**1. Introduction**

476 New Advances in the Basic and Clinical Gastroenterology

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The aim of this chapter is to present different types of biliary reconstructions used in the surgical treatment of iatrogenic bile duct injuries (IBDI).

IBDI remain an important problem in gastrointestinal surgery. The most frequently, they are caused by laparoscopic cholecystectomy which is one of the commonest surgical procedure in the world. The early and proper diagnostics of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Choice of the proper treatment of IBDI is very important, because it may avoid these serious complications and improve quality of life in patients. Non-invasive, percutaneous radiological and endoscopic techniques are recommended as initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. The goal of surgical treatment is to reconstruct the proper bile flow to the alimentary tract. In order to achieve this goal, many techniques are used. There are contradictory reports on the effectiveness of bile duct reconstruction methods in the literature.

#### **2. Historical perspectives of reconstructive biliary surgery**

The first descriptions of the anatomy of the liver and bile ducts originate 2000 years BC in Babylon. The presence of gallbladder stones were found in mummy priestess who lived in the eleventh century BC. Historical records derived from ancient Mesopotamia, Greece, Egypt and Rome, also demonstrate the presence of biliary tract diseases in those days. The first surgical procedures within the bile ducts were simple and uncomplicated. In 1618, Fabricus removed gallstones from the gallbladder. In 1867, Bobbs performed cholecystostomy. Cholecystostomy procedures were also performed by: Sims in 1878, Kocher in 1878 and Tait in 1879. The first planned cholecystectomy, performed on July 15, 1882, by the Berlin surgeon Langenbuch (1846-1901), was a breakthrough in the development of biliary surgery. In 1890, Couvoissier the performed the first choledochotomy. Development of operations performed on the bile ducts caused the the problem of iatrogenic bile duct injuries. In 1891, Sprengel, first described the case of bile duct injury. With the rise of this problem, the first reports of surgical reconstruction of the

Recontructive Biliary Surgery in the Treatment of Iatrogenic Bile Duct Injuries 479

laparoscopic cholecystectomy (LC), choledochotomy, and previous biliary reconstruction. The second group includes the operations performed on other abdominal organs, such as gastric resection (Bilroth II partial resection), liver resection, liver transplantation, pancreatic resection (pancreatoduodenectomy, extended distal pancreatic resection and pancreatic cyst drainage), biliary-enteric and porto-caval anastomoses, and lymphadenectomy or other procedures within the hepatoduodenal ligament.Cholecystectomy is the most common

Data regarding the exact prevalence of IBDI after OC and laparoscopic LC vary depending on the literature source. However, according to most authors IBDI occur 2-4 times more likely after laparoscopic cholecystectomy than after open cholecystectomy. IBDI number has increased in recent years, twice in connection with the introduction of laparoscopic

**Author IBDI incidence following OC IBDI incidence following LC** 

0.81% 0.5% 0.36-0.47% 0.95% 0.4-0.6% 0.07-0.95% 0.21% 0.4% 0.4-0.6% 0.1-1.1% 0.6%

cause of IBDI. Injuries caused during cholecystectomy represent 92.5% of IBDI.

cholecystectomy. Table 2 summarizes IBDI incidence following OC and LC.

0.2% 0.7% 0.19-0.29% 0.6% 0.3% 0.0-0.5% 0.18% 0.2% 0.1-0.3% 0.0-0.7% 0.3%

BDI iatrogenic bile duct injuries; OC open cholecystectomy; LC laparoscopic cholecystectomy.

Table 2. Incidence of IBDI following cholecystectomy.

Iatrogenic: postoperative, following endoscopic and percutaneous procedures

Congenital strictures: Biliary atresia and congenital cysts

Following blunt or penetrating trauma of the abdomen

Abscess or inflammation of liver or subhepatic region

Bile duct injuries:

Inflammatory strictures:

Parasitic, viral infection

Recurrent pyogenic cholangitis Primary sclerosing cholangitis Radiation-induced strictures

Toxic drugs

Papillary stenosis

Mc Mahon 1995 Strasberg 1995 Shea 1996 Targarona 1998 Lillemoe 2000 Gazzaniga 2001 Savar 2004 Moore 2004 Misra 2004 Gentileschi 2004 Kaman 2006

Mirizzi's syndrome Chronic pancretitis

Cholelithiasis and choledocholithiasis

Chronic ulcer or diverticulum of duodenum

Table 1. Main causes of benign biliary strictures.

injuried bile ducts have appeared. In 1892, Doyen, as first, described the biliary ductal endto-end anastomosis. The idea of biliary-alimentary anastomoses appeared as early as the nineteenth century. Cholecystoenterostomy (anastomosis between the gallbladder and colon), made by Winiwater in 1881, was the he first recorded biliary-alimentary anastomosis. In 1905, Mayo made the first biliary reconstruction as the end-to-side anastomosis between the common bile duct anastomosis (CBD) and the duodenum called choledochoduodenostomy. In 1908, Monprofit described biliary-alimentary anastomosis with a loop of small intestine Roux-Y as a way to repair the biliary tract. In 1909, Dahl reported a similar case. In 1944, Manteuffel performed hepaticojejunostomy conncting intrahepatic biliary ducts with a small intestine. In 1948, Cole attempted to produce mucosal-intestinal anastomosis by moving a segment of small intestine mucosa by incision the proximal hepatic duct. However, in this method, the mucosal fragment had not got sufficient blood supply. This technique was modified in 1969 by Smith, who described it as a mucosal graft. In 1964, Gilbert and in 1969, Grassi used in the insertion of the small intestine pedunculated on biliary vessels in the biliary reconstruction. The role of the Berlin surgeon Kehr (1862-1916), as the creator of the most widely used today T biliary drain, should be also emphasized. The French surgeons, Couinaud in 1954 and in 1956, Hepp and Couinaud, described the hepatic hilum of the liver and long extrahepatic left hepatic duct, using it to perform a wide biliary-alimentary anastomosis, after the dissection of tissue within the hilum the liver to perform, in cases of intrahepatic bile duct injuries. In 1948, Longmire and Sanford also described a technique of isolating the left hepatic duct to use it for a biliaryintestinal anastomosis, consisting of partial resection of the left lobe of the liver. In 1957, this technique has been modified and used by Soupault and Couinaud to isolate the hepatic segment of the third hepatic segment in order to perform the biliary-intestinal anastomosis in the case of atypical sectoral biliary system. In 1994, Blumgart described the technique of the hilar and intrahepatic biliary-enteric anastomosis. In 1965, Thomford and Hallenbeck described the modification of an animal model of biliary-enteric anastomosis using Roux-Y loop, consisting of the jejunostomy (intestinal loop sutured into the abdominal shell) which allowed postoperative endoscopic control and dilatation of the anastomosis. In 1984, Hutson described the application of this technique in patients with postoperative stenosis within the biliary anastomosis. This method of reconstruction has not been widely accepted and incorporated into the standard surgical treatment of iatrogenic bile duct injuries (IBDI). In Poland, the modified biliary-enteric anastomosis with using Roux-Y loop sutured into the hole in the layer of musculo-fascial, was first described in 1997 by Jędrzejczyk et al. [8]. The increase in the IBDI incidence has been reported in the early 90's, which was connected with the introduction of laparoscopic cholecystectomy. The first laparoscopic cholecystectomy was performed in 1986 by Muhe.

#### **3. Pathogenesis of bile duct injuries**

Iatrogenic bile duct injury account for about 95% of all benign biliary strictures (BBS). "Benign biliary strictures" is a broad concept encompassing not only strictures caused by injuries, but also as a result of other causal factors [1, 11 12]. Causes of BBS can be divided into several groups and they are summarized in table 1.

There are two basic groups of surgical procedures, which may lead to IBDI. The first group are the operations performed on the bile ducts: an open cholecystectomy (OC) and

injuried bile ducts have appeared. In 1892, Doyen, as first, described the biliary ductal endto-end anastomosis. The idea of biliary-alimentary anastomoses appeared as early as the nineteenth century. Cholecystoenterostomy (anastomosis between the gallbladder and colon), made by Winiwater in 1881, was the he first recorded biliary-alimentary anastomosis. In 1905, Mayo made the first biliary reconstruction as the end-to-side anastomosis between the common bile duct anastomosis (CBD) and the duodenum called choledochoduodenostomy. In 1908, Monprofit described biliary-alimentary anastomosis with a loop of small intestine Roux-Y as a way to repair the biliary tract. In 1909, Dahl reported a similar case. In 1944, Manteuffel performed hepaticojejunostomy conncting intrahepatic biliary ducts with a small intestine. In 1948, Cole attempted to produce mucosal-intestinal anastomosis by moving a segment of small intestine mucosa by incision the proximal hepatic duct. However, in this method, the mucosal fragment had not got sufficient blood supply. This technique was modified in 1969 by Smith, who described it as a mucosal graft. In 1964, Gilbert and in 1969, Grassi used in the insertion of the small intestine pedunculated on biliary vessels in the biliary reconstruction. The role of the Berlin surgeon Kehr (1862-1916), as the creator of the most widely used today T biliary drain, should be also emphasized. The French surgeons, Couinaud in 1954 and in 1956, Hepp and Couinaud, described the hepatic hilum of the liver and long extrahepatic left hepatic duct, using it to perform a wide biliary-alimentary anastomosis, after the dissection of tissue within the hilum the liver to perform, in cases of intrahepatic bile duct injuries. In 1948, Longmire and Sanford also described a technique of isolating the left hepatic duct to use it for a biliaryintestinal anastomosis, consisting of partial resection of the left lobe of the liver. In 1957, this technique has been modified and used by Soupault and Couinaud to isolate the hepatic segment of the third hepatic segment in order to perform the biliary-intestinal anastomosis in the case of atypical sectoral biliary system. In 1994, Blumgart described the technique of the hilar and intrahepatic biliary-enteric anastomosis. In 1965, Thomford and Hallenbeck described the modification of an animal model of biliary-enteric anastomosis using Roux-Y loop, consisting of the jejunostomy (intestinal loop sutured into the abdominal shell) which allowed postoperative endoscopic control and dilatation of the anastomosis. In 1984, Hutson described the application of this technique in patients with postoperative stenosis within the biliary anastomosis. This method of reconstruction has not been widely accepted and incorporated into the standard surgical treatment of iatrogenic bile duct injuries (IBDI). In Poland, the modified biliary-enteric anastomosis with using Roux-Y loop sutured into the hole in the layer of musculo-fascial, was first described in 1997 by Jędrzejczyk et al. [8]. The increase in the IBDI incidence has been reported in the early 90's, which was connected with the introduction of laparoscopic cholecystectomy. The first laparoscopic cholecystectomy

Iatrogenic bile duct injury account for about 95% of all benign biliary strictures (BBS). "Benign biliary strictures" is a broad concept encompassing not only strictures caused by injuries, but also as a result of other causal factors [1, 11 12]. Causes of BBS can be divided

There are two basic groups of surgical procedures, which may lead to IBDI. The first group are the operations performed on the bile ducts: an open cholecystectomy (OC) and

was performed in 1986 by Muhe.

**3. Pathogenesis of bile duct injuries** 

into several groups and they are summarized in table 1.

Congenital strictures: Biliary atresia and congenital cysts Bile duct injuries: Iatrogenic: postoperative, following endoscopic and percutaneous procedures Following blunt or penetrating trauma of the abdomen Inflammatory strictures: Cholelithiasis and choledocholithiasis Mirizzi's syndrome Chronic pancretitis Chronic ulcer or diverticulum of duodenum Abscess or inflammation of liver or subhepatic region Parasitic, viral infection Toxic drugs Recurrent pyogenic cholangitis Primary sclerosing cholangitis Radiation-induced strictures Papillary stenosis

Table 1. Main causes of benign biliary strictures.

laparoscopic cholecystectomy (LC), choledochotomy, and previous biliary reconstruction. The second group includes the operations performed on other abdominal organs, such as gastric resection (Bilroth II partial resection), liver resection, liver transplantation, pancreatic resection (pancreatoduodenectomy, extended distal pancreatic resection and pancreatic cyst drainage), biliary-enteric and porto-caval anastomoses, and lymphadenectomy or other procedures within the hepatoduodenal ligament.Cholecystectomy is the most common cause of IBDI. Injuries caused during cholecystectomy represent 92.5% of IBDI.

Data regarding the exact prevalence of IBDI after OC and laparoscopic LC vary depending on the literature source. However, according to most authors IBDI occur 2-4 times more likely after laparoscopic cholecystectomy than after open cholecystectomy. IBDI number has increased in recent years, twice in connection with the introduction of laparoscopic cholecystectomy. Table 2 summarizes IBDI incidence following OC and LC.


BDI iatrogenic bile duct injuries; OC open cholecystectomy; LC laparoscopic cholecystectomy.

Table 2. Incidence of IBDI following cholecystectomy.

Recontructive Biliary Surgery in the Treatment of Iatrogenic Bile Duct Injuries 481

biloma within the peritoneal cavity in the case of bile leakage. In doubtful cases, you can perform abdominal CT to accurately depict the reservoir of bile. Accurate assessment of biliary tree can be made using cholangiography. Percutaneous cholangiography (percutaneous transhepatic cholangiography, PTC) is useful to evaluate the bile ducts proximal to the injury. Endoscopic cholangiography (endoscopic retrograde cholangiopancreatography, ERCP) plays a very important role in the imaging of biliary tract injuries. During ERCP it is possible to supply minor injuries through the establishment of the prosthesis into the lumen of the damaged bile ducts. The advantage of magnetic resonance cholangiography (cholangio-MR) imaging is the high accuracy of the biliary tree and it is non-invasive. This investigation is primarily used to assess the biliary tract before

Different IBDI classifications are described in the literature. In our opinion, the Bismuth classification is the most useful in a clinical practice (described in figure 1). It is based on location of the injury in the biliary tract. This classification is very helpful in prognosis after repair, but does not involve the wide spectrum of possible biliary injuries. The another classification is the Strasberg scale which, in difference from the Bismuth scale, allows to distinguish small (bile leakage from the cystic duct) and serious injuries performed during laparoscopic cholecystectomy, but it does not play an important role in choice of surgical treatment method. The Mattox classification of IBDI takes into consideration a kind of injuring factor (contusion, laceration, perforation, transsection, distraction or interruption of the bile duct or the gallbladder). There are several classifications of IBDI performed during laparoscopic cholecystectomy (Steward and Way, Schmidt, Hannover) in the literature.

 I. II. III. IV. V. I. Common bile duct (CBD) and low common hepatic duct (CHD) > 2cm. from hepatic duct confluence. II. Proximal CHD < 2cm from confluence. III. Hilar injury with no residual CHD – confluence intact. IV. Destruction of confluence – right and left hepatic ducts separated. V. Involvement of aberrant right

Non-invasive, percutaneous radiological end endoscopic techniques are recommended as initial treatment of IBDI. When these techniques are not effective, surgical management is

the reconstructive surgery.

**6. Classification of iatrogenic bile duct injuries** 

sectoral hepatic duct alone or with concomitant injury of CHD.

**7.1 Non-invasive treatment of iatrogenic bile duct injuries** 

**7. Treatment of iatrogenic bile duct injuries** 

Fig. 1. Bismuth classification of IBDI.

considered.

There are many factors that increase the IBDI risk during surgery. Coexisting chronic or exacerbated inflammation of the operated area, obese patient, the presence of abundant adipose tissue around the hepatoduodenal ligament, not sufficiently broad insight into the operative field, and bleeding increases the difficulty of surgery and promote bile duct injuries. The conditions in which laparoscopic cholecystectomy is performed, also affect the rate of IBDI formation. Adverse factors include older age, male gender and long duration of symptoms prior to surgery. Biliary anomalies and variability of the arteries are also the factors associated with increased IBDI risk. Unusually reputed hepatic duct may be mistakenly regarded as the cystic duct and ligated or cut. Excessive, more than is necessary, dissection around the hepatoduodenal ligament during cholecystectomy may lead to damage to the axial arteries running along the CBD. Vascular damage is the cause of postoperative biliary strictures due to ischemia . According to the literature, during the distal bile duct injury the axial artery damage usually occurs (incidence 10-15% of cases), while during high biliary injuries of the proximal bile duct damage to the branches of the proper hepatic artery occurs (incidence 40-60% of cases).
