Ch. 54 – Biliary System

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1568 Section X Abdomen Postcholecystectomy pain No biloma Pain after laparoscopic cholecystectomy No jaundice Jaundice CT/Ultrasound LFTs * Significant postcholecystectomy pain Biloma Biliary leak (cystic duct stump leak, duct of Luschka leak, major ductal injury) CT/Ultrasound LFTs Common bile duct injury or stricture ERCP No biloma Retained stone Figure 54-19 Workup and diagnostic algorithm of patients with right upper quadrant pain after laparoscopic cholecystectomy. CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; LFT, liver function test. *Signifi cant and persistent pain should by itself necessitate evaluation of the biliary system even if no biloma is found. Cystic duct Common bile duct Right hepatic artery Common hepatic duct Figure 54-20 The classic laparoscopic cholecystectomy bile duct injury. The cystic duct and common bile duct are aligned by traction on the gallbladder. A segment of the common bile and hepatic ducts is resected. (From Branum G, Schmitt C, Baillie J, et al: Management of major biliary complications after laparoscopic cholecystectomy. Ann Surg 217:532-541, 1993.)
is jaundice with or without abdominal pain. Patients may also present months or years after prior surgery with cholangitis or cirrhosis secondary to a biliary tract injury. Diagnosis and Management The management of bile duct injury is dependent on the timing of diagnosis and extent and level of injury. Inappropriate management of biliary strictures may result in signifi cant morbidity and mortality secondary to complications such as biliary cirrhosis or cholangitis. In a 12year review of 130 patients with postoperative biliary strictures, the causes of mortality were all related to the presence of liver parenchymal disease with portal hypertension. Twenty-three of these patients had evidence of portal hypertension at the time of referral. 27 Management of the Bile Duct Injury Recognized at the Time of Cholecystectomy Isolated, small, non–cautery-based partial lateral bile duct injury recognized at time of cholecystectomy can be managed with placement of a T tube. The T tube can be placed at the site of the injury if this is similar in size to a choledochotomy. However, if the biliary injury is more extensive, or if there is signifi cant thermal damage owing to cautery-based trauma, or if the injury involves more than 50% of the circumference of the bile duct wall, an end-to-side choledochojejunostomy with a Roux-en-Y loop of jejunum should be performed. Similarly, major bile duct injuries, including transections of the common bile or common hepatic duct, can be repaired if recognized at the time of cholecystectomy. Isolated hepatic ducts smaller than 3 mm or those draining a single hepatic segment can be safely ligated. Ducts larger than 3 mm are more likely to drain several segments or an entire lobe and need to be reimplanted. It cannot be overstated that signifi cant experience and judgment are critical to the decision to conduct a repair at the time of injury. If one is uncertain or underexperienced, and no colleague with suffi cient expertise is immediately available, placing a drain followed by referral to an experienced center is the most appropriate course of action. Management of the Bile Duct Injury Recognized After Cholecystectomy Most large series report the incidence of ductal injury after laparoscopic cholecystectomy to be 0.3% to 0.85%. Historically, after open cholecystectomy, 10% of patients presented within the fi rst week, 70% within 6 months, and 80% within 1 year. In a recent study of 156 patients referred for management of biliary strictures resulting from bile duct injuries, 9.3% of injuries were recognized during laparoscopic versus 0% during open cholecystectomy. 28 In this series of 156 patients with postoperative biliary strictures, 49 patients (31.4%) presented with leaks, 42 (26.9%) presented with jaundice, and 50 (32.1%) presented with cholangitis. 28 In general, patients with a bile leak will present early, whereas patients with postoperative biliary strictures alone often present with jaundice or cholangitis months to years after the initial injury. Diagnosis Abdominal imaging with ultrasonography or CT should be performed in patients with signs of abdominal pain or peritonitis, sepsis, or any other clinical sus- Chapter 54 Biliary System 1569 Figure 54-21 Transhepatic cholangiography confi rming ligation of the common hepatic duct just distal to the bifurcation (arrow). picion of biloma. Such patients must be stabilized with immediate parenteral antibiotics and image-guided percutaneous drainage of any fl uid collections. Patients with signs and symptoms of cholangitis should undergo urgent cholangiogram with bile duct drainage. Cholangiography should be performed to establish the presence of ductal stricture, identify the level of the stricture, and identify the nature of the injury when necessary. In one study of 88 patients with bile duct injuries from laparoscopic cholecystectomy, attempts at repair were unsuccessful in 27 of 28 (96%) when preoperative cholangiograms were not performed, and 69% unsuccessful when data from cholangiograms were incomplete. 29 It is important that the method of cholangiography should provide detail of the intrahepatic ductal system and the bile duct confl uence. Although PTC is the imaging method of choice for most postoperative biliary strictures, expertise with this is not available at all centers (Fig. 54-21). ERCP may be easier to obtain in a patient with a biliary stricture and cholangitis who requires urgent cholangiography and biliary decompression. However, this is only useful in patients with bile duct continuity. Cystic duct leaks or small tangential injuries can be treated with endoscopic stenting. In situations in which the biliary stricture is too tight to pass with ERCP, PTC may be performed for proximal biliary decompression. CT arteriography should be considered in the preoperative evaluation of patients with benign biliary
Page 1 and 2: Biliary System Ravi S. Chari, MD an
Page 3 and 4: Vater, where it empties into the du
Page 5 and 6: Urinary excretion (95% of biliary s
Page 7 and 8: The pain is most commonly triggered
Page 9 and 10: Cholangiography Cholangiography fun
Page 11 and 12: Cholesterol Gallstones The pathogen
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Page 15 and 16: A B After endoscopic sphincterotomy
Page 17 and 18: Surgery for Calculous Biliary Disea
Page 19 and 20: Box 54-4 Indications for Intraopera
Page 21: transduodenal approach may be feasi
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Page 27 and 28: A Recurrent Pyogenic Cholangitis Ch
Page 29 and 30: Management IV antibiotics and aggre
Page 31 and 32: Box 54-6 Todani Modifi cation of Al
Page 33 and 34: Figure 54-31 Operative photography
Page 35 and 36: ant abdominal pain. A heterogeneous
Page 37 and 38: Figure 54-35 Bismuth classifi catio
Page 39 and 40: sectable disease; however, intraope
Page 41 and 42: tion and mimic either pancreatic ca

Ch. 54 – Biliary System

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