Follow-Up After Repair of Bile Duct Injury

Abstract

A patient who sustains a bile duct injury and/or has a bile leak after cholecystectomy can develop a benign biliary stricture during the follow-up. Repair of a bile duct injury/benign biliary stricture in the form of end-to-end repair or hepatico-jejunostomy can restricture during the follow-up. Most anastomotic strictures occur in the first 2 years but they can occur even up to 10 years, hence the need for long-term follow-up. Follow-up is clinical and with liver function tests (LFT), ultrasonography (US), and isotope hepato-biliary scintigraphy. Suspected anastomotic stricture is confirmed by magnetic resonance cholangiography (MRC). Treatment of choice for anastomotic stricture is non-surgical (endoscopic or percutaneous transhepatic balloon dilatation and stenting). If the previous repair was inadequate, reoperation may be performed to do a proper hepatico-jejunostomy. Repeat hepatico-jejunostomy is technically challenging and results are inferior to those of primary hepatico-jejunostomy. Some patients with recurrent benign biliary stricture may require hepatectomy. Patients with anastomotic stricture can develop and die of biliary complications during the follow-up.

Also see Invited Commentary on Follow-Up after Repair of Bile Duct Injury by Graeme J Poston (pp 202–203)

Invited Commentary on Follow-Up after Repair of Bile Duct Injury

• Graeme J Poston 

1. Department of Surgery, University of Liverpool, Liverpool, UK

   Graeme J Poston

2. Aintree University Hospital, Liverpool, UK

   Graeme J Poston

Iatrogenic bile duct injury remains the most feared complication of cholecystectomy, whether laparoscopic or open, and in many countries is an increasing source of medico-legal litigation. Following apparently successful bile duct reconstruction, patients face loss of life expectancy [38, 25] and frequently never recover the quality of life they enjoyed prior to the index cholecystectomy [41,42,43,42]. The fundamental issue, as this chapter by Prof Kapoor demonstrates, is that subsequent complications, the most important being the consequences of stricture at the site of the bile duct repair (by whatever method is employed for biliary reconstruction) can occur many years, and even decades later [6, 45,46,44]. As such, these patients need to be offered long-term follow-up, if necessary for life. The problem is that the symptoms of early stricture can be very subtle, especially if the initial injury is Strasberg E4 necessitating a double repair to separate right and left hepatic duct systems, when if one side strictures and the other hepatico-jejunostomy anastomosis remain patent, then jaundice does not occur, and the presentation is not classical for cholangitis. Therefore, ideally such follow-up should be within a tertiary hepato-biliary center, which will also have access to all the necessary skills and disciplines (interventional radiology, biliary endoscopy, hepato-biliary surgery, including possible liver transplantation) required to manage this complication when it occurs.

If a patient remains asymptomatic and well, then they only need to be reviewed six monthly during the first year after bile duct repair surgery, and then annually thereafter. Follow-up of well patients requires no more than clinical review and routine blood liver function tests. It is this author’s (GP) experience that alkaline phosphatase levels not infrequently never recover to within the normal range in these circumstances, and so persistent modestly elevated alkaline phosphatase levels, in the absence of any other abnormality (clinical or biochemical) per se, do not require further investigation. However, recurrent bouts of low grade sepsis, in particular with deteriorating blood liver function tests, jaundice, and/or itching require immediate investigation. Biliary ultrasound scanning may detect intrahepatic biliary radical dilatation (IHBRD), but this may be subtle, possibly unilateral or may be only sectoral or segmental (and therefore difficult to interpret by an inexperienced sonographer). Magnetic resonance cholangiography (MRC) with liver specific contrast is the ideal early investigation in these circumstances, but is best interpreted by a radiologist who specializes in this field. It is this author’s (GP) experience [43] that percutaneous dilatation of such strictures (with or without self-expanding metal stent SEMS) is effective in the majority of cases, and revision hepatico-jejunostomy only infrequently required. If percutaneous transhepatic cholangiography (PTC) is attempted then it is crucial to remember that if an obstructed bile duct system is entered but the anastomotic stricture cannot be crossed then do not simply withdraw the cholangiogram needle as bile will now leak from the liver capsule and cause biliary peritonitis. It is imperative, therefore, that in the investigation and management of this late complication that there is extremely close collaboration at all stages between the interventional radiologist and the hepato-biliary surgeon.