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Operative Management of Bile Duct Strictures


Bile duct strictures can result from a myriad of conditions, both benign and malignant. These strictures represent a significant clinical problem and if not managed correctly can result in major morbidity, both short and long term, and possible mortality. Complications of untreated or improperly treated strictures include cholangitis, biliary cirrhosis, portal hypertension, and end-stage liver disease. The goal of treatment is to reestablish unobstructed biliary flow into the intestinal tract.

Pathogenesis

The most common cause of bile duct stricture is surgery of the gallbladder or biliary tree. In the era of open surgery the incidence of bile duct injury following cholecystectomy was 0.2% to 0.3% Since the introduction of laparoscopic cholecystectomy, the rate of bile duct injury has doubled. Several studies have published an injury rate of 0.4% to 0.6%. This rate of injury has remained essentially stable. Less than 30% of bile duct injuries are recognized intraoperatively. Therefore most patients will go on to develop a leak or stricture. The classification of these injuries and strictures has been defined by Strasberg and Bismuth and is shown in Figs. 114.1 and 114.2 .

FIGURE 114.1, Various patterns of biliary tract injury. (A) Classic injury. (B and C) Variants of the classic injury. (D to F) Different injuries resulting from the cystic duct originating from an aberrant right hepatic duct.

FIGURE 114.2, Classification of bile duct strictures based on the level of the stricture in relation to the confluence of the hepatic ducts. Types 3, 4, and 5 are typically considered complex injuries.

Not all bile duct strictures caused by a previous surgery result from laparoscopic cholecystectomy. Endoscopic, percutaneous, and operative procedures on the bile duct may result in stricture. Injury may also occur during gastric and duodenal procedures, liver resection and transplantation, and pancreatic procedures. These injuries typically involve a failure to recognize the extrahepatic biliary tree at the time of antral or duodenal dissection/division. The anatomy in this region may be distorted by inflammation or a neoplastic process. The intrapancreatic bile duct may be injured during surgery of the pancreatic head or ampulla of Vater. Inflammatory or congenital conditions may also cause strictures of the bile duct ( Box 114.1 ). Benign and malignant neoplasms of the biliary tree and surrounding organs are additional causes of biliary stricture ( Box 114.2 ).

Box 114.1
Causes of Benign Biliary Strictures

Iatrogenic

  • Postoperative strictures following biliary procedures

  • Laparoscopic cholecystectomy

  • Open cholecystectomy

  • Common bile duct exploration

  • Prior stricture repair

  • Endoscopic retrograde cholangiopancreatography

  • Endoscopic sphincterotomy

  • Percutaneous biliary manipulation

  • Postoperative strictures following other operative procedures

  • Gastrectomy

    • Duodenal ulcer procedures

  • Hepatic resection

    • Hepatic transplantation

    • Pancreatic procedures

    • Portacaval shunt

    • Stricture at biliary-enteric anastomosis

Traumatic

  • Blunt injury

  • Penetrating injury

Inflammatory

  • Chronic pancreatitis

  • Cholelithiasis and choledocholithiasis

  • Mirizzi syndrome

  • Primary sclerosing cholangitis

  • Duodenal ulcer

  • Duodenal diverticulum

  • Crohn disease

  • Sphincter of Oddi stenosis

  • Viral infections

  • Toxic drugs

  • Radiation fibrosis

  • Subhepatic abscess

  • Parasitic infestations

Congenital

  • Choledochal cyst

  • Caroli disease

  • Congenital stricture, webs

  • Biliary atresia

Box 114.2
Neoplastic Causes of Biliary Stricture

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