Management of Biliary Injuries after Open and Laparoscopic Cholecystectomies

Salah Obaid Hamad,Basher Abbas Abdulhassan,Mohammad Yaseen Alkhoja,Raafat Rauof, Ahmed Alturfi
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Keywords : Cholecystectomy, iatrogenic bile duct injuries, Complications.
Medical Journal of Babylon  14:1 , 2017 doi:1812-156X-14-1
Published :16 July 2017


Bile duct injuries during laparoscopic and open cholecystectomy are still serious problems which may cause secondary biliary cirrhosis resulting in chronic liver failure. Injuries occur as a result of technical errors or misidentification of biliary ducts. BDIs are major cause of patient morbidity and litigation. This study aimed to evaluate the management of bile duct injuries (radiological, endoscopic or surgical management) following open and laparoscopic cholecystectomy in a tertiary referral hospital. A prospective clinical study was conducted 50 patients (9 males and 41 females) who sustained bile duct injuries during open and laparoscopic cholecystectomy. Patients were thoroughly investigated to decide the final management, and they were followed up to two years post operation to find out short- and long-term complications. The most common presentations of those patients were biliary fistula, 18 (36%) and jaundice, 14 (28%). After resuscitation, the definite managements were percutaneous drain under ultrasound guide for one patient (2%), Endoscopic retrograde cholangio pancreatographystenting or sphinectrotomy for 5 patients (10%) andhepaticojejunostomy for complete common hepatic duct transection for 43 patients (86%), most of which were done 8weeks after the primary operation. One patient succumbs before any intervention. According to the results of this study, patients with bile duct injuries are preferably treated in hepato-biliary department, where all radiological, endoscopic and experience surgeon available. Roux-en-hepaticojejunostomy is the procedure of choice for the management of patients sustaining complete transaction injury of common hepatic duct, while percutaneous drain is an excellent option for the drainage of intraperitoneal bile collection, without need for open drainage.


Bile duct injury (BDI) is a serious and potentially life-threatening complication of cholecystectomy, with severe consequences in some patients [1,2]. Apart from early postoperative complications, there is also a risk of long-term sequelae such as strictures of the common bile duct and repeated attacks of cholangitis [3]. In addition, such injuries represent a vast economic burden to the society and they raise a high rate of medico-legal claims [2]. Before the advent of laparoscopic cholecystectomy (LC) in the late 1980s, open cholecystectomy (OC) was the prevalent mode of treatment for gall-stones with an incidence of BDIs between 0.1 and 0.3% [4].During the early era of LC, the incidence was 1–2 %. However, with growing experience of laparoscopic surgeons and availability of better operating instruments, the rate of iatrogenic BDIs has dropped to 0.3–0.6% [5] and the LC is now accepted as the treatment of choice for symptomatic gallstones [4,5]. Two major risk factors can predispose for BDIs; patients related risk factors are either anatomical or pathological. Misidentification of common bile duct (CBD), and anatomical variation are among the most important anatomical factors. On the other hand, acute severe and chronic cholecystitisare well-known pathological factors. Operator factors (surgeon and assistants) are associated with imperfect operative technique e.g. excessive upward retraction on the gallbladder or insufficient lateral retraction or excessive tenting of the bile duct may confound correct anatomical identification [6]. Magnetic resonance cholangiopancreato-graphy (MRCP) is the most sensitive and accurate test frequently used for the diagnosis of complications of cholecyst-ectomy including BDIs even though percutaneous transhepatic cholangiography (PTC) can better delineate certain complications, e.g.common bile duct (CBD) strictures [7]. Other investigations in use are endoscopic retrograde cholangiopancreatography (ERCP) ultra-sonography, and intra-operative cholangio-graphy [8,9]. The treatment of BDIs has changed since the introduction of laparoscopic surgery. Most bile leaks are now treated with endoscopic procedures like stents and endoscopic sphincterotomy, whereas the more severe cases will still need a repair of the common bile duct [10]. This study aimed to evaluate the management of bile duct injuries (radiological by peritoneal dialysis (PD) catheter, endoscopic by ERCP or surgical management in form of bilio-enteric anastomosis) following open and LC in a tertiary care center and to choose the best option in proper time according to the level of injury and general conditions of the patients

Materials and methods

A prospective study from December 2013 to April 2016 was conducted in Gastroenterology and Hepatology Teaching Hospital/Medical City/Baghdad. Patients with biliary complication after open or LC either in our center or those referred to our center from other tertiaries whether they need surgical intervention or not were eligible for this study. All patients were evaluated by a multidisciplinary team and the best available treatment option was decided. The information regarding primary operative procedure, presenting symptoms, the type and level of biliary tract injury, diagnostic procedures, and therapeutic interventions before and after referral was obtained from patient records.
     The prospective diagnosis of biliary injury as well as the complications occurring to the other organs, particularly the liver, was made according to history, clinical presentation, blood investigations, liver function tests,sonography, magnetic resonance MRCP and CT scan in some patients. Exclusion criteria involve the presence of biliary leak or obstructive jaundice secondary to external traumatic injuries (blunt and penetrating injuries), biliary stricture secondary to liver transplantation, and hepatocellular jaundice. After applying these criteria, a total of 50 patients with BDIs satisfied the requirement of this study. They were 9 men (18%) and 41 women (82%) with mean age of 41.6±11.3 years at the time of repair surgery. The primary surgery of three patients was done in our center, while the other 47 patients were referred from other hospitals in Baghdad and other Iraqi governorates.. Other demographic data for those patients are presented in table 1.
     The anatomic extend of BDIs was classified according to Strasberg-Bismuth classification system [11].  Three definitive treatments were adopted which were radiological interventions, endoscopic therapy and surgical interventions (hepaticojejunostomy-HJS). Patients having surgical repair were further classified in two groups based on time period from injury to repair into: intermediate (3 days to 6 weeks), and late (after 6 weeks). In patients with collection and/or sepsis, biliary drainage and treatment of sepsis preceded the definitive repair.
After discharge, patients were followed regularly in the outpatient clinics, and both short- and long-term complications were recorded. Postoperative complications were considered short-term when occur within 30 days of repair surgery; otherwise, they were considered long-term complications. The follow-up time was the period extending from the date of repair surgery to the last follow-up visit or death. This time ranged from 0 to 24 months with an average of 13.24±37 months.


Demographic Data of Patients Fifty patients (47 patients referral and three patients from our center) with BDIs had been treated in Gastroenterology and Hepatology Teaching Hospital (GE&HTH)/ Medical City/Baghdad. Table (1) shows the demographic date of patients.


This prospective study aimed to evaluate the management of BDIs after LC or OC in a referral tertiary center. Generally, data regarding BDIs in Iraq are very rare, and there are no reliable records for the annual incidence of these injuries. However, dealing with 50 patients with BDIs within less than 30 months (the duration of the study) reflects a high rate of BDIs following cholecystectomy. In one study, Al-Hilfi and Ahmed [12] investigated the risk factors associated with the incidence of vesculobiliary injuries. They found that acute cholecystitis (72%), private hospitals (20%) and inexperienced surgeon (20%) are the main risk factors. Among the many factors accused for this high rate is the dissection method. Patients’ records showed that 44% of the primary surgery employed in fundibular technique to avoid surgical induced morbidity, while only 6% had the critical view of safety, may be due to the relative novelty of last method. Vettoretto et al. [13] showed that critical view of safety is more proper to be used than infundibular technique especially for young surgeons. Recently, Al-Helfy [14] successfully used methylene blue as an alternative method to eliminate BDIs during LC although more studies are required to reach solid conclusion. The other factor is the type of surgery. The current study revealed that most (80%) of referred cases with BDIs underwent LC. Three facts could be extracted from this result. Firstly it is in accordance with the general concept that more BDIs are associated with LC compared to OC. Secondly, it reflects the presence of adequate facilities for conducting LC in most Iraqi governorates. In this regard, Aziz et al. [15] in Egypt, reported more BDIs in OC than LC (61% vs 39%) and attributed this result not to the procedure itself but to the predominant of OC because of lacking facilities for conducting LC in many Egyptian regions. Finally, this result confirms the conclusion of Al-Hilfi and Ahmed [12] in that many surgeons still do not satisfy the learning curve. In this study BDI (E2) represented 40% of injuries, High injuries (E3 to E5) represented 40% of injuries. In comparison to other study, high injuries (E3 to E5) represented 37% of injuries [16].American study comprising 83,000 patients revealed that about 60% of the leaks were related to the cystic duct. We found that the Strasberg (type E) injuries are the most common type of injury which is called the classical injury. This agrees with other study [5]. Sometimes, pre-operative level of BDIs which defined by MRCP were different from actual intra operative finding, which means that (E3) injury preoperative could be (E2) or (E4) injury. We thought this false higher MRCP staging occurred when there is filling defect (stone or sludge) above the stricture giving the impression of higher level injury, while false down MRCP staging occurred when separated right and left ducts (Strasberg E4) enface on each other on antero-posterior MRCP picture forming structure like CHD (Strasberg E3) giving false impression of lower injury. Timing of repair is very crucial for successful proper management of BDIs. Unfortunately, the optimum period was not well-defined [17]. Sahajpalet al. [18] proposed two periods to minimize the risk of biliary stricture which are immediately (within 72 hrs) or late (after 6 weeks) of injury. Most patients in this study had late surgical repair. In this concern, it is well-known that immediate recognition and repair of such cases are associated with better outcome [19]. However, delayed referral to the tertiary center is very common, and in most cases the inflammatory response was in its peak when the patient referred to the center. Murret al. [20] considered the inflammation and infection as unfavorable conditions for immediate surgery. A minimum period of 4–6 weeks between injury and repair is desirable for resolution of tissue edema and inflammation and for dilatation of the proximal ductal system [21]. For that reasons, the definitive repair in most patients was postponed until the inflammation subsides. Three management options were considered in this study which were PD catheter, ERCP, and surgery. PD was done under US guide to aspirate intraperitoneal collection as a definitive way of treatment (in one patient with type A injury), or as a bridge for definitive treatment (in 27 patients). On the other hand, 5 patients (with A or D types)were successfully treated by ERCP stenting or sphinectrotomy. Other 9 underwent unnecessary and unsuccessful ERCP, with high complications rate, presumably that they have partial BDIs before full radiological assessment. ERCP should not be used as a diagnostic tool for BDIs especially (type E1-E5) injuries (figure 3) as it carries a considerable rate of morbidity, while MRCP can solve diagnostic dilemma (figure 1). Other studies report nonsurgical management of major bile duct injuries to be successful in 19% to 22% of the cases referred [22, 21]. The outcome of therapeutic endoscopy depends on the type of injury. In selected patients, the overall success may reach 93% [11,23]. The endoscopic or radiologically guided intervention may not be successful as a primary treatment in the more complex injuries but it is certainly advantageous in recurrent anastomotic strictures or in patients not suitable for surgery [22,24].The vast majority of the patients (43 patients) in this study were treated by surgery, 42 were treated by hepaticojejunostomy. The other one had Double-barreled hepatico-jejunostomy. Roux-en-Y hepaticojejuno-stomy is still the gold standard definitive procedure for iatrogenic bile duct injuries. In one study, 59.38%cases had undergone Roux-en-Y hepaticojejunostomy for CBD and CHD injuries [4]. There was only one patient (2%) who died pre-operatively before biliary reconstruction operation due to sepsis, and no intra-operative or postoperatively mortality occurs. This result is close to that obtained by Aziz et al. [15] who reported 4% mortality among Egyptian patients with LC-BDIs underwent surgical repair, and to that obtained by Sahajpal et al. [18] reported who reported 1% mortality among American patients having similar repair. Many factors are known to influence the mortality rate, the most important of which are patient’s conditions at referring time, duration of follow up period and accessibility of the patient to specialized health center. Thus variation in mortality rate between different studies does not precisely reflect the proper or improper management of BDIs. Complications following BDIs management are not uncommon. The most prevalent shor-term complication in this study is superficial wound infections (10%). In almost similar study, it was found 13% of the patients experienced short-term complications with only 4% of them having wound infections [18]. Generally, such complications are expected and could be treated successfully without major impact. Long-term complications, on the other hand, could be disastrous. In the current study, 18% of patients had long- complications after two years follow-up, with incisional hernia and biliary stricture most prevalent. This rate of complications is considered reasonable when compare with the international studies. Almost very close results have been obtained by Sahajpal et al. [18] who had 16% of their patients with long-term complications, 2 of whom had bile duct stricture, and 2 patients with incisional hernia. Collectively, these data indicate that early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results. Roux-en-hepaticojejunostomy is the procedure of choice preferred by hepatobiliary surgeons for the management of complete transaction CHD injuries. PD catheter is an excellent option, for the drainage of intraperitoneal bile collection, without need for open drainage. Endoscopic intervention by ERCP is an invasive procedure and should be considered only when definitive treatment is decided that is mainly for minor BDIs (types A and D). Adoption of the critical view of safety method of cystic duct and artery identification by the surgeons can prevent major duct injury in most instances.




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