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REVIEW ARTICLE Table of Contents   
Year : 2000  |  Volume : 6  |  Issue : 2  |  Page : 67-78
Endoscopic management of postcholecystectomy bile duct injuries: Review


Department of Medicine Gastroenterology Division, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

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Date of Submission30-Jun-1999
Date of Acceptance04-Nov-1999
 

   Abstract 

Injuries to the biliary tree arising as a consequence of cholecystectomy, continue to be significant complicating factors. The advent of laparoscopic cholecystectomy has resulted in a further rise in the incidence of these injuries. Various means of investigation are available to assess the site, extent and severity of the damage to the biliary tree. Lately, the endoscopic option seems to have gained popularity in the management of these patients as it can combine both the investigative and therapeutic arms in one common procedure. This procedure is recommended as the primary modality of intervention gaining precedence over the radiological and surgical options. Since limitations exist in managing these patients with endoscopic retrograde cholangiopancreatography, a combined approach between the endoscopist, surgeon and radiologist, is the most practical option. In this article, we review the various types of biliary injuries, their reported incidence, etiological factors, the diagnostic means available, and the endoscopic management of each.

Keywords: Postcholecystectomy: bile duct injury: leak: stricture: endoscopic management.

How to cite this article:
Al Karawi MA, Sanai FM, Mohamed AE, Mohamed SA. Endoscopic management of postcholecystectomy bile duct injuries: Review. Saudi J Gastroenterol 2000;6:67-78

How to cite this URL:
Al Karawi MA, Sanai FM, Mohamed AE, Mohamed SA. Endoscopic management of postcholecystectomy bile duct injuries: Review. Saudi J Gastroenterol [serial online] 2000 [cited 2020 Nov 25];6:67-78. Available from: https://www.saudijgastro.com/text.asp?2000/6/2/67/33482


Cholecystectomy has been the standard treatment for gallbladder disease. The introduction of laparoscopic cholecystectomy (LC) in the early 90's resulted in an increase in the rate of complications[1],[2],[3]. Some of these complications are recognized during the procedure and corrected immediately; others are discovered late and need either re-laparotomy or endoscopic intervention. Endoscopic retrograde cholangiopancreatography (ERCP) is now a well­-established method for both diagnosis and treatment of bile duct injuries (BDI). Although BDI can frequently occur with gastrectomy, hepatic resection and common bile duct (CBD) exploration, the most common cause continues to be cholecystectomy[4] With the widespread use of LC for the management of symptomatic cholecystolithiasis and the mandatory learning phase of every surgeon embarking on this procedure, there has been an increase in the number of complications being referred for endoscopic intervention and management. Although ERCP is the treatment of choice even for other biliary diseases such as choledocholithiasis,  Sphincter of Oddi More Details dysfunction and malignancy of the biliary tree, it unfortunately holds the possibility of inducing complications such as pancreatitis, cholangitis, bleeding and perforations. However, the rate of complications encountered during ERCP does not obviate the need for endoscopic management of various biliary tract injuries. With the advent of LC and its preference over open cholecystectomy (OC) by the majority of surgeons and patients, there has been an increasing demand to manage the subsequent complications of this form of surgery with the least invasive of methods. Endoscopic management has gained rapid popularity in remedying these problems[3],[5],[6] Furthermore, ERCP has also been evaluated for preoperative diagnosis of biliary disease and many studies have been published accordingly[7],[8],[9]


   Types of Biliary Injuries Top


After gall-bladder resection, two types of biliary injuries are encountered-biliary leaks and strictures. These injuries are similar in their site and features, regardless of the method adopted for cholecystectomy-laparoscopic or open. Undetected CBD stones may lead to the development of a biliary leak, which can occur within a few days after laparoscopic cholecystectomy with the increase of intraductal pressure subsequently leading to the spontaneous release of cystic duct clips. Cystic duct stump leak counts as the most common of BDI after LC[1],[10]. Leaks can also occur by direct injury to the CBD and can be found anywhere in the biliary tree. Injuries to the biliary tract are of different types and many different classifications have been proposed. Amongst these, Strasberg's group classification scheme[11] is perhaps the most popular. According to this there are five types of biliary injuries-Type A injury corresponds to a leak from a minor bile duct which is still in continuity with the CBD (i.e. cystic duct leaks and those ducts that arise from the gall bladder bed). Type B leaks are characterized by occlusion of part of the biliary tree. Type C leak are from a duct that is not in communication with the CBD; and type D leaks are caused by lateral injury to extrahepatic bile ducts [Figure - 1]. Type E are again subdivided into E1-5 with circumferential injury of major ducts, corresponding to Bismuth class [1],[2],[3],[4],[5] [Figure - 1].


   Incidence Top


Studies from different parts of the world have reported a comparatively similar incidence of bile duct injuries. Although, the incidence of BDI for LC has been cited in the relatively low range of 0.2 to 0.6%[12],[13],[14],[15],[16],[17], it is commonly in the range of 0.6 to 1.5%[18] and 0.1 to 0.2%(18) for open surgery. The perceptible difference in the rates between the two approaches has been a source of constant review by surgeons. Large-scale audits have been undertaken to determine the true extent of BDI, but these are limited by probable under-reporting[11]. Similarly, the rates of different types of injury may also vary depending on whether the origin of the series is surgical, radiological or endoscopic[19]. Earlier literature envisaged a drop in the complication rates of laparoscopic cholecystectomy as expertise with the procedure increased[1],[20]. However, some centers have reported a consistently steady state, if not higher, incidence of injury in later years compared to earlier experience[21]. A report of 10,000 cases of LC from US military institutions by Wherry et al where comparisons were made between initial experiences in 1994[16] and later experiences in 1996[17], failed to show the anticipated drop in incidence of BDI. This was inferred by others to be related to a higher number of LC being performed yearly [Figure - 2], with more surgeons entering their "learning ­phase"[22]. In contrast though, some reports have indicated a decrease in the rate of injuries[10]. Biliary injury rates reported from England and Wales by Dunn et a1[13] ranged between 0.3-0.8%, similar to a series from Europe (0.3%)(20) and USA (0.25­0.5%)[14]. Bile duct injuries reported during open cholecystectomy was 0.1-0.2%[1],[15],[23]. Gilleland and Traverso[24] reported a total BDI of 0.8% during OC while Scott et al[25] in a meta-analysis of 12,397 patients undergoing LC reported a similar incidence of 0.7%. In terms of specifics, the rate of major BDI was reported between 0.3 to 0.6% for LC[18]; and that for OC had reached a figure of 0.075%.


   Etiology Top


Perhaps the greatest risk for BDI is at the hands of an inexperienced surgeon in the period of the so-called `learning curve'. By all estimates, this is the most consistent risk factor in these injuries. In their analysis of LC, Scott et a1[25] compared the incidence of BDI against the surgeons' experience thereby demonstrating the significance of the `learning curve' [Figure - 3]. An increased risk is also evident in those surgeries that are performed with acute or chronic cholecystitis, since the underlying inflammation poses problems in identifying the hepatobiliary anatomy. Flowers et al[26] have discounted this after comparing results of LC between cases of acute cholecystitis and elective surgery. Inadequate exposure, patient obesity and failure to identify structures before clamping, ligating or dividing them also serve as etiologic factors[4]. These factors lead to injury in the form of a ductal tear or to inadvertent placing of a clip across a bile duct[27]. Specifically for LC, some authors have hypothesized the lack of tactile sensation, possible tenting of the common hepatic duct (CHD) during retraction of the neck of the gallbladder, absence of a three dimensional view and a short cystic duct, as possible mechanisms of BDI[28] . Vascular occlusion in an attempt to achieve haemostasis from bleeding cystic and hepatic arteries have been identified as rare causes of post-operative biliary strictures [29]. The use of laser and cautery for dissection have also been alternatively cited as aetiological factors in BDI30). Undetected or retained CBD stones postoperatively, are also known to be causative factors in the development of BDI. These may lead to development of both leaks and strictures. Such stones have been found in about 25% of postcholecystectomy leaks[3]. intraoperative biliary exploration for stones may lead to ductal damage and also subsequent stricture formation.

Biliary leaks that have developed as a result of the above factors may subsequently lead to stricture formation in the aftermath of the intense connective tissue response with fibrosis and scarring that occur after BDI. Conversely, strictures in turn may also result in leaks as the intraductal pressure builds up leading to spontaneous release of cystic duct clips. Strictures developing at the site of biliary anastomoses undertaken for leaks or complete transections are also well-recognized[31] Congenital anomalies of the drainage system such as a low cystic duct insertion or insertion of the right hepatic duct into the cystic duct commonly leads to erroneous ligations by the surgeon. After all, aberrant anatomy of the extrahepatic biliary tree and adjacent hepatic arteries occur in more than 50% of patients[32]. This fact, however, does not translate into an incidence-based relationship since the vast majority of biliary leaks occur in patients with normal anatomy[2]


   Clinical Features Top


Clinicians should be aware of the various presentations of post-cholecystectomy biliary injuries since early recognition of the problem may obviate the need for future complicated remedial measures[22]. Some of these injuries present early while others manifest late based upon the type or site of BDI. An attempt will be made to categorize their different presentations along the lines of leaks and strictures, although it would be prudent to mention that in a few instances the distinction between the two forms becomes blurred; and at other times the two may co-exist.


   Biliary Leaks Top


The onset of clinical manifestations of the leaks may range from nausea, vomiting, abdominal pain, ileus, fever, jaundice, abdominal tenderness and guarding. These symptoms are related to the inflammatory response evoked by the presence of bile in the peritoneal cavity. Rarely, abdominal distension results from the free flow of bile into the peritoneal cavity leading to biliary ascites[33]. Palpable masses resulting from a biloma are rare[34]. Jaundice is reported in less than half the cases[35] . In those patients who have an in-dwelling drain postoperatively, bilious drainage should immediately raise the suspicion of a biliary injury. Therefore, early presentations in the form of biliary peritonitis, sterile bilomas or subhepatic abscesses usually reflect leakage rather than stricture.


   Biliary Strictures Top


Strictures on the other hand may manifest as painless aberrations of liver enzymes with the pattern of cholestasis, accompanied by cholangitis, with or without sepsis. This is the most common presentation[36]. Less commonly, patients may present with a painless jaundice without any cholangitis. Late manifestations extending into years are usually the result of minor injuries or incomplete strictures. The delay in diagnosis may present as advanced biliary cirrhosis and its sequelae.


   Investigations Top


In the evaluation of bile leaks, blood investigations are not very helpful unless there is simultaneous injury to the liver or accompanying stricture. However, in the case of biliary strictures, these are frequently abnormal. Among the biochemical parameters of liver function the most common finding is the elevation of serum alkaline phosphatase. Serum bilirubin levels fluctuate and may occasionally be even normal. The aminotransferases are either normal or mildly elevated, except during episodes of cholangitis. In the scenario where the injury has eventually resulted in advanced liver cirrhosis, derangement of the synthetic liver function may be seen. In the presence of postoperative pain, ultrasonography and CT scans can detect intraabdominal free fluid or loculated-type collections suggesting a biloma formation. In the presence of intraabdominal collection, percutaneous drainage should be performed and the presence of bile be confirmed. These imaging techniques also play an important role in investigating patients with strictures where the biliary tree is dilated. Another important means of evaluating the BDI is by hepatobiliary (HI DA) scintigraphy. Scintigraphy can follow initial evaluation by the above techniques to determine persistence of a leak and the need for endoscopic management. Scintigraphy gains its importance from the surmise that CT scan and ultrasonography are nonspecific and a biloma may be mistakenly identified as a resolving hematoma, seroma or an abscess. On the other hand radionuclide scans are very sensitive in detecting bile leaks[37],[38]. A failure of excretion of the radionuclide into the small bowel with extra biliary accumulation indicates a bile leak or an actual biloma. Some investigators have recommended this mode of evaluation as a primary screening test in the diagnosis of biliary leak[39]. This form of imaging has the advantage that the nature of the intra-abdominal fluid can be more clearly delineated by demonstrating a leak site as originating from the biliary tree. Unfortunately, the ability of the HIDA scans in detecting strictures and delineation biliary anatomy is limited[40]

The gold standard for the evaluation of biliary injuries continues to be cholangiography - whether it is percutaneous transhepatic (PTC) or endoscopic transpapillary is a matter of specific indication and at times, personal choice. PTC is performed only in those selective cases where ERCP is not successful[41]. In areas of complete ligation, PTC is the preferred choice since it allows the evaluation of the proximal biliary tree that is to be used in the surgical reconstruction. In addition, access for stenting is also fulfilled through the same route. Aside from the above scenario of complete ductal ligation where only the distal CBD may be visualized, ERCP fulfills the diagnostic purpose in probably all other situations. Whatever the eventual choice of approach to the biliary tree, cholangiography provides the anatomical details of the biliary tree. In the setting of a preoperative investigative step as has been recommended by certain investigators[7],[8],[9], cholangiography further avoids the misidentification of the right hepatic, right sectorial, CBD etc. as the cystic duct. In the presence of abnormal LFT prior to surgery, most investigators agree to the need for performing a preoperative or intraoperative cholangiogram. This has been shown to reduce the incidence of subsequent injuries to the biliary tract. In a study by Andren-Sandberg et al[42], it was shown that about 50% of CBD injuries occurred prior to intraoperative cholangiography, implying that the value lies more in the demonstration rather than the prevention of injury. Similarly, Macintyre and Wilson[43] found no correlation between the routine use of intraoperative cholangiography and CBD injuries. Nevertheless, intraoperative cholangiogram helps in the early detection of biliary injury and thereby facilitates management. ERCP as a postoperative procedure is performed in those patients in whom ultrasonography, CT scan or hepatobiliary scintigraphy has shown biliary dilatation or intraperitoneal collection[44]. This has been shown to be the most reliable test for definitive diagnosis of BDI and helps in identifying the exact anatomical site of leakage [Figure - 4] and obstruction [Figure - 5] with a sensitivity of 96.7%[44]. In the situation where an external bile fistula has developed following intra-operative injury, a sinogram may be done through the drainage tract itself and help define the site of the leak and the anatomy of the biliary tree.


   Endoscopic Management Top


Biliary Leaks

The treatment goal in BDI is the re-establishment of bile flow by the reduction of the intraductal pressure gradient across the papilla. This is done with the view towards preventing bile duct strictures and subsequent secondary biliary cirrhosis, recurrent cholangitis and choledocholithiasis. There are various approaches to the treatment of biliary leaks like surgical correction, radiological assistance and endoscopic intervention. In this review we will only be concentrating on the endoscopic aspect. The management of biliary injuries, including leaks, requires a team with a focused understanding and approval between a skilled endoscopist, an interventional radiologist and a hepatobiliary surgeon. This multidisciplinary approach encompasses the utilisation of ERCP, PTC or a combination of these approaches to facilitate internal stenting.

Endoscopic management of the BDI has gained rapid popularity among physicians and surgeons alike. The factor responsible for this preference is the relatively less invasive nature of this procedure compared to the surgical and percutaneous options. Once recognized, bile duct leaks can be treated in the same session. The basis behind endoscopic therapy rests on the reduction or elimination of intraductal pressure gradient across the papilla. This facilitates the flow of bile into the duodenum and away from the injured site. In the scenario where a leak develops in the presence of choledocholithiasis, endoscopic sphincterotomy and stone extraction from the CBD may be sufficient without the need for stent or nasobiliary tube (NBT) placement[45]. This is especially important since stones form the causative factor in about 25% of BDI. However, the problem of whether to extract silent CBD stones continues to arouse controversy, especially since some series have reported that 50% of such stones may pass spontaneously[46]. In instances where stones are not the underlying cause of the injury, papillotomy, stent placement, NBT decompression or any combination of these three options, can be indicated. These stents heal the leaks probably by removing the physiological pressure gradient through sphincterotomy and tamponading the leak site. Type A and D injuries are usually treated in this way. Some type B and C injuries without complete transection, and where some form of continuity has been maintained may be also treated in a similar manner. Bergmann et a1[6] in their study reported a successful stent placement in 89% of cystic duct, aberrant or peripheral hepatic ducts. In this study, surgical treatment was compared with endoscopic stent placement and it was found that 75% of patients treated surgically developed late strictures and those managed endoscopically had this complication in 71% of cases. They inferred that bile leaks should be treated endoscopically and failing this should then proceed for the surgical option. The lower morbidity and mortality rates with endoscopic therapy in comparison to surgery, have also encouraged gastroenterologists in advocating this approach[47],[48] Early detection of a leak in the presence of peritonitis mandates the use of systemic antibiotics. This is done along with percutaneous drainage of biloma or biliary ascites when either is detected. ERCP or PTC subsequently play an adjunctive role in maintaining bile drainage by means of papillotomy and/or stent placement. Endoscopic sphincterotomy by itself may be sufficient in treating minor leaks, but stent placement or nasobiliary drainage are required in major leaks[48],[49]. Although most experts accept that elimination of transampullary pressure is a key factor in the healing of bile leaks, the ideal way of achieving this is still uncertain[50]. No definite consensus exists on the size of the stent to be used and this is usually left to the endoscopist's timely discretion. A general rule of the thumb applies where a smaller stent is used for a smaller leak, and a bigger stent for a large leak. The duration of time that a stent should be left in-situ is surrounded by controversy. Different authors have advocated different time duration of stent placements based on their estimation of the time required for leak closure. Foutch et al[49] in treating 23 patients with leaks left their stents/NBT for a mean of 6.2 weeks (range I­16 weeks). In a review of BDI management, Vechio et at[51] advocated removing the stent after 3 to 6 weeks after accepting a period of 1 to 3 weeks as the time required for leak closure after endoscopic treatment. Similarly Bjorkman et al[52] , in treating 15 patients with bile leaks advocated stent removal after 7 to 45 days. In our opinion stent removal should be done after an average of 3 weeks. Nevertheless, individualization to the patient may be done depending on the site and size of the leak and the presence of other co-morbid factors like cholangitis, strictures etc. The uncertainty of the time required for leak closure entails that repeated ERCPs may be performed to determine definitive leak closure. This difficulty can be overcome by opting for a nasobiliary drain through which closer monitoring of the leak is possible[49], and no additional ERCP for tube removal is needed. However, NBT cannot be kept for long periods because of discomfort to the patient. If a bile duct injury and leak is recognized during the LC, conversion to open cholecystectomy intraoperatively is mandatory. Biliary leaks when large or undetected for a significant period of time may result in the development of biliary ascites or a biloma respectively. Although, ERCP may allow healing of the leak but it cannot offer treatment for the bile collection within the abdominal cavity. This requires interventional radiology in the form of guided percutaneous aspiration of the bilious material. Smaller collections may be managed conservatively but larger collections should be aspirated[34]. Aspiration is beneficial in two ways relieving patient's symptoms of abdominal pain and distension, and reducing intraductal pressure by diverting the bile flow externally. When fistulous tracts have developed secondary to these leaks, they are managed in a similar way consisting of biliary diversion by endoscopic or percutaneous drainage. This stage of stabilization may result in the closure of the fistula. Alternatively, the length of time the fistula has persisted, the volume of bile drained and the presence of associated sepsis, are factors associated with non closure of these fistulae. In such a scenario, a more aggressive approach is suggested by Branum et al[27] who advocate surgery after the initial stage of stabilization, and non closure of the fistulae.

Biliary Strictures

The basis for stent placement in biliary strictures is to bridge the defect, dilate the narrow area and act as a splint to prevent a future stricture formation. The endoscopic approach to biliary stricture implies performing ERCP with sphincterotomy followed by hydrostatic balloon dilatation or bougie of the narrowed area to match the size of the duct immediately distal to the stenosis. This is followed by a stent insertion to prevent the formation of the stricture by the fibrosing process. A variation of this form of treatment exists where endoscopists use either repeated balloon dilatations or temporary stent insertions. Balloon dilatations or stent exchange may be performed at regular intervals as and when indicated. However, it is worthy to note that most endoscopists no longer recommend the usage of isolated balloon dilatations in managing these strictures.

Unlike biliary leaks where there is an increasing preference for ERCP as the primary modality of treatment, strictures unfortunately pose a more complex problem. Their treatment therefore is controversial. However, a recent trend towards ERCP as the least invasive form of initial therapy has again been recommended. In a comparison between surgical and endoscopic treatment by David et a1[53], it was found that the overall complication rate was similar at 26% for surgical and 35% for endoscopic patients. The authors concluded that endoscopic stenting should be considered for the initial attempt at definitive management of those patients suited for such therapy in the hope of avoiding re-operation. Success of endoscopic therapy is evaluated by comparison to surgical outcome.

The type of stents used has not seen much experimentation since the early reports of metal stents indicated a high rate of failure[54],. This problem is further compounded by the fact that metal stents are difficult to extract once they are inserted and this may again have its inherent complications. In a study undertaken on dogs where self-expandable metal stents were inserted, the bile ducts showed marked narrowing secondary to extensive fibrosis. This was in obvious contrast to the minimal changes seen after using plastic or covered metal stents[55].

Time duration of stent placement is usually 3 months with subsequent stent exchanges taking place for a total of 1-2 years. Stent exchanges should be accompanied by balloon dilatation on every occasion[53],[56] Similarly, balloon dilatations without stenting are also not recommended since strictures are likely to recur with this modality of treatment.

Success rates of endoscopic management of certain type E biliary injuries [53],[54],[56],[57],[58],[59],[60] has been widely reported [Table 1] and some authors have claimed an equal patency rate of biliary ducts after surgical correction or therapeutic endoscopy[8],[9]. For type E3 hilar strictures, both the right and left main hepatic ducts should be selectively stented. Endoscopic stenting is feasible in those patients where the obstruction is partial, with a short stenotic segment, or if the patient presents months to years after surgery[18]. However, in those patients where complete ductal ligation has taken place, surgery should be the primary modality of treatment after initial cholangiographic assessment[61]. This may well be the case in most type B and C injuries also. It is important to stress that in such cases surgery be performed by the most skilled hepatobiliary surgeon.

The problem of stricture recurrence is unfortunately a real one. Endoscopic, percutaneous and surgical modalities of treatment are all faced with this complication. The incidence of stricture re­formation after endoscopic stenting is amenable to re­-stenting, albeit with a higher morbidity. David et al[53] compared the surgical and endoscopic management of benign biliary strictures. They reported a re-stricturing rate of 17% for both patient groups after a mean follow-up of 50 months for surgery and 42 months for ERCP. Operative management of strictures is not only technically difficult, with a significant postoperative morbidity and mortality but also has a high rate of re-stricturing. Satisfactory long term results are seen in about 70-90% of patients[4]. Two-­thirds of the recurrent strictures occur in the first two years and 90% within 7 years. The percentage of patients with good results is inversely related to the number of previous repairs[4[. In the group of patients who present late after the BDI, there may be an increased likelihood of finding stones above the stricture [Figure - 6]. The pathogenesis of these stones is related to the prolonged intraductal cholestasis.

Combined Leaks and Strictures

A combination of these two primary types of postcholecystectomy BDI can be seen in some cases. The leak usually results from a stricture, which leads to a build-up of intraductal pressure causing the spontaneous release of the clips. Retained stones in the CBD also function by the same mechanism in causing leaks. The treatment, however for these patients remains the same as that described for the above scenarios i.e. removal of the obstructing lesion and redirecting the flow of bile into the duodenum. Other therapeutic modalities, interventions, subsequent complications and outcomes are also similar. Not much information is available on a categorized basis for the outcome plotted against different interventions for these combined type of injuries.

Percutaneous management of these injuries is also of known importance since this constitutes the largest nonsurgical experience. Since this approach requires going through the liver tissue to access the biliary channels, a certain amount of complications can be anticipated. These include infections, hemobilia and bile leaks in approximately 20% of patients[4]. The percutaneous route is known to carry a higher morbidity rate than the endoscopic one. Also, this form of management is limited in those cases where there has been loss of ductal continuity or where the ducts are proximally decompressed, making access extremely difficult. Success rate of percutaneous dilatation and stenting ranges between 55 to 92%[57],[58] and is also associated with a long-term re-stricturing rate of 30 to. 50%[59]. The percutaneous transhepatic approach can be combined with the endoscopic route to bypass difficult strictures or in situations of a complicated access to the papilla. This is referred to as the Rendezvous Maneuver [60],[62] and by this technique stenting of the biliary tree can be achieved in difficult cases.

Needless to mention, endoscopic management of biliary injuries was not the norm in the past. Recent advances in endoscopic techniques such as therapeutic stenting and nasobiliary drainage has added a new dimension to postcholecystectomy BDI treatment. Added to this is the pathologic basis of these biliary leaks that result in bile spillage into the surrounding tissue leading to severe inflammation and a significantly decompressed biliary ductal system. This makes identification of the affected area and subsequent surgical repair, almost impossible in the early period. Moreover, the length of the bile duct available for anastomosis and the experience and skill of the surgeon are factors of paramount importance in opting for a nonsurgical approach.

Some Practical Hints

It is also important to know some of the difficulties that can be encountered in the management of bile duct injuries. For instance, cannulation of the papilla may be, in some cases, rather difficult as a consequence of the collapsed bile duct in the event of a major leak. This can be overcome by inserting a guidewire, which helps in identifying the route to the proximal part of the duct by bypassing the leak. The guidewire can also be useful in performing a small sphincterotomy to facilitate easy access for stenting and other therapeutic maneuvers. In similar scenarios of major BDI where access to the ducts has become difficult, a hybrid or tracer guidewire can also be used to cannulate the papilla and over this the catheter may be introduced. This is followed by withdrawal of the guidewire, visualizing the biliary tree for confirmation of the leak site and catheter position, and then eventually placing the stent. In such situations, it may be quite common to unintentionally overfill the pancreatic duct. Therefore, precautions should be taken to consciously avoid the complication of chemical pancreatitis. On the other hand, in the case of a benign stricture the tissue may be stiff and this requires dilatation with a bougie or a balloon. This is followed up by long-term stenting with one or two stents for a period of one or two years with stent exchange taking place every three months to avoid clogging. However, in cases where the stricture is of a shorter duration, the tissue may yet be soft and therefore requires a shorter duration of bougie not extending beyond six months.

In cases where the stricture is too tight, the tracer guidewire can again be utilized to access the proximal biliary tree. Rarely, it may not be feasible to endoscopically access the papilla or to cannulate a completely ligated duct. In this case, the Rendezvous Maneuver, a combination of PTC and ERCP, can be utilized to achieve drainage and long-term stenting.

In our experience in Riyadh Armed Forces Hospital, we have managed endoscopically a total of 96 cases of BDI, of which 34 were leaks and 62 strictures. Most of these injuries resulted as a complication of cholecystectomy, while the rest of these were seen in the setting of road traffic accidents, partial hepatic resections etc. The site of biliary leak was cystic duct stump in 11, CBD in 13, CHD in 6, right hepatic duct in 2, and gallbladder bed in 2 patients. Thirteen of these patients also had associated stone extraction. Endoscopic management was provided based on the individual findings in the different patients. ES alone was performed in 9 patients, 3 had stenting alone and 12 patients had ES along with stenting. NBD was used only in 2 patients. Endoscopic management was unsuccessful in 7 patients, including two who had complete ligation of CBD. Successful biliary leak closure was achieved in 79.41% (27 patients). There were no ERCP related major complications. A total of 62 patients were found to have biliary strictures after undergoing cholecystectomy. All patients who were given a trial of endoscopic management underwent stricture dilatation along with sphincterotomy and stent placement across the narrowed area. Biliary stones found in those patients were extracted. There were no complications encountered in these patients apart from the expected intermittent presentations of cholangitis resulting from the clogging of stents in their mandatory period of follow-up. Actual treatment failure occurred in 4 of those patients who underwent the trial of the above routine, and consequently, had to be referred for surgical management.


   Conclusion Top


In view of the higher incidence and the changing demography of the BDI with the introduction of LC, endoscopic therapy of these injuries is being more commonly sought as the primary modality of intervention. With the increasing popularity and availability of LC in the treatment of symptomatic gallstones, coupled with an increasing number of surgeons entering the `learning phase' for this procedure, it is expected that the need for ERCP would overhaul the other modalities available for BDI management. Whether it is in the investigation or in the treatment of the BDI, it is of paramount importance to approach these injuries in co­ordination with the endoscopist, interventional radiologist and the hepatobiliary surgeon. When the need for surgery becomes essential due to the nature of the injury or to nonresponse to other forms of treatment, it should be undertaken in a specialized hepatobiliary surgical unit.

 
   References Top

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Correspondence Address:
Mohamed Ali Al Karawi
Gastroenterology Division A-41, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


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    Abstract
    Types of Biliary...
    Incidence
    Etiology
    Clinical Features
    Biliary Leaks
    Biliary Strictures
    Investigations
    Endoscopic Manag...
    Conclusion
    References
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