**7.2.2 Surgical reconstructions of iatrogenic bile duct injuries**

Over 2/3 bile duct injuries are recognized at least a few days after surgery, during which the injury occurred. The surgical treatment of elective IBDI is made using different methods of biliary reconstructions. The main aim of surgical treatment is the reconstruction of proper flow of bile to the alimentary tract. The following operations are performed in biliary injuries surgical treatment: Roux-Y hepaticojejunostomy, end-to-end ductal biliary anastomosis with T drainage or endoprothesis conducted into the duodenum according to Górka, choledochoduodenostomy, Lahey hepaticojejunostomy, jejunal interposition hepaticoduodenostomy, Blumgart (Hepp) anastomosis, Heinecke-Mikulicz biliary plastic reconstruction and Smith mucosal graft.

#### **Conditions of proper healing of each biliary anastomosis**


#### **7.2.2.1 Types of surgical reconstructions performed in IBDI**

#### *7.2.2.1.1 End-to-end ductal anastomosis (EE)*

We recommend this method as the first, because end-to-end ductal anastomosis (EE) is the most physiological biliary reconstruction [1, 46, 48, 49]. In this type of reconstruction, extensive mobilization of the duodenum with the pancreatic head through the Kocher maneuver, excision of the bile duct stricture, and refreshment of the proximal and distal stumps should be performed. Anastomosis is performed in a single layer with interrupted absorbable PDS 4-0 or 5-0 sutures. This reconstruction is not recommended by most authors due to the higher number of anastomosis strictures in comparison with Roux-y hepaticojejunostomy (HJ). We recommend EE first, because in some patients, extensive mobilization of the duodenum with the pancreatic head by the Kocher maneuver allows to perform the tension-free anastomosis after the extensive length-loss of the bile duct. Excision of the bile duct stricture, dissection and refreshing of the proximal and distal stumps as far as the tissues are healthy and without inflammation, and the use of non-traumatic, monofilament-interrupted sutures 5-0 allows the achievement of good long-term results. Using of an internal Y tube conducting from the right and left hepatic ducts into the duodenum through EE and the papilla of Vater also allows the proper healing of this anastomosis. This reconstruction can be performed when the bile duct loss is from 0.5 to 4 cm. It allows the achievement of very good long-term results with effectiveness comparable with HJ. It is important that establishing a physiological bile pathway allows proper digestion and absorption, which causes a higher gain weight in patients following EE, which was noted in study performed in our department. Another essential advantage of EE is possibility of of endoscopic control after surgery.The lower number of early complications is observed after EE than HJ, which is associated with opening of the alimentary tract and the higher number of performed anastomoses (biliary-enteric and entero-enteric) in patients with HJ. The disadvantage is the higher incidence of recorded postoperative stenosis at the anastomosis due to poorer blood supply of the operated area. It can't be performed in patients with bile duct loss more than 4 cm. The diameter of both anastomosed ends should be comparable. If there is a difference between a diameter of anastomosed ends, the thinner end should be incised longitudinally in the anterior surface in order to extend it before creation of anastomosis. This repair should not be carried out in bile ducts that are too thin (diameter less than 4 mm). In our opinion a patient, whom we perform first or exceptionally second bile ducts repair, is a candidate for EE. Because of a number of advantages, EE is recommended as the first method of choice for patients with IBDI.

#### *7.2.2.1.2 Roux-Y hepaticojejunostomy*

484 New Advances in the Basic and Clinical Gastroenterology

Endoscopic treatment is recommended as initial treatment of benign biliary strictures, biliary

In the case of intraoperative recognition of bile duct injury, it is recommended that intraoperative cholangiography or conversion from laparoscopic cholecystectomy to open, allowing a better insight into the operative field and immediate repair. The injury should be repaired by an experienced hepatobiliary surgeon. If it is impossible, a patient should be transferred to a referral hepatobiliary surgery center, after adequate drainage of a subhepatic region. If the cut bile duct is less than 2-3 mm in diameter, without communication with the main biliary system, it should be ligated in order to avoid postoperative bile leak leading to development of the biloma and abscess in the subhepatic region. Bile ducts with a diameter of 3-4 mm or more should be surgically repaired because they drain the larger area of the liver. Interruption of CHD or CBD continuity can be repaired by immediate tension-free end-to-end ductal anastomosis with or without a T tube, using absorbable sutures. Security of the immediately repaired bile duct with a T tube is controversial. If the bile duct loss is too long and immediate end-to-end biliary anastomosis

fistula in the presence and in patients not not qualified to surgical treatment.

is not possible without tension, hepaticojejunostomy Roux-Y is recommended.

Over 2/3 bile duct injuries are recognized at least a few days after surgery, during which the injury occurred. The surgical treatment of elective IBDI is made using different methods of biliary reconstructions. The main aim of surgical treatment is the reconstruction of proper flow of bile to the alimentary tract. The following operations are performed in biliary injuries surgical treatment: Roux-Y hepaticojejunostomy, end-to-end ductal biliary anastomosis with T drainage or endoprothesis conducted into the duodenum according to Górka, choledochoduodenostomy, Lahey hepaticojejunostomy, jejunal interposition hepaticoduodenostomy, Blumgart (Hepp) anastomosis, Heinecke-Mikulicz biliary plastic

The anastomosed edges should be healthy, without inflammation, ischemia and fibrosis.

We recommend this method as the first, because end-to-end ductal anastomosis (EE) is the most physiological biliary reconstruction [1, 46, 48, 49]. In this type of reconstruction, extensive mobilization of the duodenum with the pancreatic head through the Kocher maneuver, excision of the bile duct stricture, and refreshment of the proximal and distal stumps should be performed. Anastomosis is performed in a single layer with interrupted absorbable PDS 4-0 or 5-0 sutures. This reconstruction is not recommended by most authors due to the higher

**7.2.2 Surgical reconstructions of iatrogenic bile duct injuries** 

**Conditions of proper healing of each biliary anastomosis** 

**7.2.2.1 Types of surgical reconstructions performed in IBDI** 

 The anastomosis should be tension-free and properly vascularized. It should be performed in a single layer with absorbable sutures.

reconstruction and Smith mucosal graft.

*7.2.2.1.1 End-to-end ductal anastomosis (EE)* 

**7.2 Surgical treatment of iatrogenic bile duct injuries** 

**7.2.1 Immediate repair of IBDI** 

Roux-Y hepaticojejunostomy (HJ) is the most frequently performed surgical reconstruction of IBDI. In this surgical technique, a proximal common hepatic duct is identified and prepared and the distal common bile duct is sutured. End-to-side or end-to-end HJ is performed in a single layer using interrupted absorbable polydioxanone (PDS 4-0 or 5-0) sutures. Most authors prefer HJ due to the lower number of postoperative anastomosis strictures. According to Terblanche et al, HJ is effective in 90% of cases [50]. However, after this reconstruction, bile flow into the alimentary tract is not physiological, because the duodenum and upper part of the jejunum are excluded from bile passage. Physiological conditions within the proximal gastrointestinal tract are changed as a result of duodenal exclusion from bile passage. An altered bile pathway is a cause of disturbances in the release of gastrointestinal hormones. There is a hypothesis that in patients with HJ, the bile bypass induces gastric hypersecretion leading to a pH change secondary to altered bile synthesis and release of gastrin. A higher number of duodenal ulcers is observed in patients with HJ, which may be associated with a loss of the neutralizing effect of the bile, including bicarbonates and the secondary gastric hypersecretion. Laboratory investigations revealed increased gastrin and glucagon-like immunoreactivity (GLI) plasma levels and decreased triglycerides, gastric inhibitory polypeptide (GIP), and insulin plasma levels in patients with HJ. An altered pathway of bile flow is also a cause of disturbance in fat metabolism in patients undergoing HJ. Moreover, the total surface of absorption in these patients is also decreased due to exclusion of the duodenum and upper jejunum from the food passage. In

Recontructive Biliary Surgery in the Treatment of Iatrogenic Bile Duct Injuries 487

reconstruction of hilar IBDI. In this technique, dorsal surface of the left hepatic duct parallel to the quadrate hepatic lobe. Dissection and opening of the left hepatic duct longitudinally

Other methods of IBDI reconstruction, such as Lahey hepaticojejunostomy, jejunal Heinecke-Mikulicz biliary plastic operation Kirtley operation and others are performed sporadically.

External T-drainage - using a typical Kehr tube with insertion of its short branches into the

External Y-drainage - insertion of short branches of the Kehr tube into both right and left hepatic ducts, splinting of the anastomosis and conducting of its long branch through the

Internal Y-drainage - insertion of short branches of the Kehr tube into both right and left hepatic ducts, splinting of the anastomosis and conducting of its long branch into the

Rodney Smith drainage - using two straight rubber tubes splinting the biliary-enteric anastomosis that are brought via hepatic ducts and through liver parenchyma and conducted through the abdominal wall outside. This drainage type is used in high intrahilar biliary-enteric anastomosis. In the past, it was used in Smith "mucosal graft technique".

Drainage using is still controversial. The advantage of biliary drainage is limitation of the inflammation and fibrosis occurring after the surgical procedure. In some authors' opinion, the presence of the biliary tube prevents anastomosis stricture. The disadvantage of biliary drainage is a higher risk of postoperative complications. There are recommendations (according to Mercado et al) to use transanastomotic stents when there is a thin bile duct less than 4 mm in diameter, and when there is inflammation within the ductal anastomosed

**8. Treatment of iatrogenic bile duct injuries – Assesment of results in the** 

The early postoperative morbidity rate is 20-30% and mortality rate 0-2%. The most frequent early complication is wound infection (8-17.7%). Other complications are the following: bile collection, intra-abdominal abscess, biliary-enteric anastomosis dehiscence, biliary fistula, cholangitis, peritonitis, eventration, pneumonia, circulatory insufficiency, intra-abdominal bleeding, sepsis, infection of the urinary tract, pneumothorax, acute pancreatitis, thrombosis

edges that makes proper healing of the anastomosis questionable.

and embolic complications, diarrhea, ileus and multi-organ insufficiency.

**surgical treatment of iatrogenic bile duct injuries** 

**8.1 Short-term results and early complications** 

allows to create a wide anastomosis of 1-3 cm in diameter.

*7.2.2.2.1 External T-drainage* 

*7.2.2.2.2 External Y-drainage* 

**7.2.2.3 Internal Y-drainage** 

**7.2.2.5 No drainage** 

duodenum by the papilla of Vater. **7.2.2.4 Rodney-Smith drainage** 

jejunal loop and abdominal wall outside.

**7.2.2.2 Types of surgical biliary drainage used in IBDI reconstructions** 

bile duct and conducting of its long branch through the abdominal wall outside.

our department a significantly lower weight gain in patients undergoing HJ in comparison to patients following physiological end-to-end ductal anastomosis was reported [1, 49]. The another disadvantage of HJ is a lack of capability of control endoscopic examination and endoscopic dilatation of strictured biliary anastomosis. In order to resolve this problem, a longer jejunal loop (jejunostomy) is prepared and sutured to the abdominal subcutaneous tissue in the right subcostal region. Jejunostomy can be open or closed with possibility of opening in a case of biliary anastomosis stricture, which should be endoscopically dilated. Jejunostomy is asscociated with bile loss of about 40 ml/day in patients.

#### *7.2.2.1.3 Choledochoduodenostomy (ChD)*

Choledochoduodenostomy (ChD) is actually rarely performed operation recommended by some authors only in cases of injury within the distal portion of the common bile duct. It guarantees physiological bile flow into duodenum and anastomosis endoscopic control, and it is easier technically. It is recommended in some cases of distal strictures, when use of the jejunal loop due to numerous adhesions is impossible. It should be performed on the large common bile duct (>15 mm diameter) because the postoperative strictures are more frequent within the narrow duct. ChD should be created between the duodenum and the distal CBD in order to decrease a risk of so-called sump syndrome noted in 0.14-3.3% of cases in the literature. In patients following ChD, recurrent ascending cholangitis due to bile reflux is noted in 0-4%. A higher rate of bile duct cancer in patients with ChD in comparison of HJ (7.6 vs. 1.9%) was reported in the literature .

#### *7.2.2.1.4 Jejunal interposition hepaticoduodenostomy (JIHD)*

Jejunal interposition hepaticoduodenostomy, using 25-35 cm of the jejunal loop, is performed in some surgical centers including our department. This reconstruction includes three (biliaryenteric, enteric-duodenal and entero-enteric) anastomoses. Biliary-enteric anastomosis is performed in a single layer with interrupted absorbable sutures 5-0 and enteric-duodenal in a single layer with interrupted or continuous absorbable sutures 4-0. In our opinion, JIHD should be used only in patients in good general condition, without active inflammation within the peritoneal cavity, with protein level more than 6 g/dl and serum bilirubin level less than 20 mg/dl. Good condition of the duodenal wall is important factor for proper healing of hepaticoduodenostomy with jejunal interposition. The advantage of this reconstruction is physiological bile flow into the duodenum, which prevents duodenal ulcer caused by changes in the neurohormonal axis within the upper alimentary tract. This method of reconstruction is recommended mainly in patients with concomitant duodenal ulcer The disadvantage is a higher number of early complications due to presence of three anastomoses.

#### *7.2.2.1.5 Reconstructions of hilar bile duct injuries*

The repair of hilar IBDI requires special surgical techniques. In the past, so-called "mucosal graft technique" described by Smith in the 1960s was performed. This reconstruction involves creating a mucosal dome of jejunum (by removing a seromuscular patch) near the end of Roux-Y loop through which a straight rubber tube is brought via hepatic ducts and through liver parenchyma. This technique is based on the hypothesis that jejunal mucosa grafts to the biliary epithelium and mucosa-to-mucosa anastomosis is created. Short-term results were good, but in long-term results a high number of anastomosis strictures was observed. Therefore, currently, not Smith but Blumgart-Hepp technique is used in reconstruction of hilar IBDI. In this technique, dorsal surface of the left hepatic duct parallel to the quadrate hepatic lobe. Dissection and opening of the left hepatic duct longitudinally allows to create a wide anastomosis of 1-3 cm in diameter.

Other methods of IBDI reconstruction, such as Lahey hepaticojejunostomy, jejunal Heinecke-Mikulicz biliary plastic operation Kirtley operation and others are performed sporadically.

#### **7.2.2.2 Types of surgical biliary drainage used in IBDI reconstructions**

#### *7.2.2.2.1 External T-drainage*

486 New Advances in the Basic and Clinical Gastroenterology

our department a significantly lower weight gain in patients undergoing HJ in comparison to patients following physiological end-to-end ductal anastomosis was reported [1, 49]. The another disadvantage of HJ is a lack of capability of control endoscopic examination and endoscopic dilatation of strictured biliary anastomosis. In order to resolve this problem, a longer jejunal loop (jejunostomy) is prepared and sutured to the abdominal subcutaneous tissue in the right subcostal region. Jejunostomy can be open or closed with possibility of opening in a case of biliary anastomosis stricture, which should be endoscopically dilated.

Choledochoduodenostomy (ChD) is actually rarely performed operation recommended by some authors only in cases of injury within the distal portion of the common bile duct. It guarantees physiological bile flow into duodenum and anastomosis endoscopic control, and it is easier technically. It is recommended in some cases of distal strictures, when use of the jejunal loop due to numerous adhesions is impossible. It should be performed on the large common bile duct (>15 mm diameter) because the postoperative strictures are more frequent within the narrow duct. ChD should be created between the duodenum and the distal CBD in order to decrease a risk of so-called sump syndrome noted in 0.14-3.3% of cases in the literature. In patients following ChD, recurrent ascending cholangitis due to bile reflux is noted in 0-4%. A higher rate of bile duct cancer in patients with ChD in comparison

Jejunal interposition hepaticoduodenostomy, using 25-35 cm of the jejunal loop, is performed in some surgical centers including our department. This reconstruction includes three (biliaryenteric, enteric-duodenal and entero-enteric) anastomoses. Biliary-enteric anastomosis is performed in a single layer with interrupted absorbable sutures 5-0 and enteric-duodenal in a single layer with interrupted or continuous absorbable sutures 4-0. In our opinion, JIHD should be used only in patients in good general condition, without active inflammation within the peritoneal cavity, with protein level more than 6 g/dl and serum bilirubin level less than 20 mg/dl. Good condition of the duodenal wall is important factor for proper healing of hepaticoduodenostomy with jejunal interposition. The advantage of this reconstruction is physiological bile flow into the duodenum, which prevents duodenal ulcer caused by changes in the neurohormonal axis within the upper alimentary tract. This method of reconstruction is recommended mainly in patients with concomitant duodenal ulcer The disadvantage is a

The repair of hilar IBDI requires special surgical techniques. In the past, so-called "mucosal graft technique" described by Smith in the 1960s was performed. This reconstruction involves creating a mucosal dome of jejunum (by removing a seromuscular patch) near the end of Roux-Y loop through which a straight rubber tube is brought via hepatic ducts and through liver parenchyma. This technique is based on the hypothesis that jejunal mucosa grafts to the biliary epithelium and mucosa-to-mucosa anastomosis is created. Short-term results were good, but in long-term results a high number of anastomosis strictures was observed. Therefore, currently, not Smith but Blumgart-Hepp technique is used in

higher number of early complications due to presence of three anastomoses.

Jejunostomy is asscociated with bile loss of about 40 ml/day in patients.

*7.2.2.1.3 Choledochoduodenostomy (ChD)* 

of HJ (7.6 vs. 1.9%) was reported in the literature .

*7.2.2.1.5 Reconstructions of hilar bile duct injuries* 

*7.2.2.1.4 Jejunal interposition hepaticoduodenostomy (JIHD)* 

External T-drainage - using a typical Kehr tube with insertion of its short branches into the bile duct and conducting of its long branch through the abdominal wall outside.

#### *7.2.2.2.2 External Y-drainage*

External Y-drainage - insertion of short branches of the Kehr tube into both right and left hepatic ducts, splinting of the anastomosis and conducting of its long branch through the jejunal loop and abdominal wall outside.

#### **7.2.2.3 Internal Y-drainage**

Internal Y-drainage - insertion of short branches of the Kehr tube into both right and left hepatic ducts, splinting of the anastomosis and conducting of its long branch into the duodenum by the papilla of Vater.

#### **7.2.2.4 Rodney-Smith drainage**

Rodney Smith drainage - using two straight rubber tubes splinting the biliary-enteric anastomosis that are brought via hepatic ducts and through liver parenchyma and conducted through the abdominal wall outside. This drainage type is used in high intrahilar biliary-enteric anastomosis. In the past, it was used in Smith "mucosal graft technique".

#### **7.2.2.5 No drainage**

Drainage using is still controversial. The advantage of biliary drainage is limitation of the inflammation and fibrosis occurring after the surgical procedure. In some authors' opinion, the presence of the biliary tube prevents anastomosis stricture. The disadvantage of biliary drainage is a higher risk of postoperative complications. There are recommendations (according to Mercado et al) to use transanastomotic stents when there is a thin bile duct less than 4 mm in diameter, and when there is inflammation within the ductal anastomosed edges that makes proper healing of the anastomosis questionable.
