Ch. 54 – Biliary System

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