1. Classification and management of bile duct injury
Good morning senior and my fellow colleague, my name is Ray, I am from the department of surgery of Prince of Wales Hospital currently rotating in the hepatobiliary and pancreatic surgery
Welcome to the joint hospital grand round. Today my presenting topic will be classification and management of bile duct injury
It is a very large topic and hopefully in this 12 minutes of time I will be able to give you a very brief idea on what to do when you are facing a case of bile injury unluckily.
Dr. Hung Ka Wai Ray
Team 1 Hepatobiliary and Pancreatic Surgery
Prince of Wales Hospital

2. Introduction Laparoscopic cholecystectomy
Standard treatment of symptomatic gallstone disease
> 750, 000 were performed annually in the United States
Less pain, fewer wound complication, quicker recovery
The only potential disadvantage is a higher incidence of major bile duct injury [1], 0.3% open vs 0.6% laparoscopic
[1] Acute bile duct injury. The need for a high repair. Surg Endosc 2003;17:
Nowadays, laparosopic cholecystectomy is considered as the standard treatment of managing symptoamtic gallstone disease. > 750,000 of lap. chole were performed every year in the United States. It is world known to be associated with less pain, fewer wound complication and quicker recovery when compared to open chole. However, it was found to be associated with a high incidence of major bile duct injury , according to the lithture, the incidence of duct bile duct injury is 0.3% in open cholecsytectomy vs 0.6% in lap. Chole

3. Introduction
Bile duct injury is a very serious complication that lead to mortality, significant morbidity and impaired quality of life
Causes:
Iatrogenic
Cholecysectomy (80-85%) [2]
Gastrectomy
Pancreatectomy
ERCP
Trauma
Duodenal ulcer
[2] Bile duct injuries during laparoscopic cholecystectomy: primary and long term results from a single institution. Surg Endosc 2007; 21:
Bile duct injury, although not common, is a very seriuos complication that lead to mortality and morbidity. It also significantly affect the QOL of the patient.
Iatrogenic injury account for most of the cases and ~ 80-85% are occuring during cholecystectomy. Other iatrogenic cause including injury during gastrectomy, pancreatectomy, ERCP
Non iatrogenic cause include trauma and duodenal ulcer

4. Presentation Intraoperative Postoperative
Direct observation of a divided duct
Bile in the operative field
Abnormal intra-operative cholangiography
Postoperative
Bile leak
Bile in the drain
Biloma, biliary fistula, or bile ascites
Bile peritonitis in severe cases
Biliary obstruction
Obstructive jaundice
Cholangitis
As the presentation of the bile duct injury can be very subtle, in order to establish the diagnosis, one need to very cautios about that.
Intraoperative identification account for a minority of cases, we may be seeing a divided duct directly. There may be bile leakage in the operative field. Or it may also be cofirmed by an abnormal intraopeartive cholangiography
Post operative identification account for the majority of the cases. The patient usually present with bile leak or bile duct obstruction.
There may be bile seen in the drain, or a biloma found in the ultrasound / CT scan. In very severe cases, the patient can present with bile peritonitis
In cases of biliary obstruction, the patient may presented with OJ / cholangitis

5. Classification Bismuth Strasberg et al. Stewart et al. McMahon et al.
AMA
Neuhaus et al.
Csendes et al.
Hanover
Lau and Lai
Siewert et al.
Cannon et al.
Kapoor Sandha et al.
EAES
In the litheture, a lot of different classification has been reported
Bismuth classification had been used for a long time in the era of open cholecystectomy. Nowadays, for bile duct injury in laparoscopic cholecytectomy, Stragsberg classification is widely used.

6. Strasberg et al. Starsberg classification is divided into 9 type A-E
And type E is further divided into E 1-5

7. Strasberg et al.
Type A refer to cystic duct leaks or leaks from small ducts in the liver bed
Type B refer to occlusion of a part of the biliary tree, almost invariably the abberrant right hepatic duct
Type C refer to transection without ligation of the aberrant right hepatic ducts
Type D refer to lateral injuries to major bile ducts

8. Strasberg et al.
For type E1-E5, actually it is referring to the Bismuth classification 1-5
E1 is the low CHD injury with stump > 2 cm
E2 is the low CHD injury with stump < 2 cm
E3 refer to hilar injury with a preserved communication between the left and right IHD
E4 refer to hilar injury with loss of communication between the left and right IHD
E5 refer to aberrant right hepatic duct alone or concomitantly with CHD

9. Management Depend on the timing of recognition of the injury
Intraoperative vs postoperative recognition
For the management, it depend on then timing of recognition and can be divided into intraoperative vs postoperative group

10. Intraoperative recognition
Account for 25%–32.4% [3]
First consult an experienced hepatobiliary surgeon
Convert to laparotomy with cholangiography
Define the nature of the injury
If expertise a/v
Immediate repair can minimize the morbidity
Higher successful rate, fewer morbidty and mortality [4]
If expertise not a/v
Injudicious attempts at exploration may cause further biliary and vascular injury
Subhepatic drain to prevent collection
External biliary drainage
Refer to a specialized hepatobiliary unit
[3] Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy.
Factors that influence the results of treatment. Arch. Surg. 1995; 130: 1123–8.
[4] Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann. Surg 2005;241:786-90
Injuries identify during the intraoperative period account for ~ 25% of cases.
The first thing we should do is not repair of the injury but consult an experienced hepatobiliary surgeon when we are facing a bile duct injury.
We should also convert to laparotomy and perform a cholangiorahpy to confirm and identify the injury
When expertise a/v immediate repair always can minimize the morbidity. It is found that, if the injury is repaired by a HBP surgeon, it is associated with a higher successful rate, fewer morbidity and mortality
However, when expertise is not a/v, injudicious attempts at exploration only cause further biliary and vascular injury.
The patient should be managed with subhepatic drainage to prevent collection and external biliary drainage for diversion and refer to a specialized HBP unit.

11. Postoperative recognition
Aim of management
Control sepsis and limit inflammation
Delineate the biliary anatomy and associated vascular injury
Re-establish the biliary enteric continuity
On the other hand, majority of the injury usually identify during the postoperative period.
The aim of the management can be divided into 3 stages,
Stage one will be control the sepsis and limit inflammation
Stage 2 will be delineate the biliary anatomy and associated vascular injury
Stage 3 will be re-establish the biliary enteric continuity
Factors influencing the success rate are the complete eradication of abdominal infection, complete cholangiography, use of correct surgical technique and repair by an experienced biliary surgeon
[5] Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes, HBP2009, 11,

12. Control sepsis Fluid resuscitation Broad spectrum antibiotic
Investigation
USG / CT to asses collection +/- drainage
For the control of sepsis, the patient should be managed with fluid resuscitation, started on broad spectrum antiboitc
Imaging including USG / CT should be performed to look for and collection and drainage should be arranged if necessary

13. Delineate the biliary anatomy
Cholangiography
ERCP
PTC
MRCP
For delineation of the biliary anatomy, cholangiography including ERCP, PTC, MRCP should be arranged

14. Associated vascular injury
CTA / MRA
Incidence is around 16.7%-47%[6]
Most commonly involving the right hepatic artery
Does not usually lead to early significant complications
Impact on bile duct injury [7]
Associated with increased intraoperative bleeding during repair
Difficult reconstruction
Higher incidence of anastomotic stricture due to bile duct ischamemia
Delayed repair if VBI is present
[6] Management and outcome of patinets with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 2004; 135: 613-8
[7] Management of bile duct injury after laparoscopic cholecystectomy: a review, ANZ J Surg 80 (2010) 75-81
Beside cholangiography, angiograhpy such as CTA / MRA should also be arranged to look for associated vascular injury.
Associated vascular injury is occurred in ~ % and most commonly involving the right hepatic artery
Due to the dual supply of the liver, it usually does not cause early significant complication
However, it is shown that it is associated with increased intraoperative bleeding during repair, difficult reconstruction and the incidence of anastomotic stricture is also higher due to bile duct ischaemia
Therefore, in case of concomitant vascular injury, delayed repair should be consider and it is also found to be associated with less complication and a higher successful rate

15. Re-establish the biliary enteric continuity
According to the type of injury
Surgery vs endoscopic treatment
Once the patient is stabilized and other factor including inflammation, detailed anatomy of the injury is established, we can consider to re-establish the biliary enteric continuity
The management is depend on the type of injury
Both surgical and sometime endoscopic treatment can be used for treatment.

16. Re-establish the biliary enteric continuity
Strasberg classification
Surgical treatment A
ERCP + sphincterotomy + stent B
Hepaticojejunostomy C D
Primary repair if small injury with no devascularization
Hepaticojejunostomy if extensive injury E
For type A, as there is no loss of biliary continuity, it can be management with ERCP + sphincterotomy + stenting
For type B and C, as it involve injury to the biliary system and loss of continuity, HJ is needed
For type D, lateral injury of the CBD, in case of small injury, it can be treated with primary repair. However, for more extensive injury, A HJ is also needed
For type E, bile duct injury of the CHD, HJ is needed to re-establish the biliary enteric continutiy

17. Treatment of Complication
Stricture
Balloon dilatation and biliary stenting
Hepaticojejunostomy has higher successful rate
Secondary biliary cirrhosis
Liver transplantation
A very small group of patient can remain asymptomatic for a long period of time and being diagnosed years after the index surgery.
They usually presented to us for biliary obstruction due to stricture.
In the mild case, it can be treated with endoscopic dilatation and biliary stenting
Of course HJ still remain the gold standard of treatment with a higher successful rate
For severe case with secondary biliary cirrhosis, liver transplantation is the last resort for them.

18. Reference
[1] Acute bile duct injury. The need for a high repair. Surg Endosc 2003;17:
[2] Bile duct injuries during laparoscopic cholecystectomy: primary and long term results from a single institution. Surg Endosc 2007; 21:
[3] Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy.Factors that influence the results of treatment. Arch. Surg. 1995; 130: 1123–8.
[4] Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann. Surg 2005;241:786-90

19. Reference
[5] Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes, HBP2009, 11,
[6] Management and outcome of patinets with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 2004; 135: 613-8
[7] Management of bile duct injury after laparoscopic cholecystectomy: a review, ANZ J Surg 80 (2010) 75-81