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  • Iatrogenic biliary injuries associated with laparoscopic cholecystectomy (most common), or other foregut operations.
  • Operative approach depends on the time the injury is diagnosed (eg, immediately, early [≤ 4 weeks after injury], or late [> 4 weeks after injury]).
    • If the patient is hemodynamically stable, immediate biliary reconstruction is indicated when an injury is identified intraoperatively during a laparoscopic cholecystectomy or other operation and a hepatobiliary surgeon is available to perform the repair.
    • For patients with early or late injuries, operative management typically requires delayed biliary reconstruction with a biliary-enteric anastomosis.
  • The aim of operative intervention is definitive treatment of patients with iatrogenic common bile duct or more proximal biliary injuries after the residual inflammation from the acute injury has resolved.
  • If the injury has been thoroughly evaluated and the biliary system has been sufficiently decompressed and drained for 6 weeks or more, reconstruction is required if a biliary stricture persists or if biliary-enteric discontinuity remains.

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Biliary Decompression

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  • Few contraindications exist for biliary decompression. This may be achieved using a percutaneous transhepatic approach or endoscopic retrograde-guided stent placement. Rarely, operative decompression may be required.

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Percutaneous Transhepatic Approach

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Absolute

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  • Active coagulopathy.

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Relative

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  • Hepatic malignancy.
  • Hydatid disease.
  • Ascites.
  • Contrast-related anaphylaxis.

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Endoscopic Retrograde Approach

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Absolute

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  • Patients who cannot cooperate with the study.

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Relative

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  • Active or recent acute pancreatitis.
  • Recent myocardial infarction.
  • Severe cardiopulmonary disease.

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Biliary Stricture Dilation

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  • Contraindications depend on approach (transhepatic or endoscopic retrograde), as outlined earlier.

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Biliary Reconstruction

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Absolute

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  • Incomplete preoperative evaluation.
  • Inability to tolerate general anesthesia.
  • Surgeon's lack of expertise in performing complex biliary reconstruction.

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Relative

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  • Acute cholangitis.
  • Early biliary injury without adequate biliary drainage (< 6 weeks).

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  • The patient should be supine with biliary drainage catheters positioned as outlined earlier.

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Antibiotics

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  • Systemic antibiotics are administered and tailored according to the bile culture from the operating room sample.

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Deep Vein Thrombosis Prophylaxis

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  • Pharmacologic deep vein thrombosis prophylaxis is routine with subcutaneous unfractionated or low-molecular-weight heparin.
  • Early ambulation should be encouraged.

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Drain Management

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  • Drains are monitored for bilious output and are removed if bilious drainage is not present following advancement to a regular diet.
  • Persistent bilious drain output (drain fluid bilirubin level > 3.0 mg/dL) should warrant cholangiography on or after postoperative day 4.
    • If an anastomotic leak is detected, the external or internal biliary drains can be exchanged if needed, and advanced past the anastomosis. Percutaneous drains control the ongoing peritoneal contamination.
    • After 6 weeks, cholangiography should be repeated. If the leak has resolved, the drains can be removed.

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