Biliary Tract: Biliary Injury

Biliary Injury

Basics

  • Definitions:
    • Biliary Injury: Injury to Bile Ducts
    • Bile Leak: Active Bile Leakage
      • ISGLS Definition: Drain Bilirubin 3x Serum Bilirubin on POD#3
        • Similar Definition to Pancreatic Leak
    • Biloma: Bile Fluid Collection
  • Output:
    • Low Output: < 300 cc/Day – Will Likely Close Spontaneously
    • High Output: > 300 cc/Day – Need ERCP
  • More Common After Laparoscopic Cholecystectomy than Open
    • Open: 0.002%
    • Laparoscopic: 0.7%
      • Major Injury: 0.2%
      • Minor Injury/Leak: 0.5%

Causes

  • Most Common Cause Overall/Type A: Cystic Duct Stump (Inflammation Dislodges Clip)
  • Most Common Cause of Type D: Excessive Fundal Cephalad Retraction
  • Most Common Cause of Type E: CBD Mistaken for Cystic Duct

Presentation

  • RUQ Pain
  • Fever
  • High Bilirubin
  • Biliary Drainage from Drain or Surgical Incision
  • Timing:
    • Few (8-33%) are Found Intraoperatively
    • Typically Present within 1 Week of Surgery
    • Presentation Can Be Delayed with Biliary Stricture

Diagnosis

  • Initial Imaging: CT (Higher Sensitivity) or US
  • Confirmation of Active Leak: HIDA
  • Site Determination: MRCP or ERCP

Ligated CBD Seen on ERCP 1

Classification

Strasberg Classification (Most Common)

  • Type A: Leak from Cystic Duct or Duct of Luschka
  • Type B: Occlusion of Aberrant Right Hepatic Duct
  • Type C: Leak from Transection of Aberrant Right Hepatic Duct
  • Type D: Partial Transection of CBD
  • Type E: Complete Transection of CBD
    • E1: > 2 cm From Confluence
    • E2: < 2 cm From Confluence
    • E3: At Confluence but Confluence Intact
    • E4: Destruction of Confluence
    • E5: Occlusion of CHD & Aberrant Right Hepatic Duct

Bismuth Classification

  • Type I: > 2 cm From Confluence
  • Type II: < 2 cm From Confluence
  • Type III: At Confluence, Confluence Intact
  • Type IV: Destruction of Confluence
  • Type V: Aberrant Right Hepatic Duct Injury
    • With or Without Concomitant CHD Injury

Other Classification Systems

  • McMahon Classification
  • Stewart-Way Classification
  • Hannover Classification
  • Mattox Classification

Strasberg Classification of Biliary Injury 2

Treatment

Intraoperative Identification

  • < 50% Circumference: Primary Repair (Over T-Tube)
    • Should Convert to an Open Procedure if Still Laparoscopic
    • May Also Consider ERCP with Stenting
  • ≥ 50% Circumference: Roux-en-Y Hepaticojejunostomy
    • *Use Jejunum as Duodenum is Too Far Away & Unable to Mobilize Sufficiently
  • Small Hepatic Ducts (< 3 mm) that Drain a Single Segment Can Safely Be Ligated
  • *If Surgeon Has Limited Experience or Limited Resources: Stop Dissection, Leave Drains & Transfer to a Higher Level of Care

Postoperative Identification

  • Biloma: Percutaneous Drain
  • Leak, Lateral Injury or Partial Stricture: ERCP & Stent
    • Stent Removed After 4-6 Weeks
  • Complete Transection/Occlusion: Hepaticojejunostomy
    • Timing:
      • Early (≤ 3-7 Days): Immediate Repair
      • Late (> 3-7 Days): Wait 6-8 Weeks
        • Tissue Too Friable – Benefit from Initial Drainage & Decompression
    • Significant Atrophy of Liver Segment May Require Segmental Liver Resection

Traumatic Injury

Hepaticojejunostomy After Biliary Injury 1

References

  1. Salama IA, Shoreem HA, Saleh SM, Hegazy O, Housseni M, Abbasy M, Badra G, Ibrahim T. Iatrogenic biliary injuries: multidisciplinary management in a major tertiary referral center. HPB Surg. 2014;2014:575136. (License: CC BY-3.0)
  2. Chun K. Recent classifications of the common bile duct injury. Korean J Hepatobiliary Pancreat Surg. 2014 Aug;18(3):69-72. (License: CC BY-NC-3.0)