Management for a complicated biliary stricture after iatrogenic bile duct injury

Abstract

Bile duct injury (BDI) remains to be a serious complication of biliary surgery. Biliary stricture is likely to occur in cases without proper management of BDI, may be causing such severe complications as repeated strictures, cholangitis or impairment to liver function. Here, we reported a 69-year-old man with a one-more-year history of recurrent cholangitis caused by iatrogenic BDI. The patient underwent a reconstruction of choledochojejunostomy, with liver quadrate lobectomy, and hilar cholangioplasty. The procedure was difficult, but the recovery was smooth. Only through comprehensive pre-operative evaluation and meticulous intraoperative manipulate, the technical challenge of re-operation for complicated biliary stricture after BDI should be easily addressed. cholangiopancreatography (MRCP) and computed tomographic angiography of the liver and biliary tract. MRCP showed stricture at hilar bile duct and dilatation of intrahepatic bile duct (Figure 1). Following a thorough discussion of treatment options and associated benefits and risks with the patient, we decided to proceed with a reconstruction of choledochojejunostomy. Risks and complications of the procedure included biliary leak, cholangitis, bleeding, anastomotic strictures, biliary cirrhosis, and the need for further surgeries. Pre-operative preparationPrior to the procedure, complete blood count, liver function test, coagulation function test, and cardiopulmonary function assessment were ordered (all normal) in addition to a full physical examination and patient history. Antibiotics were administered in that sequence no more than 30 minutes prior to the incision. Appropriate consent was obtained from the patient per our institutional protocol.Equipment preference card   Water knife;  Bile duct probes;  Fine catheter;  4-0 Vicryl suture;  5-0 Prolene suture;  Self-retaining wound retractor. ProcedureThe operative procedure is demonstrated in Figure 2. The patient was placed in the supine position. After general anesthesia was induced, a Foley catheter was placed. Through the original incision, a down L-shaped incision below the right rib edge was made. Dense adherence was found in the area of biliary-enteric anastomosis, which was 40 cm away from enteric-enteric anastomosis. Part of the right and quadrate lobe of liver (about 4 cm × 4 cm) was marked and removed. Then, bile duct above the anastomosis was separated by water knife. After finding the original anastomosis, the bile duct was confirmed by a puncture. Part of the anterior wall of the bowel was incised. Anastomotic scar hyperplasia was significantly associated with stenosis. It was found that left and right hepatic was interrupted, and anastomosis of left hepatic duct almost closed.Bile duct wall was separated from the liver tissue until opening the diameter of right hepatic duct to 2 cm, and the left to 2.5 cm. Due to the confluence of left and right hepatic duct to be adhered scar tissue, it was reshaped into an "8" shape with satisfaction. After exploration of the bile duct ...

Post-cholecystectomy acute injury: What can go wrong?

“…Ever since the introduction of laparoscopic cholecystectomy, there are many reports regarding increasing incidence of bile duct injuries associated with this procedure 234. Many reports have described the mechanisms and safety measures to be observed during laparoscopic cholecystectomy to prevent this catastrophe 11121314.…”

“…Since then, it has been established as a gold standard treatment for symptomatic calculous cholecystitis. However, it is associated with three times the higher incidence of bile duct injuries when compared to open procedures 12. Although the reported incidence remains less than 1%, still it causes a substantial burden to the health care system due to large number of cholecystectomies performed across the globe 1234…”

Reliable reconstruction of the complex high-location bile duct injury: a novel hepaticojejunostomy

“…BDI, especially the CHBDI is still a challenging issue for hepatobiliary surgeons, even for those experienced surgeons. According to the type of injury, percutaneous, endoscopic, and surgical treatments could be used to cope with the management of BDI [14]. In recent decades, surgical interventions with Roux-en-Y HJ has been regarded as the best treatment option for the BDI [10, 15].…”

“…In recent decades, surgical interventions with Roux-en-Y HJ has been regarded as the best treatment option for the BDI [10, 15]. However, for CHBDI, resection of segment IV b base and partial segment V is recommended to achieve adequate boundary of healthy (non-ischemic, non-inflammation and non-scarred) ducts and improve the surgical space, which therefore inevitably leave multiple small intrahepatic bile duct openings [13, 14, 16, 17]. In such a situation, the traditional HJ anastomosing the hepatic duct to the jejunum using mucosa-to-mucosa anastomosis is difficult for small bile ducts and limits the operative space [11, 18].…”

Platelet-rich fibrin can accelerate the healing of common bile duct anastomosis in a rat.

“…One of the main problems in hepatobiliary surgery and liver transplantation is biliary complications (27)(28)(29)(30). Biliary leaks and strictures are still very common and cause major morbidity and mortality after these operations.…”