Bile Duct Stricture

  •           Major causes of benign biliary stricture
  • – Iatrogenic biliary injury during cholecystectomy
  •          Minor causes
  • – Chronic pancreatitis
  • – PSC
  • – Trauma
  • – Liver transplantation
  • – Choledocholithiasis
  • Causes of biliary injury during cholecystectomy
  • – Misinterpretation of the biliary ductal anatomy
  • – Inaccurate placement of clips, suture, or cautery to to control hemorrhage
  • – Tenting of the bile duct during control of the cystic duct
  • – Ineffective retraction and exposure
  • Types of Bile duct injury (3 types):
  • 1.Complete bile duct obstruction:
  •                   – Jaundice develop rapidly in the early post-operative period after cholecystectomy
  • 2. Transection of extrahepatic bile duct/ Ineffective placement or dislodgement of cystic duct ligature/ Bile leak from gall bladder fossa as a result of a divided cystohepatic duct or duct of luschka
  •                  – Manifests as development of bile ascites
  • 3.Partial bile duct obstruction
  •                   – Intermittent episode of pain, jaundice or cholangitis, usually within 2 years of the cholecystectomy

When to suspect bile duct injury in post-operative period after laparoscopic cholecystectomy?

  • – Persistent abdominal pain
  • Main differential diagnosis of cholangitis in a patient with a history of cholecystectomy
  •                  – Bile duct stricture
  •                  – Choledocholithiasis

 

                                                 Treatment of Benign Biliary Stricture

                                                      (Post-operative Biliary Stricture)

                         Surgery

  • – Best management option
  • – Resection of the stricture and end-to-side Roux-en-y choledochojejunostomy/ hepaticojejunostomy
  • – Long-term biliary reconstruction for a benign bile duct stricture is good, cure rate 85-98%

                          Endoscopic treatment/ percutaneous treatment

  • – Balloon dilatation with/without stent placement as long as the remaining duct has not been disrupted
  • – Biliary stenting

** Non-operative management is best reserved for patients with

  •                   –  Biliary cirrhosis
  •                   – Significant co-morbid illness
  •                   – High recurrent strictures

 


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