NEW METHODS: Clinical Endoscopy
A simultaneous endoscopic and laparoscopic approach for management of early iatrogenic bile duct obstruction Aijaz A. Sofi, MD, FACP,1 Jianlin Tang, MD, FACS,2 Yaseen Alastal, MD,1 Ali T. Nawras, MD, FACG1 Toledo, Ohio, USA
Background: Bile duct occlusion secondary to inadvertent application of a surgical clip or suture usually is managed with endoscopic or surgical exploration. Objective: To evaluate the safety and efficacy of a novel method of simultaneous endoscopic and laparoscopic approach in patients with acute iatrogenic bile duct obstruction. Design: Single arm study and single center design. Setting: University medical center. Patients: Three consecutive patients diagnosed with complete or near-complete obstruction of a bile duct after cholecystectomy were identified for inclusion. Interventions: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopy was performed simultaneously. Surgeon removes the surgical clips or suture from the bile duct with concurrent ERCP by endoscopist to assess and treat bile duct injury following resolution of the block. Main Outcome Measurements: Technical and clinical success rate and adverse events. Results: All of the patients were seen between 5 and 7 days after cholecystectomy. The diagnosis of obstructed bile duct was established by ERCP. The guidewire failed to negotiate across the obstruction in one of these patients. In another patient, a guidewire could be passed, but a biliary stent could not be deployed across the high-grade stricture. In a third patient, only a single biliary stent (7F 11 cm) could be placed across the obstruction, with significant difficulty. In all the patients, simultaneous ERCP and laparoscopy were performed immediately to remove the surgical clips and/or sutures from the bile duct, followed by placement of biliary stents. Limitations: Small series. Conclusion: The concurrent endoscopic and laparoscopic approach for the management of acute iatrogenic common bile duct obstruction is associated with rapid and complete recovery.
Bile duct injury (BDI) is a well-known adverse event of cholecystectomy.1 Inadvertent application of a surgical clip or suture on a bile duct during cholecystectomy
can cause obstructive jaundice. Diagnosis usually is established during ERCP. At times, endoscopic therapy is attempted, with placement of a biliary stent across the
Abbreviations: BDI, bile duct injury; CBD, common bile duct.
Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.04.039
DISCLOSURE: All authors disclosed no financial relationships relevant to this article.
Received January 24, 2014. Accepted April 21, 2014. Current affiliations: Department of Medicine, Division of Gastroenterology (1); Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA (2).
Use your mobile device to scan this QR code and watch the author interview. Download a free QR code scanner by searching “QR Scanner” in your mobile device's app store. www.giejournal.org
Reprint requests: Ali T Nawras, MD, FACG, FASGE, Division of Gastroenterology, Department of Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614. If you would like to chat with an author of this article, you may contact Dr Nawras at [email protected] or [email protected].
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 511
Iatrogenic bile duct obstruction
obstruction.2 Failure of initial endoscopic therapy warrants either percutaneous transhepatic cholangiography for adequate visualization of the entire biliary tract and biliary drainage3 and/or surgical exploration.
METHODS In this case series, we describe a novel method of simultaneous endoscopic and laparoscopic approaches of management in patients who are seen with iatrogenic bile duct obstruction during the early postoperative period. Three patients with iatrogenic bile duct obstruction underwent a simultaneous endoscopic-laparoscopic method of treatment.
Case 1 A 46-year-old man was seen 6 days after laparoscopic cholecystectomy, with symptoms of upper abdominal pain and jaundice. Liver function test results included bilirubin (total) of 9.0 mg/dL (normal range, 02.-1.2 mg/dL), alanine aminotransferase 289 IU/L (normal range, 4-42 IU/L), aspartate aminotransferase 150 IU/L (normal range, 10-39IU/L), and alkaline phosphatase 492 IU/L (normal range, 40-125 IU/L). In view of a strong clinical suspicion of acute obstructive cholestasis, ERCP was performed to rule out a bile duct stone versus a clipped bile duct. ERCP revealed complete obstruction of the common hepatic duct by a surgical clip (Fig. 1A). Multiple attempts to advance the guidewire across the obstruction in the common hepatic duct were unsuccessful. Laparoscopy was performed to remove a surgical clip from the common bile duct (CBD) with concurrent ERCP to assess the biliary tree injury during and after the removal of surgical clips. Two surgical clips blocking the CBD were identified during laparoscopy and subsequently removed under continuous cholangiographic monitoring (Fig. 1B). Concurrent ERCP revealed complete filling of the biliary tree and a bile leak at the site of the surgical clip after its removal (Fig. 1C); therefore, a single biliary stent (10F 12 cm) was placed. The stent was removed 4 weeks later, and a cholangiogram at that time did not reveal any stricture or leak (Fig. 1D). The patient remained asymptomatic in the 30-month follow-up period after the procedure, and liver function test results stayed normal.
Sofi et al
Take-home Message Iatrogenic bile duct obstruction often is managed by endoscopic or open surgical exploration. A simultaneous laparoscopic-endoscopic approach in patients with acute iatrogenic bile duct obstruction without transection is associated with rapid and complete recovery.
deployed across the obstruction (Fig. 2A). Attempts to dilate the stricture were unsuccessful. Exploratory laparoscopy was performed, during which 3 Prolene sutures (Ethicon, Somerville, NJ) noted on the CBD were subsequently removed. Repeat ERCP performed concurrently during laparoscopy revealed significant bile duct leakage at the site of the sutures after their removal, but there was no residual stricture (Fig. 2B). A biliary stent (10F 15) was placed in the CBD across the site of the bile leak. Six weeks later, ERCP findings were normal (Fig. 2C). The patient remained asymptomatic at 26month follow-up, and his liver function test results stayed normal.
Case 3 A 27-year-old woman was referred for evaluation of jaundice 1 week after laparoscopic cholecystectomy. Her liver function tests revealed total bilirubin of 6.7 mg/dL, alkaline phosphatase of 162 IU/L, alanine aminotransferase of 342 IU/L, and aspartate aminotransferase of 101 IU/L. Because of a high probability of a retained bile duct stone, ERCP was performed, which revealed a high-grade stricture of the CBD caused by a surgical clip at the level of the cystic duct (Fig. 3A). A single stent (7F 11 cm) was placed across the stricture, with significant difficulty. Because of the slight plausibility of bile duct fibrosis from a surgical clip recently placed during laparoscopic cholecystectomy, a decision to do a combined endoscopic-laparoscopic approach for management of bile duct obstruction was made. During laparoscopy, a clip was found obstructing the CBD and was subsequently removed. Concurrent ERCP revealed complete resolution of the CBD stricture; 2 biliary stents were subsequently placed in the CBD. ERCP after the removal of the biliary stents revealed a normal biliary tree (Fig. 3B). The patient was asymptomatic with normal liver function test results at a 20-month follow-up.
Case 2 A 61-year-old man was seen with persistent upper abdominal pain and nausea for 5 days after his laparoscopic cholecystectomy. He was immediately referred to our institution for evaluation of a suspected biliary leak. His liver function test results did not reveal any abnormality. Because of a high clinical suspicion of bile leakage, ERCP was performed. Significant obstruction of the CBD was seen at the level of the cystic stump on ERCP. The guidewire could be passed, but a biliary stent could not be 512 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
RESULTS The combined endoscopic-laparoscopic method was attempted in a total of 3 cases over the last 21/2 years. By using this novel endoscopic-laparoscopic method in patients seen with acute iatrogenic bile duct obstruction, we found that all patients had rapid and complete recovery. No adverse events were encountered in any patient treated with this technique. www.giejournal.org
Sofi et al
Iatrogenic bile duct obstruction
Figure 1. A, Complete occlusion of the common bile duct at the level of surgical clips (arrow). B, Laparoscopic photograph of a surgical staple on the common bile duct (arrow). C, ERCP after laparoscopic removal of surgical clips demonstrates bile leakage (arrow) at the site of surgical clips. D, Normal occlusive cholangiogram result at 4 weeks’ follow-up.
DISCUSSION BDI during cholecystectomy may result from inadvertent duct laceration, excessive traction, cautery injury, partial or complete duct ligation, or transection of the bile duct.3 BDIs often are missed intraoperatively, and a high index of suspicion is required to identify these adverse events early during the postoperative period. Complete or partial clip ligation of a bile duct (without transection), one of the types of BDI, usually is seen postoperatively with jaundice. Evaluation by liver US followed by cholangiography (MRCP or ERCP) is recommended to visualize the location and extent of BDI and additionally to exclude the presence of a retained bile duct stone as the cause of bile duct obstruction. If complete obstruction of the major bile duct by a metallic clip or suture is identified in the postoperative period, it is often managed by open surgical procedures to establish a new bilioenteric conduit.4 However, there is a significant risk of post-anastomotic strictures after surgical repair.5 In case of partial obstruction with an intact bile duct, endoscopic therapy may be attempted if the endoscopist is able to pass the guidewire and deploy a stent across the stricture.2,6 In the latter setting, the patient usually requires multiple sessions of endoscopic therapy aimed at slow, incremental dilation of the stricture.2,6 Sometimes
percutaneous transhepatic cholangiography is required to delineate complete biliary anatomy when the endoscopist is unable to pass a guidewire across the stricture.4,7 Laparoscopy, at present, has no established role in the management algorithm of patients with iatrogenic bile duct injuries.8 In our case series, patients were seen with symptoms within a week after laparoscopic cholecystectomy. In accordance with the currently available medical literature, cases 1 and 2 were candidates for open laparotomy with primary repair or perhaps Roux-en-Y hepaticojeunostomy.4 However, by using a combined endoscopic-laparoscopic approach, we were able to avoid the need for this major surgical procedure. During the simultaneous endoscopic-laparoscopic procedure, the surgeon should approach the site of obstructed bile duct via a suction-irrigation system, and sharp dissection is absolutely avoided. Although there is a risk of arterial damage to a bile duct from surgical clipping,9 the results of removing the clip and simultaneous placement of stents were excellent in our cases of patients who were seen within a week of the BDI incident. Therefore, the risk of clinically significant ischemic injury to the bile duct may be decreased if the clips are removed early in the postoperative course. Case 3 could have benefitted from endoscopic therapy for dilation of the stricture. However, multiple
www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 513
Iatrogenic bile duct obstruction
Sofi et al
Figure 2. A, Retrograde cholangiogram demonstrates a significant stricture of the common bile duct (arrow). B, Cholangiogram showing bile leakage (arrow) after laparoscopic removal of surgical sutures. C, Normal cholangiogram result at 6 weeks’ follow-up.
Figure 3. A, ERCP demonstrates a significant stricture of the common bile duct secondary to a surgical clip. B, Normal cholangiogram result after removal of the biliary stent.
sessions of endoscopic therapy usually are needed to achieve an adequate response.6 On the other hand, a single session of the combined endoscopic-laparoscopic approach produced satisfactory
results in our patient (case 3). Therefore, the combined endoscopic-laparoscopic method may be a more cost effective and convenient approach when the patient is seen within a week of BDI.
514 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
www.giejournal.org
Sofi et al
Iatrogenic bile duct obstruction
The possibility of complete transection of a bile duct could exist in patients who are seen with iatrogenic bile duct obstruction. This may be revealed only after metallic clips or sutures are removed during laparoscopy. The combined laparoscopic-endoscopic approach may not be feasible in this setting; therefore, open surgery for reconstruction of bilioenteric continuity would be required in these cases. Because of a high likelihood of failure of biliary repair if the procedure is performed by an inexperienced surgeon,10 we advise that the proposed combined laparoscopic-endoscopic method be attempted only at centers where biliary surgeons with adequate experience in reconstructive biliary surgery are readily available. The limitations of this series are its small number of patients, single-center design, and single-arm study method. There is a need to further evaluate the efficacy and safety of the technique presented in this case series by other centers with expertise in the management of BDI. In conclusion, the simultaneous endoscopic-laparoscopic approach for the management of patients with acute iatrogenic bile duct obstruction was associated with rapid and complete recovery in our case series. The combined endoscopic-laparoscopic method could be attempted in patients seen within a week of iatrogenic bile duct obstruction without transection.
REFERENCES 1. Waage A, Nilsson M. Iatrogenic bile duct injury: a population-based study of 152 776 cholecystectomies in the Swedish Inpatient Registry. Arch Surg 2006;141:1207-13. 2. Costamagna G, Pandolfi M, Mutignani M, et al. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001;54: 162-8. 3. Lau WY, Lai EC, Lau SH. Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg 2010;80:75-81. 4. Rauws EA, Gouma DJ. Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy. Best Pract Res Clin Gastroenterol 2004;18:829-46. 5. Schmidt SC, Langrehr JM, Hintze RE, et al. Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Br J Surg 2005;92:76-82. 6. Vitale GC, Tran TC, Davis BR, et al. Endoscopic management of postcholecystectomy bile duct strictures. J Am Coll Surg 2008;206:918-23; discussion 924-5. 7. Lau WY, Lai EC, Lau SH. Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg 2010;80:75-81. 8. Azagra JS, De Simone P, Goergen M. Is there a place for laparoscopy in management of postcholecystectomy biliary injuries? World J Surg 2001;25:1331-4. 9. Chapman WC, Halevy A, Blumgart LH, et al. Postcholecystectomy bile duct strictures: management and outcome in 130 patients. Arch Surg 1995;130:597-602; discussion 602-4. 10. Kapoor VK. Management of bile duct injuries: a practical approach. Am Surg 2009;75:1157-60.
GIE on Twitter GIE now has a Twitter account. Followers will learn when the new issues are posted and will receive up-to-the-minute news as well as links to author interviews, podcasts, and articles. Search on Twitter for @GIE_Journal and follow all of GIE’s tweets.
www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 515
A simultaneous endoscopic and laparoscopic approach for management of early iatrogenic bile duct obstruction Aijaz A. Sofi, MD, FACP,1 Jianlin Tang, MD, FACS,2 Yaseen Alastal, MD,1 Ali T. Nawras, MD, FACG1 Toledo, Ohio, USA
Background: Bile duct occlusion secondary to inadvertent application of a surgical clip or suture usually is managed with endoscopic or surgical exploration. Objective: To evaluate the safety and efficacy of a novel method of simultaneous endoscopic and laparoscopic approach in patients with acute iatrogenic bile duct obstruction. Design: Single arm study and single center design. Setting: University medical center. Patients: Three consecutive patients diagnosed with complete or near-complete obstruction of a bile duct after cholecystectomy were identified for inclusion. Interventions: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopy was performed simultaneously. Surgeon removes the surgical clips or suture from the bile duct with concurrent ERCP by endoscopist to assess and treat bile duct injury following resolution of the block. Main Outcome Measurements: Technical and clinical success rate and adverse events. Results: All of the patients were seen between 5 and 7 days after cholecystectomy. The diagnosis of obstructed bile duct was established by ERCP. The guidewire failed to negotiate across the obstruction in one of these patients. In another patient, a guidewire could be passed, but a biliary stent could not be deployed across the high-grade stricture. In a third patient, only a single biliary stent (7F 11 cm) could be placed across the obstruction, with significant difficulty. In all the patients, simultaneous ERCP and laparoscopy were performed immediately to remove the surgical clips and/or sutures from the bile duct, followed by placement of biliary stents. Limitations: Small series. Conclusion: The concurrent endoscopic and laparoscopic approach for the management of acute iatrogenic common bile duct obstruction is associated with rapid and complete recovery.
Bile duct injury (BDI) is a well-known adverse event of cholecystectomy.1 Inadvertent application of a surgical clip or suture on a bile duct during cholecystectomy
can cause obstructive jaundice. Diagnosis usually is established during ERCP. At times, endoscopic therapy is attempted, with placement of a biliary stent across the
Abbreviations: BDI, bile duct injury; CBD, common bile duct.
Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.04.039
DISCLOSURE: All authors disclosed no financial relationships relevant to this article.
Received January 24, 2014. Accepted April 21, 2014. Current affiliations: Department of Medicine, Division of Gastroenterology (1); Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA (2).
Use your mobile device to scan this QR code and watch the author interview. Download a free QR code scanner by searching “QR Scanner” in your mobile device's app store. www.giejournal.org
Reprint requests: Ali T Nawras, MD, FACG, FASGE, Division of Gastroenterology, Department of Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614. If you would like to chat with an author of this article, you may contact Dr Nawras at [email protected] or [email protected].
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 511
Iatrogenic bile duct obstruction
obstruction.2 Failure of initial endoscopic therapy warrants either percutaneous transhepatic cholangiography for adequate visualization of the entire biliary tract and biliary drainage3 and/or surgical exploration.
METHODS In this case series, we describe a novel method of simultaneous endoscopic and laparoscopic approaches of management in patients who are seen with iatrogenic bile duct obstruction during the early postoperative period. Three patients with iatrogenic bile duct obstruction underwent a simultaneous endoscopic-laparoscopic method of treatment.
Case 1 A 46-year-old man was seen 6 days after laparoscopic cholecystectomy, with symptoms of upper abdominal pain and jaundice. Liver function test results included bilirubin (total) of 9.0 mg/dL (normal range, 02.-1.2 mg/dL), alanine aminotransferase 289 IU/L (normal range, 4-42 IU/L), aspartate aminotransferase 150 IU/L (normal range, 10-39IU/L), and alkaline phosphatase 492 IU/L (normal range, 40-125 IU/L). In view of a strong clinical suspicion of acute obstructive cholestasis, ERCP was performed to rule out a bile duct stone versus a clipped bile duct. ERCP revealed complete obstruction of the common hepatic duct by a surgical clip (Fig. 1A). Multiple attempts to advance the guidewire across the obstruction in the common hepatic duct were unsuccessful. Laparoscopy was performed to remove a surgical clip from the common bile duct (CBD) with concurrent ERCP to assess the biliary tree injury during and after the removal of surgical clips. Two surgical clips blocking the CBD were identified during laparoscopy and subsequently removed under continuous cholangiographic monitoring (Fig. 1B). Concurrent ERCP revealed complete filling of the biliary tree and a bile leak at the site of the surgical clip after its removal (Fig. 1C); therefore, a single biliary stent (10F 12 cm) was placed. The stent was removed 4 weeks later, and a cholangiogram at that time did not reveal any stricture or leak (Fig. 1D). The patient remained asymptomatic in the 30-month follow-up period after the procedure, and liver function test results stayed normal.
Sofi et al
Take-home Message Iatrogenic bile duct obstruction often is managed by endoscopic or open surgical exploration. A simultaneous laparoscopic-endoscopic approach in patients with acute iatrogenic bile duct obstruction without transection is associated with rapid and complete recovery.
deployed across the obstruction (Fig. 2A). Attempts to dilate the stricture were unsuccessful. Exploratory laparoscopy was performed, during which 3 Prolene sutures (Ethicon, Somerville, NJ) noted on the CBD were subsequently removed. Repeat ERCP performed concurrently during laparoscopy revealed significant bile duct leakage at the site of the sutures after their removal, but there was no residual stricture (Fig. 2B). A biliary stent (10F 15) was placed in the CBD across the site of the bile leak. Six weeks later, ERCP findings were normal (Fig. 2C). The patient remained asymptomatic at 26month follow-up, and his liver function test results stayed normal.
Case 3 A 27-year-old woman was referred for evaluation of jaundice 1 week after laparoscopic cholecystectomy. Her liver function tests revealed total bilirubin of 6.7 mg/dL, alkaline phosphatase of 162 IU/L, alanine aminotransferase of 342 IU/L, and aspartate aminotransferase of 101 IU/L. Because of a high probability of a retained bile duct stone, ERCP was performed, which revealed a high-grade stricture of the CBD caused by a surgical clip at the level of the cystic duct (Fig. 3A). A single stent (7F 11 cm) was placed across the stricture, with significant difficulty. Because of the slight plausibility of bile duct fibrosis from a surgical clip recently placed during laparoscopic cholecystectomy, a decision to do a combined endoscopic-laparoscopic approach for management of bile duct obstruction was made. During laparoscopy, a clip was found obstructing the CBD and was subsequently removed. Concurrent ERCP revealed complete resolution of the CBD stricture; 2 biliary stents were subsequently placed in the CBD. ERCP after the removal of the biliary stents revealed a normal biliary tree (Fig. 3B). The patient was asymptomatic with normal liver function test results at a 20-month follow-up.
Case 2 A 61-year-old man was seen with persistent upper abdominal pain and nausea for 5 days after his laparoscopic cholecystectomy. He was immediately referred to our institution for evaluation of a suspected biliary leak. His liver function test results did not reveal any abnormality. Because of a high clinical suspicion of bile leakage, ERCP was performed. Significant obstruction of the CBD was seen at the level of the cystic stump on ERCP. The guidewire could be passed, but a biliary stent could not be 512 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
RESULTS The combined endoscopic-laparoscopic method was attempted in a total of 3 cases over the last 21/2 years. By using this novel endoscopic-laparoscopic method in patients seen with acute iatrogenic bile duct obstruction, we found that all patients had rapid and complete recovery. No adverse events were encountered in any patient treated with this technique. www.giejournal.org
Sofi et al
Iatrogenic bile duct obstruction
Figure 1. A, Complete occlusion of the common bile duct at the level of surgical clips (arrow). B, Laparoscopic photograph of a surgical staple on the common bile duct (arrow). C, ERCP after laparoscopic removal of surgical clips demonstrates bile leakage (arrow) at the site of surgical clips. D, Normal occlusive cholangiogram result at 4 weeks’ follow-up.
DISCUSSION BDI during cholecystectomy may result from inadvertent duct laceration, excessive traction, cautery injury, partial or complete duct ligation, or transection of the bile duct.3 BDIs often are missed intraoperatively, and a high index of suspicion is required to identify these adverse events early during the postoperative period. Complete or partial clip ligation of a bile duct (without transection), one of the types of BDI, usually is seen postoperatively with jaundice. Evaluation by liver US followed by cholangiography (MRCP or ERCP) is recommended to visualize the location and extent of BDI and additionally to exclude the presence of a retained bile duct stone as the cause of bile duct obstruction. If complete obstruction of the major bile duct by a metallic clip or suture is identified in the postoperative period, it is often managed by open surgical procedures to establish a new bilioenteric conduit.4 However, there is a significant risk of post-anastomotic strictures after surgical repair.5 In case of partial obstruction with an intact bile duct, endoscopic therapy may be attempted if the endoscopist is able to pass the guidewire and deploy a stent across the stricture.2,6 In the latter setting, the patient usually requires multiple sessions of endoscopic therapy aimed at slow, incremental dilation of the stricture.2,6 Sometimes
percutaneous transhepatic cholangiography is required to delineate complete biliary anatomy when the endoscopist is unable to pass a guidewire across the stricture.4,7 Laparoscopy, at present, has no established role in the management algorithm of patients with iatrogenic bile duct injuries.8 In our case series, patients were seen with symptoms within a week after laparoscopic cholecystectomy. In accordance with the currently available medical literature, cases 1 and 2 were candidates for open laparotomy with primary repair or perhaps Roux-en-Y hepaticojeunostomy.4 However, by using a combined endoscopic-laparoscopic approach, we were able to avoid the need for this major surgical procedure. During the simultaneous endoscopic-laparoscopic procedure, the surgeon should approach the site of obstructed bile duct via a suction-irrigation system, and sharp dissection is absolutely avoided. Although there is a risk of arterial damage to a bile duct from surgical clipping,9 the results of removing the clip and simultaneous placement of stents were excellent in our cases of patients who were seen within a week of the BDI incident. Therefore, the risk of clinically significant ischemic injury to the bile duct may be decreased if the clips are removed early in the postoperative course. Case 3 could have benefitted from endoscopic therapy for dilation of the stricture. However, multiple
www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 513
Iatrogenic bile duct obstruction
Sofi et al
Figure 2. A, Retrograde cholangiogram demonstrates a significant stricture of the common bile duct (arrow). B, Cholangiogram showing bile leakage (arrow) after laparoscopic removal of surgical sutures. C, Normal cholangiogram result at 6 weeks’ follow-up.
Figure 3. A, ERCP demonstrates a significant stricture of the common bile duct secondary to a surgical clip. B, Normal cholangiogram result after removal of the biliary stent.
sessions of endoscopic therapy usually are needed to achieve an adequate response.6 On the other hand, a single session of the combined endoscopic-laparoscopic approach produced satisfactory
results in our patient (case 3). Therefore, the combined endoscopic-laparoscopic method may be a more cost effective and convenient approach when the patient is seen within a week of BDI.
514 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
www.giejournal.org
Sofi et al
Iatrogenic bile duct obstruction
The possibility of complete transection of a bile duct could exist in patients who are seen with iatrogenic bile duct obstruction. This may be revealed only after metallic clips or sutures are removed during laparoscopy. The combined laparoscopic-endoscopic approach may not be feasible in this setting; therefore, open surgery for reconstruction of bilioenteric continuity would be required in these cases. Because of a high likelihood of failure of biliary repair if the procedure is performed by an inexperienced surgeon,10 we advise that the proposed combined laparoscopic-endoscopic method be attempted only at centers where biliary surgeons with adequate experience in reconstructive biliary surgery are readily available. The limitations of this series are its small number of patients, single-center design, and single-arm study method. There is a need to further evaluate the efficacy and safety of the technique presented in this case series by other centers with expertise in the management of BDI. In conclusion, the simultaneous endoscopic-laparoscopic approach for the management of patients with acute iatrogenic bile duct obstruction was associated with rapid and complete recovery in our case series. The combined endoscopic-laparoscopic method could be attempted in patients seen within a week of iatrogenic bile duct obstruction without transection.
REFERENCES 1. Waage A, Nilsson M. Iatrogenic bile duct injury: a population-based study of 152 776 cholecystectomies in the Swedish Inpatient Registry. Arch Surg 2006;141:1207-13. 2. Costamagna G, Pandolfi M, Mutignani M, et al. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001;54: 162-8. 3. Lau WY, Lai EC, Lau SH. Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg 2010;80:75-81. 4. Rauws EA, Gouma DJ. Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy. Best Pract Res Clin Gastroenterol 2004;18:829-46. 5. Schmidt SC, Langrehr JM, Hintze RE, et al. Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Br J Surg 2005;92:76-82. 6. Vitale GC, Tran TC, Davis BR, et al. Endoscopic management of postcholecystectomy bile duct strictures. J Am Coll Surg 2008;206:918-23; discussion 924-5. 7. Lau WY, Lai EC, Lau SH. Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg 2010;80:75-81. 8. Azagra JS, De Simone P, Goergen M. Is there a place for laparoscopy in management of postcholecystectomy biliary injuries? World J Surg 2001;25:1331-4. 9. Chapman WC, Halevy A, Blumgart LH, et al. Postcholecystectomy bile duct strictures: management and outcome in 130 patients. Arch Surg 1995;130:597-602; discussion 602-4. 10. Kapoor VK. Management of bile duct injuries: a practical approach. Am Surg 2009;75:1157-60.
GIE on Twitter GIE now has a Twitter account. Followers will learn when the new issues are posted and will receive up-to-the-minute news as well as links to author interviews, podcasts, and articles. Search on Twitter for @GIE_Journal and follow all of GIE’s tweets.
www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 515
