1.
Bile Duct Injury
Dr. Dhaval Mangukiya/Dr. Chintan Patel
Dept. of GI & HPB Surgery/GI
Endoscopy
SIDS Hospital & Research Center

2.
Detection
• Immediate (acute bile duct injury) - within 24–
48 h
• Delayed - after 48 h
• Late – Benign Biliary Stricture

3.
Diagnosis
No drains in primary Surgery
• Bilioma
• Biliary Peritonitis
• Biliary ascites
Drain in Situ
• External Biliary fistula

4.
Diagnostic tools
Scenario 1
• Symptomatic Cholelithiasis
• Case of Elective cholecystectomy POD 2
• Straight forward dissection (acc to surgeon)
• “Pain” – Explainable
• Fever - 99 F
• Vomiting

5.
Diagnostic tool
Scenario 1
• CBC - Normal
• LFT – “Expectation of Surgeon”
• Imaging – USG
– Post cholecystectomy status
– Mild free fluid in GB fossa

6.
Diagnostic tool
Scenario 1
• Persistent symptoms POD 5
• High TLC
• Call for Opinion
– Repeat USG/CT Scan/MRI
– ERCP

7.
Type A Injury
• Endotherapy is primary therapy
• EST +/- Stenting effective in
most situations

8.
Type A Injury with retained CBD stone
• Endotherapy is primary treatment
• EST, stone extraction +/- Stenting

9.
Juxtaposition of duodenal diverticulum
and implications

10.
Diagnostic tool
Scenario 2
• Acute on Chronic Cholecystitis
• Difficult cholecystectomy
• Drain kept
• Bile on POD 1 – 150 cc
• Stable patient

11.
Diagnostic tool
• CBC/LFT – TLC 12000 rest normal
• Call for opinion
– Buscopan/UDC
– CT/MRCP
– ERCP

12.
Bile Duct Leaks – Results of
Endotherapy

13.
Endotherapy for Bile Leaks –
Outcomes
Reuver P R et al. Gut 2007
• 500 pts (1999 – 2005) with BDI
• 203 underwent endoscopic management
• Leaks – 93
• CBD strictures – 110
• 26% had attempts at surgical correction before referral

14.
Endotherapy for Bile Leaks –
Outcomes
Type –A Type –B
Median time before referal 10 days 15 days
Duration of stenting 1.7 months 2.8 months
Stent related complications 16.4% 3.8%
Overall success 97% (65/67) 89% (23/26)
Reuver P R et al. Gut 2007

15.
Points
• Interpretation of LFT with scenario
• USG guided tap or drain
• CT or MRI with correlation of USG
• ERCP early when suspected distal obstruction

16.
Immediate/Delayed
• What to Do?
• When to Do?
• How to Do?

17.
What to do?
• Per op detection of Injury
– Clean Surgery
– Bleeding (Vascular injury)
– Use of energy Source
– Operation theatre setting
– Assistance/Instruments
– “Size of Bile Duct”

18.
Bile Duct Arterial supply

19.
What to do
• Post op detection
– Sepsis
– Classification
– Referral

20.
Strasberg system
Strasberg SM, Herd M, Soper NJ. An analysis of biliary injury during laparoscopic
cholecystectomy. J Am Coll Surg. 1995;180:101–105

21.
When to do?
• Early repair
• Intermediate
• Delayed

22.
• Out of 122 repairs performed, only 4 (3.3%)
cases were operated on between 8 days and 6
weeks. Those with arterial injuries were
repaired after 3 months, when a complete
diagnosis of the injury and control of sepsis
was achieved.
• Cho JY, Jaeger AR, Sanford DE, et al. Proposal for standardized tabular
reporting of observational surgical studies illustrated in a study on primary
repair of bile duct injuries. J Am Coll Surg. 2015;221:678–688.
When to do?

23.
• A case series of 69 bile duct injuries reported a
significant association between the time of
repair (3 days to 6 weeks) and the occurrence
of bile leak or anastomotic stricture.
• Sahajpal AK, Chow SC, Dixon E, et al. Bile duct injuries associated with
laparoscopic cholecystectomy. Arch Surg. 2010;145:757 – 763.
When to do?

24.
• Series of 157 patients observed better
outcomes in the ‘‘on-table’’ repair and early
repair (less than 3 weeks) groups compared
with those in the late repair (> 3 weeks)
group, with no difference in recurrent
cholangitis or reoperation.
• PereraMTPR,SilvaMA,HegabB,etal.Specialistearlyandimmediaterepair of
post-laparoscopic cholecystectomy bile duct injuries is associated with an
improved long-term outcome. Ann Surg. 2011;253:553–560.
When to do?

25.
• Outcomes after immediate and early repairs were
comparable to late repairs when performed by
specialists [recurrent cholangitis:11%, 12%, and 10%; P
= 0.96, NS; re-stricture:18%,5%, and 29%; P = 0.01;
nonsurgical intervention: 14%, 5%, and 24%; P<0.03;
redo surgery: 4%, 2%, and 5%; P = 0.81, NS; overall
morbidity: 21%, 14%, and 39%; P<0.02]. On
multivariate analysis, immediate and early repairs done
by nonspecialist surgeons were independent risk
factors (P < 0.05) for recurrent cholangitis [50% and
27%], re-stricturing (75% and 61%), redo
reconstructions (31% and 61%), and overall morbidity
(75% and 84%)
When to do?

26.
• Using a different definition for timing of repair
(<1 month, 1–12 months, and >12 months),
Sicklick et al reported no association with
postoperative complications.
• French survey, Ianelli et al reported better
outcomes in those who were repaired after 45
days after injury.
• Sicklick JK, Camp MS, Lillemoe KD, et al. Surgical management of bile duct injuries
sustained during laparoscopic cholecystectomy. Ann Surg. 2005;241:786 – 795.
• 19. Iannelli A, Paineau J, Hamy A, et al. Primary versus delayed repair for bile duct
injuries sustained during cholecystectomy: results of a survey of the Association
Francaise de Chirurgie. HPB (Oxford). 2013;15:611–616.
When to do?

27.
• Timing of Surgical Repair After Bile Duct Injury
Impacts Postoperative Complications but Not
Anastomotic Patency
• Ismael Dominguez-Rosado, MD, Dominic E. Sanford, MD,y
Jingxia Liu, MS, PhD,z William G. Hawkins, MD,y and Miguel A.
Mercado, MD
• Annals of Surgery Volume 264, Number 3, September 2016
When to do?

28.
How to do?

29.
• Roux en Y limb
• Hepp Couinaud Technique
• Internal Stenting
• Intermittant / Continuous

30.
Benign Biliary Stricture
Dr. Dhaval Mangukiya/Dr. Chintan Patel
Dept. of GI & HPB Surgery/GI
Endoscopy
SIDS Hospital & Research Center

31.
Etiology
• Postoperative injury after
cholecystectomy (80%)
• Pancreatitis (10%)
• PSC
• Orthotopic liver
transplantation (OLT)
• Mirizzi syndrome (1%)
• Radiation
• Blunt abdominal trauma
• Portal biliopathy
• Polyarteritis nodosa and systemic
lupus erythematosus (SLE)
• Tuberculosis and histoplasmosis
• Chemotherapeutic drugs
• Sphincter of Oddi dysfunction or
papillary stenosis
• Choledochal cysts
• Recurrent pyogenic cholangitis
• Inflammatory strictures
• Endoscope-related strictures
• HIV cholangiopathy
• Idiopathic
• Miscellaneous

32.
• Costamagna G, Tringali A, Mutignani M, et al. Endotherapy of postoperative biliary
strictures with multiple stents: results after more than 10 years of follow-up.
Gastrointest Endosc 2010;72:551-7.
• De Palma GD, Persico G, Sottile R, et al. Surgery or endoscopy for treatment of
postcholecystectomy bile duct strictures? Am J Surg 2003;185:532-5.
• Kuzela L, Oltman M, Sutka J, et al. Prospective follow-up of patients with bile duct
strictures secondary to laparoscopic cholecystectomy, treated endoscopically with
multiple stents. Hepatogastroenterology 2005;52:1357-61.
• Tuvignon N, Liguory C, Ponchon T, et al. Long-term follow-up after biliary stent
placement for postcholecystectomy bile duct strictures: a multicenter study.
Endoscopy 2011;43:208-16.

33.
Type
Bismuth H, Majno PE. Biliary strictures: classification based on the principles of surgical treatment.
World J Surg. 2001;25:1241e1244

34.
Protocol for Endotherapy
• Serial incremental biliary dilatation with successive stent/s placement
 Sphincterotomy is performed - necessity for repeated stent exchanges & side by
side stent placement
 Endotherapy is usually unsuitable / unsuccessful when complete duct transection
 One of two protocols commonly followed –
Amsterdam protocol
Rome protocol

35.
SIDS Data – Surgery (30 Patients)
• Biliary Stricture (19)
– HJ (14)
– CBD Exploration (2)
– Redo HJ (1)
– Left Hepatectomy (1)
– CBD stitch removal (1)
• Bile Duct Injury (11)
– Endobiliary stent and
drainage
– External drainage
• Either Laparoscopic or
open
Outside SIDS Elective HJ - 15

36.
• Bile duct injury after laparoscopic
cholecystectomy: New classification and
Novel approach for the management in
emergency situations.
• Presented at DDW June 2018
• Dr Dhaval Mangukiya, Dr Chintan Patel
• Dr Keyur Bhatt, Dr Pankaj Desai
SIDS Data

37.
SIDS Data Endoscopy
• Strasberg A (102)
– 91 patients had drains
kept during surgery
– 11 patients had Biloma
& pigtail was done
• Strasberg B – E (76)
– 39 HJ (Avg 62nd day)
– 34 Multiple Stenting
Type of injury Number of
patients
Type I 102
Type II 34
Type IIIA 19
Type IIIB 15
Type IIIC 4
Type IIID 2
Type IV 2

38.
Chronic Pancreatitis
• Frey’s procedure
• Frey’s procedure + choledochojejunostomy
• Frey’s procedure + opening of the bile duct in
the cored-out head of the pancreas
• Frey’s procedure + choledochoduodenostomy
• Whipple’s operation

39.
341 THE MAJORITY OF PATIENTS REMAIN STENT-FREE 5 YEARS AFTER TEMPORARY
INDWELL OF A SINGLE FULLY COVERED SELF-EXPANDING METAL STENT FOR
TREATMENT OF BENIGN BILIARY STRICTURES SECONDARY TO CHRONIC
PANCREATITIS - RESULTS OF A MULTI-CENTER STUDY
• Jacques Deviere , Nageshwar R. Duvvur, Andreas Püspök et al
• 78% of pts remained stent-free 5 years after stenting
• A randomized comparison to treatment using multiple plastic stents is
warranted
• June 2018 Volume 87, Issue 6, Supplement, Pages AB72–AB73
Chronic Pancreatitis

40.
Benign Biliary Stricture
• Only Endoscopic management for Cystic duct
stump blowout with or without retained CBD
stone
• Combination of ERC stent with Surgery at
optimum time interval for Type B,D,E1,E2 BBS
• Only Surgical management for bile duct injury
with peritonitis and Type C,E3,E4,E5 BBS
• Interventional radiology utilised for bilioma, post
bilioenteric anastomotic stricture and Acute
cholangitis with non faesible scenario for
Endoscopist

41.
Benign Biliary Stricture
• Only Endoscopic management for Cystic duct
stump blowout with or without retained CBD
stone
• Combination of ERC stent with Surgery at
optimum time interval for Type B,D,E1,E2 BBS
• Only Surgical management for bile duct injury
with peritonitis and Type C,E3,E4,E5 BBS
• Interventional radiology utilised for bilioma, post
bilioenteric anastomotic stricture and Acute
cholangitis with non faesible scenario for
Endoscopist

42.
THANK YOU
• Bile Duct Injury and its consequences is the
morbid condition can be best managed by
comprehensive care with well equipped
multidisciplinary endoscopic and surgical
department