Christopher J. Sonnenday
Presentation
A 38-year-old woman presents to the emergency room with right upper-quadrant pain, nausea, emesis, and subjective fever. She underwent a laparoscopic cholecystectomy 4 days ago for acute cholecystitis. Past medical history is notable for obesity and two uncomplicated pregnancies.
On physical exam, the patient appears uncomfortable and diaphoretic. She is alert and oriented. Vital signs are notable for a temperature of 38.7°C, pulse of 110 beats per minute, blood pressure of 130/80, respiratory rate of 18, and an oxygen saturation of 99%. Her sclerae are anicteric. The abdomen is mildly distended with diffuse tenderness to light palpation, and more focal tenderness in the right upper quadrant. Her laparoscopic port site incisions are dry and intact without erythema or induration.
Differential Diagnosis
Abdominal pain following laparoscopic cholecystectomy, particularly pain significant enough to require an emergency room evaluation, should immediately prompt evaluation for technical complications of the procedure. Postoperative pain following laparoscopic cholecystectomy, now often accomplished as an outpatient operation, is generally moderate and should improve each subsequent postoperative day. It is unusual for otherwise healthy patients to require narcotic analgesics after the first 3 to 5 postoperative days. Patients who do not follow this expected course should be evaluated thoroughly, as early recognition and treatment of postcholecystectomy complications are paramount to limiting the impact of these events on the patient.
Complications common to any laparoscopic procedure should always be considered when evaluating the patient with abdominal pain following laparoscopic cholecystectomy. Inadvertent injury to bowel from trocar placement or instrument passing may present with peritonitis and postoperative sepsis. Evidence of urinary tract or surgical site infection should be queried. Constipation or ileus may also be seen in some patients, but lack of return of bowel function should lead to consideration of a more serious underlying complication.
The major complications specific to laparoscopic cholecystectomy include postoperative hemorrhage, a retained common bile duct stone, and bile duct injury. Bleeding complications following cholecystectomy are rare and often present in the first 24 to 48 hours postoperatively. Common etiologies include hemorrhage from the cystic artery stump or liver parenchyma along the gallbladder fossa. A retained common bile duct stone may present days to weeks following cholecystectomy and is typically associated with signs and symptoms of obstructive jaundice, cholangitis, and/or pancreatitis. Bile duct injury represents the most feared technical complication of cholecystectomy and can present in protean ways dependent on whether the primary injury results in a biliary leak or obstruction. Maintaining a high index of suspicion for bile duct injury in patients with unexpected problems following cholecystectomy is essential to making an early and definitive diagnosis. Sending a patient with unusual postoperative pain home from the clinic or emergency room without proper assessment can have catastrophic consequences if underlying intra-abdominal sepsis or biliary obstruction is left to go unaddressed.
Workup
Evaluation of the postcholecystectomy patient with suspected complications should proceed in a methodical manner. Initial maneuvers include administration of appropriate analgesia and fluid resuscitation as indicated. Laboratory evaluation should include a complete blood count, metabolic panel, liver profile, amylase, lipase, coagulation profile, and urinalysis. The initial laboratory results can be helpful in guiding the selection of appropriate imaging procedures and other interventions. Laboratory evaluation may initially be underwhelming, though a leukocytosis may be present. The total bilirubin may be normal or only slightly elevated (2 to 4 mg/dL) in the case of a complete biliary transection with free leak. Reabsorption of bile from the peritoneum may elevate the bilirubin slightly. Marked elevation of the transaminases is not typical and should raise concern of an associated vascular injury when present. Biliary injuries are typically not associated with abnormalities of the serum amylase and lipase. When associated with an obstructive pattern to the liver profile, biochemical evidence of pancreatitis may indicate a retained common bile duct stone rather than a bile duct injury.
Initial diagnostic imaging may include ultrasound, to assess for perihepatic fluid collections and biliary ductal dilatation, or computed tomography (CT) in select patients. If identified, significant perihepatic collections may be percutaneously drained. If bilious, a biliary leak is diagnosed, and the evaluation should proceed with direct cholangiography either by endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic cholangiography (PTC). If the fluid visualized on ultrasound or CT is not easily drained, or if the question of a biliary injury is still open, a hepatobiliary iminodiacetic acid (HIDA) nuclear medicine scan may be performed. HIDA scans can detect extravasation of biliary drainage and may also demonstrate failure of bile excreted from the liver to enter the duodenum. Further anatomic detail is not available from HIDA scans, but the test may be sufficient to confirm a suspicion of biliary injury before proceeding to more invasive means of cholangiography. CT angiography, with dual arterial and portal venous phases, can be used to define associated vascular injury. Magnetic resonance cholangiopancreatography (MRCP) is an attractive noninvasive imaging option if the diagnosis of a biliary injury is still in doubt. MR cholangiography can define an interrupted or strictured bile duct, and contrast agents (e.g., Eovist) with biliary excretion can be used to document biliary leaks on delayed images.
ERC is the best initial invasive study in a patient with a suspected or confirmed biliary injury following cholecystectomy. In injuries in which the continuity of the extrahepatic biliary tree is preserved, ERC may be both diagnostic and therapeutic. Endoscopic sphincterotomy and placement of an endobiliary stent is often sufficient to treat biliary leaks from the cystic duct stump or small accessory ducts. Incomplete transections may be bridged by endobiliary stents, with the need for subsequent operative intervention determined over time. In cases of common bile duct ligation, or in instances where a segment of the extrahepatic duct is excised with the gallbladder leaving an open proximal and distal extrahepatic bile duct, ERC may not be adequate to provide anatomic detail of the proximal biliary tree, nor able to facilitate crossing the injury. In these cases, PTC with placement of transhepatic biliary drains is typically necessary, and PTC should be performed in all patients with suspected bile duct injury in whom ERC was either not technically feasible or not definitive.
PTC in a patient with a recent ductal ligation or leak, and thus a decompressed biliary system, is difficult and often requires sophisticated interventional radiology resources and expertise. It is often necessary to place additional percutaneous drains to control bile leakage and drain infected bilomas until the biliary drainage is adequately diverted. These patients truly require multidisciplinary management to ensure that procedures are coordinated with the goals of improving the patient’s condition, defining the relevant anatomy, and facilitating eventual definitive repair. For this reason, the hepatobiliary surgeon needs to be involved in all decisions about placement of drains and transhepatic catheters, and the timing of these procedures.
Direct cholangiography allows classification of the type of biliary injury (Figure 1) according to the Bismuth-Strasberg classification. Type A injuries occur due to leakage from the cystic duct stump or accessory ducts draining directly into the gallbladder (ducts of Luschka) and present as a biliary leak and/or subhepatic biloma. Type B injuries are defined as ligation and division of an anomalous segmental hepatic duct, typically the duct draining segment 6 (± segment 7). This injury is often facilitated by the associated anomaly where the cystic duct drains into the right posterior duct. The proximal and distal ends of the anomalous segmental duct are clipped and divided during control of the cystic duct. Type B injuries are often asymptomatic or may present late with abdominal pain or cholangitis involving the occluded liver segment. Normally, the liver behind a type B injury will atrophy over time, often indolently. Type C injuries occur in the same anatomic setting as type B injuries, though the proximal ductal segment is not ligated and leaks freely into the peritoneal cavity. The difficulty in type C injuries lies in their diagnosis, as ERC typically misses the leaking segment as it is not opacified via the main biliary tree. Cholangiograms should be carefully inspected to make sure all liver segments are visualized; when the posterior segment is not seen, PTC may be diagnostic and allow control of the leak.
FIGURE 1 • The Bismuth-Strasberg classification of biliary injuries following laparoscopic cholecystectomy. (Reproduced from Winslow ER, Fialkowski EA, Linehan DC, et al. “Sideways”: results of repair of biliary injuries using a policy of side-to-side hepaticojejunostomy. Ann Surg. 2009;249(3):426–434, with permission.)
In type D injuries, a lateral injury to the extrahepatic bile duct occurs, either sharply or by thermal injury. The biliary tree remains in continuity, and the injury may manifest with a leak initially or a stricture in a delayed presentation. These injuries may be diagnosed accurately by ERC, which can also provide definitive treatment via endobiliary stenting.
Type E injuries are defined by complete disruption of biliary–enteric continuity due to transection, excision, and/or ligation of the extrahepatic biliary tree. Injuries that include a free biliary leak will prevent early with bile peritonitis and sepsis. Injuries with occlusion of the proximal hepatic drainage may present in a delayed fashion with jaundice and/or cholangitis, although still typically within 2 weeks of cholecystectomy as all biliary drainage is occluded. Type E injuries are further described according to the Bismuth classification (E1 to E5, as depicted in Figure 1), with important implications about the complexity of definitive repair. The majority of type E injuries will require PTC to definitively reveal the anatomic details of the injury and to establish stable biliary drainage.
In the present case, CT demonstrates the patient to have a large right upper-quadrant fluid collection. The collection is percutaneously drained, revealing frank bilious output that grows gram-negative organisms in culture. Antibiotics are initiated. ERC reveals an obstructed bile duct at the level of the cystic duct. PTC is performed demonstrating a complete transection of the hepatic duct within 2 to 3 mm of the bifurcation (type E3 injury, Figure 2, panel A). A transhepatic biliary drain is left in place, providing external biliary drainage (Figure 2, panel B,C).
FIGURE 2 • Type E3 biliary injury managed with U tube percutaneous biliary drainage and delayed Roux-en-Y hepatico-jejunostomy. PTC on postoperative day 5 following laparoscopic cholecystectomy reveals type E3 injury with biliary leak (panel A). A wire was able to be passed from percutaneous access to the right hepatic across the hepatic duct bifurcation and retrieved from percutaneous access to the left hepatic duct, allowing placement of a U tube for external biliary drainage (panel B). The patient recovered over the ensuing 12 weeks, during which time the biliary leak resolved with stable U tube drainage (panel C). At the time of hepati-cojejunostomy, the U tube was exchanged for individual bilateral biliary catheters placed across the anastomosis. The catheters were removed 3 weeks after repair when cholangiogram revealed a well-healed patent hepati-cojejunostomy (panel D).
Diagnosis and Treatment
The management of bile duct injuries should be catered to the condition of the patient, timing of the injury, and anatomic details according to the Bismuth-Strasberg classification. Principles that apply in all cases include control of sepsis, drainage of all bile collections, and establishment of secure biliary drainage. Ongoing reassessment of the patient’s clinical condition, with reimaging as clinically indicated to detect undrained bilomas, will get even the frailest patients through what can be tenuous early stages of their injury, allowing definitive repair to be performed in an elective fashion on a healthy patient. Timing of definitive repair for those patients that require biliary reconstruction is an individualized decision that requires careful surgical judgment.
Specific treatment strategies for bile duct injuries can be determined according the Bismuth-Strasberg classification, as summarized in Table 1. The decision making about the urgency of intervention and the need for surgical reconstruction varies based upon the timing of the patient’s presentation, and the patient’s clinical condition. Injuries recognized at the time of cholecystectomy, or within the immediate postoperative period (48 to 72 hours), can be considered for early repair.
TABLE 1. The Bismuth-Strasberg Classification of Biliary Injuries Following Laparoscopic Cholecystectomy
In the case of injuries recognized intraoperatively at the time of cholecystectomy, immediate repair should only be performed when adequate surgical experience and expertise are available and the extent of the injury is completely understood. The inability to perform good quality cholangiography, or the lack of surgical experience with biliary–enteric anastomoses, are examples of contraindications to immediate repair. Other relative contraindications to early repair include an associated vascular injury, hemodynamic instability, excessive blood loss, or a thermal injury to the duct with extensive devitalized tissue.
In the case of patients who present in the first 48 to 72 hours after cholecystectomy, early repair may be considered if the patient is clinically well without signs of sepsis or hepatic dysfunction, and the anatomic details of the injury are well understood with cholangiography. Relative contraindications to early repair include associated vascular injury, thermal injury with extensive devitalized tissue, and Class E3 or greater injuries where achieving a quality repair to healthy tissue can be difficult in the acute setting.
In patients presenting beyond 72 hours from cholecystectomy, and/or with signs of intra-abdominal sepsis, the initial priorities should be appropriate resuscitation, broad-spectrum antibiotics, cross-sectional imaging, and percutaneous drainage of all significant fluid collections. Direct cholangiography via ERC or PTC is the next step, with an attempt to obtain definitive internal or external biliary drainage. Once biliary drainage is established, the pressure of time is removed and the patient should be allowed to recover from the cholecystectomy and any associated sepsis. Most hepatobiliary surgeons will wait 6 to 8 weeks or more before proceeding with biliary reconstruction. This delay allows for the resolution of any associated peritonitis, provides time for collateralized biliary blood flow to be established, and allows the patient to rehabilitate physically.
Surgical Approach
The preferred method for repairing most injuries is a Roux-en-Y hepaticojejunostomy (Table 2), and the key principles include creation of a tension-free anastomosis to healthy hepatic ducts that drain all biliary segments. Direct end-to-end repair of the extrahepatic bile duct is often unsatisfactory when a significant section of the duct has been devitalized or removed, and is associated with a high rate of additional complications especially stricture.
TABLE 2. Key Technical Steps and Potential Pitfalls in Roux-en-Y Hepatico-jejunostomy Procedure
Care should be taken to choose a part of the proximal jejunum that reaches easily to the right upper quadrant. The small bowel should be divided at an appropriate place with a GIA stapler, and the mesentery divided to allow the Roux limb maximum mobility. Division of the first vascular arcade of the small bowel mesentery can usually be done safely, though the end of the Roux limb should always be inspected for sufficient perfusion. A retrocolic Roux-en-Y hepatico-jejunostomy, brought to the right upper quadrant through a defect made in the mesocolon to the right of the middle colic vessels and above the duodenum, provides the most direct route to the porta and can avoid any undue tension created by draping the Roux limb over the colon. In patients with previous abdominal surgery, time should be taken to meticulously lyse any adhesions that tether the small bowel mesentery. In cases where patients have a foreshortened mesentery, due to previous surgery, radiation, or other conditions, a medial visceral rotation of the right colon will expose the root of the small bowel mesentery that can be mobilized up to the level of the duodenum and neck of the pancreas.
A few important principles apply to the dissection of the porta in the setting of a biliary injury. The mechanism of bile duct injury in these cases often arises from unintentional dissection of a long segment of the bile duct, which can strip the duct of its blood supply that runs through the periductal adventitial tissue. In early repair cases, it is therefore important to identify a portion of the duct that has not been completely dissected, and carefully expose or shorten the hepatic duct in a location that is amenable to construction of the biliary anastomosis. In E1 or E2 injuries, it may be possible therefore to stay below the true hepatic duct bifurcation, but care should be taken not to sew to a traumatized end of the hepatic duct. Opening the duct on its anterior surface, with a ductotomy extended toward the long extrahepatic portion of the left hepatic duct can expose healthy tissue and avoid further dissection behind the duct which can further compromise ductal blood supply. In later repair cases, avoiding dissection behind the hepatic duct is really essential, as this allows preservation of any collateralized blood supply that has been created at the site of the injury. This principle of “anterior-only” dissection also avoids creating additional vascular injury, as the right hepatic artery is often directly behind the hepatic duct at this level and can be obscured or difficult to identify in a chronically inflamed or scarred field.
All biliary anastomoses should be performed under loupe magnification, using fine monofilament absorbable suture, typically in an interrupted fashion. Placement of subhepatic drains to monitor for biliary leak is typically performed. After completion of the biliary anastomosis, the Roux limb can be further anchored to relieve tension by taking seromuscular bites of the jejunum and tacking it to the former gallbladder fossa, portal plate, or umbilical fissure.
Special Intraoperative Considerations
For E3 injuries or higher, the hepatic duct bifurcation needs to be exposed by lowering the portal plate. This involves incising into the liver parenchyma to get above the hepatic duct bifurcation, beginning above the long extrahepatic course of the left hepatic duct. This can often be done with a blunt technique and judicious use of electrocautery but can be facilitated in difficult cases by the use of an ultrasonic or hydrojet dissector. Bleeding may be encountered during this technique, but can be stopped by packing gauze or other hemostatic material into the hepatotomy for a period of time. Returning to this area after completing other tasks, such as creating the enteroenterostomy of the Roux limb, allows performance of the biliary anastomosis in a dry and controlled field.
Controversy exists over the need for transhepatic biliary catheters to serve as a stent across a fresh biliary-enteric anastomosis. In the case of early repairs, many surgeons will go to the operating room without transhepatic catheters. Intraoperative placement of retrograde transhepatic biliary catheters is difficult and potentially adds additional trauma to the liver. Therefore in these cases, routine postoperative stenting is not possible or advised. In the case of delayed repairs, a transhepatic biliary catheter is typically in place at the time of repair, and may be passed across the new biliary–enteric anastomosis. These tubes typically can be capped off (“internalized”) in the immediate postoperative period if no evidence of anastomotic leak, used for postoperative cholangiography to interrogate the new anastomosis, and removed 3 to 6 weeks after repair.
Associated vascular injury is not uncommon in bile duct injury and may be associated with both acute liver injury and delayed biliary stricture due to ischemia. Significant vascular injury associated with a measurable rise in liver enzymes and systemic inflammatory response is a relative contraindication to early repair of bile duct injury, as the patient may not be optimized for a complex operation. Delayed repair also allows for collateral blood flow to involved biliary segments to mature over time. Fortunately, segmental hepatic vascular injuries do not typically require reconstruction due to the redundant blood flow to the liver. Exceptions to this general rule would include ligation or severe stenotic injury to the main portal vein or proper hepatic artery.
Postoperative Management
The postoperative period in patients undergoing a biliary-enteric anastomosis is typical of other major upper abdominal operations. Appropriate analgesia, early mobilization, and sequential advancement in diet should occur in all patients. Wounds should be monitored for signs of infection, especially in patients with indwelling percutaneous biliary drains, which predispose to surgical site infection. Patients should be monitored for biliary leak or other signs of intra-abdominal infection. In cases where a closed suction drain is left at the time of operation, the output should be monitored for bilious fluid. Typically the drain(s) can be removed in 3 to 4 days once the patient has resumed a diet if the output is nonbilious. In the case of a low-volume biliary leak, observation with continued external drainage may be the only necessary intervention, as such leaks will resolve. In the case of a more significant leak, or a leak associated with signs of sepsis, percutaneous biliary drainage may be necessary if not already in place. Reoperation is typically not necessary for management of a biliary leak.
In the intermediate and long term, biliary stricture is the most significant potential postoperative event. As many as 15% of patients undergoing biliary reconstruction may develop an anastomotic stricture, with the vast majority able to be managed by percutaneous transhepatic dilatation and stenting without the need for operative revision. As most biliary strictures may present indolently, a liver profile should be followed for signs of cholestasis. Often an isolated rise in the alkaline phosphatase is the initial sign of a biliary stricture. A liver profile should be checked every 3 to 6 months for the first 2 years, and then annually thereafter. The majority of anastomotic strictures will present in the first 2 years postoperatively, though rarely may present even in a markedly delayed fashion.
Case Conclusion
With percutaneous biliary drainage and antibiotics, the patient improves and is sent home. After an 8-week delay, biliary reconstruction is performed with a Roux-en-Y hepaticojejunostomy. The biliary catheter is passed across the new biliary enteric anastomosis and removed after a follow-up cholangiogram at 3 weeks postoperatively reveals a widely patent anastomosis (Figure 2, panel D). At 3-year follow-up, the patient is clinically well with a normal liver profile.
TAKE HOME POINTS
· Patients who present following cholecystectomy with unusual pain or signs of infection should be considered to have a bile duct injury until proven otherwise.
· Initial diagnostic imaging of a patient with a suspected bile duct injury should include ultrasound and/or CT to assess for perihepatic fluid collections.
· Initial management of bile duct injury should include control of sepsis, drainage of all bilomas, and establishment of secure internal or external biliary drainage.
· Patients who present beyond 48 to 72 hours from the time of their injury, and/or who show signs of intra-abdominal sepsis, are best managed with a delayed operative repair.
· A broad, tension-free anastomosis using absorbable suture is the preferred method for reestablishing biliary–enteric continuity.
· Biliary stricture is the primary significant long-term complication of hepaticojejunostomy; serial liver profile monitoring may detect an indolent stricture before clinically apparent.
SUGGESTED READINGS
Couinaud C. Exposure of the left hepatic duct through the hilum or in the umbilical of the liver: anatomic limitations. Surgery. 1989;105(1):21–27.
Melton GB, et al. Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life. Ann Surg. 2002;235(6):888–895.
Sicklick JK, et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005;241(5): 786–792; discussion 793–795.
Winslow ER, et al. “Sideways”: results of repair of biliary injuries using a policy of side-to-side hepatico-jejunostomy. Ann Surg. 2009;249(3):426–434.