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.

1612

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.

1613

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

1614

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.

1615

 

sclerosing cholangitis, a rare disease of unknown cause, can result in multiple strictures of the

intrahepatic and extrahepatic bile ducts. This chapter focuses primarily on postoperative bile duct

strictures and primary sclerosing cholangitis.

POSTOPERATIVE BILE DUCT STRICTURES

Pathogenesis

1 Most benign bile duct strictures result from operations in or near the right upper quadrant. More than

80% of strictures occur after injury to the bile ducts during cholecystectomy. The exact incidence of bile

duct injury is unknown because many cases may go unreported in the literature. Data suggest that the

incidence of bile duct injury during open cholecystectomy is 1 in 500 to 1,000 cases. The incidence of

bile duct injury during laparoscopic cholecystectomy is clearly higher. Although a wide range in the

incidence of injury can be found in reported series, the most accurate data most likely come from

surveys encompassing thousands of patients. These reports reflect the results from a large number of

surgeons in both community and teaching hospitals. The results of such series suggest an incidence of

bile duct injury during laparoscopic cholecystectomy ranging from 0.3% to 0.7%.1 Furthermore, the

incidence of bile duct injury associated with laparoscopic cholecystectomy does not appear to have

diminished in more recent surveys, suggesting that the previously observed increase is not simply the

result of a learning curve associated with the laparoscopic technique. Finally, due to the high frequency

of laparoscopic cholecystectomy, it is estimated that one in every two or three surgeons will create a

bile duct injury during his or her career.

ETIOLOGY

Table 62-1 Causes of Benign Bile Duct Strictures

A number of factors are associated with bile duct injury during either open or laparoscopic

cholecystectomy, including acute or chronic inflammation, inadequate exposure, patient obesity, and

failure to identify structures before clamping, ligating, or dividing them. More specific causes of bile

duct injury also exist. Bleeding from the cystic or hepatic arteries can lead to bile duct injury during

attempts to gain hemostasis. The generous application of Ligaclips at either open or laparoscopic

cholecystectomy to hilar areas not well visualized can result in placing a clip on or across a bile duct,

with resultant injury (Fig. 62-1). Failure to recognize congenital anatomic anomalies of the bile ducts,

such as insertion of the right hepatic duct into the cystic duct or a long common wall between the cystic

duct and the common bile duct, can also lead to injury (Fig. 62-2). It should also be noted that a

significant discussion has ensued regarding the optimal timing of performing a laparoscopic

cholecystectomy in the setting of acute inflammation of the gallbladder. Although 30-day postoperative

morbidity and mortality rates may remain independent of timing, it is clear that patients who undergo

1605

laparoscopic cholecystectomy beyond 24 hours are more likely to require an open procedure, and

sustain significantly longer postoperative and overall lengths of hospital admission (and therefore

cost).2

A number of technical factors are associated with laparoscopic cholecystectomy that can also increase

the risk of bile duct injury compared with the open procedure. These factors include the use of an endviewing laparoscope, which alters the surgeon’s perspective of the operative field. The issue of visual

alignment and perspective has become even more topical with the proliferation of single incision

laparoscopic cholecystectomy which is known to be associated with a higher rate of common bile duct

injury than the traditional 4-incision laparoscopic technique utilizing an angled scope.3 Excessive

cephalad retraction of the gallbladder fundus can cause the cystic duct and common bile duct to become

aligned in the same plane. This distortion often results in the classic laparoscopic injury, in which the

common bile duct is mistaken for the cystic duct and clipped and divided (Fig. 62-3).4 The role of

intraoperative cholangiography (IOC) in preventing bile duct injury during laparoscopic

cholecystectomy is controversial. Individual series have failed to demonstrate that either performing

routine or selective IOC affects the incidence of bile duct injury. Although an initial retrospective

nationwide cohort analysis of Medicare patients undergoing laparoscopic cholecystectomy between

1992 and 1999 demonstrated that common bile duct injuries occurred in 0.39% of patients in which IOC

was performed versus 0.58% in patients not undergoing IOC (unadjusted relative risk, 1.49; 95%

confidence interval 1.42–1.57),5 a more recent Medicare-based study (2000 to 2009) analyzing over

92,000 patients undergoing cholecystectomy identified no statistically significant association between

IOC and common bile duct injury.6 The authors therefore concluded that IOC is not effective as a

preventive strategy against common duct injury during cholecystectomy.6 Furthermore, the proper

interpretation of IOC can minimize the extent of injury. Nevertheless, only 27% of surgeons in the

United States perform IOC routinely.7 Finally, ample evidence exists to support the conclusion that the

experience of the surgeon in performing laparoscopic cholecystectomy can be correlated with the risk of

bile duct injury.

Figure 62-1. Percutaneous transhepatic cholangiogram in a patient with a bile duct stricture secondary to iatrogenic injury during

cholecystectomy. Numerous surgical clips can be seen in the area of the stricture. (Reproduced with permission from Lillemoe KD,

Pitt HA, Cameron JL. Postoperative bile duct strictures. Surg Clin North Am 1990;70:1356–1380.)

1606

Figure 62-2. Operative cholangiogram demonstrating a right lobe segmental bile duct entering the cystic duct (arrow). Division of

the cystic duct proximal to this insertion can result in a bile leak or obstruction of bile flow from a significant segment of the liver.

Figure 62-3. Classic laparoscopic bile duct injury. The common bile duct is mistaken for the cystic duct and transected. A variable

extent of the extrahepatic biliary tree is resected with the gallbladder. The right hepatic artery, in background, is also often injured.

In recent years, there has been a growing understanding of surgeon cognitive factors associated with

bile duct injury during laparoscopic cholecystectomy. An analysis examining 252 biliary injuries during

laparoscopic cholecystectomy using human error factor and cognitive science techniques found that 97%

of injuries were caused by visual-perceptual illusion or inadequate visualization.8 Further work from the

same group has determined a major explanation for the surgeon’s frequent inability to recognize bile

duct injury. These bile duct injuries appear to be associated with confirmation bias, which is a

propensity to seek cues to confirm a belief and to discount cues that might discount the belief. Although

cognitive factors are important for the understanding of the psychological issues associated with bile

duct injuries, surgeons must continue to have the appropriate corrective mechanisms in place to

minimize the chance of these injuries, including knowledge of anatomy, typical mechanisms of injury,

and an appropriate level of suspicion and logic. An example of such a corrective mechanism occurs

within the operative technique of laparoscopic cholecystectomy, which defines the “critical view of

safety,” and therefore helps prevent misidentification and injury of the major bile ducts.9 This

anatomical-based safety concept can be further developed by including the orientation and relative

positions of the multiple structure of interest within adjacent regional anatomy (hepatic artery, sulcus of

Rouvier, umbilical fissure, and common bile duct).

The importance of ischemia of the bile duct in the formation of postoperative strictures has been

1607

emphasized. Injury to the hepatic artery at the time of biliary injury during laparoscopic

cholecystectomy has been recognized at an increased incidence, as high as 50%, when investigated at

the time of presentation.10 The true impact of an arterial injury however, remains debated. It is clear

that the most common site of vasculobiliary injury is the right hepatic artery.11 Damage to this vessel

can lead to a higher injury level on the bile duct than the gross observed mechanical injury.

Vasculobiliary injuries may also have specific effects on the arteries (pseudoaneurysm with delayed

hemorrhage), bile ducts (necrosis, stenosis, cholangitis) and/or liver (necrosis, atrophy) over variable

lengths of time.11 Finally, concurrent hepatic artery and portal vein injuries can have catastrophic

effects on the liver, including rapid necrosis. A more clinically common cause of ischemia can be

unnecessary dissection around the bile duct during cholecystectomy or bile duct anastomosis, which can

divide or injure the major arteries of the bile duct that run in the 3-o’clock and 9-o’clock positions.

Another important factor contributing to the formation of biliary strictures is the intense connective

tissue response with fibrosis and scarring that can occur after bile duct injury. Experimental studies of

bile duct ligation in a canine model have demonstrated immediate and sustained elevation of bile duct

pressure and progressive increase in bile duct diameter. Histologic changes at 1 month after ligation

have shown that the bile duct wall is thickened, with a reduction of mucosal folds and loss of surface

microvilli, associated with a well-defined epithelial degeneration. Biochemical analysis of connective

tissue response to ligation showed that collagen synthesis and prolene hydroxylase activity is increased

within 2 weeks in the obstructed bile duct and is sustained throughout the period of observation.

Finally, a marked local inflammatory response can develop in the adjacent tissue in association with bile

leakage, which occurs with many bile duct injuries. This inflammation can be further intensified in the

face of infection. This inflammation results in fibrosis and scarring in the periductal tissue, further

contributing to stricture formation. These factors can be of major importance in bile duct injuries during

laparoscopic cholecystectomy, which are frequently associated with bile leaks.

After cholecystectomy and common bile duct exploration, the two most common operations

associated with bile duct injury are gastrectomy and hepatic resection. The most common situation

resulting in bile duct injury during gastrectomy involves dissection of the pyloric region and the first

portion of the duodenum in the face of inflammation from peptic ulcer disease. The injury occurs during

mobilization of the duodenum either for creation of a Billroth I gastroduodenostomy or for closure of

the duodenal stump. Biliary injury during liver resection is most likely to occur during dissection of the

hepatic hilum.

In addition to iatrogenic bile duct injury occurring during cholecystectomy or other operations, bile

duct strictures can also occur at biliary anastomoses. Such strictures can occur at a biliary-enteric

anastomosis performed for reconstruction after resection for benign or malignant disease of the

pancreaticobiliary system, or after end-to-end bile duct anastomosis performed for hepatic

transplantation (even in the context of chronic immunosuppressive therapy) or for repair of traumatic

injury. Ischemia of the anastomosis caused by excessive skeletonization of the duct in preparation for

the anastomosis is an important factor in many such strictures.

1608

Algorithm 62-1. Algorithm for diagnosis and management of bile duct injury associated with laparoscopic cholecystectomy.

Unfortunately, the recurrence of bile duct strictures after an initial attempt at repair is not uncommon

and can also account for a number of anastomotic strictures.12,13 A number of other factors have been

evaluated in patients who have a recurrent bile duct stricture, including the location of the stricture, the

length of follow-up, the influence of previous operations, the type of operation performed, the type of

sutures used, and the use and duration of postoperative stenting.14 Previous attempts at repair,

performance of a procedure other than choledochojejunostomy or hepaticojejunostomy, and stricture

location higher in the biliary tree appear to be associated with a higher incidence of recurrent stricture.

Finally, long-term follow-up of a bile duct anastomosis is important because strictures can develop years

after the original anastomosis.

Clinical Presentation

2 Most patients with biliary injuries present early after their initial operation (Algorithm 62-1). After

open cholecystectomy, only approximately 10% of postoperative strictures are actually suspected within

the first week, but nearly 70% are diagnosed within the first 6 months, and more than 80% are

diagnosed within 1 year of surgery. In series reporting bile duct injuries during laparoscopic

cholecystectomy, the injury is usually recognized either during the procedure (25% to 30%) or, more

commonly, in the early postoperative period.

Patients suspected of having a postoperative bile duct injury within days to weeks of initial operation

usually present in one of two ways. One presentation is the progressive elevation of liver function test

results, particularly total bilirubin and alkaline phosphatase levels. These changes can often be seen as

early as the second or third postoperative day. The second mode of early presentation is with leakage of

bile from the injured bile duct. This presentation appears to occur most often in patients presenting with

bile duct injuries after laparoscopic cholecystectomy. Bilious drainage from operatively placed drains or

through the wound after cholecystectomy is abnormal and represents some form of biliary injury. In

patients without drains (including patients in whom the drains have been removed), the bile can leak

freely into the peritoneal cavity or it can loculate as a collection. Free accumulation of bile into the

peritoneal cavity results in either biliary ascites or bile peritonitis. Similarly, a loculated bile collection

can result in sterile biloma (Fig. 62-4) or in an infected subhepatic or subdiaphragmatic abscess.

Patients with postoperative bile duct strictures who present months to years after the initial operation

frequently have evidence of cholangitis. The episodes of cholangitis are often mild and respond to

antibiotic therapy. Repetitive episodes usually occur before the definitive diagnosis. Less commonly,

patients may present with painless jaundice and no evidence of sepsis. Finally, patients with markedly

delayed diagnoses may present with advanced biliary cirrhosis and its complications.

Figure 62-4. Large bile duct collection (biloma; arrow) occurring after bile duct injury. (Reproduced with permission from

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

1609

Figure 62-5. A: Percutaneous transhepatic cholangiogram demonstrating bile duct stricture at hepatic duct bifurcation with

proximal duct dilatation. B: Percutaneous transhepatic cholangiogram demonstrating stricture (arrow) at a hepaticojejunostomy

anastomosis. BD, bile duct; int, intestine.

Laboratory Investigation

Liver function tests usually show evidence of cholestasis. In patients with bile leakage, the bilirubin can

be normal or minimally elevated because of absorption from the peritoneal cavity. When elevated,

serum bilirubin usually ranges from 2 to 6 mg/dL, unless secondary biliary cirrhosis has developed.

Serum alkaline phosphatase is usually elevated. Serum aminotransferase levels can be normal or

minimally elevated except during episodes of cholangitis. If advanced liver disease exists, hepatic

synthetic function can be impaired, with lowered serum albumin and a prolongation of prothrombin

time. Serum electrolytes and complete blood count are typically normal unless there is associated biliary

sepsis.

Radiologic Examination

The imaging techniques of abdominal ultrasound and computed tomography (CT) play an important

initial role in the evaluation of patients with benign postoperative biliary strictures. In patients who

present in the early postoperative period with evidence of a bile leak or biliary sepsis, these studies are

useful to rule out the presence of intra-abdominal collections that might require drainage (Fig. 62-4). CT

and ultrasound are also important in the initial evaluation of the patient presenting with a bile duct

stricture months to years after initial operation. Both studies can confirm biliary obstruction by

demonstrating a dilated biliary tree. CT is especially useful in identifying the level of obstruction of the

extrahepatic bile duct.

In patients suspected of having early postoperative bile duct injury, a radionucleotide biliary scan can

confirm bile leakage. In patients with postoperative external bile fistula, injection of water-soluble

contrast media through the drainage tract (sinography) can often define the site of leakage and the

anatomy of the biliary tree.

3 The “gold standard” for evaluation of patients with bile duct strictures is cholangiography.

Percutaneous transhepatic cholangiography (PTC) is usually more valuable than endoscopic retrograde

cholangiography (ERC) in patients with major bile duct injuries following laparoscopic

cholecystectomy. PTC is more useful in that as it defines the anatomy of the proximal biliary tree that is

to be used in the surgical reconstruction (Fig. 62-5). Furthermore, PTC can be followed by placement of

percutaneous transhepatic catheters, which can be useful in decompressing the biliary system both to

treat or prevent cholangitis and to control an ongoing bile leak. These catheters can also be of assistance

in surgical reconstruction and provide access to the biliary tree for nonoperative dilation. ERC is less

1610

useful than PTC in major bile duct transections during laparoscopic cholecystectomy because the

discontinuity of the extrahepatic bile duct usually prevents adequate filling of the proximal biliary tree

(Fig. 62-6). Often, ERC can demonstrate a normal-sized distal bile duct up to the site of the stricture

without visualization of the proximal biliary system (Fig. 62-7). This finding is frequently the case in

patients with injury during laparoscopic cholecystectomy, when the distal bile duct is often clipped and

divided. The development of magnetic resonance cholangiopancreatography (MRCP) has provided a

noninvasive technique that provides excellent delineation of the biliary anatomy. The quality of these

images has led some surgeons to advocate this technique as the initial step in the evaluation of patients

with suspected bile duct injuries and may eliminate the need for a diagnostic ERC in many patients.

MRCP is especially worth considering if the referral surgeon has a low pretest probability of utilizing

transhepatic stents for subsequent reconstructive purposes.

Figure 62-6. A: Endoscopic retrograde cholangiogram showing a relatively normal biliary tree in a patient with a postoperative

bile collection (see Fig. 62-5). B: Percutaneous transhepatic cholangiogram of the same patient, showing entire right hepatic

posterior lobe segment obstructed as the result of ligation of the segmental duct. The patient had an unrecognized anatomic variant

similar to that shown in Figure 62-2.

Preoperative Management

4 The preoperative management of a patient with a postoperative bile duct stricture depends primarily

on the timing of the presentation. Patients presenting in the early postoperative period can be septic

with either cholangitis or intra-abdominal bile collections. Sepsis must be controlled first with broadspectrum parenteral antibiotics, percutaneous biliary drainage, and percutaneous or operative drainage

of biliary leaks. Once sepsis is controlled, there is no hurry in proceeding with surgical reconstruction of

the bile duct stricture. The combination of proximal biliary decompression and external drainage allows

most biliary fistulas to be controlled or even to close. The patient can then be discharged home to allow

several weeks to elapse for resolution of the inflammation in the periportal region and recovery of

overall health.

1611

 

Specific Conditions

Acute Cholangitis

10 Acute cholangitis can be a morbid condition and thus prompt recognition and initiation of treatment

is paramount. Acute cholangitis is defined by bacterial infection of an obstructed biliary ductal system.

Table 61-5 lists the various causes of cholangitis. The most common cause for cholangitis is

choledocholithiasis; however, malignant strictures that have required endoscopic or percutaneous

manipulation are becoming a routine cause of acute cholangitis at tertiary referral centers. The

spectrum of clinical severity can range from a mild self-limited course to a more severe potentially lifethreatening disease characterized by fulminant sepsis with multiorgan dysfunction. The classic triad of

RUQ pain, fever, and jaundice, known as Charcot triad, commonly defines the clinical presentation of

cholangitis. Development of septic shock and mental status changes in this setting is known as Reynolds

pentad.

Acute cholangitis is a clinical diagnosis supported by laboratory and radiographic studies. Elevated

bilirubin, alkaline phosphatase, and transaminase levels in conjunction with a leukocytosis are

commonly present. Radiographic studies will confirm the presence of an abnormal dilated biliary ductal

system.

The management of cholangitis should follow three principles: (1) vigorous resuscitation and

hemodynamic support, (2) broad-spectrum antibiotics, and (3) relief of biliary obstruction (Algorithm

61-2).89 The majority (80%) of patients who present with acute cholangitis will improve with fluid

resuscitation and administration of antibiotics, and therefore CBDE with biliary decompression can be

performed in a more elective and stable environment. Emergent biliary decompression will be required

in 20% of patients who do not respond clinically within 12 to 24 hours of initiation of medical

management or in patients who present with a toxic clinical picture. Biliary decompression can be

achieved either endoscopically or percutaneously. In patients with a perihilar obstruction, strictured

biliary-enteric anastomosis, or nonfunctioning percutaneous biliary drainage catheters are best managed

via the percutaneous route. If the obstruction is within the distal biliary tree then endoscopic biliary

drainage is recommended. This can be accomplished by endoscopic biliary CBDE and stone extraction or

by simple biliary decompression with placement of a plastic biliary stent in unstable patients. In the

setting in which either percutaneous or endoscopic drainage is not possible or available, then surgical

1598

CBD exploration and biliary drainage with a T-tube is indicated.

Intrahepatic Stones

Intrahepatic stones, or hepatolithiasis, are a form of primary CBD stones that are infrequently

encountered in Western countries and are primarily prevalent in Southeast Asian countries. Intrahepatic

stones are defined as stones present above the confluence of the left and right hepatic ducts. These

stones are primarily brown pigment stones that contain more cholesterol, and less bile acids and

bilirubin than extrahepatic stones. The Japanese have classified intrahepatic stones, as type I for patients

with intrahepatic stones only, type IE for patients with intra- and extrahepatic bile duct stones, type L for

left-sided intrahepatic duct stones, type R for right-sided intrahepatic duct stones, and type C for caudate

stones. Type I stones account for approximately 45% to 50% of intrahepatic stones identified in Asian

countries,90 however in Italy type I stones account for approximately 75% of intrahepatic stones.91

Intrahepatic stones typically occur in the setting of chronic biliary stasis secondary to processes, such as

(i) choledochal cysts, (ii) biliary strictures, and (iii) biliary parasites. Interestingly, the majority (70%)

of patients with intrahepatic stones do not have concomitant gallbladder stones.

Algorithm 61-2. Management of acute cholangitis. (Adapted from Cameron: Current Surgical Therapy. 11th ed. 2014.)

Intrahepatic stones typically present with RUQ or epigastric abdominal pain associated with jaundice

and fever. The previously discussed diagnostic modalities (US, CT, MRCP, and endoscopic and

percutaneous cholangiogram) have similar advantages and disadvantages when evaluating patients with

intrahepatic stones. Ultimately, an endoscopic or percutaneous cholangiogram will be required for

complete evaluation. The percutaneous transhepatic approach with placement of biliary drainage

catheters is preferred since it allows for direct access to the intrahepatic bile ducts for subsequent

therapeutic interventions. With advancements in percutaneous transhepatic techniques, intrahepatic

stones can be managed nonsurgically in many cases using similar endoscopic techniques of stone

extraction or stone lithotripsy mentioned previously; however, surgery also plays a critical role in the

management of intrahepatic stones. If the intrahepatic stone disease is isolated to a single segment or

lobe of liver and is associated with significant parenchymal atrophy or biliary strictures, then hepatic

1599

resection of this portion of liver should be considered. If stones occur in the setting of a stricture at the

biliary confluence, then a Roux-en-Y hepaticojejunostomy may be warranted.

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Chapter 62

Biliary Injuries and Strictures and Sclerosing

Cholangitis

Chad G. Ball and Keith D. Lillemoe

Key Points

1 Most bile duct injuries or strictures currently occur in association with laparoscopic cholecystectomy,

with an overall incidence of 0.3% to 0.7%.

2 Recognition of a bile duct injury during laparoscopic cholecystectomy is uncommon (<30% of

cases), but if recognized, repair as either an end-to-end duct-to-duct anastomosis in very selected

cases or hepaticojejunostomy should be performed.

3 Cholangiography, usually performed by a percutaneous transhepatic route, should be performed in

all cases to define the proximal biliary anatomy needed for reconstruction and to allow placement of

biliary catheters to control the ongoing bile leak.

4 Patients with biliary injuries most commonly present in the early postoperative course, usually with

bile leakage. Despite recognition of an ongoing bile leak, urgent return to the operating room should

be avoided.

5 The repair of a bile duct injury recognized in the postoperative period requires a

hepaticojejunostomy in almost all cases and should be performed with transanastomotic biliary

stents.

6 A successful result following repair of a bile duct injury can be expected in 80% to 90% of patients.

Return to a normal quality of life is also expected. In the modern era, death associated with either

bile duct injury or the operative repair is uncommon, occurring in less than 2% of patients.

7 Percutaneous or balloon dilatation of biliary strictures can lead to successful outcomes in selective

patients, although the long-term results generally favor surgical reconstruction.

8 Primary sclerosing cholangitis is an autoimmune disease characterized by intrahepatic and

extrahepatic inflammatory strictures of the bile ducts. Patients are at risk for the development of

cholangiocarcinoma and/or end-stage liver disease. There is no known specific effective medical

therapy for primary sclerosing cholangitis. Primary sclerosing cholangitis has become one of the

most common indications for liver transplantation.

9 Bile duct strictures associated with alcoholic chronic pancreatitis are best managed by biliary bypass.

Biliary injuries and strictures are among the most difficult challenges that a surgeon faces. Although

numerous technologic developments have facilitated diagnosis and management, bile duct injuries and

strictures remain a significant clinical problem. If they go unrecognized or are managed improperly,

life-threatening early complications such as sepsis and multisystem organ failure or late implications of

biliary cirrhosis, portal hypertension, and cholangitis can develop. To avoid these complications,

virtually every patient with a bile duct stricture should undergo evaluation and treatment with the goal

of relieving the obstruction to bile flow and its associated hepatic injury. Finally, the occurrence of a

major bile duct injury during an elective cholecystectomy remains one of the most common indications

for charges of medical practice in the United States.

Benign bile duct strictures can have numerous causes (Table 62-1). Most biliary strictures occur after

primary operations on the gallbladder or biliary tree. With the introduction of laparoscopic

cholecystectomy, bile duct injuries and associated strictures have been seen with increased frequency.

Operative injury to the bile ducts can also occur during nonbiliary operations on the gallbladder or

biliary tree or as a result of external penetrating or blunt abdominal trauma. Inflammatory conditions

and fibrosis caused by chronic pancreatitis, gallstones in the gallbladder or the bile duct, stenosis of the

sphincter of Oddi, or biliary tract infections can also cause benign bile duct strictures. Finally, primary

1604

 

and Western countries. The majority (75%) of these stones are cholesterol stones with only a minority

being black-pigmented stones.66,67 It is estimated that approximately 10% to 15% of patients with

symptomatic gallstones will have CBD stones and the vast majority of patients with secondary CBD

stones will have gallstones.68,69

Clinical Presentation

7 CBD stones, similar to gallbladder stones, can have an asymptomatic course and pass spontaneously

into the duodenum without clinical consequence.69 The exact incidence and frequency in which this

occurs is unknown. In nonjaundiced patients with nondilated bile ducts on US, the incidence of CBD

stones at the time of cholecystectomy is approximately 5% with one-third of these patients passing the

stone(s) spontaneously (Fig. 61-12).

When symptomatic, the presentation of CBD stones can vary between mild biliary colic to fulminant

sepsis from acute cholangitis, biliary pancreatitis, or hepatic abscesses. Biliary colic is the most common

presentation and it is characterized by intermittent RUQ abdominal pain due to the increased pressure

that develops within the obstructed bile duct. These episodes can also be associated with jaundice and in

the absence of a superimposed bile infection this process can occur sporadically over time as the stone

intermittently obstructs the flow of bile, resulting in development of acute ascending cholangitis. Biliary

pancreatitis is the second most common presentation of CBD stone disease.

Predictors of Common Bile Duct Stones

There is no single biochemical or radiologic test that accurately predicts the presence of CBD stones.

Numerous studies have assessed the predictive value of serum liver biochemical tests (total bilirubin,

alkaline phosphatase, ϒ-glutamyl transpeptidase, alanine aminotransferase, and aspartate

aminotransferase) and the utility of transabdominal US in predicting the diagnosis of CBD stones.

Although liver biochemical tests have a strong negative predictive value of 97%, they only have a

positive predictive value of 15% to 50% when they are abnormal in patients with suspected CBD

stones.70,71 Transabdominal US is a valuable test in diagnosing gallbladder stones however, its utility in

detecting CBD stones is poor with a sensitivity of 22% to 55%.72 Therefore, a thorough history and

physical examination, in conjunction with the appropriate biochemical and imaging studies, are required

when clinical suspicion for CBD stones exists.

Table 61-4 A Proposed Strategy to Assign Risk of Choledocholithiasis in Patients

with Symptomatic Cholelithiasis Based on Clinical Predictors

Numerous prognostic nomograms, formulas, and algorithms have been developed to assist the

clinician in establishing the diagnosis of CBD stones.72 The American Society for Gastrointestinal

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Endoscopy proposed a risk-stratification scheme based on common predictive factors previously

identified (Table 61-4).72 Using this scheme, patients can be categorized into low (<10%), intermediate

(10% to 50%), or high (>50%) probability of choledocholithiasis. This scheme has subsequently been

validated in a large multi-institutional series of patients with suspected choledocholithiasis.73

Diagnostic Studies

Biochemical Liver Profile

Serum chemistry analysis of liver enzymes (AST and ALT) as well as total bilirubin and alkaline

phosphatase levels are routinely performed in patients being evaluated for calculous biliary pathology.

Elevated total bilirubin (>4 mg/dL) and alkaline phosphatase levels have typically been correlated with

the presence of CBD stones. In addition, elevated gamma-glutamyltransferase levels, although not

routinely obtained, has been correlated with the presence of CBD stones with a sensitivity of 85%.

Ultrasonography

Transabdominal US (Fig. 61-13A) plays a critical role in the diagnosis of gallbladder stones and has the

advantages of being noninvasive, widely available, and inexpensive. Unfortunately, studies have shown

that US is limited in its ability to reliably detect CBD stones (sensitivity of 15% to 30%); primarily due

to its inability to adequately assess the distal CBD because of overlying bowel in this region. The value

of US in the assessment of CBD stones is in its ability to detect a dilated CBD. A normal CBD diameter is

3 to 6 mm although a mild increase in CBD diameter with increasing age can be seen.74 A CBD diameter

≥8 mm is considered abnormal and suggestive of CBD stones in a jaundiced patient with gallstones.

The sensitivity in detecting a dilated CBD on US is 77% to 87% with a negative predictive value of 95%

when a normal CBD is seen.71 It is important to note that CBD stones can still be present in the absence

of a dilated CBD.

Endoscopic ultrasound (EUS) is a semi-invasive procedure that can assess for distal CBD stones with a

sensitivity and specificity of 88% to 94% and 94% to 95%, respectively.75,76 EUS is superior to other

invasive diagnostic studies in its ability to detect small (<5 mm) CBD stones and is associated with an

extremely low complication rate (0.1% to 0.3%).77 Certain treatment algorithms are recommending an

EUS-first approach prior to ERCP in patients at intermediate risk of CBD stones, when the diagnosis of

choledocholithiasis is unclear, or in patients with severe gallstone pancreatitis. If no stones are seen on

EUS, an ERCP can be avoided. Use of this approach will depend on the local expertise and availability of

this technology and the increased clinical and financial costs must be taken into consideration.

Laparoscopic intraoperative US using a high-frequency (7.5- to 10- MHz) probe allows for successful

evaluation of the CBD in 88% to 100% of cases with a sensitivity of detecting CBD stones of 71% to

100%.78 In addition, laparoscopic US, similar to EUS, allows for the adequate evaluation of the distal

bile duct for stones. It is important to note that all types of US modalities are limited by the inability to

provide a therapeutic intervention.

Computed Tomography

Overall helical CT (Fig. 61-13B) has shown a slighter better sensitivity (65% to 88%) and specificity

(73% to 97%) rate in detecting CBD stones when compared to transabdominal US. This comes at an

increased cost to the healthcare system and potentially unnecessary radiation exposure. The utility in CT

is its ability to assess for other conditions that may have similar presenting symptoms as CBD stones. CT

cholangiography has not been widely adopted across centers and therefore is still in evolution.

Magnetic Resonance Imaging

Magnetic resonance cholangiopancreatography (MRCP) has proven to be a useful adjunct in the

diagnosis of CBD stones (Fig. 61-13C). MRCP has the advantage of being noninvasive and providing

detailed biliary anatomy. This comes at an increased cost as well as an inability to provide any

therapeutic intervention. The accuracy of detecting CBD stones with MRCP is between 93% and 100%

and it has a sensitivity of 85% to 92% and specificity of 97%.79,80 Recent data suggest that MRCP may

not be that sensitive in detecting small CBD stones, as evidenced by a sensitivity of 33% to 70% in

patients with CBD stones <6 mm.81 Selective use of MRCP in patients at low and intermediate risk of

CBD stones can identify patients who may benefit from an endoscopic or intraoperative bile duct

exploration.

Cholangiography

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8 The gold standard in the diagnosis of CBD stones has been direct cholangiography. This traditionally

has been accomplished by invasive methods such as ERCP, percutaneous transhepatic cholangiography

(PTC), and intraoperative cholangiography (IOC).

ERCP is currently the most routinely used invasive method in the assessment of patients with

presumed CBD stones (Fig. 61-13D). ERCP typically involves an endoscopic sphincterotomy followed by

catheter access of the biliary tree for cholangiogram. ERCP sensitivity has been reported to be between

89% and 93% with a specificity of 100%.82,83 The primary advantage of ERCP is that it allows for

therapeutic intervention if stones are identified. However, since ERCP is an invasive procedure it is

associated with increased morbidity. Complications that can develop after ERCP are pancreatitis (1.3%

to 6.7%), ascending biliary infection (0.6% to 5%), hemorrhage (0.3% to 2%), and perforation (0.1% to

1.1%).72 Due to its invasiveness and associated complications, ERCP should be reserved for those

patients at high risk of having CBD stones.

Figure 61-13. CBD stones are identified (white arrow) on ultrasonography (A), computed tomography (B), MRCP (C), and ERCP

(D).

PTC is comparable to ERCP in terms of success rate (>90% with dilated intrahepatic bile ducts) and

complication rate (∼5%); however, it is typically used in cases in which ERCP was unsuccessful or

aberrant gastroduodenal anatomy is present.

IOC, which can be accomplished laparoscopically or open, is primarily performed as adjunct to

cholecystectomy (Fig. 61-12). IOC has an overall success rate for detecting CBD stones of >95% with a

sensitivity and specificity of 59% to 100% and 93% to 100%, respectively.72 To improve upon its

accuracy, adequate filling of the intrahepatic bile ducts as well as flow of contrast into the duodenum

should be identified and appropriately documented. CBD stones identified on IOC can then be addressed

immediately with a laparoscopic or open CBD exploration or postoperatively via ERCP (discussed

further below). Traditionally, the three primary purposes of performing an IOC were to define biliary

ductal anatomy, identify CBD stones, and serve as an educational tool. There is still considerable debate

on whether or not IOC, more specifically laparoscopic IOC, should be performed routinely versus

selectively during laparoscopic cholecystectomy.84 Advocates argue that asymptomatic CBD stones can

be identified and biliary injuries prevented by performing routine IOC. Proponents of selective IOC

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argue that patients should be risk-stratified and only those patients at considerable risk should undergo

IOC.

Management

Before the laparoscopic era, IOC was routinely performed and identification of CBD stones was

managed immediately with open CBD exploration and T-tube biliary drainage. In the current era,

patients should be appropriately risk-stratified by a thorough history and physical examination with

appropriate biochemical liver profile and imaging adjuncts to assess for possible CBD stones. As

described above, there are many diagnostic options available to the practicing surgeon to assess for CBD

stones and once the diagnosis of CBD stones is established, many options, from a therapeutic standpoint,

are also available to the treating surgeon. These options include (i) endoscopic, (ii) percutaneous, (iii)

laparoscopic, and (iv) open approaches or a combination of any of these techniques.

The choice of the best diagnostic test and ultimate therapeutic intervention is dictated in great part by

the local expertise of the radiologist, gastroenterologist, interventional radiologist, and surgeon at the

treating institution (Algorithm 61-1). Hence, no single standardized approach to the diagnosis and

management of CBD stones has been established. Nonetheless, patients at low to intermediate risk of

CBD stones can be evaluated by less invasive diagnostic methods preoperatively (MRCP or EUS) or

intraoperatively with IOC. Patients at high risk of stones should undergo preoperative ERCP. The

clinical scenario in which the CBD stones present, asymptomatic (incidental stone) versus symptomatic

(cholangitis, biliary pancreatitis, or jaundice), must be put into context and incorporated into the

treatment decision plan.

Algorithm 61-1. Algorithm for the management of common bile duct stones.

Endoscopic Approach

9 ERCP with endoscopic sphincterotomy allows for the diagnosis and treatment of CBD stones. ERCP

with stone extraction is effective in removing stones in 85% to 95% of cases. Stone extraction is

typically accomplished with either a balloon catheter or stone basket. Additional techniques, such as

mechanical lithotripsy, extracorporeal shock-wave lithotripsy, or intracorporeal lithotripsy with laser or

electrohydraulic probes have been used to manage large stones (>15 mm), multiple stones, hard

stones, and/or intrahepatic stones.

Circumstances in which ERCP with sphincterotomy should be considered as the initial therapeutic

intervention are (i) acute cholangitis secondary to distal CBD stone, (ii) gallstone pancreatitis with

biliary obstruction, (iii) in frail medically unfit patients, and (iv) in patients who require

cholecystectomy whom are found to be at high risk or have CBD stones. Additionally, it is

recommended that preoperative ERCP be undertaken if expertise in laparoscopic CBD exploration is not

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available. Preoperative ERCP will allow the treating clinician to identify circumstances (i.e., large

stones, impacted stones, duodenal diverticula, aberrant gastroduodenal anatomy, or bile duct stricture)

in which the patient may not be amendable to endoscopic stone extraction and thus would require either

percutaneous or surgical biliary drainage depending on the available expertise at the treating

institution.

An alternative approach for patients at low or intermediate risk of CBD stones would be to perform

an IOC at the time of cholecystectomy with plans to perform an ERCP either intraoperatively or

postoperatively, if indicated. In the latter situation, this would require another anesthetic intervention

and the surgeon runs the risk that complete bile duct clearance is not achieved endoscopically and

additional procedures would be required.

Percutaneous Approach

From a therapeutic standpoint, simple percutaneous biliary drainage for decompression of an obstructed

biliary tree can be performed safely and efficiently with minimal difficulty. However, percutaneous

transhepatic CBD stone removal is more labor intensive and normally requires multiple sessions after

initial access of the biliary tree. Maturation (at least 7 days) of the transhepatic fistula from the skin to

the bile duct is required prior to attempting percutaneous stone extraction with either balloon catheter

or stone basket. In addition, various procedures, such as mechanical lithotripsy, electrohydraulic

lithotripsy, and extracorporeal shock-wave lithotripsy can then be performed via a percutaneous route

once a mature transhepatic fistula has been established.

Laparoscopic Approach

Concomitant laparoscopic common bile duct exploration (LCBDE) at the time of laparoscopic

cholecystectomy is a method that allows for the complete management of secondary CDB stones and

gallstones in one setting. The main advantage of this approach is that all of the calculous biliary

pathology is addressed with one intervention and under one anesthetic procedure. Studies have shown

that the success rate of this concomitant approach is approximately 94% to 97%, which is similar to

outcomes seen with endoscopic clearance.85,86 The morbidity of a LCBDE (7%) compares favorably to

ERCP. However, LCBDE has yet to gain widespread use, due in great part to the lack of adaptation and

expertise across institutions. LCBDE is ideal for patients with CBD stones incidentally identified at the

time of IOC or those suspected to be at high risk of having CBD stones. LCBDE can be performed via a

transcystic, transcholecystic, or choledochotomy technique. Cystic and CBD diameter and stone size,

location, and number need to be considered when determining the appropriate LCBDE technique.

Laparoscopic transcystic CBDE is the preferred technique and allows for the extraction of small (<1

cm) CBD stones if the diameter and quality of the cystic duct allows. A tortuous or low-inserting cystic

duct, large (>1 cm) stones, and/or common hepatic or intrahepatic stones are relative contraindications

to this technique. This technique avoids the need for a choledochotomy and thus potential need for a Ttube. The transcystic approach involves placement of a guide wire into the CBD through the cystic

ductotomy made for the IOC. With the guide wire in place, a cholangiocatheter can be advanced into

the CBD, which is then saline irrigated in attempt to flush small stones out of the bile duct under

fluoroscopic guidance. An adjunct to this maneuver is to dilate the major papilla with a Fogarty balloon

catheter and/or administer intravenous glucagon prior to flushing the CBD in order to facilitate the

passage of stones. A 3-mm choledochoscope can be passed into the CBD for direct visualization and

stone extraction can be accomplished with the use of a basket. An adjunct to this technique is to dilate

the cystic duct prior to stone extraction. These techniques can also be applied to the transcholecystic

approach, which involves making an incision in the body of the gallbladder. At the completion of either

of these approaches, the cystic duct can be easily closed as it is typically done during laparoscopic

cholecystectomy, and biliary drainage with a T-tube is not necessary.

An alternative laparoscopic approach is to perform a laparoscopic choledochotomy. The advantage to

this approach is that multiple stones, larger stones (>1 cm), or common hepatic or intrahepatic stones

can be removed. In this approach, an anterior longitudinal incision on the CBD below the cystic duct is

made to allow for adequate access but also to avoid unwanted injury to the arterial supply of the bile

duct. Similar techniques of CBDE, discussed previously, can then be undertaken to clear the CBD of

stones. The disadvantage of this approach is that advanced laparoscopic biliary skills are required and

conventionally, the choledochotomy is closed over a T-tube. The potential benefits of leaving a T-tube is

that it allows for the postoperative decompression of the biliary tree, potentially minimizes bile

strictures, and allows for access to the biliary tree postoperatively in case of retained stones

87; this

approach has been associated with a higher morbidity rate when compared to the transcystic approach.

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The increased complication rate is primarily attributed to the placement of the T-tube, and is due to (i)

bile leakage, (ii) wound issues at T-tube insertion site, (iii) dislodgement or displacement of T-tube

leading to biliary obstruction, and (iv) persistent biliary fistula.88 Alternative biliary drainage

approaches, such as intrabiliary stenting, endoscopic nasobiliary drainage, percutaneous transhepatic

biliary drainage, C-tube, and J-tube drainage via the cystic duct after laparoscopic choledochotomy,

have been investigated and have shown promising results.87 Moreover, recent data suggest that routine

biliary drainage with a T-tube is not indicated and primary closure of the CBD is superior to drainage

with a T-tube in regard to postoperative complications and biliary-specific complications.87

Open Approach

In the previous era of open cholecystectomies, open CBD exploration was routinely performed and was

the standard treatment for CBD stones. It was associated with a low morbidity rate and low stone

retention rate (1% to 3%). In the current era of advanced endoscopic, percutaneous, and laparoscopic

approaches, open CBD exploration is infrequently performed. However, when other approaches fail,

open CBD exploration may be necessary. This technique starts with a wide Kocher maneuver to allow

for exposure and palpation of the entire bile duct. The choledochotomy is similar to the one made

laparoscopically and the methods of stone extraction are also similar with the added benefit that digital

manipulation is possible. A 12-French T-tube is usually placed and secured with interrupted sutures (4-0

absorbable sutures). Completion cholangiography is mandatory to assess for CBD clearance and for

leakage around the T-tube. The T-tube is left to gravity bag until postoperative days 3 to 7 when a Ttube cholangiogram is performed and if no obstruction is present the tube can be clamped and

eventually pulled after 4 to 6 weeks once the tract has matured. If retained stones are identified, the

biliary tree can be accessed percutaneously via the T-tube, once the tract has matured, and the stones

can be removed.

Certain patients with impacted stones at the ampulla or with primary bile duct stones, history of

recurrent stones, intrahepatic stones, or a benign distal bile duct stricture may require an open biliary

drainage procedure, such as a transduodenal sphincteroplasty or choledochoduodenostomy or Roux-en-Y

biliary bypass (i.e., choledochojejunostomy or hepaticojejunostomy) as definitive therapy. The

advantage of a choledochoduodenostomy is that endoscopic access to the bile duct is maintained,

however if a side-to-side choledochoduodenostomy is performed, the patient is at risk for developing a

sump syndrome (obstruction of the distal limb of the bile duct with food debris leading to possible

obstruction of the anastomosis, cholangitis, and/or pancreatitis). This syndrome is avoided with a Rouxen-Y biliary bypass, however at the cost of losing access to the bile duct endoscopically.

ETIOLOGY OF ACUTE CHOLANGITIS

Table 61-5 Etiologies of Acute Cholangitis

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rates of 67% to 100% and specificity rates of 69% to 100%.41

US remains the initial test of choice, as it is relatively inexpensive, and may be performed at the

bedside in the ICU. However, a negative US in a patient with a high clinical suspicion for AAC may

benefit from a HIDA scan to improve diagnostic yield.43 Treatment of AAC is either a cholecystectomy

in the stable patient or more likely, PC tube placement in the critically ill, unstable patient.

Figure 61-7. CT guided placement of a 10-French cholecystostomy tube for acute cholecystitis in a nonoperative patient. Note

transhepatic (across the liver) placement. These tubes may be placed using US or CT guidance. (Image courtesy of Aarti Sekhar,

MD and David Schuster, MD, Emory University Department of Radiology.)

Chronic Cholecystitis

In most patients (>90%), gallstones are the causative factor of chronic cholecystitis and lead to

recurrent episodes of cystic duct obstruction manifesting as recurrent biliary colic. These recurrent

attacks can lead to scarring and a nonfunctioning, noncontracting gallbladder. A patient with chronic

cholecystitis present similarly to those with symptomatic cholelithiasis (i.e., biliary colic) and it is often

difficult to distinguish between the two conditions. Diagnosis is accomplished with a US documenting

gallstones in the setting of recurrent episodes of RUQ abdominal pain. Patients may exhibit atypical

symptoms or a clinician may desire confirmation of a causal relationship to the calculi seen on US, and a

HIDA scan may be useful in this situation.28 The treatment for chronic cholecystitis is cholecystectomy.

Gallstone Pancreatitis

Gallstone pancreatitis develops as a result of choledocholithiasis (gallstones that have migrated into the

CBD). Stone impaction at the distal CBD near the Ampulla of Vater, where the CBD and pancreatic duct

join, may interfere with the flow of exocrine pancreatic secretions resulting in reflux into the pancreatic

duct with subsequent autolysis secondary to release of digestive enzymes. It is the second most common

cause of pancreatitis after alcohol abuse. The clinical diagnosis of pancreatitis is made by the

constellation of upper abdominal pain, serum amylase or lipase >3 times the upper level of normal,

and/or imaging studies demonstrating acute inflammation of the pancreas, although imaging is not

generally required.44

Treatment for pancreatitis is dependent on the severity of the local and systemic response and beyond

the scope of this chapter. However, the underlying cause, the lodged stone, must be addressed. Recent

guidelines from the International Association of Pancreatology (IAP),44 suggest that the majority of

stones will pass by themselves, and only if there is evidence of cholangitis (see below under cholangitis)

should endoscopic retrograde cholangiopancreatography (ERCP) be performed for stone extraction.

Regardless of the need for stone extraction, the gallbladder should be removed to prevent further

episodes of pancreatitis.

The timing of the cholecystectomy in the setting of gallstone pancreatitis is controversial. It was

previously thought that given the acute inflammation, the risk of injury to the CBD or other structures

was too high for immediate surgery and an interval cholecystectomy (4 to 8 weeks from the initial

admission) was indicated. Evidence now supports early intervention with cholecystectomy being

performed during the index admission.45,46

CHOLECYSTECTOMY

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Historical Perspectives

Laparoscopic cholecystectomy is the most common gastrointestinal surgical procedure performed in the

United States, with more than 750,000 procedures performed yearly. Carl Langenbuch was the first to

describe the open cholecystectomy in Germany in 1882. A century later, laparoscopic cholecystectomy

was introduced and has since become the preferred method for removal of the gallbladder with over

90% of elective procedures and 70% of urgent cholecystectomies being performed laparoscopically.25

True contraindications to the laparoscopic approach to cholecystectomy, include (i) patient inability

to tolerate pneumoperitoneum, (ii) bleeding diatheses, and (iii) decompensated cirrhosis, given the risk

of fracturing of the liver and bleeding.22 Patients at higher risk for complications following the

laparoscopic approach are those with AC, morbid obesity, previous upper abdominal surgery, and wellcompensated cirrhosis.

Technique

The procedure traditionally is performed using four ports. The abdomen is typically entered near the

umbilicus and the abdomen is insufflated to 15 mm Hg. Three further operating ports are placed under

direct visualization: two 5-mm ports in the RUQ subcostally in a position to grasp the fundus of the

gallbladder and retract it cephalad and another in a position to grasp the infundibulum (often in the

anterior axillary and midclavicular lines, respectively), and a third 5-mm trocar or 10/12-mm trocar is

placed in the subxiphoid/midepigastric region (Fig. 61-8).

The fundus and infundibulum are grasped to retract the gallbladder cephalad exposing the cystic duct

and the triangle of Calot (defined by the liver edge, cystic duct, and common hepatic duct), which holds

the cystic artery (Fig. 61-8). The dissection of the lymphatic and fatty tissue within the triangle should

allow for visualization of two distinct structures entering the gallbladder (the cystic artery and cystic

duct) creating what is known as the critical view. The cystic duct and artery are fully encircled and

individually controlled with two surgical clips placed toward the porta hepatis and one toward the

gallbladder and then divided. The peritoneum surrounding the gallbladder is then incised, and using the

two 5-mm RUQ ports, the gallbladder is maximally retracted in order to develop the adventitial plane

between the gallbladder and Glisson capsule (Fig. 61-9). The gallbladder is then removed off the liver

from the infundibulum toward the fundus. Hemostasis within the gallbladder fossa is assured and the

gallbladder is extracted through the umbilical port, which may need to be enlarged in the setting of

significant calculi, within an impermeable plastic bag, which decreases the risk of infection at the site of

removal. This is especially true if the gallbladder is acutely inflamed, gangrenous, or perforated as the

risk of infection at the extraction site is increased.

Figure 61-8. A: Trocar placement for laparoscopic cholecystectomy. The laparoscope is placed through a 10-mm port just above

the umbilicus. Additional ports are placed in the epigastrium, subcostally in the midclavicular, and near the anterior axillary lines.

B: The “critical view” of safety. The triangle of Calot is dissected free of all tissue except for the cystic duct and artery, and the base

of the liver bed is exposed. When this view is achieved, the two structures entering the gallbladder can only be the cystic duct and

artery. Visualization of the common bile duct is not necessary.

If the anatomy is unclear, a cholangiogram may be useful and can be performed laparoscopically via

access of the gallbladder infundibulum or proximal cystic duct. A cholangiogram is performed by

ligating the cystic duct or gallbladder proximally and incising the anterior surface of the gallbladder

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infundibulum or proximal cystic duct for placement of a cholangiocatheter. At this point, a radio-opaque

contrast agent is injected, and under fluoroscopy the biliary ductal anatomy is defined. Newer

techniques of fluorescent-assisted cholangiogram using systemically injected near-infrared dyes, such as

indocyanine green or methylene blue, may assist in identification of the critical structures without

requiring intraoperative catheter placement or ionizing radiation exposure making the procedure less

technically demanding.47

Laparoscopic cholecystectomy in the elective setting for symptomatic cholelithiasis, or as an interval

operation in the setting of AC, can often be performed in the outpatient setting. Factors that may

influence admission include starting the operation later in the day, uncontrolled pain or nausea, and

longer operative time (greater than 1 hour).48

Other Approaches

As practitioners and patients have become more exposed and familiar with the laparoscopic treatment of

various surgical conditions, desire for even more minimally invasive, and to a certain degree cosmetic

approach has increased. This led to the development of the single-incision approach to laparoscopic

cholecystectomy (SILS). This is performed by placing a multiport access device through the umbilicus

and inserting various instruments through the single port in order to dissect the critical structures and

the gallbladder. The safety of SILS in elective cholecystectomies has been proven in various clinical

trials.49,50 The proponents of SILS espouse the cosmetic appeal, although this metric was not supported

in a Cochrane review.50 Detractors point to the increased operative time and increased hernia rates.51

Robotic SILS was developed to improve upon the limitations of standard SILS (reduced visualization

and limited traction). The intuitive computer software assists in triangulation of the arms through the

single umbilical port and due to proprietary port design (Fig. 61-10), the issue of instrument

interference is decreased. This approach, however, may significantly increase the overall cost to the

patient and healthcare system with no proven benefit to date in terms of outcomes when compared to

conventional laparoscopy. Nonetheless, given the new technology it is still early in the experience and

further studies are required to truly determine the niche, if any, for robotic and SILS

cholecystectomies.52–54

Open cholecystectomy has been relegated to a relative rare operation since the introduction and wide

spread acceptance of laparoscopic surgery. The open technique is still employed in certain clinical

settings, such as (i) the need for a potential second procedure, like concurrent CBD procedure, (ii)

known complicated anatomy, or (iii) need for conversion from a laparoscopic procedure to an open

procedure due to inability to identify anatomy or unexpected findings in approximately 10% to 15% of

planned operations.55 Open cholecystectomy can be performed through either an upper midline or right

subcostal (Kocher) incision. Unlike laparoscopic cholecystectomy, dissection often begins at the fundus

and proceeds in a retrograde, dome-down fashion toward Calot triangle with identification of the cystic

artery and duct at the gallbladder neck.

Serious complications of laparoscopic or open cholecystectomy are rare and the associated mortality

rate is <0.3%. The most severe complication of cholecystectomy is a biliary tract injury. The incidence

of bile duct injury following laparoscopic cholecystectomy is between 0.3% and 0.6% (vs. 0.2% and

0.3%, historically for open surgery). Major vascular injuries, especially to the right hepatic artery, may

occur in association with biliary injuries due to their close anatomic relationship. Otherwise, vascular

injuries to hepatic vessels and other major causes of bleeding are rare.

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Figure 61-9. A: The peritoneum overlying the cystic duct–gallbladder junction is opened with blunt dissection. B: The cystic duct

is isolated. C: The cystic duct is clipped proximal and distal and divided with the hook scissors. D: The cystic artery is dissected,

clipped, and divided. E: The gallbladder is dissected from the liver by scoring the serosa with electrocautery.

Spillage of stones into the peritoneal cavity during laparoscopic cholecystectomy occurs in 5% to 40%

of cases. Intra-abdominal abscess, subcutaneous abscess, and fistulization of stones through the

abdominal wall have all been described and therefore every attempt should be made to remove spilled

stones. Large stones or massive spills should be removed as best possible to prevent delayed

complications, but mandatory laparotomy does not appear necessary.56

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Figure 61-10. (A) Single port robotic (umbilical placement) and (B) conventional port positioning for robotic cholecystectomy:

red, green, and yellow = robot arms (arms 1, 2, and 3, respectively); blue = camera port; white = assistant port if needed.

Special Considerations

Gallbladder Cancer

A gallbladder containing an unsuspected cancer is removed in 0.2% to 3% of all laparoscopic

cholecystectomies.57 If cancer is suspected preoperatively (30% of cases), the gallbladder should be

extracted in an impermeable bag to reduce the risk of seeding the peritoneum and/or port sites. If a

gallbladder cancer is discovered, additional hepatic resection may be required and appropriate referral

to a hepatobiliary specialist is indicated. Of note, severe AC may present in a similar manner on

imaging as a gallbladder cancer and complicate management decisions as to whether an upfront en-bloc

resection should be performed (Fig. 61-11).

Cholecystoenteric Fistulae

Fistulization occurs in approximately 1% to 2% of all patients undergoing a cholecystectomy. The most

common site of fistulization is to the duodenum and colon.58 A fistula develops secondary to

decompression of the gallbladder into the adjacent bowel loop during an episode of AC. Complications

of a cholecystoenteric fistula are rare, but a large gallstone may pass into the bowel and cause a

mechanical bowel obstruction, usually distally in areas of narrow caliber, such as the ileocolic valve or

sigmoid colon. This obstruction is known as a gallstone ileus. If this complication occurs, the initial

management involves removal of the gallstone through an enterotomy with possible bowel resection.

Decision to proceed with removal of the biliary-enteric fistula and cholecystectomy at the time of

operation rests on surgical judgment, taking patient fitness and degree of tissue inflammation into

account.59 Staging the operative repair of the fistula and cholecystectomy to a later date should be

considered. An association between the presence of a cholecystoenteric fistula and gallbladder cancer

has been suggested, therefore a certain degree of clinical suspicion for cancer is warranted in this

scenario.

Figure 61-11. En bloc cholecystectomy and segment 4b/5 liver resection (blue arrow head) for concern of gallbladder carcinoma. A:

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Final pathology demonstrated acute on chronic cholecystitis secondary to presences of large pigmented gallstone (yellow arrow). B:

There is evidence of perforation into segment 4 of liver with resulting abscess and fibrosis (white arrow) mimicking a gallbladder

cancer on imaging.

Figure 61-12. Operative cholangiography showing calculi filling the common bile duct and common hepatic duct (A). These

calculi are still present at 48 hours (B) but have passed at 6 weeks (C). (Adapted from Collins C, Maguire D, Ireland A, et al. A

prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of

choledocholithiasis revisited. Ann Surg 2004;239(1):28–33.)

Cholecystitis During Pregnancy

After appendicitis, biliary disease is the second most common gastrointestinal ailment requiring surgical

consideration during pregnancy.60 The development of biliary disease in pregnancy appears to be

secondary to the hormonal changes that occur during pregnancy which both increase the cholesterol

secretion in bile and decrease bile acid secretion and gallbladder contractility. Gallstones develop in up

to 3% of pregnant women with gallbladder sludge seen in up to 30% of cases. Medical therapy alone is

associated with a failure rate that varies depending on the trimester of pregnancy (92% for first

trimester, 69% for second trimester, and 44% for third trimester).61 Fetal demise unfortunately occurs

in 12% of nonoperatively treated woman with AC, and is significantly higher in women who develop

gallstone pancreatitis. The risk of miscarriage after an operative intervention for AC is between 2.2%

and 5.6%.62 There are no prospective studies evaluating cholecystectomy during pregnancy, but

evidence-based guidelines suggest that laparoscopic surgery is safe in any trimester, although trocar

positioning may need to be adjusted.63

CHOLEDOCHOLITHIASIS

Overview

Choledocholithiasis, defined as the presence of stones in the extrahepatic biliary tree, is a routine, yet to

a certain degree diagnostic and therapeutically challenging, gastrointestinal illness encountered by the

practicing general surgeon. The last few decades have seen considerable advancements in both the

diagnostic modalities and treatment approaches available in the management of choledocholithiasis or

as more commonly referred to CBD stones. In this section, we will discuss the clinical presentation and

management of CBD stones.

Classification and Etiology

CBD stones are typically classified as primary or secondary stones. Primary CBD stones originate within

the bile duct and are more commonly seen in patients from Southeast Asian countries. Primary CBD

stones can also develop in conditions associated with bile stasis, such as: (i) benign biliary strictures, (ii)

bile duct cysts (choledochal cysts), or (iii) sphincter of Oddi dysfunction. These stones are

characteristically pigmented stones, which form de novo as a result of bactericidal action on calcium

bilirubinate, thus producing a soft brown-pigmented stone.64,65

Secondary stones originate from the gallbladder and migrate into the bile duct. They are the most

common type of CBD stone accounting for approximately 85% of CBD stones seen in the United States

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