Lecture notes for medical students

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2. Introduction

3. Introduction
• Bile duct injury (BDI)
• Rare but potentially devastating condition
• Biliary peritonitis & sepsis, cholangitis, portal
hypertension & secondary biliary cirrhosis
• Significant morbidity & mortality
• Iatrogenic BDI
• Increased financial burden (patient or hospital)

4. Anatomy

5. Anatomy
• Calot’s triangle – between
inferior surface of liver,
Cystic duct & CHD
• Contents – Cystic artery,
RHA, Cystic lymph node

6. Bile Duct Injuries (BDI)

7. Bile Duct Injuries (BDI)
• Iatrogenic injury
• Cholecystectomy
• Gastrectomy
• Pancreatectomy
• ERCP
• Trauma
• Duodenal ulcer

8. Risk factors

9. Risk factors
 Inflammation in the porta,
 Variable biiary anatomy,
 Inappropriate exposure,
 Aggressive attempts at hemostasis,
 Surgeon inexperience.
97% due to visual misperception, only 3% accounts for
technical skills and knowledge.

10. Classification

11. Classification
• location of injury
• mechanism & type of injury
• effect on biliary continuity
• timing of identification
Each plays significant role in determining appropriate
management & operative repair

12. Classification of BDI
Bismuth classification (1982)
• Era of Open Chole
• Based upon level of biliary strictures with respect to
hepatic bifurcation
• Type 1-5.
• Helps surgeon choose appropriate site for repair
• Degree of injury correlates with surgical outcomes

13. Strasberg classification(1995)
Type Criteria
A Leak from Cystic duct or small ducts in liver bed
B Injury to sectoral duct(aberrant RHD) with obstruction
C Injury to sectoral duct with consequent bile leak
D Lateral injury to extrahepatic duct
E1 Transection >2 cm from the confluence
E2 Transection <2 cm from the confluence
E3 Transection at the confluence
E4 Separation of major ducts in the confluence
E5 Complete occlusion of all bile ducts.

14. Clinical Presentation (post-op)

15. Clinical Presentation (post-op)
• Obstruction
• Clip ligation or resection of CBD  obstructive
jaundice, cholangitis
• Bile Leak
• Bile from intra-op drain or
• More commonly, localized biloma or free bile ascites /
peritonitis, if no drain
• Fever,abd pain , jaundice, or bile leakage from
incision.
• Diffuse abdominal pain & persistent ileus several
days post-op  high index of suspicion  possible
unrecognized BDI

16. Strasberg classification

17. Prevention

18. 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
• Expose “Critical view of safety” before dividing cystic duct
• Convert to open, if unable to mobilise infundibulum or
bleeding or inflammation in Calot’s triangle
• Routine intra-op cholangiogram
• “Fundus-first” dissection

19. Critical view of safety
• Calot’s triangle dissected
free of all tissue except
cystic duct & artery
• Base of liver bed exposed
• When this view is achieved,
the two structures entering
GB can only be cystic duct
& artery

20. Management

21. Recognized at the Time of Cholecystectomy
• Conversion to an open operation and use of
cholangiography.
• Goals ..
Maintenance of ductal length, elimination of any bile
leakage that would affect subsequent management, and
creation of a tension-free repair.

22. • Ducts smaller than 3 mm drain only a single segment or
subsegment of liver..simple ligation.
• Ducts larger than 3 mm usually drain more than a single
segment of liver,if transected.. should be reimplanted into
the biliary tree.
• Injury occurs to a larger duct, but is not caused by
electrocautery and involves less than 50% of the
circumference of the wall, a T tube placed through the
injury

23.  Low injuries to the bile duct can be reimplanted into the
duodenum.
 Most injuries to the bile duct occur higher in the biliary tree, close
to the hilum, thus not allowing for tension-free anastomosis to
the duodenum. Therefore, in almost all cases of bile duct injury,
a resection of the injured segment with mucosa to mucosa
anastomosis using a Roux-en-Y jejunal limb (end-to-side
choledochojejunostomy ) is preferred.
 Transanastomotic stenting has been shown to improve
anastomotic patency.

24. Identified After Cholecystectomy

25. Identified After Cholecystectomy
Goals of Therapy in Iatrogenic Bile Duct Injury
1.Control of infection limiting inflammation
Parenteral antibiotics
Percutaneous drainage
2.Clear and thorough delineation of entire biliary anatomy.
MRCP/PTC , ERCP
3.Re-establishment of biliary enteric continuity
Tension-free, mucosa-to-mucosa anastomosis
Roux-en-Y hepaticojejunostomy
Long-term transanastomotic stents if involving
bifurcation or higher

26. Approach..
• Should undergo imaging to assess for a fluid collection
and evaluate the biliary tree.
• Ultrasonography can achieve both these goals.
• Cross-sectional imaging via CT will generally provide
more useful data.
• Radionucleotide scanning to confirm bile leakage, but
with any documentation of a leak, CT will be necessary
to plan management.

27.  CT or U/S guided (or surgical) drainage
 Sepsis control  Broad-spectrum antibiotics & percutaneous
biliary drainage to control any bile leak  most fistulas will
be controlled or even close.
 1.5% mortality rate due to uncontrolled sepsis
 No rush to proceed with definitive management of BDI.
 Delay of several weeks allows local inflammation to resolve
& almost certainly improves final outcome.

28.  Definitive management is to reestablish durable biliary
enteric drainage.
 Combination of percutaneous and endoscopic biliary
dilations and stenting may establish continuity.
 Surgical reconstruction has the highest patency rates.
 performed between a minimally inflamed bile duct to
intestines in a tension-free, mucosa to mucosa fashion.

29. Interventional Radiologic and Endoscopic
Techniques

30. Interventional Radiologic and Endoscopic Techniques
 Using balloon dilation techniques, the stricture is dilated and a
catheter is left in place to decompress the system, allow healing,
document resolution and, if necessary guide repeat dilations.
 This approach is successful in up to 70% of patients.
 Endoscopic balloon dilation of bile duct strictures is generally
reserved for those with primary bile duct strictures or patients who
have undergone choledochoduodenostomy for reconstruction,
because the Roux limb does not usually allow for endoscopic
strategies.

31. MRCP / CT cholangiography
• Noninvasive
• May avoid invasive procedures like ERCP or PTC
• Do not allow intervention
• Interpretatation in presence of bile collection difficult

32. Biliary enteric anastomosis
• Most laparoscopic BDI –
complete discontinuity of
biliary tree
• Surgical reconstruction,
Roux-en-Y
hepaticojejunostomy
• tension-free, mucosa-to-
mucosa anastomosis with
healthy, nonischemic bile
duct

33. Treatment summary

34. Treatment summary
• Strasberg Type A – ERCP + sphincterotomy + stent
• Type B & C – traditional surgical 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 with biliary stent

35. Causes of benign stricture
I. Congenital strictures
Biliary atresia
II. Bile duct injuries
A. Postoperative strictures
(1) Cholecystectomy or common bile duct
exploration (accounting 80% of nonmalignant stricture)
(2) Biliary-enteric anastomosis
(3) Hepatic resection
(4) Portocaval shunt
(5) Pancreatic surgery
(6) Gastrectomy
(7) Liver transplantation
B. Stricture after blunt or penetrating trauma

36. Causes of benign stricture

37. Causes of benign stricture
C. Strictures after endoscopic or percutaneous
biliary intubation
III. Inflammatory strictures
A. Cholelithiasis or choledocholithiasis
B. Chronic pancreatitis
C. Chronic duodenal ulceration
D. Abscess or inflammation of liver or subhepatic
space
E. Parasitic infection
F. Recurrent pyogenic cholangitis (Oriental
cholangiohepatitis)
IV. Primary sclerosing cholangitis
V. Radiation-induced stricture

38. Causes of malignant stricture

39. Causes of malignant stricture
• Primary tumors
1. Cholangiocarcinoma
2. GB Cancer
3. Pancreatic
adenocarcinoma
4. Ampullary carcinoma
5. Hepatoma
6. Gastric carcinoma
Metastatic tumors
1. pancreatic
adenocarcinoma
2. Colon cancer
3. Breast cancer
4. Lung cancer
5. Melanoma
6. Ovarian cancer

40. Biliary Fistula

41. Biliary Fistula
• A fistula is an epithelium-lined tract
between 2 epithelium-lined surfaces.
• cholecystocutaneous fistula is an abnormal
epithelial tract that allows communication
between the gallbladder and the skin.
• Biliary fistulae can be internal or external.

42. • External biliary fistulae, in turn, can be
further subdivided based on etiology into
spontaneous, therapeutic, traumatic, and
iatrogenic fistulae.
• spontaneous or deliberate as in the case of a
therapeutic percutaneous cholecystostomy
used to treat cholecystitis or empyema of
the gallbladder,

43. • Spontaneous cholecystocutaneous fistula is
a rare complication of neglected calculous
biliary disease
• adenocarcinoma of the gall bladder.

44. Pathophysiology

45. Pathophysiology
• The cystic duct or gallbladder is almost
always obstructed in patients with
spontaneous cholecystocutaneous fistula.

46. Examination
•

47. Examination
• The patient may be febrile and diaphoretic
because of the infection.
• The external opening is usually in the right
upper quadrant, although external openings
in the periumbilical area, the lumbar area,
and even the gluteal area
•

48. Examination
• Discharge may be purulent in the presence
of empyema, mucoid in the presence of a
mucocele because of obstruction, or bilious
in the absence of obstruction. Small stones
within the discharge often confirm the
diagnosis.

49. Differential diagnosis

50. Differential diagnosis
• Infected epidermal inclusion cyst
• Discharging tuberculoma
• Pyogenic granuloma
• Chronic osteomyelitis of ribs with
sequestrum
• Metastatic carcinoma

51. Treatment

52. Treatment
• Conservative
– Infection
– obstruction
• Both the gallbladder and fistula need to be
resected to achieve a cure.

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