What is the management of a Bismuth (Biliary Injury Classification) 4 biliary injury?

Management of Bismuth Type 4 Biliary Injury

Hepaticojejunostomy with Roux-en-Y reconstruction performed by an experienced HPB surgeon at a specialized center is the recommended treatment for Bismuth type 4 biliary injuries.1

Understanding Bismuth Type 4 Injury

Bismuth type 4 biliary injury involves damage to the first branches of the hepatic duct, specifically at the hilar plate level with involvement of secondary biliary branches. This represents one of the most complex biliary injuries requiring specialized management.1, 2

Initial Management

• Prompt referral to a specialized hepatobiliary (HPB) center is crucial for optimal outcomes. Delayed referral (>96 hours) is associated with significantly higher morbidity, more surgical interventions, and longer hospital stays.3
• Initial management should focus on controlling biliary sepsis and converting acute injury to a controlled external biliary fistula through drainage.4
• Broad-spectrum antibiotics should be started immediately in patients with biliary fistula, biloma, or bile peritonitis using piperacillin/tazobactam, imipenem/cilastatin, meropenem, or other appropriate agents.1
• Complete imaging of the biliary tree is essential before definitive repair, using modalities such as percutaneous transhepatic cholangiography (PTC), MRCP, or other appropriate techniques.1

Timing of Definitive Repair

• Immediate repair should only be attempted by experienced HPB surgeons.1
• For most cases, especially those with inflammation, infection, or vascular injury, delayed repair is preferred after controlling bile leakage and infection.1
• Current evidence suggests that definitive repair can be performed 4-6 weeks after effective control of local inflammation and infection, rather than waiting the previously recommended 3 months.1
• The repair of complex vasculobiliary injuries (involving both biliary and vascular structures) should be delayed to allow for accurate imaging workup and strategic planning.1

Surgical Approach

• For Bismuth type 4 injuries (equivalent to Type II3 in some classifications), hepaticojejunostomy with Roux-en-Y reconstruction is the treatment of choice.1
• The surgical procedure must follow the fundamental principle of "anastomosis and reconstruction must build upon healthy, non-ischemic, non-inflamed, and non-scarred bile duct."1
• For insufficient functional remnant liver, duct-to-duct anastomosis or hepaticojejunostomy should be performed.1
• When chronic liver abscess, secondary diffuse hepatolithiasis, or segment atrophy is present, resection of the affected bile duct and affected tributary sectionectomy plus hepaticojejunostomy is advised.1

Management of Associated Vascular Injuries

• Concomitant vascular injuries, particularly to the hepatic artery, are common with complex biliary injuries.1
• Systematic immediate repair of isolated injuries of the right hepatic artery is not recommended, and the benefit/risk ratio should be evaluated carefully.1
• For vasculobiliary injuries (involving both biliary and vascular structures), management depends on the evidence and extent of liver injury (ischemia, necrosis, or atrophy).1

Long-term Follow-up

• Long-term outcomes are dependent on the Bismuth level, with higher-level injuries (like type 4) having less favorable outcomes.5
• Construction of an access loop during hepaticojejunostomy is recommended for Bismuth level III and IV injuries to facilitate potential future interventions.5
• Regular follow-up is essential as recurrent biliary strictures can occur several years after repair.4

Pitfalls and Caveats

• Many repair failures occur due to failure to follow the fundamental principle of using healthy, non-ischemic tissue for reconstruction.1
• The boundaries of ischemia and devitalization caused by thermal injury are often unclear at the early stage, which can lead to anastomotic leakage and short-term stenosis if not properly addressed.1
• Attempting repair without proper expertise can lead to worse outcomes; referral to specialized centers is crucial.3
• Using scarred bile duct wall or surrounding tissue to restore continuity will inevitably lead to surgical failure.1