A novel pattern of complex bile duct injury characterized by distal ligation and proximal perforation: temporary T-tube drainage as a bridge to definitive reconstruction—a case report and literature review

Abstract

Bile duct injury (BDI) is a serious complication of cholecystectomy. We report a previously unrecognized pattern of complex BDI in a 30-year-old man who presented one week after open cholecystectomy with biliary peritonitis. Endoscopic retrograde cholangiopancreatography demonstrated an abrupt common bile duct (CBD) cutoff, while magnetic resonance cholangiopancreatography revealed a biloma with features suggestive of biliary peritonitis. Exploratory laparotomy confirmed distal CBD ligation with proximal common hepatic duct perforation. Because of severe inflammation and friable tissues, definitive reconstruction was deferred, and temporary T-tube drainage was established. The T-tube was maintained for ~3 months before removal. The established tract remained temporarily patent after removal, permitting transient bile drainage during progressive fibrosis and closure. The patient was closely monitored clinically, with serial liver function tests and ultrasonography. After adequate biliary-tree dilatation, Roux-en-Y hepaticojejunostomy was performed. At 2-year follow-up, he remained asymptomatic without recurrent biliary complications.

Introduction

Bile duct injury (BDI) is one of the most serious complications of cholecystectomy and remains associated with considerable morbidity, mortality, impaired quality of life, and increased healthcare costs despite advances in surgical practice [1]. Complex BDIs represent the most challenging subgroup and generally include injuries involving the biliary confluence (Bismuth types III–V or Strasberg types E3–E5), high biliary strictures following failed repair, vascular-associated injuries, and injuries occurring in the setting of portal hypertension or secondary biliary cirrhosis [2]. These injuries require accurate anatomical assessment, appropriate timing of intervention, and management in specialized hepatobiliary centers because delayed diagnosis or inappropriate treatment may result in recurrent cholangitis, secondary biliary cirrhosis, and liver failure [3, 4].

Although a wide spectrum of BDIs has been described, simultaneous distal common bile duct (CBD) ligation with proximal common hepatic duct (CHD) perforation has not, to our knowledge, been previously reported. We present this unusual injury pattern and its successful staged management using temporary T-tube drainage as a bridge to delayed Roux-en-Y hepaticojejunostomy, together with a review of the relevant literature.

Case presentation

A 30-year-old man presented to the Department of General Surgery one week after undergoing open cholecystectomy for symptomatic cholelithiasis at another healthcare center. He complained of progressively worsening abdominal pain, mild abdominal distension, nausea, and vomiting.

On examination, he had mild abdominal distension and generalized abdominal tenderness. A healing midline laparotomy incision was noted. Abdominal ultrasonography demonstrated moderate to massive free intraperitoneal fluid. Following initial resuscitation and baseline laboratory investigations, endoscopic retrograde cholangiopancreatography (ERCP) demonstrated an abrupt cutoff of the CBD, while magnetic resonance cholangiopancreatography (MRCP) revealed a biloma with features of biliary peritonitis, consistent with a major BDI.

Exploratory laparotomy confirmed biliary peritonitis with a large volume of intraperitoneal bile. Intraoperative findings revealed distal CBD ligation with proximal CHD perforation (Figs 1 and 2). Because of severe local inflammation and friable tissues, definitive reconstruction was deferred. A T-tube was inserted through the perforation to establish controlled external biliary drainage (Fig. 3). The patient recovered uneventfully and was discharged on postoperative day 5.

Figure 1.

Intraoperative photograph demonstrating the transected end of the CBD identified during exploratory laparotomy.

Figure 2.

Schematic representation of the pathology, distal ligation and proximal perforation. Original figure developed by the authors.

Figure 3.

Schematic representation of applying t-tube in the perforation point while the distal is still ligated. Original figure developed by the authors.

The T-tube was maintained as temporary external biliary drainage for approximately three months, allowing resolution of the acute inflammatory process and progressive dilatation of the proximal biliary tree. After this period, the T-tube was removed. The established tract did not close immediately and remained temporarily patent, allowing continued external bile drainage for a limited period before progressively undergoing fibrosis and eventual closure.

Following T-tube removal, the patient was closely monitored clinically and with serial liver function tests and ultrasonography for evidence of biliary obstruction or cholangitis and to assess progressive dilatation of the proximal biliary tree. Once adequate biliary-tree dilatation had been achieved and before clinically significant complications related to biliary stasis developed, the patient underwent elective Roux-en-Y hepaticojejunostomy. The postoperative course was uneventful, and he was discharged on postoperative day 5. At two-year follow-up, he remained asymptomatic, with no evidence of recurrent biliary complications or anastomotic stricture.

Discussion

BDI remains one of the most serious complications of cholecystectomy and continues to pose a major challenge in hepatobiliary surgery. Its occurrence has been attributed to the interplay of dangerous disease, dangerous anatomy, and dangerous surgery, three major factors that increase the risk of injury during cholecystectomy [5]. Misinterpretation of biliary anatomy, particularly misidentification of the CBD as the cystic duct, remains the leading mechanism of injury, although severe inflammation, anatomical variations, and technical errors also contribute [5, 6].

Complex BDIs represent the most challenging subgroup of biliary injuries. They generally include injuries involving the hepatic duct confluence (Bismuth types III–V or Strasberg types E3–E5), isolated sectoral duct injuries, high biliary strictures following failed repair, injuries associated with vascular damage, and injuries occurring in the setting of portal hypertension or secondary biliary cirrhosis [2]. Successful management requires accurate anatomical assessment, appropriate timing of intervention, and referral to specialized hepatobiliary centers to optimize long-term outcomes.

Early recognition and appropriate initial management are critical determinants of outcome. Delayed diagnosis may result in bile leakage, biloma formation, biliary peritonitis, sepsis, or late biliary strictures, whereas inappropriate early repair may further damage healthy ductal tissue and compromise subsequent reconstruction [3, 4]. ERCP and MRCP are complementary imaging modalities for defining the level and extent of injury. In our patient, ERCP demonstrated an abrupt cutoff of the CBD, while MRCP revealed a biloma with features of biliary peritonitis, indicating simultaneous distal obstruction and proximal bile leakage.

Most reported BDIs involve transection, clipping, ligation, thermal injury, ischemic injury, or damage at the hepatic duct confluence [7, 8]. However, to our knowledge, no previous report has described the simultaneous occurrence of distal CBD ligation with proximal CHD perforation. Based on the mechanism and anatomical characteristics observed in our patient, we propose this as a previously undescribed subtype of complex BDI characterized by distal ligation of the CBD or CHD with proximal perforation of the biliary tree (CHD, biliary confluence, right hepatic duct, or left hepatic duct). This injury pattern may occur during technically difficult cholecystectomy, particularly in the presence of severe or subacute cholecystitis, where inflammation and distorted anatomy increase the risk of biliary injury. Patients may present in the early postoperative period with an external biliary fistula when an abdominal drain has been placed or with bile leakage resulting in biloma, biliary peritonitis, or bile ascites in the absence of drainage. MRCP may help identify the site and extent of proximal biliary leakage, whereas ERCP can demonstrate distal biliary obstruction or an abrupt cutoff. Recognition of this pattern is important for diagnosis, operative planning, and selection of an appropriate reconstructive strategy.

The timing of definitive reconstruction should be guided by the patient’s clinical condition and local operative findings [9]. In the presence of generalized biliary peritonitis, severe inflammation, or friable tissues, immediate reconstruction carries a higher risk of failure. In such circumstances, the initial objective should be source control through thorough peritoneal lavage and establishment of controlled external biliary drainage using a T-tube inserted through the perforation site. This approach provides effective biliary drainage, controls bile leakage, and allows resolution of the local inflammatory process before definitive reconstruction.

In our patient, the T-tube was maintained for approximately three months as a temporary controlled external drainage route. After resolution of the acute inflammatory process and progressive dilatation of the proximal biliary tree, the T-tube was removed. Importantly, the established tract did not close immediately following removal but remained temporarily patent, providing a transient pathway for bile drainage while progressive fibrosis and tract obliteration occurred. Thus, T-tube removal represented a transition from controlled external drainage toward spontaneous tract closure rather than an abrupt, unmonitored onset of complete biliary obstruction.

During this transition, the patient was closely monitored clinically and with serial liver function tests and ultrasonography to detect early evidence of biliary obstruction, bile stasis, jaundice, or cholangitis and to assess progressive dilatation of the proximal biliary tree. Definitive reconstruction was undertaken after adequate biliary-tree dilatation had been achieved and before clinically significant complications related to prolonged biliary obstruction developed. Roux-en-Y hepaticojejunostomy was then performed as the definitive reconstruction.

Intermittent T-tube clamping represents an alternative strategy for gradually reducing external biliary drainage while maintaining a controlled route for decompression. In the present case, however, the established tract was allowed to progressively close following T-tube removal under close clinical, biochemical, and ultrasonographic surveillance. The timing of definitive reconstruction was determined by the patient’s clinical status and degree of biliary-tree dilatation rather than by allowing prolonged unmonitored biliary obstruction. Based on this experience, we propose a management algorithm for this injury pattern (Fig. 4).

Figure 4.

Proposed management algorithm for bile duct injury characterized by proximal common hepatic duct perforation and distal common bile duct ligation. Original figure developed by Mirwais Safi.

Associated vascular injury is another important determinant of outcome. Concomitant hepatic artery injury may compromise biliary blood supply, increasing the risk of ischemia, anastomotic leakage, and late biliary stricture [10, 11]. Long-term follow-up is essential because recurrent cholangitis, biliary stricture, secondary biliary cirrhosis, and portal hypertension may develop even after technically successful reconstruction [12–15]. In our patient, no biliary complications or anastomotic stricture developed during 2 years of follow-up.

This case expands the spectrum of complex bile duct injuries by describing a previously unreported combination of distal CBD ligation and proximal CHD perforation. Recognition of this injury pattern and implementation of an individualized staged management strategy, including temporary T-tube drainage when immediate reconstruction is unsafe, may facilitate successful delayed Roux-en-Y hepaticojejunostomy in carefully selected patients.

Conclusion

Complex bile duct injuries remain challenging complications of cholecystectomy and may result in significant early and late morbidity if not recognized and managed appropriately. We describe a previously unreported pattern characterized by distal CBD ligation with proximal CHD perforation, resulting in simultaneous biliary obstruction and bile leakage.

Early diagnosis, accurate anatomical assessment, and timely referral to specialized hepatobiliary centers are essential for optimal outcomes. In patients with severe inflammation and biliary peritonitis, temporary T-tube drainage may provide an effective bridge to delayed Roux-en-Y hepaticojejunostomy. In this case, subsequent T-tube removal was followed by temporary persistence of the established tract, allowing a controlled transition toward tract closure and progressive biliary-tree dilatation. Close clinical, biochemical, and ultrasonographic monitoring permitted timely definitive reconstruction before clinically significant complications of biliary obstruction developed. This staged approach may represent a useful option in carefully selected patients when immediate reconstruction is considered unsafe.

Author contributions

Mirwais Safi: Provided overall supervision of patient management, guided operative decision making, contributed to the conception of the report, developed the discussion and literature review, and participated in drafting and final revision of the manuscript. Muhibullah Saifi: Assisted with literature search, contributed to drafting selected sections of the manuscript, and supported data interpretation. Nasrullah Shefayee: Contributed substantially to drafting and revising the manuscript, and ensured compliance with journal standards and ethical requirements. Hamidullah Hamid, Ehsanullah Safi, Nasratullah Nasrat, Maihan Abdullah: Contributed to patient care, data collection, and manuscript editing. All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Conflicts of interest

All authors confirm that they have no financial or personal relationships that could inappropriately influence or bias the content of this work.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.

Data availability

All data supporting the findings of this study are available from the corresponding author upon reasonable request.