Aust.
533
N.Z. J . Surg. 1992,62.533-539
IATROGENIC INJURIES TO THE EXTRAHEPATIC BlLlARY TRACT A. J . RICHARDSON, N. TAIT,G. MUGUTIAND J. M. LITTLE Department of Surgery, Westmead Hospital, Westmead, New South Wales, Australia Iatrogenic injuries to the extrahepatic biliary tract continue to occur and result in significant morbidity. Over the last 10 years, 26 patients have been referred to Westmead Hospital for management of iatrogenic biliary tract injuries. Of these injuries, 22 occurred during cholecystectomy, three during hepatectomy and one during a pancreaticoduodenectomy . The principles of avoidance and repair are discussed. It is concluded that these injuries, although uncommon, continue to occur and that the best treatment results are achieved in specialized hepatobiliary units.
Key words: balloon dilatation, biliary stricture, extrahepatic bile ducts.
Introduction The majority of injuries to the extrahepatic biliary tract are iatrogenic in nature and as such, preventable. Repair of an extrahepatic biliary tract injury may be extremely difficult and carry grave longterm consequences for the patient. This analysis was undertaken to review the experience of a single hepatobiliary surgery unit in an attempt to define management problems in what remains a controversial area.
Methods The records of all patients with iatrogenic injury to the extrahepatic biliary tree referred for treatment at Westmead Hospital from 1979-91 were examined retrospectively. The information extracted included demographic characteristics, mode of injury, operative findings and treatment, type of injury, outcome and follow-up. Patients whose injury was related to malignancy, sclerosing cholangitis, blunt or penetrating trauma and ampullary stenosis were excluded.
Results There were 19 females and seven males in the series with a mean age of 47 years (range 19-66). Twenty-two injuries occurred during cholecystectomy and three during hepatectomy (two for trauma). One patient developed a biliary stricture after a pancreaticoduodenectomy .
Correspondence: Prof. J . M . Little, Department of Surgery, Westmead Hospital, Westmead, NSW 2145, Australia. Accepted for publication 30 January 1992
PATIENTS HAVING INITIAL REPAIR AT WESTMEAD HOSPITAL
Eleven patients were examined at Westmead Hospital after their injury but before any repair was attempted. According to the Bismuth criteria,' there were five type 1, three type 2 , one type 3 and one type 4 injuries. Additionally, one patient had had an aberrant segment V duct ligated. Nine of these injuries occurred during cholecystectomy , four being recognized in the immediate postoperative period and referred to Westmead Hospital. All of these patients were jaundiced and two were seriously ill with biliary peritonitis. The other five presented with jaundice and cholangitis with two presenting within 1 year of cholecystectomy and three presenting at 6 years, 7 years and 30 years after cholecystectomy . Nine patients underwent operation. Seven patients underwent choledochojejunostomy and one patient had an hepaticojejunostomy with separate anastomosis of each duct to the Roux-en-Y jejunal loop. The other patient had multiple biliary calculi with a 30 year history of recurrent cholangitis and was treated by resection of segments I1 and 111with separate anastomoses of the divided left hepatic duct and common hepatic duct. Of two patients with extrahepatic bile duct injuries after right hepatic lobectomy for trauma, one patient who had sustained multiple injuries, was treated with external biliary drainage. This patient died 17 days after admission as a result of multiple organ system failure. The other patient was explored, but despite a long and arduous procedure it proved impossible to identify the common hepatic duct. He subsequently returned to the country where, surprisingly, his liver function tests and jaundice improved and he was lost to follow-up.
34
27
1
4
2
I
2
1
3
F
F
M
M
F
F Ligation aberrant
segment V duct 2
F
F
M
3
4
5
6
7
8
9
10
11
22
32
46
43
34
23
64
42
1
M
2
67
I
M
Repair
Right hepatic lobectomy for trauma. Multiple injuries Right hepatic lobectomy for trauma 3 weeks before re-exploration
Cholecystectomy (9 days before admission). Jaundice Cholecystectomy (10 days previously). Biliary peritonitis, multiple intraabdominal abscesses Cholecystectomy (7 days previously). Jaundice and cholangitis Laparoscopic cholecystectomy (2 months previously). Jaundice and cholangitis Cholecystectomy. Cholangitis
Unable to identify proximal common hepatic duct, dense adhesions
External drainage of biliary tree
No operative procedure
Choledochojejunostomy
Choledochojejunostomy
Choledochojejunostomy
Choledochojejunostomy
Cholecystectomy (6 years previously) Choledochojejunostomy Jaundice and cholangitis Choledochojejunostomy Cholecystectomy (7 years previously). Jaundice and cholangitis Cholecystectomy (30 years previously). Resection of segments 11 & 111, Recurrent cholangitis with multiple choledochojejunostomy and intrahepatic stones hepaticojejunostomy Roux loop with separate anastomoses Cholecystectomy 8 days before admission. Jaundice and biliary to right and left hepatic ducts peritonitis
Age Cause and presentation
I
Patient Sex Type of Injury
~~
Table 1. Patients having initial repair
Died 17 days after admission of multiple organ system failure Jaundice resolved lost to follow-up
N o further problems, 5 years follow-up
Well, 3 months follow-up
Well, 6 months follow-up
No further problems 1 year follow-up
Recurrent cholangitis, percutaneous dilatations required, required choledochoscopy via access loop for removal of debris 2 years following repair No further problems 3 years follow-up
Died 8 months post-operatively of lymphoma
Died 2 months after operation of recurrent gastrointestinal haemorrhage No further problems 7 years follow-up
Outcome
VI P w
1
3
I
I
4
2
1
5 8 F
5 8 F
3 1 F
6 3 F
6 6 M
5 7 F
6 5 F
2
3
4
5
6
I
8
2
4 5 F
~
No. previous repairs
Cholecystectomy 1 year previously Cholecystectomy 1 1 years previously Cholecystectorny 3 years previously Laparoscopic cholecystectomy 1 month previously Cholecystectomy 9 years previously Cholecystectomy I6 years previously Biliary peritonitis, jaundice
Biliary peritonitis due to rupture of choledochoduodenostomy Cholangitis
Cholangitis jaundice
Cholangitis jaundice biliary cirrhosis
Cholangitis jaundice
Presenting problem
1 (procedure abandoned)
Jaundice cholangitis and biliary cirrhosis I (intraoperative end-to-end Cholangitis repair I6 years previously)
I (choledochoduodenostorny) I (choledochoduodenostomy 5 years previously) I (choledochoduodenostomy) I (hepaticojejunostomy)
Cholecystectomy 4 25 years previously
4 years previously
Cholecystectomy 4
Type of Injury Cause
1
Patient Age Sex
Table 2. Patients seen after attempted repairs
No further cholangitis
Outcome
Jaundice relieved, no further cholangitis
Jaundice relieved, no further cholangitis Jaundice relieved, no further cholangitis
Roux-en-Y loop with separate anastomosis to R & L ducts (with stent) Choledochojejunostomy with T-tube splint Choledochojejunostomy
Required percutaneous dilatation for duct enteric stricture 15 months later (Case no. 8; Table 3), no problems since then Liver split and segment I11 Jaundice relieved, no further cholangitis bypass Jaundice relieved, no Take down of choledochoduodenostomy, further cholangitis choledochojejunostomy No further cholangitis Choledochojejunostomy Choledochojejunostomy
Choledochojejunostomy
Repair
Returned overseas I year
7 months
5 years
6 years
3 years
5 years since dilatation
5 years
Follow-up
536
RICHARDSON ETAL.
The patient who had ligation of the segment V duct was treated non-operatively and had no attacks of cholangitis in 5 years of follow-up. Of the nine patients who underwent operation, two have died. One patient who had a choledochojejunostomy died two months after operation of recurrent gastrointestinal haemorrhage due to a false aneurysm of the common hepatic artery. The other death which occurred in the patient who had resection of segments I1 and 111 with separate anastomoses, was due to lymphoma 8 months postoperatively although there was no recurrence of jaundice or cholangitis. Of the five patients who underwent choledochojejunostomy, no patient had recurrence of jaundice or cholangitis or subsequent hospitalization in followup periods ranging from 3 to 80 months (mean =
2 3 ) . The other patient who had a type IV injury required multiple percutaneous dilatations (case no. 4; Table 1) and also choledochoscopy via the access loop for removal of particulate matter. These patients are summarized in Table 1. P A T I E N T S S E E N AFTER A T T E M P T E D R E P A I R S
Eight patients have undergone biliary reconstruction after one or more repairs elsewhere. Two of these had previously undergone four attempted repairs each, and the other six patients had each undergone one previous repair. These are summarized in Table 2 . PERCUTANEOUS DILATATION
Nine patients underwent percutaneous dilatations of biliary strictures and these are summarized in
Table 3. Patients who underwent percutaneous dilatations of biliary strictures No.
_-
Age at presentation to Westmead
Sex
Cause
Problem at presentation Left hepatic lobectomy, multiple strictures, biliary cirrhosis, emphysema Stricture of anastomosis, duodenal carcinoma High CHD stricture, refused surgery Stenosis choledochoduodenostomy haemorrhagic pancreatitis Right hepatic lobectomy, stricture of anastomosis Recurrent stricture at common hepatic duct enteric anastomosis Stricture of duct enteric anastomosis Whole duct septem excised from hilar plate to duodenum, right and left ducts anastomosed separately to Roux loop, stricture of anastomosis Stricture of duct enteric anastomosis, biliary cirrhosis
I
63
Hydatid surgery
2 3 4
53 33 21
Choledochoduodenostomy Cholecystectomy Cholecystectomy
5
36
6
57
Hydatid surgery, choledochoduodenostomy Cholecystectomy
7 8
62 23
Pancreaticoduodenectomy Cholecystectomy
9
58
Cholecystectomy
Table 4. Patients who underwent percutaneous dilatation of biliary strictures No. previous operations ___ No.
No. dilatation
Results
2
3
4 3 I
8
5
1
Jaundice relieved, n o cholangitis
9
3
I
Jaundice relieved, no cholangitis
I 2
2 6
Died 1 month Died of carcinoma at 2 months Recurrence at 4 months, left main duct repair Jaundice relieved, no cholangitis Jaundice relieved, no cholangitis Jaundice relieved, no cholangitis Jaundice relieved, no cholangitis
Follow-up
Jaundice relieved, lost to follow-up after 12 months Asymptomatic at 8 years follow-up Required dilatation - 1985, 1988, 1990 More than 5 years since last dilatation Required choledochoscopy via access loop - 1988, repeat dilatation - 1991 Required dilatation of biliary enteric anastomosis 15 months after operation, now 4 years without further problems Two years since dilatation
EXTRAHEPATIC BILE DUCTS
Tables 3 and 4. Seven have been treated by percutaneous dilatation alone without any operative procedure being performed at Westmead Hospital. Cases 8 and 9 had biliary reconstructions, with subsequent biliary enteric anastomotic stenoses treated by percutaneous dilatation. OPERATIVE CHOLANGIOGRAPHY
Of the 22 patients whose injury occurred during cholecystectomy, it was known that operative cholangiography had been performed in 12, had definitely not been performed in seven, and had been performed in three although one of those had had an aberrant segment V duct ligated rather than an injury to the common bile duct. SURGEON
Thirteen of the 22 cholecystectomies resulting in biliary injuries were performed by consultant surgeons. In the other nine the seniority of the surgeon was not known.
Discussion Cholecystectomy is by far the most common cause of injury to the extrahepatic biliary tract in Western countries. The reported incidence of this injury at cholecystectomy ranges from 0.06 to 0.3% .2-4 AIthough it is impossible to give an accurate figure, it is probably at the lower end of this range in Australia. Johnston has described the major causes of bile duct injury as falling into three categories: dangerous pathology; dangerous anatomy; and dangerous s ~ r g e r y .It~ appeared that the majority of patients in this series were undergoing elective rather than emergency procedures and that the factors involved in creation of the injury fell into the latter two categories rather than the first. Kune made a similar observation in another Australian series and has eloquently defined the operative steps in the avoidance of this injury.6 Tragically, these injuries are most common in young, healthy females. The mean age of 47 years in this series and the fact that 19 of the 26 patients who sustained an injury were female is very similar to that of other reported series.2,33637,8,9 A previous report from Sweden attributed most injuries to trainee surgeons who were performing between their 25th and 100th cholecystectomy.3 In this series, information was not available on nine of the operating surgeons, but at least 13 of the 22 injuries occurred when a consultant surgeon was operating. Moosa, in a large series of iatrogenic bile duct injuries, found that a trained surgeon operated in 64% of the cases and assisted in another 10% . 9 The place of routine operative cholangiography remains controversial. It is often stated in the litera-
537
ture, that this is now unnecessary as missed stones can be dealt with endoscopically .l o We disagree with this premise because operative cholangiography is, in association with careful dissection and identification of the major structures, a useful addition in the attempt to accurately identify and record the anatomy." It does not add a great deal to the operating time and may help to prevent some of these injuries and lead to earlier detection of injuries that do occur. Warren believed that virtually all biliary strictures occurred within 3 years of the injury.I2 This was not our experience in that some strictures appeared many years later. It is only possible to hypothesize about the pathology of these late strictures although it would seem the most likely precipitating factor is ischaemia due to disruption of the biliary blood supply which is then complicated by biliary infection as the stricture progresses. Similarly, although 80-90% of recurrences after operative repair occur within 5-7 years a small number may recur many years after operative repair. I 3 3 l 4 Only one aberrant segmental duct injury was identified but it is suspected that many of these injuries go unrecognized. Aberrant segmental ducts, mostly either the right anterior sectoral or right posterior sectoral duct, may join the common hepatic duct or the common bile duct in up to 20% of cases.15 As the majority of these ducts pass across Calot's triangle, they may be inadvertently ligated or divided. Additionally, a subvesical duct may join either the common hepatic duct or right hepatic duct in up to 50% of cases and is at risk of injury.I6 Some authors have suggested that injured ducts 2 mm or greater in diameter should be repaired because of the risk of cholangitis.17.'* We believe that there is a significant body of e~perimental'~ and cIinical evidence20-22to suggest that segmental atrophy will occur with a low risk of cholangitis as opposed to the significant risks of operative repair if an aberrant segmental duct is inadvertently divided. However, it should be stressed that the object should be identification and preservation of those structures whenever possible. We agree with Hadjis et al. that ligation and careful postoperative followup of the patient should be all that is r e q ~ i r e d . ' ~ Surgery remains the mainstay of treatment of biliary strictu~sbut there is a higher rate of stricture recurrence if the patient requires several attempts at repair.8214Similarly, the level of the stricture correlates with the outcome, and type 111 and type IV strictures have a higher recurrence rate. 13,24 This may well be due to the more difficult dissection that may predispose to more postoperative scarring. Additionally, the principles of mucosal apposition with no tension are much more difficult to fulfil. Type I and type I1 strictures have done well in the author's hands, particularly if they were having their first
538
RICHARDSON ETAL.
repair done at Westmead Hospital. Either a choledochojejunostomy or hepaticojejunostomy using a Roux-en-Y loop is the operation of choice and it is important to suture part of the Roux loop to the anterior abdominal wall as an access loop to facilitate later percutaneous access to the biliary tree. 25,26 A segment 111 approach as originally described by Hepp and Couinaud can be helpful in hilar strictures and in patients who have undergone multiple attempts at repair. Choledochoduodenostomy is rarely indicated as it is difficult to avoid some tension on the anastomosis and there is no access loop. End-to-end repair of a completely divided duct is not indicated except perhaps if performed at the time of injury. Even then, the incidence of subsequent stricture formation is extremely high.',' This is not really surprising when one considers the axial blood supply of a biliary tract. An access loop should, as far as possible, be constructed routinely because it permits easy percutaneous access to the biliary tree without having to traverse the liver. The results of surgical repair are best when performed in specialized centres. The University of California at Los AngelesI3 and the Cleveland Clinic8 have reported a successful outcome after surgery in 86 and 82% of patients respectively, with a mean follow-up of 5 years. Way has reported a successful outcome in 78% of patients at 102 months.I4 The use of stents has been extensively debated but, overall, it is difficult to find evidence supporting their routine use. In this study stents were only used in particularly high, difficult and tenuous anastomoses because it is believed that they may predispose to infection and early stricture recurrence. Since the initial description of balloon dilatation for benign biliary structures by Burhenne,28 and Molmar and S t o c k ~ mthis , ~ ~technique has become an important tool in the management of these difficult patients. Mueller reported the results of percutaneous dilatation in three groups, namely those with anastomotic strictures (e.g. choledochojejunostomy and hepaticojejunostomy), iatrogenic strictures, and strictures due to sclerosing cholang i t i ~ . ~The ' 3 year patency rates were 67, 76 and 42% respectively. Three years is too early a time frame and it would be expected that these success rates would slowly decrease with longer follow-up. Pitt et al. attempted to compare surgical treatment with balloon dilatation and achieved a successful outcome in 88% of the surgical group versus 55% of the balloon dilatation group.' In the authors' experience, balloon dilatation has been particularly helpful in patients with anastomotic strictures. The Mayo Clinic have reported success rates of 73% at 28 months for balloon dilatation of anastomotic strictures31 and Moore has reported a success rate of 82% at 33 months.32 Balloon dilatation has been
*'
found to be less successful than surgery in the treatment of primary biliary strictures though it has been useful in the elderly patient who has undergone multiple procedures or in patients with biliary cirrhosis who are either unwilling or unfit for further surgery. In conclusion, most injuries to the extrahepatic biliary tract are iatrogenic and occur during elective cholecystectomy . With the advent of laparoscopic cholecystectomy it is quite likely that the number of cholecystectomies will increase and the principles involved in avoiding these injuries will be even more pertinent. It is important, however, that when these injuries do occur, they be managed in a specialized hepatobiliary service where access to the necessary surgical expertise, radiology and percutaneous techniques is available.
References 1. BISMUTH H. (1982) Postoperative strictures of the bile duct. In: The Biliary Tracr (Ed. L. H . Blumgart). Churchill Livingstone. 2. CSENDES A , , DIAZJ . C . , BURDILES P. & MALVENDA F. (1989) Late results of immediate primary end to end repair in accidental section of the common bile duct. Surg. Gynecol. Obstef. 168, 125-30. A ,, ALINDER G . & BERGMARK S. 3. ANDREN-SANDERG (1985) Accidental lesions of the common bile duct at cholecystectomy. Pre- and peroperative factors of importance. Ann. Surg. 201,328-32. 4. ROSENGUIST H. & MYRIN S . 0. (1960) Operative injuries to the bile ducts. Acta Chir. S c a d . 119, 92-107. 5. JOHNSTONEG. W. (1986) Iatrogenic bile duct stricture: an avoidable surgical hazard? Br. J . Surg. 73: 245-7. 6. KUNEG. A. (1979) Bile duct injury during cholecystectomy: causes, prevention and surgical repair in 1979. A u s t N . Z . J . Surg. 49, 35-40. S. C., COLEMAN J., WHILE R. I. 7. PITTM. A , , KAUTMAN & CAMERON J. L. (1989) Benign postoperative biliary strictures operate or dilate? Ann. Surg. 210, 417-25. 8 . SENEST J . F., NANUS E., GRUNDFEST-BRONIATOWSKI S., VWT D. & HERMAN R. E. (1986) Benign biliary strictures: an analytic review (1970-1984). Surgery 99, 409-13. 9. MWSAA . R . , MAYERA. D. & STABILE B. (1990) Iatrogenic injury to the bile duct. Arch. Surg. 125, 1028-31. 10. YIPA. & LAMK. H. (1988) An evaluation of routine operative cholangiography. Ausr. N . Z . J . Surg. 58, 391-5. 11. KELLEY C. J . & BLUMGART L. H. (1985) Per-operative cholangiography and post cholecystectomy biliary stricture. Ann. R . Coll. Surg. Engl. 67, 93-5. 12. WARREN K. W . , POULANTZAS J . K. & KUNEG. A . (1966) Use of a Y-tube splint in the repair of biliary strictures. Surg. Gynecol. Obstet. 122; 785-90. T . , PARPATIS S . K . , TOMPKINS R. K. & 13. MIYEMOTA LONGMIRE W. P. (1982) Factors influencing outcome in patients with post operative biliary strictures. Pitt. Am. J . Surg. 114: 14-21. 14. PELLEGRINI C. A,, THOMAS M. J . & WAY L. W.
EXTRAHEPATIC BILE DUCTS
15.
16. 17.
18.
19.
20. 21.
22.
(1984) Recurrent biliary stricture. Patterns of recurrence and outcome of surgical therapy. Am. J . Surg. 147, 175-80. CHAMPETIER J . , DAWNJ. L., YUERR., VIGNEAU B., C. Le foie. (1957) Etudes LETOUBLON C. & COUINAUD anatomiques et chirurgical. vol. 1. Masson Paris. ANON.(1982) Aberrant biliary ducts (vasa aberrantia): surgical implications. Anatornica clinica 4, 137-45. SMITH R., SHERLWK S., WOBURN (1981) Anomalies of the gall bladder, bile ducts and arteries. In: Surgery of the gall bladder and bile ducts (Ed. M. Knight), pp. 97-1 16. Butterworths, Massachusetts. THOMPSON R. W . & SCHULER J . G. (1986) Bile peritonitis from a cholecystohepatic bile ductule: an unusual complication of cholecystectomy. Surgery 99: 511-13. SCHALL., BAX M. R. & MANSENS B. J. (1956) Atrophy of the liver after occlusion of the bile ducts or portal vein and compensatory hypertrophy of the unoccluded portion and its clinical importance. Gastroenterology 31. 131-55. LONGMIRE w. P . & TOMPKlNS R. K. (1 975) Lesions of the segmental and lobar hepatic ducts. Ann. Surg. 1892,478-95. WEINBREN K . , HADJ~S N. S. & BLIJMGART (1985) Structural aspects of the liver in patients with biliary disease and portal hypertension. J . Clin. PathoI38, 1013-20. HADIISN. S . , CARRD., BELENHARN I . , BANKS L., GIBSON R. & BLUMCART L. H. Expectant management of patients with unilateral hepatic duct stricture and liver atrophy. Gut 27, 1223-7.
539 23. HADJISN. S. & BLUMGART L. H. (1988) Injury to segmental bile ducts: A reapproval. Arch. Surg. 123, 351-3. L. H . & KELLEY C. J. & BENIAMIN I. S. 24. BLUMGART (1984) Benign bile duct stricture following cholecystectomy. Br. J . Surg. 71: 836-43. E., MUTSON D. E., GUERRA I. J . , NUNEZ D., 25. RUSSELL YRIZZARY E. & SCHIFF E. (1985) Dilatation of biliary strictures through a stomatized jejunal limb. Actu Radiol. 23, 283-7. R. N., ADAMA. & CZERNIAK A. (1987) Benign 26. GIBSON biliary strictures: A proposed combined surgical and radiological management. Ausf. N . Z . J . Surg. 57, 361-8. C. (1956) L’abord et l’utilisation 27. HEPPJ . & COUINAUD du canal hipatique gauche dans les rkperations de la voie Biliaire principale. Presse medicale 64, 947-8. H. J . (1975) Dilatation of biliary tract 28. BURHENNE strictures: a new roentgenologic technique. Radiol. Clin. 44, 153-9. 29. MULNAR W. & STOCKHUM A. E. (1978) Transhepatic dilatation of choledochoenterostomy strictures. Radiology 129, 59-64. 30. NIJELLER P. R . , VANS O N N ~ N BE., E RFEKRIJCCI C J. T. er al. (1986) Biliary stricture dilatation: Multicenter review of clinical management in 73 patients. Radilogy 160, 17-22. H. J., BENDER C. E. & MAYG. R . (1987) 3 I . WILLIAMS Benign postoperative biliary strictures: Dilatation with fluoroscopic guidance. Radiology 163, 629-34. 32. MWKEA . V . . ILLESCOAS F. F., MILLSS . R. e f a / . (1987) Percutaneous dilatation of benign biliary strictures. Radio/ogy 163, 625-8.
533
N.Z. J . Surg. 1992,62.533-539
IATROGENIC INJURIES TO THE EXTRAHEPATIC BlLlARY TRACT A. J . RICHARDSON, N. TAIT,G. MUGUTIAND J. M. LITTLE Department of Surgery, Westmead Hospital, Westmead, New South Wales, Australia Iatrogenic injuries to the extrahepatic biliary tract continue to occur and result in significant morbidity. Over the last 10 years, 26 patients have been referred to Westmead Hospital for management of iatrogenic biliary tract injuries. Of these injuries, 22 occurred during cholecystectomy, three during hepatectomy and one during a pancreaticoduodenectomy . The principles of avoidance and repair are discussed. It is concluded that these injuries, although uncommon, continue to occur and that the best treatment results are achieved in specialized hepatobiliary units.
Key words: balloon dilatation, biliary stricture, extrahepatic bile ducts.
Introduction The majority of injuries to the extrahepatic biliary tract are iatrogenic in nature and as such, preventable. Repair of an extrahepatic biliary tract injury may be extremely difficult and carry grave longterm consequences for the patient. This analysis was undertaken to review the experience of a single hepatobiliary surgery unit in an attempt to define management problems in what remains a controversial area.
Methods The records of all patients with iatrogenic injury to the extrahepatic biliary tree referred for treatment at Westmead Hospital from 1979-91 were examined retrospectively. The information extracted included demographic characteristics, mode of injury, operative findings and treatment, type of injury, outcome and follow-up. Patients whose injury was related to malignancy, sclerosing cholangitis, blunt or penetrating trauma and ampullary stenosis were excluded.
Results There were 19 females and seven males in the series with a mean age of 47 years (range 19-66). Twenty-two injuries occurred during cholecystectomy and three during hepatectomy (two for trauma). One patient developed a biliary stricture after a pancreaticoduodenectomy .
Correspondence: Prof. J . M . Little, Department of Surgery, Westmead Hospital, Westmead, NSW 2145, Australia. Accepted for publication 30 January 1992
PATIENTS HAVING INITIAL REPAIR AT WESTMEAD HOSPITAL
Eleven patients were examined at Westmead Hospital after their injury but before any repair was attempted. According to the Bismuth criteria,' there were five type 1, three type 2 , one type 3 and one type 4 injuries. Additionally, one patient had had an aberrant segment V duct ligated. Nine of these injuries occurred during cholecystectomy , four being recognized in the immediate postoperative period and referred to Westmead Hospital. All of these patients were jaundiced and two were seriously ill with biliary peritonitis. The other five presented with jaundice and cholangitis with two presenting within 1 year of cholecystectomy and three presenting at 6 years, 7 years and 30 years after cholecystectomy . Nine patients underwent operation. Seven patients underwent choledochojejunostomy and one patient had an hepaticojejunostomy with separate anastomosis of each duct to the Roux-en-Y jejunal loop. The other patient had multiple biliary calculi with a 30 year history of recurrent cholangitis and was treated by resection of segments I1 and 111with separate anastomoses of the divided left hepatic duct and common hepatic duct. Of two patients with extrahepatic bile duct injuries after right hepatic lobectomy for trauma, one patient who had sustained multiple injuries, was treated with external biliary drainage. This patient died 17 days after admission as a result of multiple organ system failure. The other patient was explored, but despite a long and arduous procedure it proved impossible to identify the common hepatic duct. He subsequently returned to the country where, surprisingly, his liver function tests and jaundice improved and he was lost to follow-up.
34
27
1
4
2
I
2
1
3
F
F
M
M
F
F Ligation aberrant
segment V duct 2
F
F
M
3
4
5
6
7
8
9
10
11
22
32
46
43
34
23
64
42
1
M
2
67
I
M
Repair
Right hepatic lobectomy for trauma. Multiple injuries Right hepatic lobectomy for trauma 3 weeks before re-exploration
Cholecystectomy (9 days before admission). Jaundice Cholecystectomy (10 days previously). Biliary peritonitis, multiple intraabdominal abscesses Cholecystectomy (7 days previously). Jaundice and cholangitis Laparoscopic cholecystectomy (2 months previously). Jaundice and cholangitis Cholecystectomy. Cholangitis
Unable to identify proximal common hepatic duct, dense adhesions
External drainage of biliary tree
No operative procedure
Choledochojejunostomy
Choledochojejunostomy
Choledochojejunostomy
Choledochojejunostomy
Cholecystectomy (6 years previously) Choledochojejunostomy Jaundice and cholangitis Choledochojejunostomy Cholecystectomy (7 years previously). Jaundice and cholangitis Cholecystectomy (30 years previously). Resection of segments 11 & 111, Recurrent cholangitis with multiple choledochojejunostomy and intrahepatic stones hepaticojejunostomy Roux loop with separate anastomoses Cholecystectomy 8 days before admission. Jaundice and biliary to right and left hepatic ducts peritonitis
Age Cause and presentation
I
Patient Sex Type of Injury
~~
Table 1. Patients having initial repair
Died 17 days after admission of multiple organ system failure Jaundice resolved lost to follow-up
N o further problems, 5 years follow-up
Well, 3 months follow-up
Well, 6 months follow-up
No further problems 1 year follow-up
Recurrent cholangitis, percutaneous dilatations required, required choledochoscopy via access loop for removal of debris 2 years following repair No further problems 3 years follow-up
Died 8 months post-operatively of lymphoma
Died 2 months after operation of recurrent gastrointestinal haemorrhage No further problems 7 years follow-up
Outcome
VI P w
1
3
I
I
4
2
1
5 8 F
5 8 F
3 1 F
6 3 F
6 6 M
5 7 F
6 5 F
2
3
4
5
6
I
8
2
4 5 F
~
No. previous repairs
Cholecystectomy 1 year previously Cholecystectomy 1 1 years previously Cholecystectorny 3 years previously Laparoscopic cholecystectomy 1 month previously Cholecystectomy 9 years previously Cholecystectomy I6 years previously Biliary peritonitis, jaundice
Biliary peritonitis due to rupture of choledochoduodenostomy Cholangitis
Cholangitis jaundice
Cholangitis jaundice biliary cirrhosis
Cholangitis jaundice
Presenting problem
1 (procedure abandoned)
Jaundice cholangitis and biliary cirrhosis I (intraoperative end-to-end Cholangitis repair I6 years previously)
I (choledochoduodenostorny) I (choledochoduodenostomy 5 years previously) I (choledochoduodenostomy) I (hepaticojejunostomy)
Cholecystectomy 4 25 years previously
4 years previously
Cholecystectomy 4
Type of Injury Cause
1
Patient Age Sex
Table 2. Patients seen after attempted repairs
No further cholangitis
Outcome
Jaundice relieved, no further cholangitis
Jaundice relieved, no further cholangitis Jaundice relieved, no further cholangitis
Roux-en-Y loop with separate anastomosis to R & L ducts (with stent) Choledochojejunostomy with T-tube splint Choledochojejunostomy
Required percutaneous dilatation for duct enteric stricture 15 months later (Case no. 8; Table 3), no problems since then Liver split and segment I11 Jaundice relieved, no further cholangitis bypass Jaundice relieved, no Take down of choledochoduodenostomy, further cholangitis choledochojejunostomy No further cholangitis Choledochojejunostomy Choledochojejunostomy
Choledochojejunostomy
Repair
Returned overseas I year
7 months
5 years
6 years
3 years
5 years since dilatation
5 years
Follow-up
536
RICHARDSON ETAL.
The patient who had ligation of the segment V duct was treated non-operatively and had no attacks of cholangitis in 5 years of follow-up. Of the nine patients who underwent operation, two have died. One patient who had a choledochojejunostomy died two months after operation of recurrent gastrointestinal haemorrhage due to a false aneurysm of the common hepatic artery. The other death which occurred in the patient who had resection of segments I1 and 111 with separate anastomoses, was due to lymphoma 8 months postoperatively although there was no recurrence of jaundice or cholangitis. Of the five patients who underwent choledochojejunostomy, no patient had recurrence of jaundice or cholangitis or subsequent hospitalization in followup periods ranging from 3 to 80 months (mean =
2 3 ) . The other patient who had a type IV injury required multiple percutaneous dilatations (case no. 4; Table 1) and also choledochoscopy via the access loop for removal of particulate matter. These patients are summarized in Table 1. P A T I E N T S S E E N AFTER A T T E M P T E D R E P A I R S
Eight patients have undergone biliary reconstruction after one or more repairs elsewhere. Two of these had previously undergone four attempted repairs each, and the other six patients had each undergone one previous repair. These are summarized in Table 2 . PERCUTANEOUS DILATATION
Nine patients underwent percutaneous dilatations of biliary strictures and these are summarized in
Table 3. Patients who underwent percutaneous dilatations of biliary strictures No.
_-
Age at presentation to Westmead
Sex
Cause
Problem at presentation Left hepatic lobectomy, multiple strictures, biliary cirrhosis, emphysema Stricture of anastomosis, duodenal carcinoma High CHD stricture, refused surgery Stenosis choledochoduodenostomy haemorrhagic pancreatitis Right hepatic lobectomy, stricture of anastomosis Recurrent stricture at common hepatic duct enteric anastomosis Stricture of duct enteric anastomosis Whole duct septem excised from hilar plate to duodenum, right and left ducts anastomosed separately to Roux loop, stricture of anastomosis Stricture of duct enteric anastomosis, biliary cirrhosis
I
63
Hydatid surgery
2 3 4
53 33 21
Choledochoduodenostomy Cholecystectomy Cholecystectomy
5
36
6
57
Hydatid surgery, choledochoduodenostomy Cholecystectomy
7 8
62 23
Pancreaticoduodenectomy Cholecystectomy
9
58
Cholecystectomy
Table 4. Patients who underwent percutaneous dilatation of biliary strictures No. previous operations ___ No.
No. dilatation
Results
2
3
4 3 I
8
5
1
Jaundice relieved, n o cholangitis
9
3
I
Jaundice relieved, no cholangitis
I 2
2 6
Died 1 month Died of carcinoma at 2 months Recurrence at 4 months, left main duct repair Jaundice relieved, no cholangitis Jaundice relieved, no cholangitis Jaundice relieved, no cholangitis Jaundice relieved, no cholangitis
Follow-up
Jaundice relieved, lost to follow-up after 12 months Asymptomatic at 8 years follow-up Required dilatation - 1985, 1988, 1990 More than 5 years since last dilatation Required choledochoscopy via access loop - 1988, repeat dilatation - 1991 Required dilatation of biliary enteric anastomosis 15 months after operation, now 4 years without further problems Two years since dilatation
EXTRAHEPATIC BILE DUCTS
Tables 3 and 4. Seven have been treated by percutaneous dilatation alone without any operative procedure being performed at Westmead Hospital. Cases 8 and 9 had biliary reconstructions, with subsequent biliary enteric anastomotic stenoses treated by percutaneous dilatation. OPERATIVE CHOLANGIOGRAPHY
Of the 22 patients whose injury occurred during cholecystectomy, it was known that operative cholangiography had been performed in 12, had definitely not been performed in seven, and had been performed in three although one of those had had an aberrant segment V duct ligated rather than an injury to the common bile duct. SURGEON
Thirteen of the 22 cholecystectomies resulting in biliary injuries were performed by consultant surgeons. In the other nine the seniority of the surgeon was not known.
Discussion Cholecystectomy is by far the most common cause of injury to the extrahepatic biliary tract in Western countries. The reported incidence of this injury at cholecystectomy ranges from 0.06 to 0.3% .2-4 AIthough it is impossible to give an accurate figure, it is probably at the lower end of this range in Australia. Johnston has described the major causes of bile duct injury as falling into three categories: dangerous pathology; dangerous anatomy; and dangerous s ~ r g e r y .It~ appeared that the majority of patients in this series were undergoing elective rather than emergency procedures and that the factors involved in creation of the injury fell into the latter two categories rather than the first. Kune made a similar observation in another Australian series and has eloquently defined the operative steps in the avoidance of this injury.6 Tragically, these injuries are most common in young, healthy females. The mean age of 47 years in this series and the fact that 19 of the 26 patients who sustained an injury were female is very similar to that of other reported series.2,33637,8,9 A previous report from Sweden attributed most injuries to trainee surgeons who were performing between their 25th and 100th cholecystectomy.3 In this series, information was not available on nine of the operating surgeons, but at least 13 of the 22 injuries occurred when a consultant surgeon was operating. Moosa, in a large series of iatrogenic bile duct injuries, found that a trained surgeon operated in 64% of the cases and assisted in another 10% . 9 The place of routine operative cholangiography remains controversial. It is often stated in the litera-
537
ture, that this is now unnecessary as missed stones can be dealt with endoscopically .l o We disagree with this premise because operative cholangiography is, in association with careful dissection and identification of the major structures, a useful addition in the attempt to accurately identify and record the anatomy." It does not add a great deal to the operating time and may help to prevent some of these injuries and lead to earlier detection of injuries that do occur. Warren believed that virtually all biliary strictures occurred within 3 years of the injury.I2 This was not our experience in that some strictures appeared many years later. It is only possible to hypothesize about the pathology of these late strictures although it would seem the most likely precipitating factor is ischaemia due to disruption of the biliary blood supply which is then complicated by biliary infection as the stricture progresses. Similarly, although 80-90% of recurrences after operative repair occur within 5-7 years a small number may recur many years after operative repair. I 3 3 l 4 Only one aberrant segmental duct injury was identified but it is suspected that many of these injuries go unrecognized. Aberrant segmental ducts, mostly either the right anterior sectoral or right posterior sectoral duct, may join the common hepatic duct or the common bile duct in up to 20% of cases.15 As the majority of these ducts pass across Calot's triangle, they may be inadvertently ligated or divided. Additionally, a subvesical duct may join either the common hepatic duct or right hepatic duct in up to 50% of cases and is at risk of injury.I6 Some authors have suggested that injured ducts 2 mm or greater in diameter should be repaired because of the risk of cholangitis.17.'* We believe that there is a significant body of e~perimental'~ and cIinical evidence20-22to suggest that segmental atrophy will occur with a low risk of cholangitis as opposed to the significant risks of operative repair if an aberrant segmental duct is inadvertently divided. However, it should be stressed that the object should be identification and preservation of those structures whenever possible. We agree with Hadjis et al. that ligation and careful postoperative followup of the patient should be all that is r e q ~ i r e d . ' ~ Surgery remains the mainstay of treatment of biliary strictu~sbut there is a higher rate of stricture recurrence if the patient requires several attempts at repair.8214Similarly, the level of the stricture correlates with the outcome, and type 111 and type IV strictures have a higher recurrence rate. 13,24 This may well be due to the more difficult dissection that may predispose to more postoperative scarring. Additionally, the principles of mucosal apposition with no tension are much more difficult to fulfil. Type I and type I1 strictures have done well in the author's hands, particularly if they were having their first
538
RICHARDSON ETAL.
repair done at Westmead Hospital. Either a choledochojejunostomy or hepaticojejunostomy using a Roux-en-Y loop is the operation of choice and it is important to suture part of the Roux loop to the anterior abdominal wall as an access loop to facilitate later percutaneous access to the biliary tree. 25,26 A segment 111 approach as originally described by Hepp and Couinaud can be helpful in hilar strictures and in patients who have undergone multiple attempts at repair. Choledochoduodenostomy is rarely indicated as it is difficult to avoid some tension on the anastomosis and there is no access loop. End-to-end repair of a completely divided duct is not indicated except perhaps if performed at the time of injury. Even then, the incidence of subsequent stricture formation is extremely high.',' This is not really surprising when one considers the axial blood supply of a biliary tract. An access loop should, as far as possible, be constructed routinely because it permits easy percutaneous access to the biliary tree without having to traverse the liver. The results of surgical repair are best when performed in specialized centres. The University of California at Los AngelesI3 and the Cleveland Clinic8 have reported a successful outcome after surgery in 86 and 82% of patients respectively, with a mean follow-up of 5 years. Way has reported a successful outcome in 78% of patients at 102 months.I4 The use of stents has been extensively debated but, overall, it is difficult to find evidence supporting their routine use. In this study stents were only used in particularly high, difficult and tenuous anastomoses because it is believed that they may predispose to infection and early stricture recurrence. Since the initial description of balloon dilatation for benign biliary structures by Burhenne,28 and Molmar and S t o c k ~ mthis , ~ ~technique has become an important tool in the management of these difficult patients. Mueller reported the results of percutaneous dilatation in three groups, namely those with anastomotic strictures (e.g. choledochojejunostomy and hepaticojejunostomy), iatrogenic strictures, and strictures due to sclerosing cholang i t i ~ . ~The ' 3 year patency rates were 67, 76 and 42% respectively. Three years is too early a time frame and it would be expected that these success rates would slowly decrease with longer follow-up. Pitt et al. attempted to compare surgical treatment with balloon dilatation and achieved a successful outcome in 88% of the surgical group versus 55% of the balloon dilatation group.' In the authors' experience, balloon dilatation has been particularly helpful in patients with anastomotic strictures. The Mayo Clinic have reported success rates of 73% at 28 months for balloon dilatation of anastomotic strictures31 and Moore has reported a success rate of 82% at 33 months.32 Balloon dilatation has been
*'
found to be less successful than surgery in the treatment of primary biliary strictures though it has been useful in the elderly patient who has undergone multiple procedures or in patients with biliary cirrhosis who are either unwilling or unfit for further surgery. In conclusion, most injuries to the extrahepatic biliary tract are iatrogenic and occur during elective cholecystectomy . With the advent of laparoscopic cholecystectomy it is quite likely that the number of cholecystectomies will increase and the principles involved in avoiding these injuries will be even more pertinent. It is important, however, that when these injuries do occur, they be managed in a specialized hepatobiliary service where access to the necessary surgical expertise, radiology and percutaneous techniques is available.
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EXTRAHEPATIC BILE DUCTS
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