What is the management of postoperative bile duct injury?

Management of Postoperative Bile Duct Injury

Immediate referral to a tertiary hepatobiliary center is mandatory upon diagnosis of bile duct injury, as repair by non-specialized surgeons results in significantly worse outcomes with higher rates of failure, morbidity, and mortality. 1

Initial Assessment and Stabilization

• Obtain comprehensive imaging immediately: Triphasic CT scan as first-line to detect fluid collections, bilomas, and ductal dilation, followed by MRCP to definitively visualize the biliary anatomy and extent of injury 2, 3
• Laboratory evaluation must include: Complete blood count, comprehensive metabolic panel, liver function tests (AST, ALT, alkaline phosphatase, GGT), and inflammatory markers (CRP, procalcitonin) 3
• Initiate broad-spectrum antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem) for 5-7 days if signs of biliary peritonitis or sepsis are present 3
• Perform percutaneous drainage of any identified fluid collections or bilomas concurrently with other interventions 3

Classification-Based Management Strategy

Minor Bile Duct Injuries (Strasberg Type A, Low-Grade Leaks)

Endoscopic therapy is first-line treatment with success rates of 87.1-100%. 1, 2, 3

• ERCP with biliary stenting plus sphincterotomy is the preferred approach, superior to sphincterotomy alone which has higher failure rates 1, 3
• Plastic stents are recommended and left in place for 4-8 weeks, removed after retrograde cholangiography confirms leak resolution 1
• For refractory bile leaks, fully covered self-expanding metal stents are superior to multiple plastic stents 1
• Avoid sphincterotomy alone as it has higher failure rates and does not provide adequate transpapillary pressure gradient reduction 1

Benign Biliary Strictures (Strasberg Type C, E1)

• Endoscopic treatment is first-line: Multiple plastic stents placed over a long period achieve 74-90% success rates, though recurrence rates reach 30% within 2 years 1
• For strictures >2 cm from the main hepatic confluence, fully covered SEMS can be an alternative to plastic stents 1
• PTBD becomes necessary when ERCP fails or is not feasible, achieving 90% technical success and 70-80% short-term clinical success in expert centers 1

Major Bile Duct Injuries (Strasberg E2-E5, Complete Transection)

Surgical repair with Roux-en-Y hepaticojejunostomy is required, and timing is critical. 1

Timing of Surgical Repair

• Early aggressive surgical repair within 48 hours of diagnosis provides optimal results, avoids sepsis onset, reduces costs, and decreases hospital readmissions 1
• After 48-72 hours, inflammation decreases but proliferation and healing begin, significantly complicating surgical repair 1
• Delayed staged operations (waiting for bile duct dilation) fail in all cases and should be avoided 4, 5

Surgical Technique Requirements

• Roux-en-Y hepaticojejunostomy is the gold standard, showing superior 5-year outcomes compared to late repairs 1
• Tension-free bilioenteric anastomosis with good mucosal apposition and vascularized ducts is mandatory 1
• End-to-end anastomosis may be attempted if technically feasible, but is associated with increased failure rates and should generally be avoided 1, 5
• Anastomosis must be performed on healthy, non-ischemic, non-inflamed, and non-scarred bile duct tissue—failure to follow this principle is the main cause of anastomotic leakage and early stenosis 1

Critical Pitfalls to Avoid

• Never attempt repair without HPB expertise: More than 70% of bile duct injuries are initially repaired by non-specialized surgeons, leading to dramatically worse outcomes 2, 6
• Do not delay referral: Immediate transfer to a tertiary center upon diagnosis is essential, as delayed or inappropriate treatment significantly worsens long-term prognosis 1, 6
• Avoid early reconstructive surgery in the immediate postoperative phase (within 48-72 hours of the initial cholecystectomy if inflammation is severe), as it is associated with more complications than elective reconstructive surgery performed after appropriate stabilization 7
• Do not rely on endoscopic treatment alone for high-grade leaks: These represent an independent risk factor for morbidity and require surgical intervention 1

Long-Term Outcomes and Follow-Up

• Overall clinical success (absence of incapacitating biliary symptoms) is achieved in 89% of patients with appropriate multidisciplinary management 4
• Anastomotic strictures occur in 10-20% of cases (range 4.1-69%), with median time to stricture formation of 11-30 months 1
• Late complications including post-cholecystectomy biliary strictures, recurrent cholangitis, and secondary biliary cirrhosis may occur, requiring long-term surveillance 1
• Associated vascular injury, level of BDI, sepsis/peritonitis, and postoperative bile leakage are associated with worse outcomes 1

Multidisciplinary Approach Requirements

Close cooperation between gastroenterologists, interventional radiologists, and HPB surgeons is mandatory. 1

• First-line treatment consists of primary revisionary surgery in 59% of cases and percutaneous approach in 41% 4
• Second- or third-line treatment may be required in 16% of patients 4
• Robotic procedures may offer advantages through enhanced visualization, better tissue handling, and more precise surgery, particularly when tissue fragility is present 1