Figure 62-9. Technique of biliary reconstruction. A: A Silastic stent is sutured to the preoperatively placed transhepatic catheter,

which protrudes through the transected hepatic duct and through the catheter tract in the hepatic parenchyma. B: A Roux-en-Y

jejunal loop is then anastomosed to the hepatic duct and (C) the Silastic stent is placed through the anastomosis. D: A completed

Roux-en-Y hepaticojejunostomy with a transanastomotic stent.

Long-Term Results

6 Historically, excellent long-term results were achieved in 70% to 90% of patients who underwent

repair of bile duct strictures (Table 62-2). The definition of satisfactory results in most series requires

that patients have no symptoms, jaundice, or cholangitis. Length of follow-up is important in analyzing

final results because recurrent strictures can occur up to 20 years after the initial procedure (Fig. 62-

10).12,13 Approximately two-thirds of restrictures are evident within 2 years, and 90% are seen within 7

years. The percentage of patients with good results is inversely related to the number of previous

repairs. Other factors that favor a good outcome include young age at the time of stricture repair, use of

a Roux-en-Y biliary-enteric anastomosis, absence of infection and hepatic fibrosis, and use of

transhepatic stents.

RESULTS

Table 62-2 Results of Surgical Management of Bile Duct Strictures

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As illustrated earlier, in the era before laparoscopic cholecystectomy, excellent long-term results were

obtainable in tertiary care centers specializing in the management of these problems. Questions had

arisen as to whether the excellent results of bile duct strictures after open cholecystectomy could be

directly transferred to patients sustaining laparoscopic bile duct injuries. Some researchers had

suggested that the mechanism of bile duct injury during laparoscopic cholecystectomy, the complex

nature of many of these injuries, and the frequent association of significant inflammation and fibrosis

secondary to sustained, unrecognized bile leakage might result in poor long-term results. Furthermore,

the high percentage of these patients who have undergone unsuccessful operations, often performed by

the primary laparoscopic surgeon, might also lead to a poor long-term outcome. Evidence for the latter

hypothesis was provided by a review of the records of 85 patients who underwent a total of 112 biliary

repairs.24 Four factors determined the success or failure of treatment in this series. These factors

included performance of preoperative cholangiography, the choice of surgical repair, details of the

operative repair, and experience of the surgeon performing the repair. The importance of preoperative

delineation of anatomy was clear, in that 96% of procedures in which cholangiograms were not

obtained before repair were unsuccessful, and 69% of repairs were not successful when the

cholangiographic data were incomplete. When cholangiographic data were complete, the initial repair

was successful in 84% of patients. The type of repair was also of significance in influencing outcome. A

primary end-to-end ductal repair over a T-tube was unsuccessful in all patients in whom a complete

transection of the bile duct had taken place, whereas 63% of Roux-en-Y hepaticojejunostomies were

successful. Attempts at repair by the primary surgeon were successful only in 17% of cases, and in no

case was a secondary repair by the primary surgeon successful. In those cases in which the first repair

was performed by a tertiary care biliary surgeon, a 94% success rate was obtained.

The outcome of management of 142 patients with major bile duct injuries treated during the 1990s

has been reported.21 Laparoscopic cholecystectomy was the initial operation in 75% of these patients,

and 41% had undergone a previous attempt or attempts at surgical repair before referral. In this series

with a median follow-up of 58 months (range, 11 to 119 months), a successful outcome was obtained in

91% of patients. In this series the level of injury, clinical presentation, history of prior repair, and

length of biliary stenting did not influence outcome. Comparable results have been reported from other

high-volume hepatobiliary centers.22,25 These results suggest that surgical reconstruction of major bile

duct injuries after laparoscopic cholecystectomy can still result in excellent long-term results.

RESULTS

Table 62-3 Results of Transhepatic Balloon Dilation of Bile Duct Strictures

Despite the overall success of biliary reconstruction, there is a small subset of patients with major bile

duct injuries in whom standard repair techniques appear to be inadequate. Factors, such as delay in

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diagnosis, complex injuries above the hepatic confluence, associated vasculobiliary injuries, and liver

atrophy can all negatively affect the outcomes of standard reconstruction. In this select population

excellent results have been observed with major hepatectomy.26 A classic example of this scenario

would be a patient who has sustained a right posterior sectoral bile duct injury, and subsequent hepatic

atrophy with associated recurrent cholangitits. These patients typically benefit most from a right

posterior hepatic sectionectomy, as opposed to an attempt at a challenging hepaticojejunostomy

reconstruction to a small duct within an abnormal liver. Finally, in rare cases with failure of all standard

surgical techniques of reconstruction with resultant end-stage liver disease, liver transplantation may

offer the opportunity for survival.27 Interestingly, many of these extreme injuries are caused during

open cholecystectomy and therefore, trauma caused by migration from the cystic plate into the hilar

plate itself.11

Figure 62-10. The cumulative percentage of recurrent strictures with respect to the time from the initial repair until the next

repair. (Adapted from Pitt HA, Miyamoto T, Parapatis SK, et al. Factors influencing outcome in patients with postoperative biliary

strictures. Am J Surg 1982;144:14–21.)

Although large series from tertiary referral centers have reported excellent long-term results, the

overall impact of bile duct injuries on society is significant in terms of health care costs, disability, and

even mortality. In an analysis of patients undergoing laparoscopic cholecystectomy from the U.S.

Medicare database, Flum et al. demonstrated that the adjusted hazard ratio for death during the followup period was significantly higher (2.79, 95% confidence level 2.71–2.88) for patients with a bile duct

injury than in those patients without a bile duct injury.28 The hazard increased with advancing age and

comorbidities and decreased with the experience of the repairing surgeon. The adjusted hazard of death

during follow-up was 11% greater if the repairing surgeon was the same as the injuring surgeon. These

data certainly further support the referral of most patients with bile duct injuries to centers with greater

experience in the management of the injuries.

Finally, although the overall success of the surgical management of laparoscopic bile duct injuries

associated with laparoscopic cholecystectomy is excellent, there is an impression that patients may have

an impaired quality of life even after successful repair of their bile duct injury. Quality-of-life

assessments after laparoscopic cholecystectomy bile duct injury have been addressed in several recent

reports.29,30 These results have generally reported either comparable or mildly diminished quality of life

compared with matched controls. Interestingly, in one study, patients who reported pursuing a law suit

following their injury had significantly worse quality-of-life scores in all domains when compared to

those who did not entertain legal action.29 The most recent study, which spanned a 23-year period (169

month median follow-up), evaluated 62 patients who had generally undergone a Roux-en-Y

hepaticojejunostomy (86%) reconstruction, confirmed that mental health concerns were more common

place than physical or general health issues following bile duct injuries. While most patients displayed

an eventual return to their physical baseline, psychological quality of life was much more difficult to

correct over time.31

Nonoperative Management

Operative management of bile duct strictures is technically difficult and continues to be associated with

significant postoperative morbidity and mortality. Moreover, in all series, recurrent strictures develop

in a proportion of patients. These factors, in addition to technical advances in the fields of therapeutic

radiology and endoscopy, have led to the development of nonoperative techniques for management of

bile duct strictures. The optimal method for management using these techniques is dependent on the

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presence and anatomy of biliary-enteric continuity.

Percutaneous Balloon Dilation

The management of benign bile duct strictures using the percutaneous transhepatic route is indicated

primarily in patients with a failed prior biliary-enteric anastomosis to a jejunal limb. The procedure in

many cases can be performed with a combination of local anesthesia and intravenous sedation. In this

technique, access to the proximal biliary tree is gained and the stricture is traversed with a guide wire

under fluoroscopic guidance. At this point, the stricture is dilated using angioplasty-type balloon

catheters, chosen on the basis of the location of the stricture and the diameter of the normal duct (Fig.

62-11). After the procedure, a transhepatic stent is left in place across the stricture to allow access to the

biliary tree for follow-up cholangiography, repeat dilation, and maintenance of a lumen during the

healing process. In most series, numerous dilations are required.

The results from a number of series have been encouraging (Table 62-3). In a multicenter review of

bile duct strictures treated in the open cholecystectomy era, 3-year follow-up showed a 67% patency

rate for anastomotic and a 76% patency rate for iatrogenic primary bile duct strictures, yielding an

overall 70% success rate.32 A report of 51 patients with bile duct strictures after laparoscopic

cholecystectomy managed with percutaneous dilation showed a success rate of 58% with a mean followup of 76 months.33

Complications of balloon dilation are frequent. Cholangitis, hemobilia, and bile leaks can occur in up

to 20% of patients. Bleeding, usually from the hepatic parenchyma, has been reported, with transfusions

often necessary. Sepsis due to cholangitis can occur despite antibiotic prophylaxis. Sepsis and significant

bleeding seldom occur in patients dilated by a T-tube tract, suggesting that much of the morbidity is the

result of traversing the hepatic parenchyma by the large percutaneously placed catheters.

Endoscopic Balloon Dilation

Endoscopic balloon dilation is often considered technically possible only in patients with primary bile

duct strictures or with strictures at a prior primary end-to-end repair or choledochoduodenal

anastomosis. With the advent of double-balloon enteroscopy however, more patients are now able to

undergo endoscopic retrograde cholangiopancreatography (ERCP) following preceding

hepaticojejunostomies, as well as a myriad of bariatric procedures. In select cases, laparoscopic assisted

ERCP is also possible. This technique begins with ERC and endoscopic sphincterotomy. The stricture is

traversed retrograde with an atraumatic guide wire, and sequential balloon dilation is used.

Reevaluation with cholangiography is performed every 3 to 6 months. Redilation is performed as

necessary. In most cases, an endoprosthesis is left in place after dilation for at least 12 months.

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Figure 62-11. A: Transhepatic cholangiogram demonstrating stricture (arrow) at a previous choledochojejunostomy. B: Progressive

dilation of the strictured anastomosis with an angioplasty balloon catheter. C: Postdilation stenting of the anastomotic stricture for

prolonged periods. D: Subsequent cholangiogram demonstrating resolution of the anastomotic stricture. (Reproduced with

permission from Pitt HA, Kaufman SL, Coleman J, et al. Benign postoperative biliary strictures: operate or dilate? Ann Surg

1989;210:417–425; discussion 426–427.)

7 The reported experience with endoscopic dilation of benign bile duct strictures is shown in Table

62-4. The largest experience comes from the group in The Netherlands who recently reported their

experience in 110 patients.34 The mean number of stents placed was two, the mean duration of stenting

was 11 months, and stent-related complications occurred in 33% of patients with one death. Twenty

percent of patients were eventually referred for surgery. The overall reported success rate was 74%

with a mean follow-up of 7.6 years. A similar experience was reported in the United States.35 In this

series, 18 of 25 strictures were postoperative. Strictures were located at the cystic duct junction in 17

patients and in the distal bile duct in the remaining eight patients. Of 25 patients, 22 (88%) had

significant clinical benefit from the therapy. Only two complications occurred in this series – one case

each of pancreatitis and cholangitis.

Comparative Data

Comparison of results of nonoperative dilation with those of surgery has been difficult. Few centers

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have significant experience with both operative and nonoperative management. Furthermore, the

definition of a successful procedure, the reporting of complications, and the length of follow-up has not

been consistent in the literature. There are no prospective randomized studies to compare these

techniques; however, three retrospective comparative studies exist. In the first study, a retrospective

review of the results at the Johns Hopkins Hospital between 1979 and 1987 compared percutaneous

balloon dilation and surgery in 43 patients with benign postoperative bile duct strictures.19 Twenty-five

patients underwent surgical repair with Roux-en-Y hepaticojejunostomy with postoperative transhepatic

stenting for a mean of 13 ± 1.3 months. Twenty patients had percutaneous balloon dilation, a mean of

3.9 times, and were stented transhepatically for a mean of 13.3 ± 2 months. Three patients were

managed with both surgery and balloon dilation. The two groups were similar with respect to multiple

parameters that might have influenced outcome, including age, sex, associated medical problems, and

presentation with either obstructive jaundice or biliary fistulas. No patients died after any of the

procedures. Procedure-related morbidity occurred in 20% of surgical patients and in 35% of the patients

undergoing balloon dilation. For both groups, a successful outcome was defined as no evidence of

cholangitis or jaundice requiring another procedure more than 12 months from the onset of treatment.

A failed treatment was defined as the need for crossover to the other treatment modality, either

operation or dilation, or late death from liver failure, biliary sepsis, or portal hypertension. A successful

repair was achieved in 89% of the surgical patients and in only 52% of the balloon dilation patients

(Fig. 62-12). The overall late mortality rate in this series was 10%. One late death occurred in the

surgical group, whereas three late deaths followed balloon dilation (4% vs. 15%, respectively). No

deaths, however, were attributed to liver failure, biliary sepsis, or portal hypertension associated with

the bile duct stricture.

Table 62-4 Results of Endoscopic Balloon Dilatation of Bile Duct Strictures

To define further the relative benefits of the two procedures, total hospital stay and total procedural

costs were determined. As expected, initial hospitalization was longer for surgery than for balloon

dilation. When rehospitalization for further dilation, complications, or recurrences was considered, total

hospital stay did not differ significantly between the two groups. Cost data paralleled hospitalization

data and did not differ significantly between the groups. Thus, the authors concluded that until properly

designed, randomized, prospective, controlled trials can be performed, surgical repair for benign

postoperative strictures appears to be associated with fewer problems and a greater success rate.

Figure 62-12. Actuarial success rates over 72 months for surgery (89%) and balloon dilation (52%). The difference is statistically

significant (p < 0.01). (Adapted from Pitt HA, Kaufman SL, Coleman J, et al. Benign postoperative biliary strictures: operate or

dilate? Ann Surg 1989;210:417–425; discussion 426–427.)

In the second comparative study, the group from The Netherlands compared endoscopic versus

surgical treatment of benign bile duct strictures.21 Thirty-five patients were treated surgically, and 66

were treated by endoscopic stenting. Patient characteristics, initial injury, previous repairs, and the

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