Figure 62-7. Endoscopic retrograde pancreaticocholangiogram showing filling of a normal pancreatic duct (PD). The common bile

duct (CBD), however, does not fill beyond the large clip that appears to be placed across the duct. (Reproduced with permission

from Lillemoe KD, Pitt HA, Cameron JL. Postoperative bile duct strictures. Surg Clin North Am 1990;70:1355–1380.)

The management of a suspected bile duct injury after laparoscopic cholecystectomy presenting with a

bile leak deserves special mention. Often, when bile leakage is suspected, the surgeon believes that

urgent surgical exploration is necessary. Unfortunately, at laparotomy, the marked inflammation

associated with bile spillage and the small decompressed biliary tree that appears retracted high into the

porta hepatis make recognition of the injury and repair virtually impossible. In such cases, every

attempt should be made to define the biliary anatomy by preoperative cholangiography (PTC or MRCP)

and to control the bile leak with percutaneous biliary drainage. In many cases, early operative

intervention is not required because the bile collections or ascites can either be drained percutaneously

or simply is absorbed from the peritoneal cavity. Delayed reconstruction, aided by percutaneous biliary

catheters, then allows optimal surgical results.14

In patients who present with a biliary stricture remote from the initial operation, symptoms of

cholangitis can necessitate urgent cholangiography and biliary decompression. Biliary drainage is best

accomplished by the transhepatic method, although successful endoscopic stent placement can also be

accomplished. Parenteral antibiotics and biliary drainage should be continued until sepsis is controlled.

In patients who present with jaundice but without cholangitis, cholangiography should be performed to

define the anatomy. Preoperative biliary decompression in patients without cholangitis has not been

demonstrated to improve outcome.

Surgical Management

The goal of operative management of bile duct stricture is the establishment of bile flow into the

proximal gastrointestinal tract in a manner that prevents cholangitis, sludge or stone formation,

restricture, and biliary cirrhosis. This goal is best accomplished with a tension-free anastomosis between

healthy tissues. A number of surgical alternatives exist for primary repair of bile duct strictures,

including end-to-end repair, Roux-en-Y hepaticojejunostomy or choledochojejunostomy,

choledochoduodenostomy, and mucosal grafting. The choice of repair depends on a number of factors,

including the extent and location of the strictures, the experience of the surgeon, and the timing of the

repair.

Immediate Repair of Intraoperative Bile Duct Injury

In many cases, initial proper management of bile duct injury recognized at the time of cholecystectomy

can avoid the development of a bile duct stricture. Unfortunately, recognition of a bile duct injury is

uncommon during either open or laparoscopic cholecystectomy. If bile leakage is observed or atypical

anatomy is encountered during laparoscopic cholecystectomy, early conversion to an open technique

and prompt cholangiography are imperative. If a segmental or accessory duct less than 3 mm has been

injured and cholangiography demonstrates segmental or subsegmental drainage of the injured ductal

system, simple ligation of the injured duct is adequate. If the injured duct is 4 mm or larger, however, it

is likely to drain multiple hepatic segments or the entire right or left lobe and thus requires operative

repair.

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If the injury involves the common hepatic duct or the common bile duct, repair should also be carried

out at the time of injury. The aims of any repair should be to maintain ductal length and not to sacrifice

tissue, as well as to affect a repair that will not result in postoperative bile leakage. To accomplish these

goals, all repairs at the time of initial operation should involve some sort of external drainage. If the

injured segment of the bile duct is short (<1 cm) and the two ends can be opposed without tension, an

end-to-end anastomosis can be performed with placement of a T-tube through a separate

choledochotomy either above or below the anastomosis (Fig. 62-8A). Generous mobilization of the

duodenum out of the retroperitoneum (Kocher maneuver) can be useful to help approximate the injured

ends of the bile duct. An end-to-end repair, however, should be avoided if the ductal injury is near the

hepatic duct bifurcation. It must also be remembered that in the nontransplantation setting, the patient

does not have the benefit of a lower stricture rate due to chronic immunosuppression.

Figure 62-8. All biliary anastomoses performed for the reconstruction of acute bile duct injury should have external drainage. A: If

the injured segment of bile duct is short (<1 cm) and the two ends can be opposed without tension, an end-to-end anastomosis

can be performed with placement of a T-tube through a separate choledochotomy either above or below the anastomosis. The Ttube should not be brought out directly through the anastomosis. B: With more proximal injuries or if the segment of injured bile

duct is greater than 1 cm, an end-to-end bile duct anastomosis should be avoided and a Roux-en-Y hepaticojejunostomy should be

constructed. A transanastomotic stent can be placed retrograde through the transected duct and exited to the hepatic parenchyma to

allow postoperative external drainage.

Figure 62-8. All biliary anastomoses performed for the reconstruction of acute bile duct injury should have external drainage. A: If

the injured segment of bile duct is short (<1 cm) and the two ends can be opposed without tension, an end-to-end anastomosis

can be performed with placement of a T-tube through a separate choledochotomy either above or below the anastomosis. The Ttube should not be brought out directly through the anastomosis. B: With more proximal injuries or if the segment of injured bile

duct is greater than 1 cm, an end-to-end bile duct anastomosis should be avoided and a Roux-en-Y hepaticojejunostomy should be

constructed. A transanastomotic stent can be placed retrograde through the transected duct and exited to the hepatic parenchyma to

allow postoperative external drainage.

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5 For proximal injuries or if the injured segment of the bile duct is greater than 1 cm in length, an

end-to-end bile duct anastomosis should be avoided because of the excessive tension that usually exists

in these situations. In these circumstances, the distal bile duct should be oversewn, and the proximal

bile duct should be debrided of injured tissue and anastomosed in an end-to-side fashion to a Roux-en-Y

jejunal limb. The use of a Roux-en-Y jejunal limb is preferable to anastomosis to the duodenum because,

in the latter case, an anastomotic leak results in a duodenal fistula. A transanastomotic Silastic stent can

be placed retrograde through the transected duct and exiting the hepatic parenchyma (Fig. 62-8B) to

allow for postoperative external drainage.

Unfortunately, most bile duct injuries during laparoscopic cholecystectomy occur in the hands of

surgeons who are not experienced in performing complex biliary reconstruction. In such settings, the

surgeon should consider not repairing the injury and not risk further worsening the situation. The biliary

tree should be drained via a retrograde catheter to facilitate cholangiography, but the bile duct should

not be ligated. More specifically, ligation of the proximal bile duct most often leads to stump necrosis,

subsequent bile leakage and a more challenging reconstruction due to proximal migration of the injury

itself.15 The subhepatic space should be well drained to control the biliary leak. Prompt transfer to a

tertiary hepatobiliary center should then be made.

The long-term results of immediate repair of common bile duct injuries are uncertain. Most injuries

occur away from major centers, and therefore, even the successes are unlikely to be reported in the

literature. In a Swedish report, early primary repair with end-to-end anastomosis resulted in good

outcomes in only 22% of patients. Anastomotic leak requiring reoperation occurred in 32% of patients,

and late stricture occurred in another 37% of patients. In patients undergoing immediate repair with a

biliary-enteric anastomosis, good results were seen in 54% of patients, with strictures occurring in only

12% of patients. Similar poor late results were observed in another series in which 29 of 36 patients

with primary end-to-end repair had postoperative strictures within 4 years.

Elective Repair of Bile Duct Injuries and Established Strictures

Several principles are associated with successful repair of a biliary injury or stricture: exposure of

healthy proximal bile ducts that provide drainage of the entire liver; preparation of a suitable segment

of intestine that can be brought to the area of the stricture without tension, most frequently a Roux-en-Y

jejunal limb; and creation of a direct biliary-enteric mucosal-to-mucosal anastomosis. A number of

alternatives for elective repair of bile duct strictures exist. The choice of procedure is dictated by the

location of the stricture, the history of previous unsuccessful attempts at repair, and the surgeon’s

personal preference. Simple excision of a bile duct stricture and end-to-end bile duct anastomosis or

repair of the damaged duct can rarely be accomplished because of the invariable loss of duct length as a

result of fibrosis associated with the injury. Similarly, anastomosis of the proximal bile duct to the

duodenum as a choledochoduodenostomy is not suitable for most postcholecystectomy strictures

because an adequate length of bile duct for creating a tension-free anastomosis to the duodenum usually

cannot be obtained. Thus, in almost all cases, hepaticojejunostomy constructed to a Roux-en-Y limb of

jejunum is the preferred procedure.

Many surgeons believe that a transanastomotic stent is helpful in almost all cases. In the early

postoperative period, a stent is used to decompress the biliary tree and provide access for

cholangiography. If the injury involves the common bile duct or the common hepatic duct at least 2 cm

distal to the hepatic duct bifurcation, and adequate proximal bile duct mucosa can be defined, the use of

long-term biliary stents is not necessary. In these situations, the preoperatively placed percutaneous

transhepatic catheter or operatively placed T-tube is used to decompress the biliary-enteric anastomosis

for 4 to 6 weeks after surgery. When adequate proximal bile duct is not available for a good mucosa-tomucosa anastomosis, long-term stenting of the biliary-enteric anastomosis with a Silastic transhepatic

stent is recommended. For strictures involving the hepatic duct bifurcation, both the right and left main

hepatic ducts should be individually stented.

An operative technique for biliary reconstruction with transhepatic stents using the preoperatively

placed percutaneous transhepatic catheters begins with dissection of the porta hepatis, which usually

involves separating adhesions of the duodenum and hepatic flexure of the colon to the Glisson capsule

and gallbladder fossa.16 Identification of the proximal biliary segment can be difficult and can be aided

by the presence of the transhepatic biliary catheter. This is particularly true for bile duct transections

that will retract high into the porta. If a primary duct stricture exists, the bile duct is then divided at the

lowest extent of the stricture and dissected proximally. A segment of the strictured duct should be

resected and submitted for pathologic examination. The distal duct is then oversewn, and the bile duct

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proximal to the stricture is carefully dissected circumferentially in a cephalad direction for a distance

not to exceed 5 mm. Excessive dissection should be avoided to prevent vascular compromise of this

segment of duct, which will be used for the anastomosis. After mobilization and division of the bile

duct, the biliary catheters protrude through the proximal end (Fig. 62-9A). A radiologic guide wire is

then placed through these catheters. The preoperatively placed catheter can then be exchanged over the

wire for a properly sized Silastic stent. These stents are 70 cm long and range from 12 French to 22

French. Multiple side holes are present along 40% of the length of the stent. These side holes are left to

reside within the intrahepatic biliary tree and the portion of the Roux-en-Y jejunal limb used for the

biliary anastomosis. The end of the stent without the side holes exits through the hepatic parenchyma

and is brought out through a stab wound in the upper anterior abdomen. After stent placement, a Rouxen-Y jejunal limb is prepared, and the anastomosis is then performed as an end-to-side

hepaticojejunostomy (Fig. 62-9B–D).

The importance of the hilar (epicholedochal) arterial plexus in cases of proximal bile duct injuries is

also worth mention. More specifically, performing a “high” hepaticojejunostomy reconstruction to an

intact proximal hilar bridge between the right and left hepatic ducts utilizes robust crossing arterial

anatomy and is believed by many surgeons to minimize the risk of subsequent biliary stenosis.

An alternative technique has been described for management of bile duct strictures involving the

bifurcation and one or both of the hepatic ducts in which a side-to-side anastomosis of the left hepatic

duct to the Roux-en-Y limb is constructed. A long opening along the anterior surface of the left hepatic

duct is anastomosed to the side of the Roux-en-Y limb. Because it is possible to dissect the anterior

surface of the left hepatic duct high up into the hepatic parenchyma, this procedure permits anastomosis

to normal mucosa, even though there can be fibrosis and stricture at the bifurcation of the ducts and in

the distal portion of the hepatic duct. This technique can avoid the need for postoperative stenting.

Surgical Outcome

Morbidity and Mortality

Repairs of bile duct strictures are performed primarily in major medical centers by experienced

surgeons, yet these operations are still associated with significant morbidity and mortality. In 1982, a

review of 38 series published since 1900 that included more than 7,643 procedures performed on 5,586

patients reported an overall operative mortality rate of 8.3%.17 More recently the incidence of

operative mortality has decreased markedly with improved technology and a multidisciplinary

approach, as well as improved surgical experience. A recent series of 200 consecutive patients managed

at the Johns Hopkins Hospital reported three deaths in patients who did not undergo an attempt at

repair who were referred with sepsis secondary to an uncontrolled biliary leak, for a mortality rate of

1.5%. Definitive surgical reconstruction was performed in 175 patients with a perioperative mortality of

only 1.7%.18 In this series the timing of repair, the mode of presentation, previous attempts of repair,

and the level of injury did not influence outcome. Chronic liver disease can be an important factor for

operative mortality and morbidity with advanced biliary cirrhosis and portal hypertension leading to

mortality rates approaching 30%. Fortunately in the modern era, such advanced disease is uncommon.

In most series postoperative morbidity rates are in the range of 20% to 40%. In the recent Hopkins

series, complications occurred in 41% of patients. Most of the complications were minor and could be

managed with either interventional radiology techniques or conservative management. No patient

required reoperation for postoperative complications. The median length of stay in this series was 8

days.

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