
2. Sleisenger and Fordtran_s Gastrointestinal and Liver Disease 10th Edition.
3. Master Techniques in Surgery –Hepaatobiliary surgery.
4. Postoperative Biliary Strictures and Leaks Guido Costamagna and Andrés
Cárdenas
5. Biodegradable biliary stents preferable to plasticstent therapy in post-
cholecystectomy bile leakand avoid second endoscopy.
6. Biodegradable biliary stents preferable to plasticstent therapy in post-
cholecystectomy bile leakand avoid second endoscopy.
7. Laparoscopic CholecystectomyExperience With 375 Consecutive Patients.
8. Benign post-operative bile duct strictures KEITH D. LILLEMOE .
9. Recent classifications of the common bile duct injury- Kwangsik Chun, Korean J
Hepatobiliary Pancreat Surg 2014;18:69-72.
10. Management of Post-Cholecystectomy Benign Bile Duct Strictures: Review;
Sadiq S. Sikora, Indian J Surg (January–February 2012) 74(1):22–28.
11. Management of Iatrogenic Bile Duct Injuries: Role of the Interventional
Radiologist
12. An algorithmfor the managementof bile leakfollowinglaparoscopic
cholecystectomy, GASTROINTESTINAL. F AHMAD, RN SAUNDERS, GM LLOYD,
DM LLOYD, GSM ROBERTSONAnn R Coll Surg Engl 2007; 89: 51–56
REFERENCES

68. 6
8
THANKS
Resident. Bangabandhu Sheikh Mujib Medical University,
Dhaka, Bangladesh
Shehab.ndc@gmail.com