What is the management for a bile duct injury?

Management of Bile Duct Injury

The optimal management of bile duct injury requires immediate recognition, appropriate timing of repair, and selection of surgical technique based on injury type, with definitive repair performed by experienced biliary surgery specialists to minimize morbidity and mortality. 1

Classification and Initial Assessment

• Bile duct injuries (BDI) are classified based on anatomical location, with types ranging from Type I (pancreatic segmental bile duct and choledocho-pancreato-duodenal junction) to Type III (upper branches of tertiary hepatic duct) 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 2
• Broad-spectrum antibiotics should be started immediately in patients with biliary fistula, biloma, or bile peritonitis 2

Timing of Repair

• Intraoperative BDI should be repaired immediately only by experienced biliary surgery specialists 1
• If specialist expertise is unavailable during initial surgery, patients should receive drainage and be referred to specialist centers 1
• For BDI detected early postoperatively without local inflammation, primary repair can be performed 1
• In cases with abdominal infection, biliary peritonitis, vascular injury, or other complications, delayed repair is recommended after controlling bile leakage and infection 1
• Current evidence supports definitive repair at 4-6 weeks after effective control of inflammation and infection, rather than waiting the previously recommended 3 months 1, 2

Surgical Approach Based on Injury Type

Type I (Pancreatic segmental bile duct and choledocho-pancreato-duodenal junction)

• Simple BDI: Kocher incision, repair under direct vision + T-tube drainage 1
• Severe injury: Transection of common bile duct + choledochojejunostomy 1
• For late or infected cases: Staged operation with initial bile/pancreatic juice diversion followed by choledochojejunostomy 1

Types II1 and II2 (Extrahepatic bile duct and conjunctive region)

• Slight laceration: Simple suture 1
• Combined tissue defect with tension-free proximal-distal segments: Duct-to-duct anastomosis 1
• Large tissue defect or serious damage: Choledochojejunostomy 1

Type II3 (First branches of hepatic duct)

• Slight laceration: Simple suture 1
• Combined tissue defect with tension-free segments: Duct-to-duct anastomosis 1
• Large tissue defect or serious damage: Choledochojejunostomy 1
• For chronic liver abscess or secondary hepatolithiasis: Resection of affected bile duct and tributary sectionectomy plus choledochojejunostomy 1

Type II4 (Secondary branches of hepatic duct)

• With sufficient compensatory liver function: Ligation of injured bile duct 1
• With insufficient functional remnant liver: Duct-to-duct anastomosis or choledochojejunostomy 1
• For asymptomatic isolated injuries: Close follow-up 1
• With bile leakage or infection: Hepatectomy 1

Type III (Upper branches of tertiary hepatic duct)

• Ligation or suture of injured bile duct 1
• For bile leakage: PTCD or endoscopic stent placement 1
• For asymptomatic localized biliary stricture: Close follow-up 1

Fundamental Principles of Repair

• Anastomosis and reconstruction must use healthy, non-ischemic, non-inflamed, and non-scarred bile duct 1
• Many repair failures occur due to failure to follow this principle, particularly when ischemic boundaries are unclear 1
• Using scarred bile duct wall or surrounding tissue will inevitably lead to surgical failure 1

Long-term Outcomes and Follow-up

• Successful management in specialized hepatobiliary centers can achieve good outcomes in over 90% of cases 3
• Long-term follow-up (up to 20 years) is essential to ensure successful outcomes 4
• Hepaticojejunostomy with Roux-en-Y reconstruction has shown 88.3% success rate in long-term studies 4
• Complications can occur even years after repair, with anastomotic stricture developing in 11.6% of patients within 17 years 4

Management of Associated Vascular Injuries

• Concomitant vascular injuries, particularly to the hepatic artery, are common with complex biliary injuries 2
• For vasculobiliary injuries, management depends on the evidence and extent of liver injury (ischemia, necrosis, or atrophy) 2

Pitfalls and Caveats

• Delayed referral to specialized centers (averaging 12 months) has been associated with significant hepatic injury in 31.3% of patients 5
• Peritonitis and sepsis in the early phase and portal hypertension and cirrhosis in the late phase are the main causes of mortality 3
• The boundaries of ischemia from thermal injury are often unclear initially, which can lead to anastomotic leakage if not properly addressed 1
• Endoscopic and percutaneous interventional procedures may be performed as adjuncts to definitive surgical repair, particularly for optimizing the patient's condition preoperatively 6