From the Guidelines
The most effective technique for bile duct injury repair is Roux-en-Y hepaticojejunostomy, which remains the gold standard for major bile duct injuries, with success rates exceeding 90% when performed by experienced hepatobiliary surgeons 1.
Key Considerations
- Early recognition of bile duct injuries is crucial, as delayed diagnosis beyond 72 hours significantly worsens outcomes 1.
- Initial management includes fluid resuscitation, antibiotics, and biliary drainage.
- Endoscopic approaches with stenting are increasingly used for Strasberg type A and D injuries, while robotic-assisted repairs show promising results for complex reconstructions.
- Intraoperative cholangiography during cholecystectomy reduces injury risk by clarifying biliary anatomy.
Management Strategies
- For minor bile duct injuries (i.e., Strasberg A–D and conditionally E2), a direct repair, with or without the placement of a T-tube, and the placement of abdominal drains in the area is considered safe and appropriate 1.
- For major bile duct injuries (i.e., Strasberg E) associated with tissue loss and whenever an ischemic injury is suspected, a Roux-en-Y hepaticojejunostomy is the recommended method of reconstruction 1.
- Any dissection in the hilum may make subsequent reconstruction more difficult or cause further biliary or vascular injury, and thus, in case of insufficient experience in hepato-pancreato-biliary (HPB) surgery, it is recommended to place a drain in the right upper quadrant and transfer the patient to a center with experienced HPB surgeons 1.
Postoperative Care
- Postoperative care includes drain management, monitoring for bile leaks, and follow-up imaging at 3,6, and 12 months.
- The pathophysiology of bile duct injuries involves ischemic damage to the biliary tree, with inflammation and fibrosis contributing to stricture formation, making precise anatomical reconstruction essential for long-term success.
Recent Guidelines
- The 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy recommend a multidisciplinary approach, including the use of intraoperative cholangiography, endoscopic approaches, and robotic-assisted repairs 1.
From the Research
Latest Techniques for Bile Duct Injury Repair
The latest techniques for bile duct injury repair involve a multidisciplinary approach, including surgical, endoscopic, and radiological interventions. Some of the key techniques include:
- Hepaticojejunostomy, which is considered the gold standard procedure for reconstructing the bile duct in cases of bile duct injury 2
- Roux-en-Y hepaticojejunostomy, which is a commonly used technique for repairing bile duct injuries 3, 4
- Intrahepatic repair, which involves finding non-scarred, non-ischemic ducts to allow for a safe and high-quality anastomosis 3
- Percutaneous approaches, such as biliary interventions and portal vein embolization, which can be used as a first-line treatment or as a secondary treatment for failed Roux-en-Y hepaticojejunostomy 4
Factors Affecting Outcomes
Several factors can affect the outcomes of bile duct injury repair, including:
- Timing of surgery, with early repair (<14 days) and intermediate repair (14-90 days) having a higher stricture rate compared to late repair (>90 days) 5
- Type of repair, with intrahepatic repair having better outcomes compared to extrahepatic repair 3
- Use of stents, with stenting for more than 6 months having better outcomes 6
- Patient factors, such as male gender, which is associated with a higher risk of stricture formation 5
Treatment of Failed Repairs
Failed repairs can be treated with a combination of operative, radiologic, and endoscopic techniques. Some of the options include: