Saudi Journal of Gastroenterology
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Year : 2004  |  Volume : 10  |  Issue : 1  |  Page : 8-15
Management of postlaparoscopic cholecystectomy major bile duct injury: Comparison of MRCP with conventional methods

1 Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia
2 Department of Radiology, King Khalid University Hospital, Riyadh, Saudi Arabia
3 Department of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission06-Jan-2003
Date of Acceptance09-Jun-2003


Background: Postlaparoscopic cholecystectomy bile duct injury remains one of the devastating complications seen in current surgical practice. Aim of Study: This study describes the diagnostic role of magnetic resonance cholangiopancreatography (MRCP) in such injuries compared with conventional methods. Patients and Methods: Eighteen patients referred to the Division of Hepatobiliary Surgery, King Khalid University Hospital from July 1998 to September 2000 were retrospectively studied. The technique of the repair was by utilizing Roux-en-Y hepaticojejunostomy with establishment of mucosa-to-mucosa anastomosis.The study included presentation, age and gender. Results: The presentation of patients were variable and frequently included pain, jaundice with or without cholangitis in 13 patients, bile leakage with development of biliary peritonitis in three, and development of external biliary fistula in two patients. Besides lower incidence of complication, MRCP was more diagnostic and informative in planning surgery by mapping both ducts proximal and distal to site of injury or stricture in 14 out of 18 patients. The Bismuth level of bile duct injuries were type I in one, type 11 in five, type III in 11 and type IV in one patient. All patients are alive, well and no complications occurred in the immediate postoperative period. Only two patients developed stricture within four months after surgery, one of them treated conservatively with repeated dilatation and stenting was done for the other. Conclusion: Hepaticojejunostomy is the procedure of choice for repair of bile duct injuries and provides adequate bilairy drainage. MRCP is an ideal diagnostic test when bile duct injury is suspected following laparoscopic cholecystectomy

Keywords: Bile duct injury, laparoscopic cholecystectomy, MRCP

How to cite this article:
Abou El-Ella KM, Mohamed ON, El-Sebayel MI, Al-Semayer SA, Al Mofleh IA. Management of postlaparoscopic cholecystectomy major bile duct injury: Comparison of MRCP with conventional methods. Saudi J Gastroenterol 2004;10:8-15

How to cite this URL:
Abou El-Ella KM, Mohamed ON, El-Sebayel MI, Al-Semayer SA, Al Mofleh IA. Management of postlaparoscopic cholecystectomy major bile duct injury: Comparison of MRCP with conventional methods. Saudi J Gastroenterol [serial online] 2004 [cited 2022 Dec 7];10:8-15. Available from:

Laparoscopic cholecystectomy (LC), as a less invasive surgical procedure, has been established as a procedure of choice for the treatment of patients with symptomatic gallbladder stones with proven benefits over open technique. However, bile duct injury (BDI) following LC remains one of the devastating complication seen in the current surgical practice [1] . Endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) or both, are the most important diagnostic tests in recognition of bile duct injuries after LC. However, these procedures are invasive and have the potential for serious complications [2] . Magnetic resonance cholangiopancreatography (MRCP) has recently emerged as an attractive, non­invasive diagnostic modality for comprehensive evaluation of biliopancreatic diseases [3]. This study describes the role of MRCP in the management of patients with BDI after LC.

   Patients and Methods Top

This study includes all patients with BDI following LC referred to the 1-Iepatobiliary Unit at King Khalid University Hospital from July 1998 to September 2000. Only patients with major bile duct injuries were included in this study, whereas those with minor bile leaks and those with cystic duct stump leaks were excluded from analysis. The data were collected from the patients' medical records. The level and severity of BDI were graded according to the Bismuth classification [4] . The diagnostic tests included biochemical markers of liver function, liver sonography and MRCP followed by ERCP or PTC or both. The time interval between MRCP and conventional cholangiography was 24 hours. The findings of MRCP and conventional cholangiography were compared. The patients were followed up regularly after hospital discharge. Post­operative cholangiographic studies were performed only for patients with symptoms or biochemical pattern of obstructive jaundice.

   Results Top

Eighteen patients with major BDI, were referred to our unit between July 1998 and September 2000. these were 17 females and one male and the mean age was 41 years. Laparoscopic cholecystectomy was performed electively in 13 patients for chronic calcular cholecystitis. Three patients were described to have significant intra-operative bleeding and LC was converted to open because of uncontrolled bleeding. In the last two patients, LC was performed for acute cholecystitis, where there was difficulty in identifying the anatomy. Intra-operative cholangiography at LC was not performed for any of the patients.

During the pre-referral management, five patients underwent further surgical procedures; two of them underwent biliary reconstructive surgery in the form of hepatico-jejunostomy, those patients subsequently underwent re-do surgery at our centre for revision of anastomotic stricture after 9-12 months postoperatively.

The other three patients underwent laparotomy with placement of drainage catheter and referred directly. The remaining patients were referred primarily for diagnostic and therapeutic intervention. Patients were transferred with a median of eight days (range 5-365) after LC.

The bile duct injuries were detected at variable time intervals after LC. No cases were recognized at the time of initial procedure. The diagnosis of biliary injury was made within 4-14 days after LC in all patients but three, who were diagnosed within 30-45 days after the initial operation. The clinical manifestations of such injuries were abdominal pain and obstructive jaundice with or without cholangitis in 13 patients, bile leakage with development of biliary peritonitis in three and the development of external biliary fistula in two patients.

Serial biochemical markers of liver function were measured. High levels of serum transaminases, bilirubin, and alkaline phosphatase have been demonstrated in most patients, correlating with clinical suspicion of obstructive jaundice. All patients underwent screening liver sonography, which revealed dilated bilateral intrahepatic ducts in varying degrees in 15 patients and suspicion of intra-abdominal fluid collection in three patients. Those three patients underwent additional CT scan to confirm the diagnosis.

Aiming to establish the role of MRCP in the diagnosis of BDI following LC, MRCP was performed in all patients after being transferred to our center one day before ERCP or PTC. Beside lower incidence of complication, MRCP was more diagnostic and informative in planning surgery by mapping both ducts proximal and distal to site of injury or stricture in 14 out of 18 patients. MRCP provided more diagnostic information than conventional cholangiography in 12 out of these 14 patients. In these patients, ERCP showed only the cut-off sign of common bile duct (CBD) [Figure - 1], therefore PTC was needed to visualize the proximal biliary system [Figure - 2]. In contrast, MRCP showed the entire biliary system both proximal and distal to the amputated or stenotic site simultantously [Figure - 3]. In the remaining two patients, who developed anastomosic stricture after hepaticojejunostomy performed before referral to our center, MRCP and PTC yielded similar diagnostic information. Also the diagnosis was made by PTC in three patients (with bile leakage and development of biliary peritonitis) after CT showed abnormal fluid collections, and in addition, by ERCP in one patient with bile duct stricture due to misplaced metallic hemoclip in the region of the CBD.

Based on the results of radiological and operative findings, bile duct injuries were classified according to Bismuth's classification: type I in one patient, type II in five patients, type III in eleven patients, and type IV in one. Biliary enteric reconstruction was performed in our unit for all patients with BDI as a definitive surgical treatment. The technique of repair was carried out by utilizing Roux-en-Y hepatico-jejunostomy with establishment of mucosa-to-mucosa anastomosis. Temporary stenting of the anastomosis was performed by using pediatric feeding tube (8 -1 0F) or percutaneous transhepatic drainage catheter when it had already been placed. Early outcome of therapy for these BDI has been favorable. All patients are alive and well, no complications occurred in the immediate post-operative period. Patients who had an elevation in serum bilirubin preoperatively had a decline to normal within six days after definitive surgery, alkaline phosphatase remained abnormal, although decreasing at the time of hospital discharge in most of the patients.

The median inpatient stay after referral was 16 days (range 14-70) days, and median follow-up was 15 months (range 6­30) months. On follow-up, 16 patients remained asymptomatic with normal liver function, and two patients developed stricture four months after surgery, one was treated conservatively and the other required repeated dilatation and stenting.

   Discussion Top

Laparoscopic cholecystectomy is associated with a higher incidence of bile duct injury than open cholecystectomy [5] . Although recent studies have shown a low incidence of BDI during LC [6],[7] , concerns including ours remain because of the sustained increase in the number of referral for biliary reconstruction after the procedure [8] . Awareness of this serious complication is the cornerstone to prevent it.

One of the most important factors responsible for BDI during LC in our study is surgeon's experience and their resistance to convert to open technique if needed. On the other hand, LC had been performed for acute cholecystitis in two patients and for chronic symptoms in 16 patients. From this study, acute cholecystitis cannot be proven as a risk factor. However, in the presence of inflammatory changes in Calot's triangle, the anatomy might be more difficult to identify and this may lead to more extensive injury [8],[9] . Another major event is severe bleeding, which cannot be controlled laparoscopically. In three patients of our series, the laparoscopic procedure was converted to open one because of significant uncontrolled bleeding. The issue of whether the intra­operative cholangiography minimizes the occurrence of BDI during LC remains controversial [l],[9],[10] . Operative cholangiography was not performed for any patient in our series. As others, we do believe that with adequate training, accurate identification of the structures within the Calot's triangle during laparoscopy, and early conversion to open cholecystectomy when indicated, the incidence of biliary injury can be reduced to a level comparable to that of open cholecystectomy [5],[8],[11] .

The classic pattern of laparoscopic injury appears to be misidentification of the common duct for the cystic duct, with resection of a portion of the common hepatic and common bile ducts, and obstruction of the duct by hemoclips [12] . The vast majority of the injuries reported in this review were a direct result of misidentifying the anatomy by the surgeon. Common bile duct was mistaken for the cystic duct in 12 patients. Excessive traction on the gallbladder resulting in tenting of the common bile duct and despite correct identification of the cystic duct, clips incorrectly applied to the tented portion of the CBD occurred in five patients. Finally, bile duct stricture resulted from misplaced hemoclip in the region of the common duct resulting in partial obstruction in one patient. Laparoscopic BDI tends to be more severe than that, which follows open cholecystectomy. A portion of the duct is typically resected, the level of the injury is high (Bismuth type 3 or 4) and the duct diameter is usually small, all of which contribute for a poorer prognosis after repair [5] . We have also observed that BDI has become severe after LC. In the present study, there was only one patient with Bismuth type-1 lesion, in contrast, five patients had a Bismuth type-11 injury, eleven patients had type III, and one patient had type IV.

Early recognition of BDI is crucial for further management. Although it would be clearly better to recognize biliary injury at the time of LC, most injuries are not recognized at the time of operation. Also the extent of BDI was not defined inmost patients by the time they were referred [13] . Our findings were the same as those that had been previously reported [13] . In our series the clinical presentation of the patients was variable, depending on whether the injury was total bile flow obstruction or bile leakage. Twelve patients with total occlusion (clipping) of the bile duct presented early within two weeks postoperatively with abdominal pain, obstructive jaundice with or without cholangitis. One patient with bile duct stricture resulting from misplaced clips presented six weeks after the original procedure with repeated episodes of cholangitis. On the other hand, five patients with biliary leakage after LC presented with biliary peritonitis in three, and external biliary fistula in two. Patients with biliary peritonitis presented early within one week after surgery, while patients with biliary fistula presented late within four weeks because of late referral.

The diagnosis of BDI is important in planning the strategy of surgical management, and requires extensive diagnostic evaluation [14] , Our study revealed elevated levels of serum transaminases, total bilirubin, and alkaline phosphatase in most patients. Ultrasonography was helpful in the detection of fluid collection and bile duct dilatation in our patients. The diagnosis of BDI was established by MRCP in 14 patients, PTC in three patients after CT showed abnormal fluid collection, and ERCP in one patient. Endoscopic retrograde cholangiopancreatography is a useful diagnostic and therapeutic tool when the continuity of the extrahepatic biliary system has not been disturbed. In our study, ERCP was seldom of value in the precise diagnosis of complete high bile duct injury because there was discontinuity of the common bile duct preventing display of the proximal biliary anatomy. However, the procedure is of value in demonstrating incomplete stricture or stenosis. In the classic injury involving bile duct transection, ERCP shows only the cut-off sign of the CBD [2] . In these cases, it is essential that PTC is performed to determine the nature of the injury as well as to visualize the proximal biliary tree [9] . However, PTC is associated with potentially serious complications, particularly in those who have cirrhosis, ascites, perihepatic bilious fluid collection and coagulopathy. [15] Therefore, PTC should only be performed when percutaneous drainage is required or surgical intervention is planned [1] .

In this article, we evaluated the usefulness of MRCP in diagnosing BDI after LC. MRCP is the imaging modality of choice for the work-up of suspected BDI as it outlines both the intra and extra-hepatic biliary tree, and thus can provide a better map of the biliary anatomy for planning the reconstructive surgery than ERCP [16] . It has a higher accuracy in the diagnosis of BDI than ERCP or PTC, with the advantage of avoiding the adverse effects inherent with conventional cholangiography [17] . MRCP is particularly useful for patients who are in poor clinical condition and not suitable for administration of contrast media or sedation and after gastrojejunostomy or biliary­enteric anastomosis, who are unable to undergo ERCP due to altered post-surgical anatomy, as well as for those with multiple separate biliary obstruction, which would otherwise necessitate multiple PTC procedures [15] . Also it is of value when ultrasonographic examination shows a nondilated ductal system. Moreover, MRCP is valuable during follow-up of patients after surgical repair, because it is noninvasive and can demonstrate anastomotic patency and function in patients in whom no tube has been left across the anastomosis at the time of repair, and postoperative bile duct stricture or obstruction can also be seen with MRCP [3] . Despite the many advantages of MRCP over conventional cholangiography, it is only a purely diagnostic tool. While MRCP may completely replace the diagnostic role of ERCP and PTC, subsequent bilary stent, placed either endoscopically or percutaneously, is still warranted to stabilize patients with biliary leak or biliary obstruction before any attempt at repair [2] . Our data are in agreement with reports that recommended the early use of MRCP in the preoperative evaluation of patients with BDI to ascertain the diagnosis and to establish the need for a subsequent surgical, endoscopic or percutaneous procedure [15],[17] .

An important factor for surgical outcome is the timing of reconstruction. The optimum time for surgical repair of BDI is immediately after the injury has occurred. It has been shown that the morbidity and mortality of such primary repair is significantly lower than attempted surgery at a later date [18] . In our study, since the site of most total bile duct lesions is the hepatic duct (bismuth II, III, and IV), reconstruction with Roux-en-Y hepatico­jejunostomy offers the best surgical treatment. Early reconstruction was undertaken in 15 of our patients after appropriate assessment and before sepsis disrupts the operative field. Late reconstruction was undertaken in three patients with biliary peritonitis. The first step in the management among those patients was delineation of the proximal biliary anatomy via PTC and biliary stent replacement followed by CT drainage for bile collection, then definitive surgical repair to deal with BDI was postponed for 6-8 weeks by which time the intra­abdominal sepsis has subsided. Also, previous repeated and inappropriate attempts at biliary repair are associated with a poor long-term result. Woods et al observed a high incidence of failed primary biliary repair in cases referred to them [19]. We also observed an increase in referrals of complicated biliary repair performed outside our institution. Operative repair was attempted in five patients, two of them underwent hepatico jejunostomy before referral, these patients subsequently underwent re-surgery in our center for anastomotic stricture, for this reason, and we recommend early referral to a specialist center.

A strategy for the management of BDI after LC was developed in our center. When an injury is suspected, levels of serum transaminase, bilirubin, and alkaline phosphatase should be measured, and imaging studies (ultrasound or CT scan) of the abdomen should be performed. The next step is visualization of the biliary tract by MRCP not only to establish the diagnosis but also to identify the nature and the level of the lesion. Preoperative placement of percutaneous transhepatic biliary catheter into the right or left hepatic duct, or both to assist in identification of the proximal duct system at laparotomy. CT drainage immediately after the PTC for drainage of biliary ascites, and biliary enteric reconstruction usually by Roux-en­Y hepatico-jejunostomy to provide adequate biliary drainage with temporary stenting of the anastomoses. MRCP, HIDA scan or PTC if the PTD catheter was used pre-operatively can be utilized to assess the patency of the anastomoses and to exclude bile leakage postoperatively [Figure - 4].

Early results of reconstructive surgery for biliary injuries are satisfactory. There was no procedure-related mortality. Symptomatic and radiological resolution were achieved in all patients except two, who developed stricture at the anastomotic site four months after surgery, treated conservatively in one by repeated balloon dilatation and stenting in another. Our results are comparable with the others [12],[13],[14] .

   Conclusion Top

MRCP is an ideal diagnostic test when bile duct injury following laparoscopic cholecystectomy is suspected. Coordinated efforts by radiologists, endoscopists, and surgeons are necessary to optimize the management of patients with major bile duct injury. Hepatico-jejunostomy is the procedure of choice for repair of bile duct injuries that provides adequate biliary drainage.

   References Top

1. Soper NJ, Flye MW, Brunt LM, Stockmann PT. Aliperti G. Diagnosis an management of biliary complications of laparoscopic cholecystectomy. Am J Surgery 1993; 165: 663-9.  Back to cited text no. 1    
2.Lillemoe KD, Martin SA. Cameron JL, Yeo CJ, Talarnini MA, Kaushal S. Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management. Ann Surg 1997; 225: 459-71.  Back to cited text no. 2    
3.Lomanto D, Pavone P, Laghi A, Panebianco V, Mazzocchi P, Fiocca F. Magnetic resonance cholangiopancreatogaphy in the diagnosis of biliopancreatic diseases. Am J Surg 1997; 174: 33-8.  Back to cited text no. 3    
4.Bismuth H. Postoperative strictures of the bile duct. In: Blumgart LH, ed. The biliary tract. Edinburgh: Churchill Livingstone. Clinical Surgery International. 1982: 5: 209-18.  Back to cited text no. 4    
5.McMahon AJ, Fullarton G, Baxter JN, O'Dwyer PJ. Bile duct injury and bile leakage in laparoscopic cholecystectomy_. Br J Surg 1995; 82: 307-13.  Back to cited text no. 5  [PUBMED]  
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7.Nair RG, Dunn DC, Fowler S, McCloy RF. Progress with cholecystectomy: Improving results in England and Wales. Br J Surg 1997; 84: 1396-8.  Back to cited text no. 7  [PUBMED]  
8.Asbun HJ, Rossi RL, Lowell JA, Munson JL. Bile duct injury during laparoscopic cholecystectomy : Mechanism of injury, prevention and management. World J Surg 1993; 17: 547-52.  Back to cited text no. 8  [PUBMED]  
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10.Berei G, Sackier JM, Paz-Partlow M. Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy? Am J Surg 1991; 161:355-60.  Back to cited text no. 10    
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13.Mirza DF. Narsimhan KL, Ferraz Neto BH. Mayer AD, McMaster P, Buckels JAC. Bile duct injury following laparoscopic cholecystectomy: Referral pattern and management. Br J Surg 1997; 84: 786-90.  Back to cited text no. 13    
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15.Yeh T-S, Jan Y-Y, Tseng J-H, Hwang T-L, Chen M-F. Value of magnetic resonance cholangiopancreatography in demonstrating major bile duct injuries following laparoscopic cholecystectomy. Br J Surg 1999: 86: 181-4.  Back to cited text no. 15    
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Correspondence Address:
Osama Nafea Mohamed
Department of Surgery, King Khalid University Hospital, P. O. Box 7805, Riyadh 11472
Saudi Arabia
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PMID: 19861822

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