Chapter 13. Management of Bile Duct Injuries and Biliary Strictures

• 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.

Biliary Decompression

• 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.

Percutaneous Transhepatic Approach

Absolute

• Active coagulopathy.

Relative

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

Endoscopic Retrograde Approach

Absolute

• Patients who cannot cooperate with the study.

Relative

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

Biliary Stricture Dilation

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

Biliary Reconstruction

Absolute

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

Relative

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

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

Antibiotics

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

Deep Vein Thrombosis Prophylaxis

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

Drain Management

• 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 ...