What is the management of common bile duct injury?

Management of Common Bile Duct Injury

For common bile duct injuries, the optimal management approach is Roux-en-Y hepaticojejunostomy performed 4-6 weeks after effective control of inflammation and infection, with immediate repair only attempted by experienced hepatobiliary surgeons.

Classification and Initial Assessment

• Bile duct injuries (BDI) are classified based on anatomical location and extent of damage, with several classification systems available including Bismuth, Strasberg, Stewart-Way, and the more recent ATOM classification which is recommended as the most comprehensive system 1
• Complete imaging of the bile duct should be obtained before definitive repair using modalities such as percutaneous transhepatic cholangiography (PTC), MRCP, or other appropriate techniques 2, 3
• Broad-spectrum antibiotics should be started immediately in patients with biliary fistula, biloma, or bile peritonitis 3
• Detailed assessment should include evaluation of any associated vascular injuries, which are common with complex biliary injuries 3

Timing of Repair

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

Surgical Approach Based on Injury Type

Minor Injuries (Strasberg A-D)

• For minor BDIs (partial injuries without tissue loss), direct repair with or without T-tube placement and abdominal drainage is appropriate 2, 1
• Endoscopic decompression might be considered in cases of Strasberg A injury, though this has a high failure rate (up to 64%) 2

Major Injuries (Strasberg E and others with tissue loss)

• For major BDIs with tissue loss and transection, Roux-en-Y hepaticojejunostomy is the recommended method of reconstruction 2, 1, 3
• The key to successful hepaticojejunostomy is establishing an adequate caliber of anastomosis using a narrow proximal bile duct with normal mucosa 1
• Scar tissue on the stump of the bile duct must be removed after fully exposing the proximal bile duct 1
• Fine suture technique (5-0 or 6-0) should be used according to the thickness of the bile duct wall 1
• Principles of single-layer stitching, uniform margins, appropriate density, moderate knotting strength, and tension-free anastomosis should be followed 1

Fundamental Principles of Repair

• Anastomosis and reconstruction must use healthy, non-ischemic, non-inflamed, and non-scarred bile duct 3
• Many repair failures occur due to failure to follow this principle, particularly when ischemic boundaries are unclear 3
• Using scarred bile duct wall or surrounding tissue will inevitably lead to surgical failure 3

Management of Associated Vascular Injuries

• Concomitant vascular injuries, particularly to the hepatic artery, are common with complex biliary injuries 3
• Systematic immediate repair of isolated injuries to the right hepatic artery is not recommended 1, 3
• The repair of complex vasculobiliary injuries should be delayed rather than attempted intraoperatively, even by expert HPB surgeons 1

Pitfalls and Caveats

• End-to-end anastomosis is not recommended for cases with clips on the bile ducts and complete transection due to high risk of stricture formation 1
• On-table repair by non-HPB specialists is associated with worse outcomes including recurrent cholangitis, biliary strictures, revision surgery, and overall morbidity 2
• Early referral to an HPB center significantly decreases the rate of postoperative complications and biliary strictures compared to delayed referral 2
• 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 3