| disease | Extrahepatic Bile Duct Injury |
Extrahepatic bile duct injury caused by trauma is part of hilar injury. Due to the deep location of the extrahepatic bile duct and its proximity to many important blood vessels and organs, isolated bile duct injury is rare under external force. Most cases are accompanied by injuries to the portal vein, inferior vena cava, liver, pancreas, stomach, duodenum, and other structures. Shock from concurrent internal bleeding or peritonitis caused by gastrointestinal perforation can easily mask the manifestations of bile duct injury. Once a fistula forms, it can lead to severe biliary peritonitis, secondary abdominal infection, and life-threatening complications. Even if the patient is rescued, managing biliary fistula and biliary stricture remains highly complex.
bubble_chart Etiology
Extrahepatic bile duct {|###|}injury is actually more commonly iatrogenic. Its incidence is approximately 0.3–0.5%, meaning it occurs once in about 200–300 cholecystectomies. Some bile duct {|###|}injuries are identified and properly managed during the surgery itself; unfortunately, others are only discovered postoperatively, leading to serious complications, making treatment difficult and affecting outcomes. The vast majority of extrahepatic bile duct {|###|}injuries occur during cholecystectomy, while a few occur during complex partial gastrectomies when the bile duct is accidentally severed or clamped during duodenal transection or closure. They may also occur during common bile duct exploration or resection of duodenal diverticula around the ampulla of Vater. Analyzing the causes of bile duct {|###|}injury during cholecystectomy: 1. Surgical errors, such as blind clamping or mass ligation for sudden massive bleeding; excessive traction on the gallbladder during cystic duct transection, leading to mistaken identification and ligation of the common bile duct or common hepatic duct as the cystic duct. 2. Anatomical anomalies of the biliary system, such as an extremely short or absent cystic duct or its opening into the right hepatic duct. Failure to recognize these anomalies during surgery may result in {|###|}injury. 3. Severe inflammation, dense adhesions, or unclear anatomy. Careless handling during surgery may also lead to accidental {|###|}injury. It is worth noting that sometimes, even in the absence of the above objective factors, bile duct {|###|}injury may still occur during routine cholecystectomy, necessitating an examination of the surgeon’s own practices to identify the cause.
As for bile duct {|###|}injuries caused by abdominal trauma, most are accompanied by {|###|}injuries to major blood vessels and adjacent organs.The damaged bile duct can be completely ruptured or partially defective, or it may only be crushed by vascular forceps or ligated, leading to bile fistula disease, inflammation, and fibrosis, ultimately causing bile duct stenosis or occlusion. The proximal end of the narrowed or occluded bile duct dilates, with thickened walls; the distal end may also have thickened walls, but the lumen shrinks or even becomes occluded. After bile duct stenosis or occlusion, bile flow is obstructed, pressure within the bile duct increases, and bile stagnates. If this persists for a prolonged period, irreversible damage to hepatocytes will occur. Bile stasis can also lead to secondary infection by Gram-negative enteric bacilli, causing recurrent cholangitis, which further exacerbates hepatocyte damage and results in cirrhosis. In cases accompanied by external bile fistula disease, liver damage may be less severe, but secondary abdominal infections or significant loss of bile can frequently occur, leading to digestive and absorptive issues.
bubble_chart Clinical Manifestations
The clinical manifestations of bile duct injury depend on the extent of the injury, the severity of the stricture, and the presence or absence of extra-biliary fistula disease. The main symptoms are biliary fistula and/or obstructive jaundice. Patients may experience significant bile leakage from the wound after trauma or surgery, followed by upper abdominal pain, fever, and jaundice as the bile flow decreases. In some cases, jaundice gradually worsens shortly after surgery, accompanied by persistent right upper abdominal pain and fever.
The diagnosis is usually not difficult. For patients with obvious biliary obstruction, percutaneous transhepatic cholangiography (PTC) is most helpful for diagnosis, as it can confirm the diagnosis and identify the site of obstruction, aiding in preoperative surgical planning. If an external fistula is present, contrast imaging can be performed through the fistula, but it often fails to show the entire biliary tract. The diagnostic value of ERCP is not as significant as PTC, as it generally does not clearly display the bile ducts proximal to the obstruction.
bubble_chart Treatment Measures
The management of extrahepatic bile duct injury caused by abdominal trauma depends on the severity of the injury, including associated organ injuries, amount of blood loss, abdominal contamination, as well as medical conditions and technical capabilities. For patients with severe injuries and significant blood loss, active anti-shock measures should be taken while promptly controlling active bleeding and repairing or resecting the injured organs. Complex biliary injuries can initially be managed with "T"-tube drainage, followed by elective biliary repair surgery once the patient's condition stabilizes. If the injury and conditions permit, as well as in cases of iatrogenic biliary injury, the following principles should be followed: For common bile duct lacerations, carefully remove non-viable tissue from the wound edges, make an additional incision proximal or distal to the laceration, and place an appropriately sized "T"-tube with one arm passing through the laceration as internal support, then suture the laceration with fine sutures. If the laceration exceeds half the circumference or the bile duct is completely severed, trim the edges and perform an end-to-end anastomosis under tension-free conditions using 5-0 nylon or fine silk sutures, with a "T"-tube inserted as support in the same manner as above. The "T"-tube should generally remain in place for no less than six months. If tension is present during anastomosis, avoid forcibly approximating the ends. Low-position lacerations can be anastomosed to the duodenum, while high-position lacerations, including those involving the left or right hepatic ducts, may require choledochojejunostomy or hepaticojejunostomy in a Y-shape. The success of bile duct reconstruction relies on skilled surgical techniques, meticulous debridement, accurate alignment of the mucosal layer at the anastomosis site, and tension-free anastomosis. The simplest and most reliable treatment for gallbladder lacerations or cystic duct transection is cholecystectomy. Proper postoperative drainage is a crucial measure to prevent intra-abdominal infection.
The consequences of bile duct injury are severe, so preventing its occurrence is crucial. In fact, the vast majority of iatrogenic bile duct injuries are preventable. During surgery, the operator should remain focused, perform procedures meticulously, and adhere to standard operational steps. For example, when performing a cholecystectomy, the common bile duct, common hepatic duct, and cystic duct should first be exposed. After clearly identifying the relationship between these three structures, the cystic duct should be looped with a silk ligature but not yet divided. Then, the gallbladder should be dissected retrograde from the fundus until reaching the junction where the cystic duct meets the common bile duct, at which point the cystic duct can be ligated and divided. If the anatomical relationship between these three ducts is unclear during the dissection of the cystic duct, a choledochotomy may be considered to insert a probe to help determine the positions of the bile ducts. Intraoperative cholangiography can also be performed to aid in localization. Additionally, during gallbladder dissection, cutting should be kept as close to the gallbladder wall as possible. Any bleeding should be carefully controlled, avoiding mass ligation for hemostasis, and constant vigilance should be maintained for the presence of any bile duct anomalies.
