Biliary Injury

N ir H u s , M .D ., P h .D .
D ivis ion of Trau m a S e rvice s
M e m orial R e gional H os p ital
3/3/2008
History

 Pt is a 46 y.o male who presented to the ER

with severe RUQ pain, nausea and vomiting
with meals.
 PMHx: HTN, Depression
 PSHx: Denies
 Medications: Atenolol, Lexapro, Lipitor,
Wellbutrin
 Allergy: NKDA
Physical Exam

 ABD: Distended and tender to palpation in

RUQ. + Murphy's sign. No rebound or
guarding.
 Labs- within normal limits
 Except – alk phos- 139
CT Scan
 IMPRESSION-
 1. NO CT EVIDENCE OF A HEPATIC MASS.
 2. FINDINGS SUSPICIOUS FOR CHOLECYSTITIS.
CORRELATION WITH
ULTRASOUND EXAMINATION PERFORMED THE SAME
DAY IS RECOMMENDED. IF
THERE IS NO CLINICAL SUSPICION FOR
CHOLECYSTITIS, NEOPLASM OF THE
GALLBLADDER CAN HAVE THIS APPEARANCE.
 3. NONOBSTRUCTING LEFT RENAL CALCULUS.
 4. MULTIPLE LEFT PARAPELVIC CYSTS.
Ultrasound

 IMPRESSION-
 GALLSTONES.
Operating Room

 Laparoscopic Cholecystectomy with

intraoperative cholangiogram
 Findings- Acutely inflamed gallbladder with
evidence of acute as well as chronic
inflammation, necrosis, and marked
inflammatory changes
 Cholangiogram revealed no filling defects
Intraoperative cholangiogram
 Intraoperative cholangiogram

 confirming the presence of common bile duct stones. Calculi are indicated with arrows
Post Operative Course

 Patient was doing well post op

 Advance to a regular diet and discharged
home on POD 2
 All labs were within normal limits upon
discharge
POD 6
 Pt returns to the ER with complaints of
abdominal pain and distension
 AF VSS
 WBC- 11.99
 Admit
 CT Scan
 GI consult for ERCP
CT SCAN 6 days post op
CT Scan
 IMPRESSION-
THE PATIENT IS STATUS POST
CHOLECYSTECTOMY WITH DEVELOPMENT
OF FLUID IN THE GALLBLADDER FOSSA AND
SMALL AMOUNT OF SCATTERED ASCITES.
NO RIM ENHANCING COLLECTION TO
SUGGEST ABSCESS. THE POSSIBILITY OF
BILE LEAK WITH BILE PERITONITIS IS
CONSIDERED AND HEPATOBILIARY
SCINTIGRAPHY MAY BE HELPFUL FOR
FURTHER EVALUATION.
Plan

 Special Procedures for percutaneous

drainage of abscess and placement of drain

 ID consult - Tigecycline started.

 GI for ERCP
 Common Bacterium Species Found in Biliary Tract Infections[*]
Enterobacteriaceae (68% incidence)
Escherichia coli
Klebsiella species
Enterobacter species
Enterococcus species (14% incidence)
Anaerobes (10% incidence)
Bacteroides species
Clostridium species (7% incidence)
Streptococcus species (rare)
Pseudomonas species (rare)
Candida species (rare)
From Thompson JE Jr, Pitt HA, Doty JE, et al: Broad spectrum penicillin as an adequate therapy for
acute cholangitis. Surg Gynecol 1990;171:275-282.
* Cholecystitis, cholangitis, biliary sepsis, or common duct obstruction.
ERCP
 INJECTION WAS PERFORMED INTO THE COMMON DUCT, WHICH
DEMONSTRATE A COLLECTION OF CONTRAST IN THE PRE-
AMPULLARY SEGMENT OF THE COMMON DUCT AND CONTRAST IN
THE GALLBLADDER FOSSA, WHICH COULD BE SECONDARY TO
LEAKAGE FROM THE CYSTIC DUCT STUMP.

 A STENT WAS PLACED WITH ONE END ABOVE THE SURGICAL

CLIPS IN THE GALLBLADDER FOSSA AND THE OTHER END IN THE
DUODENUM.

 THERE IS NO INTRA OR EXTRAHEPATIC BILE DUCT DILATATION.

 THERE IS NO SIGNIFICANT FILLING DEFECT IN THE COMMON

DUCT.

 IMPRESSION- EXTRAVASATION OF THE CONTRAST AS

DESCRIBED ABOVE AND PLACEMENT OF STENT TO FACILITATE
CLOSURE OF THE LEAK.
Hospital Stay

 The patient had an uncomplicated hospital

stay.
 Afebrile with labs within normal limits
 Diet was advanced as tolerated
 A follow-up CT scan was ordered to assess
the size of the collection
Follow up CT Scan
Discharge

 Follow up CT scan revealed a decrease in

size of collection
 ID changed abx to po Augmentin for 2 weeks.
 GI to follow up for ERCP and stent removal in
1 week.
Bile Leaks After Laparoscopic
Cholecystectomy
 Biliary Injuries during
Cholecystectomy
 In the 1990s, high rate of biliary injury was due
in part to learning curve effect.
 In reviews by Strasberg et al. and Roslyn et al.,
the incidence of biliary injury during open
cholecystectomy was found to be 0.2-0.3%.
 The review by Strasberg et al. in 1995 of more
than 124,000 laparoscopic cholecystecomies
reported in the literature found the incidence of
major bile duct injury to be 0.5%.
 Ann Surg. 1993 Aug;218(2):129-37.
 Am Surg. 1993 Apr;59(4):243-7.
 J Am Coll Surg. 1995 Jan;180(1):101-25. Review.
Incidence
 Incidence of biliary injury when laparoscopic
cholecystectomy is performed for acute
cholecystitis is 3X greater than that for
elective laparoscopic cholecystectomy and
2X as high as open cholecystectomy for
acute cholecystitis.
 The aberrant right hepatic duct anomaly is
the most common problem.
 The most dangerous variant is when the
cystic duct joins a low-lying aberrant right
sectional duct.
 These injuries are underreported since
occlusion of an aberrant duct may be
asymptomatic and even unrecognized.
Variations in the confluence of
the left and right hepatic ducts.
 A, Typical anatomy of the
confluence.
 B, Trifurcation of left, right
anterior, and right posterior
hepatic ducts.
 C, Aberrant drainage of a
right anterior (C1) or
posterior (C2) sectoral
hepatic duct into the
common hepatic duct.
 D-F, Less common
variations in hepatic ductal
anatomy.
(From Smadja C, Blumgart L: The biliary tract and the anatomy of
biliary exposure. In Blumgart L [ed]: Surgery of the Liver and
Biliary Tract. New York, Churchill Livingstone, 1994, pp 11-24.)
Causes of Bile Leaks
 Secondary to dissection into hepatic
parenchyma
 Division of accessory bile ducts
 Dislodgement of clips
 Tears of cystic duct
 Injury to hepatic or common bile duct
Causes of Laparoscopic Biliary Injury

 Failure to properly occlude cystic duct.

 Injury to ducts in the liver bed - caused by
entering a plane deep to the fascial plate on
which the gallbladder rests.
 Misuse of cautery may cause serious bile
duct injuries with loss of ductal tissue due to
thermal necrosis.
 Pulling forcefully up on the gallbladder when
clipping the cystic duct causing a tenting
injury in which the junction of the common
bile duct and hepatic duct is occluded.
 In 1995, Strasberg and Soper modified the
Bismuth classification of bile duct injuries:
 Type A- leak from a minor duct still in continuity
with the common bile duct.
 These leaks occur at the cystic duct or from the
liver bed.
 Type B- occlusion of part of the biliary tree.
 Usually the result of an injury to an aberrant right
hepatic duct.In 2% of patients, the cystic duct
enters a right hepatic duct rather than the
common bile duct-common hepatic duct junction.
 Type C- bile leak from duct not in
communication with common bile duct.
 Usually diagnosed in early postoperative period
as an intraperitoneal bile collection.
 Type D- lateral injury to extrahepatic bile ducts.
 May involve the common bile duct, common
hepatic duct, or the right or left bile duct.
 Type E- circumferential injury of major bile
ducts.
 This type causes separation of hepatic
parenchyma from the lower ducts and duodenum.
 Strasburg Classification
Strasberg classification
laparoscopic injuries to the
biliary tract.
Type A injuries originate from
small bile ducts that are
entered in the liver bed or
from the cystic duct.
Type B and Type C injuries are
almost always involved
aberrant right hepatic duct.
Type A, C, D, and some E
injuries may cause bilomas or
fistulas.
Type B and other type E injuries
occlude the biliary tree and
bilomas do not occur.
Misidentification injuries: 2 main types.

 1) Common duct is mistaken for cystic duct

and is clipped and divided.
 2) The segment of an aberrant right hepatic
duct, between entry of the cystic duct and
junction of the common hepatic, is mistaken
to be the cystic duct.
 Intra-op Cholangiogram
 1999 Fletcher et al. found that
intraoperative cholangiography had a
protective effect for complications of
cholecystectomy in a retrospective study
of 19,000 cholecystectomies.
 Operative cholangiography is best at
detecting misidentification of the
common bile duct as the cystic duct and
will prevent excisional injuries of bile
ducts if the cholangiogram is correctly
interpreted.
 Poor at detecting aberrant right ducts,
which unite with the cystic duct before
joining the common duct
Management
 Simple type D injuries are
repaired by closure of the
defect using fine absorbable
sutures over a T- tube and
placement of a closed suction
drain in the vicinity of the
repair.
 Type D injuries that are
thermal in origin or that are
complex are best repaired by
hepaticojejunostomy.
 Significant postoperative bile leaks occur in
up to 1% of patients undergoing laparoscopic
cholecystectomy compared to 0.5% in open
cholecystectomy.
 Usually present within first week but can
manifest up to 30 days after surgery.
 Diagnosis
 Clinical- abdominal tenderness, generalized malaise and
anorexia.
 Dx of bile leak should be suspected whenever persistent
bloating and anorexia > few days
 Failure to recover as smoothly as expected is the most
common early symptom of an intraabdominal bile collection.
 Minor bile leakage is common after open or lap
cholecystectomy and is often related to disruption of small
branches of the right intrahepatic duct entering the gallbladder
bed.
 These leaks, usually from the liver, occurred in 25% of 105
patients prospectively evaluated with ultrasonography by
Elboim et al.
 Such leaks may require no therapy
 Surgical placement of a drain at the time of the original
procedure, or subsequent placement of a percutaneous drain
for symptomatic bilomas that are recognized postoperatively.
 Diagnostic Imaging
 Noninvasive imaging (US/CT scan) is essential to define biloma
that may require percutaneous or surgical drainage.
 HIDA scan may show presence of an active bile leak and general
anatomic site of leakage.
 MRCP also provides imaging of the biliary tract, demonstrating
dilation or stenosis of the biliary tract, and stones in the cystic duct
remnant, the pancreas, and the pancreatic ducts; however, it does
not allow concomitant therapeutic measures or physiologic
assessment of bile flow (so cannot detect if a leak is active).
 ERCP and percutaneous transhepatic cholangiography (PTC) can
provide an exact anatomical diagnosis of bile duct leak, while at
the same time allowing for treatment of the leak by appropriate
decompression of the biliary tree.
Treatment
 The principle of treatment is to reestablish a
pressure gradient that will favor the flow of bile into
the duodenum and not out of the leak site.
 This means removing any physiological or
pathological obstruction such as the normal
sphincter of Oddi pressure or a retained bile duct
stone.
 In cases where there is a bile duct stone, removal of
the stone with sphincterotomy is treatment of
choice.
 If there is no stone, then internal stenting with or
without sphincterotomy has shown to be effective in
treating bile leaks.
Treatment
 A retrospective study by De Palma et al. in 2002 showed
that sphincterotomy alone was highly effective in producing
closure of bile fistulas by reducing endobiliary pressure.
 Endoscopic internal stenting is currently procedure of
choice for treating bile duct leaks (usually types A, C and
D).
 7Fr and 10 Fr stents can be inserted without
sphincterotomy.
 A prompt therapeutic response with cessation of bile
extravasation in 70-95% of cases within a period of 1-7
days.
 In the past, nasobiliary drains were used because they did
not require sphincterotomy, and removal did not require
second endoscopic procedure.
 Nasobiliary drains are poorly tolerated and they are not
able to transport more than 1/3 of daily bile production
which makes them less effective than internal stents.
PTC
 Another method of non-surgical treatment of bile leaks is PTC
drainage.
 However, bile ducts are usually of normal caliber when there is
leakage, which makes the procedure difficult.
 PTC is usually reserved for instances when ERCP is
unsuccessful or in preparation for surgical repair.
 Intrahepatic bile duct injuries are not easily accessible by the
retrograde route.
 In certain instances, the distal part of the injured bile duct may be
closed and ERCP, therefore, may fail to reveal any contrast
extravasation. Bile can thus continue to leak from the proximal
part of the injury, and response to endoscopic treatment will be
lacking.
 In this case, PTC may be useful, or repair surgically.
Experimental

 ’’Histoacryl” glue approved in Europe for the

sealing of biliary fistulae

 Botulinum toxin injection to sphincter of Oddi

successful in canine models.
The End