Bile duct injury: to err is human; to refer is divine

Abstract

A 42-year-old woman sustained complete transection of common hepatic duct during routine laparoscopic cholecystectomy. The surgery was being performed at a rural setting, and the injury was identified intraoperatively. The surgeon sought the opinion of an expert biliary surgeon via telephone and discussed the possibility of an immediate end-to-end bile duct repair. Since he lacked the experience of doing biliary-enteric anastomosis, he was advised to place a subhepatic drain and transfer the patient to the hepatobiliary centre for definitive surgery. At the referral centre, the patient was evaluated and planned an immediate biliary repair. On exploration, she was found to have a major type, Strasberg E5 injury. The transected ducts were small in calibre and required double Roux-en-Y hepaticojejunostomy over transanastomotic stents. The postoperative recovery was uneventful. Transanastomotic stents were removed after 6 months, and the patient remained perfectly well at a follow-up of 1 year.

Background

Bile duct injury (BDI) represents an uncommon but potentially life-threatening complication of cholecystectomy. The incidence of BDI following laparoscopic cholecystectomy ranges from 0.5% to 0.9%.¹ Only about one-third of these injuries are detected intraoperatively.² The early bile duct repair (ie, within 72 hours of injury) is associated with shorter hospital stay and improved patient quality of life.³ The long-term outcomes have also been shown to be good after an early repair.⁴ Use of correct surgical technique and repair by an experienced surgeon are of utmost importance in achieving good results of biliary repair. Each failed repair makes a subsequent surgery difficult and negatively affects the outcome.⁵ It is prudent to refer the patient to a specialised centre for definitive management if the index surgeon is not skilled enough to perform a reasonable repair.

The present case highlights the importance of referral to a specialised centre when the BDI is encountered. A seemingly simple transection turned out to be a complex injury that required major reconstructive surgery. End-to-end repair by the primary surgeon would have been inadequate with devastating consequences.

Case presentation

A 42-year-old woman with mild right upper quadrant abdominal pain was diagnosed to have cholelithiasis on ultrasound examination. She had no history of jaundice, fever, vomiting or episode of severe abdominal pain. The abdomen was soft, and only mild tenderness was present in the right hypochondrium. No lump or organomegaly was present. The patient had no comorbidity, and her family history was unremarkable. She was evaluated and taken up for elective laparoscopic cholecystectomy at a small private hospital in the rural setting. During surgery, mild adhesion and inflammation were encountered at the Calot’s region. After the division of presumed cystic duct and artery, a gush of bile was noted coming from the hilum. On further inspection, the surgeon realised that he had transected the common hepatic duct completely. Presuming it to be a simple transection, with no segment loss or an associated vascular injury, the surgeon contemplated for an immediate, end-to-end bile duct repair. However, to be assured, he decided to seek the opinion from a specialist biliary centre, and so he contacted us via telephone. Taking into account the limited experience of the primary surgeon at performing biliary repair and a need for possible complex surgery, we advised him to place a subhepatic drain and transfer the patient to our centre.

On arrival, the patient was found to be haemodynamically stable, and there was no component of sepsis. The drain output was minimal and serobilious in nature. The ultrasound abdomen revealed minimum collection in the gallbladder fossa. Since the patient had reached to us early and sepsis had not yet set in, the decision for an immediate biliary repair was taken.

Differential diagnosis

The bile duct injury during laparoscopic cholecystectomy often goes unnoticed and present later with bile leak through the drain or intra-abdominal bile collection (biloma formation). Only 25%–30% of bile duct injuries are detected intraoperatively.² Complete occlusion of bile duct due to suture ligation or clip application can result in early postoperative jaundice. Incomplete occlusion or diathermy-related injuries can manifest after several months or even years in the form of biliary stricture.⁶

In cases of postcholecystectomy biliary fistula, common bile duct injury should be considered in all the cases. Uncommonly, the source of bile leak can be the duct of Luschka (subvesical duct) that usually gets damaged while removing the gallbladder from the cystic plate. These leaks, however, stop spontaneously, and surgical intervention is needed only in rare instances. If detected intraoperatively, these ducts can be safely clipped or ligated to prevent postoperative complications related to bile leak.⁷

Cystic duct stump blowout is another important cause of bile leak following cholecystectomy. These can also be managed conservatively in most of the cases. Percutaneous drainage for biloma and endoscopic biliary stenting may be required in some cases.

Treatment

The patient was taken up for surgery under general anaesthesia. On exploration, a minimal amount of serobilious fluid was present in the gallbladder fossa. Transected common hepatic duct (CHD) was identified at the hilum. Apart from CHD injury, another small bile duct of approximately 3 mm calibre was found severed at the hilum (figure 1). The hepatic arteries and portal vein were intact. Both injured ducts were freed of adhesions and were properly delineated with intraoperative ultrasound. The injured minor duct was identified to be the right posterior sectorial duct. Thus, the final injury was established to be a major-type Bismuth-Strasberg E5 injury (figure 2, table 1). Complex biliary reconstruction was done with two separate duct anastomosis with a Roux-en-Y jejunal limb. Both ducts were of small calibre and so transanastomotic external biliary stents were placed. The previously placed subhepatic drain was retained.

Figure 1.

Intraoperative image showing transected main bile duct along with severed right posterior sectoral duct.

Figure 2.

Bismuth-Strasberg classification of bile duct injury. (A) Bile leak from cystic duct or liver bed; (B) occlusion of the right segmental duct; (C) bile leak from divided right segmental duct; (D) lateral injury to the common hepatic duct; (E₁) main bile duct injury, >2 cm from the confluence; (E₂) main bile duct injury, <2 cm from the confluence; (E₃) hilar injury with intact confluence; E₄) confluence involved, right and left hepatic ducts are separated; (E₅) injury of aberrant right sectoral duct with concomitant injury of main bile duct.

Table 1.

Strasberg-Bismuth classification of bile duct injury

Type	Description of injury
A	Bile leak from cystic duct or liver bed.
B	Occlusion of the right segmental duct.
C	Bile leak from divided right segmental duct.
D	Lateral injury to the common hepatic duct.
E1	Common hepatic duct injury, >2 cm from the primary confluence.
E2	Common hepatic duct injury, <2 cm from the primary confluence.
E3	Injury at the hilum, confluence is intact.
E4	Injury at the hilum, confluence separated.
E5	Combined injury to the main bile duct and right segmental bile duct.

The patient recovered well in the postoperative period. Her LFT remained normal in the postoperative period. Abdominal drain output was minimal and serous in nature, thus removed on postoperative day 5. Transanastomotic stentogram was obtained on day 12 that showed patent anastomoses draining both common bile ducts and accessory right posterior duct adequately (figure 3). The patient was discharged on postoperative 13 day with stents.

Figure 3.

Postoperative stentogram done on day 12 of repair shows opacification of bilateral intrahepatic biliary ducts with intact bilio-enteric anastomosis. LHD, left hepatic duct; RHD, right hepatic duct.

Outcome and follow-up

The patient was followed-up at a regular interval, and after 6 months, both stents were removed. At 1-year follow-up, the patient remains clinically asymptomatic with normal bilirubin and alkaline phosphatase levels.

Discussion

Iatrogenic BDI is a dreaded complication of cholecystectomy and has been estimated to occur in approximately 0.5% to 0.9% of cases.¹ The introduction of laparoscopic cholecystectomy in the 1990s and its widespread application since then has resulted in a marked increase in the incidence of BDIs. In addition, BDI associated with laparoscopic cholecystectomy tend to be more complex than after an open approach.⁸

Early diagnosis of BDI is important for reducing morbidity and mortality. However, only 25%–30% of BDI are diagnosed intraoperatively.² Routine use of intraoperative cholangiography (IOC) has been found to be useful at early detection and limiting the extent of BDI. Despite its potential benefit, the role of routine IOC during cholecystectomy remains controversial and is used on a selective basis only.^{1 9 10}

The surgical biliary repair remains the mainstay treatment of BDI. The outcome of surgery greatly depends on the technique of repair and experience of the surgeon. However, in more than 70% of cases, surgeons who do not specialise in biliary reconstruction perform the initial repair.¹¹ This percentage can be much higher in the developing world where the specialised biliary centres are few and far between. Inappropriate surgery or delayed referral to a specialist centre may increase the morbidity significantly. The analysis of factors affecting outcomes of biliary repair by Stewart and Way in 1995 had shown much superior results in hands of an experienced biliary surgeon as compared with the primary surgeon (94% vs 17%). The average ‘length of illness’ was also significantly shorter (78 vs 222 days; p<0.01) when patients were managed at specialised biliary centres.¹²

The result of immediate BDI repair has comparable long-term outcomes in expert hands as compared with delayed repair. Adherence to the fundamental principles of bile duct repair with the correct surgical technique is vital for long-term success. The repair should be tension free, between well-vascularised segment of duct and mucosa and drain all segments of liver.³

Different biliary reconstructions have been reported for the surgical treatment of an iatrogenic BDI: Roux-en-Y hepaticojejunostomy, end-to-end ductal biliary anastomosis, choledochoduodenostomy and so on. End-to-end ductal anastomosis has several potential advantages like being more physiological and fewer early postoperative complications. Postoperative endoscopic access is also possible, enabling different diagnostic and therapeutic procedures.¹³ Despite these benefits, it is not feasible to perform an end-to-end ductal anastomosis in all cases of BDI. Direct ductal repair is not recommended when the injury involves more than one-third of the bile duct circumference or where the tissue loss is extensive. It cannot be carried out in the high injuries involving the biliary confluence (Strasberg E3/E4).^{14 15} Besides, the end-to-end repair is associated with an unacceptably high failure rate (60%–77%), necessitating surgical conversion to hepaticojejunostomy in approximately one-third of patients.^{12 13 16}

The important factors determining the success of biliary reconstruction include the complete eradication of intra-abdominal infection, complete characterisation of the injury with cholangiography, use of the correct surgical technique and repair performed by an experienced biliary surgeon. The timing of repair or associated vascular injury has less impact on the long-term outcome following bile duct repair.³ Thus, the current evidence does not support the old wisdom of delayed repair in all cases of BDI.

Selection of a well-vascularised biliary duct for reconstruction is vital for long-term success. The structural integrity and vascular supply of the left hepatic duct are well preserved even in cases of severe vasculobiliary injury. When the common hepatic duct is transected just below the confluence and the right hepatic artery is also severed, the left hepatic artery provides adequate vascularity to the hilum and right hepatic duct. In such situation, reconstruction using the left hepatic duct ensures a good long-term outcome.¹⁷ In cases of high biliary stricture, an intrahepatic anastomosis with healthy, vascularised ducts allows a safe and high-quality anastomosis. The 1-year outcome is clearly satisfactory in both extrahepatic and intrahepatic anastomosis, but the results are significantly better with the later approach (with or without partial segment 4 resection) as shown in few retrospective studies.^{18 19}

The benefit of a transanastomotic stents in the management of complex bile duct injuries is also debatable. Transanastomotic stents are associated with increased postoperative complications such as the development of stones, bile leak and fistula, particularly when transhepatic stents are used.²⁰ Whereas, the advantages of preoperative transhepatic biliary stenting include intraoperative identification of bile ducts, decompression of the biliary tree and enabling access for radiological intervention in the early postoperative period. The stents may also ensure a stable biliary anastomosis during the period of healing and scar contracture in the postoperative period. The stent is typically retained for a period of 6–12 months postrepair.²¹ Roux-en-Y hepaticojejunostomy with bilateral transanastomotic stenting was performed in our patient in view of non-dilated, small-calibre bile ducts, and the stents were retained for 6 months postrepair.

Conclusion

The present case emphasises the importance of early recognition of bile duct injury and its management at a specialised hepatobiliary centre. Apparently, simple injury can turn out to be a major one, necessitating complex repair surgery. Management at an experienced centre, use of correct surgical technique and complete delineation of biliary anatomy before going for surgery are vital for the long-term success of repair. On the other hand, inadequate management by an inexperienced surgeon can result in disastrous consequences.

Learning points.

• Intraoperative detection of bile duct injury during laparoscopic cholecystectomy is possible in only 25%–30% of cases.

• Early biliary repair (<72 hours) has excellent results, provided it is performed at a specialised biliary centre.

• Biliary repair by an inexperienced surgeon, use of a wrong operative technique, associated vascular injury and repair during active sepsis negatively affect the surgical outcomes.

• Each failed attempt at repair renders subsequent surgery more difficult and less rewarding.

• In cases of major bile duct injury, the patient should be referred early to an expert biliary centre for its definitive management.