Bile Duct Injury

Fazaldin Moghul; Sarang Kashyap.

Author Information

Last Update: June 30, 2020.

Go to:

Continuing Education Activity

Laparoscopic cholecystectomy is performed over 750,000 times in the United States annually. As laparoscopic cholecystectomy
has been increasingly used to treat symptomatic cholelithiasis, the number of bile duct injuries (BDI) has also increased. The
biliary tree and relationship of the cystic duct and its insertion onto the common hepatic duct is noted to have variable and
anomalous anatomy. The most common reason for injuring the bile duct is due to the misidentification of normal biliary
anatomy. Once the bile duct is injured, early recognition is crucial to facilitate appropriate treatment. This activity outlines the
evaluation and management of iatrogenic and traumatic injury to the biliary system and highlights the role of the
interprofessional team in evaluating and managing patients with this condition.

Objectives:


Describe the etiology of bile duct injury.



Outline the methods and classification systems for evaluating any injury to the biliary system.



Explain the management considerations for patients with bile duct injury based on the etiology.



Review the importance of collaboration and coordination amongst the interprofessional team members to improve
outcomes of patients with injury to their biliary system.

Earn continuing education credits (CME/CE) on this topic.

Go to:

Introduction

Injury to the biliary tree poses a unique challenge for the surgeon due to the variable anatomy, limited working space, and
morbidity of its complications.

Minimally invasive cholecystectomy is performed over 750,000 times in the United States annually. As laparoscopic
cholecystectomy has been increasingly used to treat symptomatic cholelithiasis, the number of bile duct injuries (BDI) has also
increased. The biliary tree and relationship of the cystic duct and its insertion onto the common hepatic duct is noted to have
variable and anomalous anatomy. The most common reason for injuring the bile duct is due to the misidentification of normal
biliary anatomy.[1] Once the bile duct is injured, early recognition is crucial to facilitate appropriate treatment.

Go to:

Etiology

Iatrogenic biliary injury most commonly occurs by misidentifying the common bile duct for the cystic duct during laparoscopic
cholecystectomy[2], with an incidence of 0.3 to 0.7%, which is historically three times higher than in open cholecystectomy.
[3] The variable biliary anatomy is one of the factors in the causation of this injury. Injury to the biliary tree rarely occurs in
penetrating or blunt abdominal trauma, with an incidence of 0.1% of hospital admissions for trauma. Depending on the location
and time of diagnosis, the management ranges from cholecystectomy, drainage, reconstruction to restore the flow of bile into the
intestine, or hepatic resection.[4] 

Go to:

Epidemiology

The incidence of bile duct injury increased with increasing adoption of the laparoscopic technique for cholecystectomy and
treatment of other biliary pathologies. Bile duct injury occurs in 0.3 to 0.7% of the approximately 750000 laparoscopic
cholecystectomies performed in the United States every year.[1] Iatrogenic bile duct injury is a cause of significant morbidity and
mortality, especially when not recognized intraoperatively, which only occurs 25% to 32.4% of the time.[5] This frequently
results in a reduction in quality of life for the patient and litigation for the surgeon. When the bile duct is injured
laparoscopically, the injuries tend to be more complex, due to the limited visualization and adoption of electrosurgery.[6] 

Risk factors of bile duct injury include anatomic variants, patient condition, gallbladder pathology, and surgeon related factors. A
short cystic duct or cystic duct that runs parallel to the common bile duct can lead to the misidentification of the cystic duct.
Other factors, such as variation of the cystic duct and common hepatic duct junction, a cystic duct that inserts onto the right
hepatic duct, an accessory cystic duct, or presence of ducts of Luschka also contribute to injury or leak. Patients who have severe
obesity, prior hepatobiliary surgery, or underlying liver disease can impair visualization and increase the rate of injury, though
80% of injuries occur in the absence of any risk factors. Acute cholecystitis increased the rate of bile duct injuries due to the
associated inflammation, adhesions, gallbladder wall thickening, and increased bleeding.[7] As surgeons perform more
laparoscopic cholecystectomies, the rate of bile duct injury decreases. Routine intraoperative cholangiography does not decrease
the incidence of bile duct injuries.[8] However in cases of uncertain anatomy or suspicion of BDI, an intraoperative
cholangiogram(IOC) or another alternative method to delineate biliary anatomy has been recommended.[9]

Go to:

Histopathology

Histologically, the bile duct injury may be inconspicuous, consisting of reactive and focal degenerative changes in bile duct
epithelium. These cells become ballooned and vacuolated. The pathologist may note pyknotic nuclei and mitotic figures.

In the most advanced stage, there is often portal edema with polymorphic inflammatory cells containing neutrophils. Frank
cholestasis may present with the presence of bile pigment within Kupffer cells and hepatocytes and bile duct proliferation with
canalicular bile plugs.

At late stages, portal tract fibrosis may be prominent, and appropriate treatment must precede this irreversible stage.

Go to:

History and Physical

Only approximately 25 to 40% of bile duct injuries are recognized intraoperatively. The injury manifests as biliary obstruction,
biliary leak, or biliary stricture. History of gallbladder empyema[10], gangrenous cholecystitis[11] as indications for
cholecystectomy should raise higher suspicion for BDI. If the bile duct injury is not noted immediately, the patient may present
with bile in the drain if one was left in place. Otherwise, the incision may drain bile. Fever, vague abdominal pain, nausea,
pruritis, and inability to tolerate diet are postoperative findings that can indicate a BDI.

If there is a large leak or bile collection, the patient can present with an acute abdomen[12] or sepsis.

In cases of biliary obstruction, the patient will have features of obstructive jaundice. Early recognition of the injury is essential to
minimize the morbidity associated with untreated bile duct injuries, such as cholangitis, portal hypertension, or cirrhosis.

Go to:

Evaluation

If there is a bile duct injury or leak noted intraoperatively, the surgeon must decide whether he has adequate training, staff, and
resources to evaluate and treat the injury appropriately. If the surgeon decides to proceed, cholangiography must be performed to
delineate anatomy and plan treatment.[13] If the surgeon feels he cannot safely repair the injury, no further dissection or
conversion to laparotomy should be performed, and the patient should have a drain placed and transferred to an institution with
experienced surgeons. If a cholangiogram catheter can easily be placed into the injury, this can help the next team identify the
injury and perform prompt cholangiogram. 

In patients presenting postoperatively, an abdominal ultrasound can identify the presence of a fluid collection in the gallbladder
fossa or ductal dilation, which can pair with clinical findings of abdominal pain and hyperbilirubinemia to indicate the presence
of a bile leak. CT scan is very sensitive to evaluate free fluid within the abdomen. A HIDA scan[14] can distinguish the normal
postoperative fluid collections from irrigation fluid or bile spillage intraoperatively from an active bile leak, but it is difficult to
ascertain the level of the leak from HIDA scan. A final delayed image of 3 hours post radiotracer injection is necessary if no
major leak is initially noted to confirm the absence of a leak. Endoscopic retrograde cholangiography is used to evaluate the level
of the leak and provide therapeutic intervention through stenting. Magnetic resonance cholangiopancreatography can help
diagnose a biliary leak, especially the level of the leak. 

There are many proposed classification systems of injuries to the bile duct.

The Strasberg-Bismuth classification defines injuries and biliary strictures based on their anatomic location within the biliary
system relating to the biliary confluence.[15] Type A, the most common, is a leak from the cystic duct or small ducts in the
gallbladder or liver bed. Type B is an occlusion of an aberrant right hepatic duct, while type C is transection of this aberrant right
hepatic duct with subsequent leakage. These injuries often occur in conjunction with a cystic duct that drains into an aberrant
right hepatic duct. At the level of the aberrant right hepatic duct draining into the common hepatic or common bile duct, it may
be misidentified as the cystic duct and transected. Type D is an injury to the lateral bile duct involving less than 50% of the duct
circumference. Type E injuries are defined as strictures to the hepatic ducts and are further classified by the proximal extent.
Type E1 strictures have a common duct stump of greater than 2 cm. Type E2 strictures have less than 2 cm of common duct
available for anastomosis. Type E3 strictures occur at the confluence. Type E4 strictures indicate a separation of the right and left
hepatic ducts due to the destruction of the confluence. Type E5 stricture is due to the injury of an aberrant right hepatic duct with
concomitant stricture of the common hepatic duct.[16] 

The McMahon classification system classifies injuries after laparoscopic cholecystectomy as either major or minor based on
the depth of injury. A laceration of less than 25% of the circumference of the common bile duct or cystic-CBD confluence ranks
as a minor injury. A complete transection or laceration greater than 25% to the CBD or any postoperative bile duct stricture is a
major injury.[17]

The Stewart-Way classification system stratifies injuries based on mechanism after examining surgeon operative reports and the
described process of injury.[18] Class I injuries occur with a prevalence of 7% when there is partial transection of the common
duct due to being mistaken for the cystic duct causing minimal loss of tissue. Most often this is due to the misidentification of the
cystic duct with the common hepatic duct. Less commonly, the extension of the cystic duct opening during cholangiography can
involve the common hepatic or common bile duct. Class II injuries occur with a prevalence of 2% from thermal injury or
inadvertent clipping of the lateral common hepatic duct, causing stricture or leak due to limited visibility or an attempt to control
bleeding. The common hepatic duct is only partially damaged, and there is an associated hepatic artery injury in 18% of cases,
especially in cases of anomalous origin of the right hepatic artery from the superior mesenteric artery. Class III injuries involve
complete transection of the common hepatic-common bile duct with excision of a variable portion of duct proximal to this
junction and occurs when mistaking the common duct for the cystic duct with subsequent partial excision of the duct as the
gallbladder gets removed. Class III injuries are the most common type, occurring in 60% of cases. Subdivision class IIIa injuries
have a remnant of common hepatic duct, while class IIIb involves transection at the junction of the cystic duct-CHD. In class
IIIc, the bifurcation has been excised with complete loss of the confluence. In class IIId, the transection is above the level of a
lobar duct or secondary bile duct. Class IV injuries involve trauma to the right hepatic or right segmental hepatic duct, 60% of
the time with additional injury to the right hepatic artery. Again, misidentification of the right hepatic duct as the cystic duct is
the most common mechanism or inadvertent injury to the lateral wall of an inferior lying right hepatic duct.  

Go to:

Treatment / Management

Depending on both the level and complexity of the injury, the treatment can range from simple drainage procedures to
reconstruction of the biliary system.[19] With all injuries, noted either at the time of injury or in a delayed fashion, the patient
can always transfer to a specialized center with clinicians and resources better suited to treat bile duct injuries.

The Strasberg classification can help guide treatment. In Strasberg type A injuries, the biliary system is in continuity with a leak
from the cystic duct or minor hepatic duct through the liver bed. If there is a drain already in place, the output can be monitored
to evaluate for spontaneous closure of the leak. Endoscopic stenting across the lesion can help occlude the leak and facilitate
drainage through the biliary system by decreasing the pressure in the proximal biliary system. Sphincterotomy may be necessary
in cases of retained choledocholithiasis. If the patient has peritonitis or worsening intraabdominal sepsis, exploration may be
necessary for washout. For Type A injuries involving leakage from the cystic duct stump, coil embolization the cystic duct by
interventional radiology has been described in a few cases.[20]

Strasberg type B injuries with only minimal pain and mild elevation in liver function tests can be treated conservatively and
monitored. The occlusion may go unnoticed and cause segmental cholestasis, intrahepatic stones, and atrophy of the right lobe of
the liver. If there is evidence of cholangitis due to the occlusion, the patient will require drainage of the affected segment via
percutaneous transhepatic cholangiogram with biliary drainage tube placement or hepaticojejunostomy. Segmental resection of
the involved segments may be necessary if the atrophy is significant. Endoscopic management of occlusive injuries is typically
unsuccessful as the occlusion puts the proximal biliary segment in discontinuity with the distal biliary tree.

Strasberg type C injuries are similar to type B, but the injured accessory duct is leaking instead of occluded. Both types B and C
injuries are not amenable to endoscopic intervention as the segment proximal to the injury is not in continuity with the biliary
system. Percutaneous drainage of the subhepatic biliary leak can result in spontaneous closure and prevention of biliary
peritonitis. In rare instances, the patient may require hepaticojejunostomy or hepatectomy. 

Strasberg type D injuries involve a medial partial injury to the common bile duct. If the injury is small with no evidence of
devascularization, the defect can be closed using interrupted 5-0 absorbable monofilament suture with a drain left in place,
endoscopic sphincterotomy, and stent placement. If there is devascularization, the surgeon should still repair the injury with a
drain left in place in anticipation of an expected bile leak. Endoscopic stent placement with interventional radiologic drain
placement is an alternative, especially for injuries noted in the postoperative period. A multidisciplinary approach is necessary to
ensure proper treatment and avoid further injury or complications. A HIDA scan is obtained two to four weeks after the insertion
of the endoscopic stent to evaluate for a continued leak. In the absence of a leak on HIDA, the stent is removed endoscopically,
and cholangiogram is performed. A leak noted on cholangiogram is treated with sphincterotomy or stent replacement for an
additional four weeks. The clinician should follow these patients with repeat ERCP or MRCP to evaluate for the development of
stricture, leak, or progression to a Strasberg type E injury. 

Strasberg type E injuries that are noted at the time of injury can be repaired primarily in an end to end fashion if there is no
tension on the anastomosis. This repair should be done over a T-tube that provides external drainage or a Y tube that drains into
the duodenum. If the anastomosis is not performable in a tension-free fashion, a Roux-en-Y hepaticojejunostomy is the preferred
reconstruction option. In cases of friable tissue or very dense adhesions where hepaticojejunostomy is not feasible, a pedicled
omental patch can be used as a temporary repair to control bile leak until definitive reconstruction.[21] 

Vascular injuries associated with bile duct injuries can present with hemobilia, abscess, or ischemia, for which the management
is angioembolization, percutaneous drainage, or liver resection, respectively.[22]

Go to:

Differential Diagnosis
Patients who continue to have symptoms of nausea, vomiting, jaundice, or abdominal pain after cholecystectomy may be
suffering from post-cholecystectomy syndrome (PCS).[23] The reported incidence varies from 5 to 60%, and symptoms can
result from a bile duct injury, stricture, retained stones, biliary dyskinesia, or sphincter of Oddi dysfunction.

Patients may also have symptoms of PCS caused by extra-biliary disorders, such as peptic ulcer disease, pancreas divisum,
pancreatitis, pancreatic masses, mesenteric ischemia, diverticulitis, or intestinal motility disorders.[24] Rarely, patients can have
biliary like symptoms due to extraintestinal disorders, such as a psychosomatic manifestation of psychiatric disorder or coronary
artery disease.

Go to:

Prognosis

Bile duct injury can cause serious complications, such as strictures, ascending cholangitis, cirrhosis, or portal hypertension, if
unrecognized or improperly managed. Overall, there is a reduction in long term survival and quality of life with high rates of
litigation.[25] 

The surgeon should defer management of the injury to an experienced center with trained hepatobiliary experts, as the
reconstruction performed by the surgeon causing the injury is only successful in treating the injury 21% of the time.[26] 

The factors associated with successful repair include control of intraabdominal infection, intraoperative cholangiography, using
the correct surgical reconstructive technique, and a repair performed by a hepatobiliary surgeon. The timing of repair has not
been shown to influence the success of the repair as long as there is control of intraabdominal sepsis. Studies have demonstrated
worse outcomes with early repair in the presence of intraabdominal infection.[27]

Go to:

Complications

Complications of bile duct injury vary in their potential morbidity. A biliary leak can cause biloma, abscess, wound infection,
intraabdominal infection, and sepsis. Almost all bile duct leaks are successfully treatable with endoscopic stent (96%). Bile duct
reconstruction with hepaticojejunostomy for transection or stricture can result in wound infection, bile leak, a migration of stents
in approximately 11% of patients.[28] Overall morbidity after hepaticojejunostomy reconstruction is 36% and mortality
approximately 2%. More serious complications after reconstruction include stricture (30%) which can be treated conservatively,
with a percutaneous stent, or with a redo hepaticojejunostomy. If this fails or the complication is recognized too late, the patient
may develop secondary biliary cirrhosis and require liver resection or transplant. Other surgical related complications include
dehiscence of the anastomosis, pulmonary embolism, bleeding, or uncontrolled sepsis. About 50% of patients have no
complications after hepaticojejunostomy. 

Go to:

Postoperative and Rehabilitation Care

Most patients will do well after the endoscopic management of the bile duct injury. They should not require a prolonged in-
hospital stay. For patients requiring complex repairs of the BDI will frequently have a longer inpatient stay and are candidates for
post-operative rehabilitation. In the elderly population, it may take even longer to get back to the baseline functional level.

Go to:

Consultations
Bile duct injury is a complex and challenging problem for the surgeon. It frequently requires expertise from the endoscopist,
gastroenterologists, and interventional radiologists. In more complicated cases hepatobiliary or even transplant surgeons may
need to intervene. Infectious disease physicians will need to provide input in the patient presenting with uncontrolled sepsis.
Intensivists play a vital role in the management of these patients in the immediate postoperative period after complex
reconstructions or for patients presenting with severe sepsis and multiorgan failure.

Go to:

Deterrence and Patient Education

There are different proposed techniques to prevent bile duct injury during laparoscopic cholecystectomy. The critical view of
safety(CVS) is one such technique to ensure proper identification of the cystic duct and artery to prevent common bile duct or
hepatic duct injury. The technique requires the separation of the lower third of the gallbladder from the cystic plate, clearance of
fat and fibrous tissue from the hepatocystic triangle, and identifying two and only two structures entering the gallbladder, which
are the cystic duct and cystic artery.[29] Local inflammation can cause scarring and distorted anatomy resulting in the appearance
of the common bile duct arising from the gallbladder infundibulum.[30] Difficulty cholecystectomies have higher rates of bile
duct injury and conversion to open, so if the CVS is not obtainable, the surgeon should consider a bailout cholecystostomy,
subtotal cholecystectomy, or referral to a tertiary care center. 

The rate of bile duct injury in laparoscopic cholecystectomy is less than 1%, which limits the ability to collect enough data
through randomized controlled trials to demonstrate statistical significance, though smaller studies do support the use of CVS.
SAGES created a Safe Cholecystectomy program online to teach and promote the adoption of attaining the CVS and avoid
inadvertent injury, especially in the difficult gallbladder.