Laparoscopic Biliary Injuries ( Part 3), treatment options.

Management of biliary injuries

Management of injuries recognized at the

initial operation

• There is little written about the conduct of a laparoscopic cholecystectomy once a biliary injury is suspected.
• It is also predicated on highly suggestive evidence that repair of difficult biliary injuries frequently fails when performed by surgical teams infrequently engaged in upper biliary tree surgery, such as liver resections and bile duct resections.

Intraoperative recognition of biliary injury is usually an indication for conversion.

The following two guidelines are suggested when laparotomy is undertaken for suspected injury:

1. Repair should be attempted only if the techniques of dissection or reconstruction required for repair are commonly used by the operating team.
2 The injury should not be worsened by attempting a dissection for the purpose of making an exact diagnosis.

Repair of type A, type D, and perhaps type E1 injuries require skills commonly available in community hospitals.

Types B, C, and E2 to E5 injuries require operative techniques more likely to be available at specialized hepatobiliary units.

• When these skills are not available at the time of injury, closed suction drains should be placed in the right upper quadrant and the patient referred.
  
• Simple drainage of the right upper quadrant seems to be safe, with no reports of problems arising as a result of this strategy.

If an injury is recognized during the laparoscopic cholecystetctomy and is of a type which the operating surgeon would refer for repair, then laparotomy is not indicated, unless needed to control blood loss.

• Laparoscopic drainage and referral without laparotomy is preferable.

Type A injuries are repaired by suture of the cystic duct and drainage.

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.

• Nonabsorbable sutures are contraindicated as they form a nidus for stone formation.
  
• T-tube should be brought out through a separate incision in the duct, if possible.

Avulsion of the cystic duct, a variant of type D injury, may be managed in the same manner.
Complete transection should be repaired with a Roux-en-Y hepaticojejunostomy, applying the principles of anastomosis.

Management of biliary injuries
diagnosed postoperatively

• Management depends on the type of injury, the type of initial management and its result, and on the time elapsed since the initial operation or repair.

Type A injuries

• Intraperitoneal bile collections are drained percutaneously.
• If bile leakage is continuing, intrabiliary pressure is reduced by endoscopic sphincterotomy with placement of a stent or a nasobiliary catheter.
  
• Most authors recommend placement of a stent or a nasobiliary catheter in addition to sphincterotomy and there is experimental evidence supporting this policy.
  
• Infrequently, balloon dilatation and stenting, rather than sphincterotomy and stenting, have also been used.
  
• The stent should not occlude the lumen, that is bile should be able to flow around as well as through the stent.

If ERCP fails, percutaneous transhepatic cholangiography may also be used to decompress the duct.

• There is little indication for reoperation as the first line of management of this type of injury.

Type B injuries

• Type B injuries may remain asymptomatic or present years later with right upper quadrant discomfort or pain.
  
• They may also present with cholangitis.
  
• They are sometimes diagnosed in asymptomatic patients on the basis of abnormal liver function tests found on routine screening.
  
• Symptomatic patients require hepaticojejunostomy or hepatic resection if biliary–enteric anastomosis is not possible.

In asymptomatic patients, treatment is not recommended when

1. the portion of occluded liver is small or
   
2. if the injury was remote and the liver has atrophied.

When the injury is recent and the portion of liver affected is large (e.g. the whole right hemiliver) repair is empirically recommended.

Type C injuries

• Type C injuries require drainage of the bile collections and biliary–enteric anastomosis or ligation of the transected duct.
• If the duct is very small (that is <2mm)
• Insertion of a transhepatic catheter prior to duct reconstruction is a useful aid to location of the duct at operation.
  
• It also may be used to control bile drainage and to drain the subhepatic bile collection preoperatively.
  
• Liver resection may occasionally be required when other techniques fail.

Type D injuries

• Treatment by ERCP and stenting is the treatment of choice in the postoperative period .
  
• Failure of ERCP to control biliary drainage is an indication for operative repair.
  
• These patients should be followed closely since their injury may evolve into a type E injury.
  
• When operation is required, the technique of repair is the same as when the problem is discovered at the time of initial surgery.

When type D injuries involve more than 50% of the circumference of the duct they should be considered to be type E injuries and treated as such.

Thermal injuries involving even 25% of the circumference of the duct, although technically still type D injuries, should probably be treated by hepaticjejunostomy since the full extent of the injury is often difficult to determine.

Type E injuries

• Many authors have emphasized the fact that the best chance for lasting repair is the first chance.
  
• Strictures and sometimes clip occlusions may be treated by dilatation and stents placed either by ERCP or percutaneously through the liver.
  
• One series suggests that results are equivalent to operation [Davids PH, Ringers J, Rauws EA, et al.]; however, in this study the mean interval between cholecystectomy and presentation was several years and the mean bilirubin level was 4.3 mg/dL (81 uM).
• Other papers report frequent success, although long-term follow-up is not commonly available and there seems to be declining enthusiasm for this approach except in selected circumstances.
  
• Most experiences suggest nonsurgical therapy is most likely to be successful when the strictures are mild, towards the right in this coronal plane until the cystic plate is encountered, which is divided, bringing the dissection onto the right portal pedicle invested in its sheath, in which the right bile ducts lie.
  
• Whenever possible the ducts are opened on their anterior surface for anastomosis without mobilization of the duct in order to sew to the end of the duct.

This is aimed at preventing devascularization of the duct by mobilization.

• In all high repairs exposure is facilitated by dividing the bridge of tissue between segments 3 and 4, by fully opening the gallbladder fossa which often collapses with adherence of its walls and if these maneuvers are not sufficient by resecting part of segment 4b. The latter is an invaluable adjunct in the very difficult case.
  
• For the higher injuries and E5 injuries, repair requires accessing right ducts which are separated from the left ducts.
  
• Ducts may be sewn individually or after joining them to form a single orifice.
  
• Fine absorbable sutures are used to construct the anastomosis.

The use of postoperative stents is controversial.

• There is no evidence that they are helpful if a large caliber mucosa-to-mucosa anastomosis has been achieved.
  
• Some use them when very small ducts have been anastomosed, and in that case insert the stent through the jejunum.
• Occasionally, the transhepatic tubes are left through the anastomosis for several days in order to perform postoperative cholangiography.

If stents are routinely used, how long can they be left in without declaring the result a poor outcome?

• Without a clear duration, it might be possible to leave a stent for a prolonged period without declaring that a stricture is present when in fact a stricture is being treated.
  
• Three months would seem to be a reasonable maximal duration of routine stenting, beyond which a poor outcome should be declared.
  
• This is in keeping with the morbidity associated with need for procedures and the discomfort and disability associated with the stent.

In cases in which a primary repair has failed, it is not always necessary to perform a fresh hepaticojejunostomy.

• Sometimes the problem is only a bile leak from an adequate anastomosis, or a slightly stenotic anastomosis.
  
• These can often be treated by non-operative means when the stricture is very short, reserving reoperation for failure of these procedures.

Sometimes biliary reconstruction is not possible or advisable.

• When ductal reconstruction to a part of the liver is impossible then resection should be performed.
  
• Occasionally prior failure of reconstruction leads to secondary biliary cirrhosis and end-stage liver failure.
  
• Then liver transplantation is required.
  
• In almost all examples of such unfortunate outcomes, high reconstructions have been attempted by surgeons lacking experience in the procedures.
  
• Treatment of failed repairs with metallic stents gives very poor results in the long term with 50% of treated patient suffering from repeated cholangitis.
  
• Re-repair at specialist centers is far more successful than metallic stenting.

Long-term outcome of treatment

• Most surgical series of biliary reconstruction cite very good short-term results.
  
• However, it is well known from older literature describing ductal injury during open cholecystectomy that there is a progressive restenosis rate.
  
• Two-thirds of recurrences are diagnosed in the first 2 years after repair but restenosis has been described after 10 years.
  
• The restenosis rate varies from 5 to 28%.

Results in the laparoscopic era may not be as good as these, perhaps because of increased severity of injury.

• In one large series consisting of 50 injuries, 25 hepaticojejunostomies were performed, and five of these patients required further surgery during the short-term follow-up period.
  
• Other early failures have been described.

High injuries (E3–E5) are the most difficult to repair and the most likely to recur as strictures and require additional treatment.

• This is especially true of E4 lesions, which often require anastomosis of several bile ducts.
  

One group (whose experience was that 6/7 E4 injuries required postoperative dilatations) advocates routine construction of Hudson access loops at the time of bile duct injury repair.

Whenever possible the isolated ducts on the right are incised on the anterior surface without mobilization.

Results of rerepairs are good if performed at specialized hepatopancreaticobiliary centers.

• In one series, about 40% of patients were managed with stents and of those treated operatively there was a 6% failure rate at mean follow-up of 5 years.
• Rarely, liver resection is required after failed repairs and most large liver transplantation programs have treated such patients in recent years.

A number of recent studies have examined quality of life after bile duct injury.

• One study found that survival was lower in Medicare beneficiaries, who are patients over 65 years of age.
  
• The results in terms of physical and psychological functioning are mixed.
  
• One study found no difference between normals and bile duct injury patients, but two studies found that both physical and psychological functioning were impaired after bile duct injury.

In summary, biliary injury is still an important problem besetting an excellent procedure – the laparoscopic cholecystectomy.

The key to this problem lies not in complicated repairs at tertiary centers, but in prevention.

Prevention requires commitment to perform meticulous dissection or routine cholangiography so that only structures which have been positively identified are divided.