Ch. 54 – Biliary System

An adequate incision permitting full visualization is
necessary for a good biliary-enteric anastomosis. A right
subcostal incision extended to either the midline (hockey
stick) or the left (chevron incision) is usually necessary.
The liver should be completely freed from the diaphragm,
and adhesions from previous operations should be taken
down to facilitate creation of a Roux-en-Y jejunal limb if
necessary (Fig. 54-23). The Hepp-Couinaud approach to
bile duct reconstruction is the best option in most circumstances.
This technique requires dissection of the
hilar plate to expose the left hepatic duct and allow for
a side-to-side anastomosis of the left hepatic duct to the
Roux-en-Y jejunal limb. The use of a Roux-en-Y jejunal
limb is favored over a direct choledochoduodenostomy
or choledochojejunostomy because it also allows for the
creation of an “access loop” of the proximal portion of
the Roux-en-Y limb for future interventional radiologic
access.
Interventional Radiologic and Endoscopic Techniques
Interventional radiologic techniques are useful in patients
with bile duct injuries, leaks, or postoperative strictures.
These techniques allow percutaneous drainage of abdominal
fl uid collections, preoperative identifi cation of the
ductal anatomy through percutaneous transhepatic cholangiography,
and stricture dilation with or without placement
of palliative stents for bile drainage in the patient
whose overall physiologic status precludes a major operation.
Percutaneous transhepatic dilation can be employed
in patients with intrahepatic ductal disease and in patients
in whom ERCP is not possible. It is often used as an
adjunct to operative repair in order to assist with identifi
cation of the proximal biliary tree for reconstruction and
for the dilation of anastomotic strictures.
The success rate of percutaneous transhepatic dilation
is reported between 50% and 70%. Patients with anastomotic
strictures (including biliary-enteric anastomotic
strictures) have the highest success rates. A study of 89
patients treated for major bile duct injuries following
laparoscopic cholecystectomy showed that by a mean
follow-up of 27 months, percutaneous dilation yielded
only a 64% success rate in ischemic strictures versus 92%
at 33.4 months in patients with biliary-enteric anastomotic
strictures. 33 In addition, although mortality following percutaneous
dilation is low, complication rates are reported
as high as 35%, and complications consist mainly of
hemobilia, cholangitis, and bile leaks. These procedures
often require multiple sessions of dilation to achieve
long-term success rates.
When reported from large-volume centers, endoscopic
and percutaneous methods of dilation have equivalent
effi cacy. Endoscopic dilation of benign extrahepatic
biliary strictures is also a useful adjunctive option in
patents with a dominant extrahepatic stricture causing
clinical symptoms. In general, treatment of biliary strictures
with this technique, as with interventional radiologic
methods, requires multiple sessions of dilations, and
nonischemic strictures (anastomotic strictures) respond
best. Endoscopic dilation also has a low mortality rate,
but it has a signifi cant morbidity rate. The more common
complications following endoscopic biliary interventions
Chapter 54 Biliary System 1571
Figure 54-23 End-to-side biliary reconstruction with Roux-en-Y
hepaticojejunostomy. Note than anterior row of PDS sutures is
placed fi rst to elevate anterior wall of bile duct and facilitate
exposure.
include hemobilia, bile leak, pancreatitis, and cholangitis.
In a study of 101 patients with benign biliary strictures,
66 patients were treated endoscopically, with a reported
re-stricture rate of 18% at 3 months and a complication
rate of 35%. 34 Although endoscopic and interventional
radiologic procedures are not ideal long-term treatments
for unresponsive biliary strictures, endoscopic stenting
and drainage is a successful treatment option for cystic
duct leak or small common bile duct leaks following
laparoscopic cholecystectomy.
Careful long-term follow-up of patients with biliary
strictures treated with percutaneous or endoscopic dilation
methods is required because ischemic biliary strictures
will not respond permanently to dilation. Early
retreatment (through repeat dilation or biliary-enteric reconstruction)
of postdilation recurrent strictures is essential
to prevent secondary biliary cirrhosis. The risk for additive
morbidity from the required repeat sessions and the
risk for late stricture recurrence should be considered and
discussed with patients when treatment options for
benign biliary strictures are being considered.
Outcomes
Acceptable long-term results can be achieved in most
patients undergoing operative repair of bile duct injuries.
More than 90% of patients are free of jaundice and cholangitis
after operative repair of a laparoscopic bile duct
injury. 28 The best results are obtained when the injury is
recognized during the cholecystectomy and repaired by
an experienced biliary surgeon. Postoperative injuries
identifi ed in the presence of concomitant biliary leak
should be repaired once the biliary leak has subsided
and tissue planes are less infl amed, usually 6 weeks after
initial laparoscopic cholecystectomy. Complications of