World Journal of Surgery

, Volume 32, Issue 8, pp 1714–1721 | Cite as

Liver Transplantation: The Last Measure in the Treatment of Bile Duct Injuries

  • Eduardo de Santibañes
  • Victoria Ardiles
  • Adrian Gadano
  • Martin Palavecino
  • Juan Pekolj
  • Miguel Ciardullo



Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI.


Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan–Meier test.


Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24–152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively.


Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.



The authors thank Isabel Millicay for her help with the language, and Sung Ho Hyon and James Garden for editing the manuscript.


  1. 1.
    Huang ZQ, Huang XQ (2002) Changing patterns of traumatic bile duct injuries: a review of forty years experience. World J Gastroenterol 8:5–12PubMedGoogle Scholar
  2. 2.
    Savader SJ, Lillemoe KD, Prescott CA et al (1997) Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster. Ann Surg 225:268–273PubMedCrossRefGoogle Scholar
  3. 3.
    Moossa AR, Mayer AD, Stabile B (1990) Iatrogenic injury to the bile duct. Who, how, where? Arch Surg 125:1028–1030PubMedGoogle Scholar
  4. 4.
    Flum DR, Cheadle A, Prela C et al (2003) Bile duct injury during cholecystectomy and survival in Medicare beneficiaries. JAMA 290:2168–2173PubMedCrossRefGoogle Scholar
  5. 5.
    Cooper AD, Young HS (1989) Pathophysiology and treatment of gallstones. Med Clin North Am 73(4):753–774PubMedGoogle Scholar
  6. 6.
    Carroll BJ, Birth M, Phillips EH (1998) Common bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc 12:310–314PubMedCrossRefGoogle Scholar
  7. 7.
    De Wit LT, Rauws EA, Gouma DJ (1999) Surgical management of iatrogenic bile duct injury. Scand J Gastroenterol Suppl 230:89–94PubMedCrossRefGoogle Scholar
  8. 8.
    Johnson SR, Koehler A, Pennington LK et al (2000) Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery 128:668–677PubMedCrossRefGoogle Scholar
  9. 9.
    al-Karawi MA, Sanai FM (2002) Endoscopic management of bile duct injuries in 107 patients: experience of a Saudi referral centre. Hepatogastroenterology 49:1201–1207PubMedGoogle Scholar
  10. 10.
    Loinaz C, Gonzalez EM, Jimenez C et al (2001) Long-term biliary complications after liver surgery leading to liver transplantation. World J Surg 25:1260–1263PubMedCrossRefGoogle Scholar
  11. 11.
    Oncel D, Ozden I, Bilge O et al (2006) Bile duct injury during cholecystectomy requiring delayed liver transplantation: a case report and literature review. Tohoku J Exp Med 209:355–359PubMedCrossRefGoogle Scholar
  12. 12.
    Schmidt SC, Langrehr JM, Hintze RE et al (2005) Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Br J Surg 92:76–82PubMedCrossRefGoogle Scholar
  13. 13.
    Nordin A, Makisalo H, Isoniemi H et al (2001) Iatrogenic lesion at cholecystectomy resulting in liver transplantation. Transplant Proc 33:2499–2500PubMedCrossRefGoogle Scholar
  14. 14.
    Robertson AJ, Rela M, Karani J et al (1998) Laparoscopic cholecystectomy injury: an unusual indication for liver transplantation. Transpl Int 11:449–451PubMedCrossRefGoogle Scholar
  15. 15.
    de Santibañes E, Palavecino M, Ardiles V et al (2006) Bile duct injuries: management of late complications. Surg Endosc 20:1648–1653PubMedCrossRefGoogle Scholar
  16. 16.
    de Santibañes E, Pekolj J, McCormack L et al (2002) Liver transplantation for the sequelae of intra-operative bile duct injury. HPB 4:111–115PubMedGoogle Scholar
  17. 17.
    Keeffe EB (2001) Selection of patients for liver transplantation. In: Maddrey WC, Schiff ER, Sorrel MF (eds) Transplantation of the Liver, 3rd edn. Lippincott Williams & Wilkins, Philadelphia, pp 5–34Google Scholar
  18. 18.
    Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125PubMedGoogle Scholar
  19. 19.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213PubMedCrossRefGoogle Scholar
  20. 20.
    Chapman WC, Halevy A, Blumgart LH et al (1995) Postcholecystectomy bile duct strictures. Management and outcome in 130 patients. Arch Surg 130:597-602PubMedGoogle Scholar
  21. 21.
    Roslyn JJ, Binns GS, Hughes EF et al (1993) Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 218:129–137PubMedCrossRefGoogle Scholar
  22. 22.
    Ahrendt SA, Pitt HA (2001) Surgical therapy of iatrogenic lesions of biliary tract. World J Surg 25:1360–1365PubMedCrossRefGoogle Scholar
  23. 23.
    Fletcher DR, Hobbs MS, Tan P et al (1999) Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann Surg 229:449–457PubMedCrossRefGoogle Scholar
  24. 24.
    MacFadyen BV Jr, Vecchio R, Ricardo AE et al (1998) Bile duct injury after laparoscopic cholecystectomy. The United States experience. Surg Endosc 12:315–321PubMedCrossRefGoogle Scholar
  25. 25.
    Gigot J, Etienne J, Aerts R et al (1997) The dramatic reality of biliary tract injury during laparoscopic cholecystectomy. An anonymous multicenter Belgian survey of 65 patients. Surg Endosc 11:1171–1178PubMedCrossRefGoogle Scholar
  26. 26.
    Lillemoe KD, Melton GB, Cameron JL, et al (2000) Postoperative bile duct strictures: management and outcome in the 1990s. Ann Surg 232:430–441PubMedCrossRefGoogle Scholar
  27. 27.
    Shah SR, Mirza DF, Afonso R et al (2000) Changing referral pattern of biliary injuries sustained during laparoscopic cholecystectomy. Br J Surg 87:890–891PubMedCrossRefGoogle Scholar
  28. 28.
    Vicente E, Meneu JC, Hervás PL et al (2001) Management of biliary duct confluence injuries produced by hepatic hydatidosis. World J Surg 25:1264–1269PubMedCrossRefGoogle Scholar
  29. 29.
    Bismuth H, Franco D, Corlette MB et al (1978) Long term results of Roux-en-Y hepaticojejunostomy. Surg Gynecol Obstet 146:161–167PubMedGoogle Scholar
  30. 30.
    Strasberg SM, Picus DD, Drebin JA (2001) Results of a new strategy for reconstruction of biliary injuries having an isolated right-sided component. J Gastrointest Surg 5:266–274PubMedCrossRefGoogle Scholar
  31. 31.
    Stewart L, Way LW (1995) Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 130:1123–1128PubMedGoogle Scholar
  32. 32.
    Buell JF, Cronin DC, Funaki B et al (2002) Devastating and fatal complications associated with combined vascular and bile duct injuries during cholecystectomy. Arch Surg 137:703–708PubMedCrossRefGoogle Scholar
  33. 33.
    Koffron A, Ferrario M, Parsons W et al (2001) Failed primary management of iatrogenic biliary injury: incidence and significance of concomitant hepatic arterial disruption. Surgery 130:722–728PubMedCrossRefGoogle Scholar
  34. 34.
    Connor S, Garden OJ (2006) Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 93:158–168PubMedCrossRefGoogle Scholar
  35. 35.
    Davidoff AM, Pappas TN, Murray EA et al (1992) Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 215:196–202PubMedCrossRefGoogle Scholar
  36. 36.
    Mirza DF, Narsimhan KL, Ferraz Neto BH et al (1997) Bile duct injury following laparoscopic cholecystectomy: referral pattern and management. Br J Surg 84:786–790PubMedCrossRefGoogle Scholar
  37. 37.
    Huang CS, Lein HH, Tai FC et al (2003) Long-term results of major bile duct injury associated with laparoscopic cholecystectomy. Surg Endosc 17:1362–1367PubMedCrossRefGoogle Scholar
  38. 38.
    Doctor N, Dooley JS, Dick R et al (1998) Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy. Br J Surg 85:627–632PubMedCrossRefGoogle Scholar
  39. 39.
    Melton GB, Lillemoe KD, Cameron JL et al (2002) Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life. Ann Surg 235:888–895PubMedCrossRefGoogle Scholar
  40. 40.
    Mercado MA, Orozco H, López-Martínez LM et al (2000) Survival and quality of life after bile duct reconstruction for iatrogenic injury. HPB 2:321–324Google Scholar
  41. 41.
    Braasch JW, Bolton JS, Rossi RL (1981) A technique of biliary tract reconstruction with complete follow-up in 44 consecutive cases. Ann Surg 194:635–638PubMedCrossRefGoogle Scholar
  42. 42.
    Negi SS, Sakhuja P, Malhotra V et al (2004) Factors predicting advanced hepatic fibrosis in patients with postcholecystectomy bile duct strictures. Arch Surg 139:299–303PubMedCrossRefGoogle Scholar
  43. 43.
    Pellegrini CA, Thomas MJ, Way LW (1984) Recurrent biliary stricture. Patterns of recurrence and outcome of surgical therapy. Am J Surg 147:175–180PubMedCrossRefGoogle Scholar
  44. 44.
    Röthlin MA, Löpfe M, Schlumpf R et al (1998) Long-term results of hepaticojejunostomy for benign lesions of the bile ducts. Am J Surg 175:22–26PubMedCrossRefGoogle Scholar
  45. 45.
    Raute M, Podlech P, Jaschke W et al (1993) Management of bile duct injuries and strictures following cholecystectomy. World J Surg 17:553–562PubMedCrossRefGoogle Scholar
  46. 46.
    Fernández JA, Robles R, Marín C et al (2004) Laparoscopic iatrogeny of the hepatic hilum as an indication for liver transplantation. Liver Transpl 10:147–152PubMedCrossRefGoogle Scholar
  47. 47.
    Madariaga JR, Dodson SF, Selby R et al (1994) Corrective treatment and anatomic considerations for laparoscopic cholecystectomy injuries. J Am Coll Surg 179:321–325PubMedGoogle Scholar
  48. 48.
    Bacha EA, Stieber AC, Galloway JR et al (1994) Non-biliary complication of laparoscopic cholecystectomy. Lancet 344:896–897PubMedCrossRefGoogle Scholar
  49. 49.
    Thomson BNJ, Parks RW, Madhavan KK et al (2007) Liver resection and transplantation in the management of iatrogenic biliary injury. World J Surg 31:2326–2369CrossRefGoogle Scholar
  50. 50.
    The European Liver Transplantation Registry (2007) Available at [accessed July 3, 2007]
  51. 51.
    Incucai CRESI. Available at [accessed July 3, 2007]
  52. 52.
    Penn I (2000) Post transplant malignancy: the role of immunosupperssion. Drug Saf 23:101–113PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Eduardo de Santibañes
    • 1
  • Victoria Ardiles
    • 1
  • Adrian Gadano
    • 2
  • Martin Palavecino
    • 1
  • Juan Pekolj
    • 1
  • Miguel Ciardullo
    • 1
  1. 1.General Surgery and Liver Transplant UnitHospital Italiano de Buenos AiresBuenos AiresArgentina
  2. 2.Hepatology and Liver Transplant UnitHospital Italiano de Buenos AiresBuenos AiresArgentina

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