What is Bile Duct Injury?
Damage to the biliary tree, the pathway for bile to travel from the liver to the small intestine and gallbladder, can be a complicated issue for surgeons. This is due to the differing structures in each person’s body, the small area they have to work in, and the potential for serious health issues if complications arise.
Every year, there are over 750,000 minimally invasive surgeries in the U.S. to remove the gallbladder. This is called a laparoscopic cholecystectomy, and it’s usually done to treat symptomatic cholelithiasis, which is when gallstones cause symptoms. However, as more surgeries are performed, there have also been more incidents of bile duct injuries. This could be because the biliary tree and the connecting points of the various ducts in the liver can differ widely between individuals. In fact, most injuries to the bile duct happen simply because the surgeon misidentifies the normal bile duct structure. If the bile duct does get damaged, it’s really important to spot it quickly, as this allows doctors to provide the right treatment as soon as possible.
What Causes Bile Duct Injury?
Biliary injury is a form of damage that typically happens when the common bile duct, a tube that carries bile from the liver and gallbladder, is mistakenly identified for the cystic duct during a specific kind of surgery called laparoscopic cholecystectomy (a procedure to remove the gallbladder). This kind of error happens in about 0.3 to 0.7% of cases, which is three times more common than when a similar procedure is done using an open surgery method.
The range of different bile duct structures in different people is one reason for this type of injury. But in rare cases, this type of injury could also occur from sharp or blunt force injuries to the stomach. The chance of this happening is very low, about 0.1% for hospital patients admitted for trauma injuries.
The method of treatment depends on the position of the injury and when it is diagnosed. Options could include a gallbladder removal, draining the area, reconstructing the damaged part to ensure the bile can flow into the intestine, or a partial removal of the liver.
Risk Factors and Frequency for Bile Duct Injury
When doctors use laparoscopic techniques to perform cholecystectomy (gallbladder removal) or to treat other biliary issues, there’s an increased chance of injuring the bile duct. This type of injury impacts about 0.3% to 0.7% of people undergoing gallbladder removal surgery in the United States, which amounts to around 750,000 cases each year. Unfortunately, doctors often miss these injuries when they occur, which happens just 25% to 32.4% of the time. These unnoticed injuries can worsen the patient’s health situation and the quality of life and can also lead the surgeon to face legal action.
Injuries to the bile duct during laparoscopic surgery tend to be more complicated because of the limited visibility and the use of electrosurgery, a technique that uses electric energy to cut or coagulate tissue.
- Several factors can increase the risk of a bile duct injury:
- Anatomy differences, like a short or parallel cystic duct can lead to wrong identification.
- Patient’s health conditions such as severe obesity, previously performed hepatobiliary surgeries, or the existence of liver disease can limit visibility, making surgery riskier.
- The patient’s gallbladder health can also play a role. For instance, inflammation and increased bleeding linked to acute cholecystitis can lead to more injuries.
- However, it is worth noting that bile duct injuries can occur even without these risk factors, it happens in 80% of the cases.
When surgeons have more experience with performing laparoscopic cholecystectomies, they are less likely to injure the bile duct. However, routinely using a specific technique known as intraoperative cholangiography doesn’t significantly reduce the chances of these injuries. However, if there’s uncertainty around the bile duct’s anatomy or if an injury is suspected, it’s recommended to use intraoperative cholangiography or another method to clarify the biliary structure.
Signs and Symptoms of Bile Duct Injury
Bile duct injuries often happen without being noticed right away during surgery. Only 25 to 40% of these injuries are detected immediately. The main signs of a bile duct injury include blockade of the bile ducts, leakage of bile, or tightening of the bile duct. If you’ve had surgery due to a gallbladder infection or a severe inflammation of the gallbladder, then the risk of a bile duct injury is higher.
If the injury is not identified right after the operation, other symptoms might be noticed. These can include finding bile in the surgical drain if one was inserted, or noticing bile leaking from the surgical wound. Other possible symptoms after the operation may include fever, nonspecific tummy discomfort, feeling sick, itching, and difficulty with food.
If the bile leakage is substantial or bile collects in the abdomen, the patient may manifest symptoms of a severely painful and tender abdomen or widespread infection in the body. In the case where the bile duct is blocked, the patient may show signs of obstructive jaundice. Recognizing these symptoms early is critical to reducing the harmful effects associated with untreated bile duct injuries. These consequences can include cholangitis (an infection of the bile duct), portal hypertension (high blood pressure in the vein leading to the liver), and cirrhosis (a severe liver disease).
Testing for Bile Duct Injury
If a surgeon discovers damage or leakage in the bile duct during an operation, they have to determine whether they’re equipped with the right skills, support, and resources to address the issue. If they decide to go ahead and fix the problem, they’ll have to carry out a procedure called cholangiography to better understand the anatomy and prepare for the treatment. If the surgeon thinks they can’t fix the problem safely, they should avoid any additional procedures and arrange for the patient to be transferred to a hospital with appropriate specialist surgeons. If possible, a catheter can be inserted into the injury, which can help the next team locate the problem and perform a cholangiogram quickly.
If a patient comes in after their operation, an abdominal ultrasound can detect any fluid accumulation in the gallbladder area or an expanded bile duct. This, along with other symptoms such as abdominal pain and an increase in bilirubin, could indicate a bile leak. A CT scan can accurately identify free fluid within the abdomen. A HIDA scan can differentiate normal fluid collection after surgery from fluid or bile leakage during the operation. However, it can be challenging to locate the leak using a HIDA scan. An additional procedure called endoscopic retrograde cholangiography can help determine the location of the leak and also help place a stent to avoid further complications. Magnetic resonance cholangiopancreatography is another tool that can help find the source of a biliary leak.
Several systems help doctors classify bile duct injuries. The Strasberg-Bismuth classification describes injuries based on where they’re located in the bile duct system. The McMahon classification categorizes the injuries after laparoscopic cholecystectomy as either major or minor based on the depth of the injury. Meanwhile, the Stewart-Way classification organizes injuries based on how they happened, using information from the surgeon’s reports.
Treatment Options for Bile Duct Injury
Treatment for bile duct injuries depends on the severity and complexity of the condition. Some injuries may only need a simple draining procedure, while others may require a major reconstruction of the biliary system (the system responsible for creating and transporting bile, a fluid your body uses to digest fats).
In some situations, if an injury is particularly tricky to manage, the patient might be moved to a specialist center. This is because they may have the right resources and medical staff specialized in bile duct conditions.
The Strasberg classification helps doctors decide the best treatment method for bile duct injuries. For example, Strasberg type A injuries involve a leak from the cystic duct or minor hepatic duct in the liver. Treatment for this type often includes monitoring the leak for spontaneous closure and possibly inserting a stent (a small tube) to help block the leak and allow drainage. If the leakage becomes worse, surgery might be necessary to clean the area.
For Strasberg type B injuries which cause minimal pain and mild changes in liver function tests, treatments may include conservative monitoring. If the injury blocks the bile ducts, various non-surgical or surgical methods might be introduced for drainage or removal of the affected part of the liver.
Strasberg type C injuries are quite similar to type B, with the difference being that instead of causing blockage, an accessory duct in your liver leaks. For such cases, a percutaneous drainage might be done, in which a tube is inserted through the skin to drain the fluid. In rare instances, surgery may be required to remove part of the liver (hepatectomy) or to create a new channel for bile flow (hepaticojejunostomy).
Type D injuries damage part of the common bile duct. Surgeries can help deal with this, and a stent could be employed to ensure the duct’s function.
Strasberg type E injuries are quite severe, as they often involve significant damage to the bile ducts. Often, surgical approaches, such as Roux-en-Y hepaticojejunostomy, which attaches a part of the small intestine directly to the liver, are performed as a means of bypassing the damaged ducts. If the tissues aren’t healthy enough for this kind of surgery, a temporary repair might be employed, using an omental patch (moving a piece of the omentum, which is the fatty covering of the abdomen).
Overall, your healthcare team will always strive to provide the best treatment option tailored to your condition and aimed at ensuring a smooth and effective recovery.
What else can Bile Duct Injury be?
If a patient still has symptoms like feeling sick to their stomach, throwing up, turning yellow, or having stomach pain after gallbladder surgery, they may be dealing with something called post-cholecystectomy syndrome (PCS). This can happen to anywhere from 5 to 60% of patients. The symptoms might be due to injury to the bile duct, narrowing of the area, stones left behind, problems with the movement of the bile, or issues with a particular muscle in the area called the sphincter of Oddi.
But sometimes, PCS symptoms may actually be caused by problems not related to the bile duct at all, such as:
- Peptic ulcer disease (stomach ulcers)
- Pancreas divisum (an uncommon birth defect)
- Pancreatitis (inflammation in the pancreas)
- Pancreatic masses (growths in the pancreas)
- Mesenteric ischemia (poor blood flow to the intestines)
- Diverticulitis (inflammation of little pouches that can form in your digestive system)
- Intestinal motility disorders (problems with the movement of food through the digestive tract)
Rarely, a person might have symptoms that seem like they’re due to problems with the bile duct, but are actually caused by disorders outside of the digestive system entirely. This could be a mental health disorder causing physical symptoms, or it could even be heart disease.
What to expect with Bile Duct Injury
Injuries to the bile duct can lead to serious complications like strictures (narrowing of ducts), ascending cholangitis (bile duct inflammation), cirrhosis (liver damage), or portal hypertension (high blood pressure in the liver’s veins), especially if they are not noticed or handled correctly. Such injuries can largely reduce a patient’s long-term survival and quality of life, and often lead to high rates of legal cases.
When treating bile duct injuries, it’s best to go to a specialized medical center with experts in hepatobiliary procedures, which involve the liver, bile ducts, and gallbladder. This is because, according to studies, a surgeon who caused the injury is able to successfully treat it only around 21% of the time.
Successful repair of bile duct injuries often involves controlling any abdominal infections, using real-time imaging of the bile ducts during surgery (intraoperative cholangiography), employing the proper surgical technique to rebuild the injuries, and having the procedure performed by a surgeon specializing in hepatobiliary procedures.
Whether the repair happens immediately or is delayed does not seem to affect the success rate, provided any abdominal infections are under control. However, if there is an active infection in the abdomen, research has shown that immediate repair can lead to worse outcomes.
Possible Complications When Diagnosed with Bile Duct Injury
Complications from bile duct injuries can range in severity. If the bile duct leaks, it could potentially lead to a buildup of bile in the abdominal cavity (biloma), abscesses, wound infections, abdominal infections, and a severe infection in the bloodstream (sepsis). Nearly all bile duct leaks are effectively treated with an endoscopic stent, a small tube placed in the bile duct, with a 96% success rate.
Reconstructing the bile duct (using a procedure known as hepaticojejunostomy) for conditions like transection or stricture introduces risks such as infections, bile leaks, and stents shifting in about 11% of patients. The overall rate of complications following a reconstruction procedure is about 36%, with a death rate around 2%. Serious complications after bile duct reconstruction, like a narrowing or stricture (about 30% of the time), can be managed conservatively, with a stent insertion, or with a repeat hepaticojejunostomy.
In unfortunate cases where the treatment fails or the complication is detected too late, the patient could develop secondary biliary cirrhosis, which could necessitate a liver resection or, in the extreme case, a liver transplant. Additional surgery-related complications involve the coming apart of the anastomosis (the surgical connection), a blockage in the lung artery (pulmonary embolism), bleeding, or uncontrollable sepsis. The good news is that about half of patients don’t face any complications after a hepaticojejunostomy.
The major complications include:
- Bile buildup in the abdominal cavity
- Abscesses
- Wound infections
- Abdominal infections
- Severe infection in the bloodstream
- Bile leaks
- Shifting of stents
- Narrowing or stricture of the bile duct
- Secondary biliary cirrhosis
- Anastomosis dehiscence
- Blockage in the lung artery
- Bleeding
Recovery from Bile Duct Injury
Patients usually recover well after a procedure to fix their bile duct injury with the help of an endoscope and they should not need to stay in the hospital for a long time. However, those who need more complicated repairs of their bile duct injury may need to stay in the hospital longer and be considered for recovery exercises after the operation. For older patients, it could take even more time to get back to their normal activity level.
Preventing Bile Duct Injury
During a laparoscopic cholecystectomy, a surgical procedure to remove the gallbladder, different methods are used to avoid damaging the bile duct, a tube that transports bile from the liver to the small intestine. One of these methods is called the Critical View of Safety (CVS). This technique helps to correctly identify the cystic duct and artery, which are important components of the gallbladder, to prevent damage to the common bile duct or hepatic duct, both of which carry bile from the liver.
The CVS method involves detaching the lower third of the gallbladder from the cystic plate (a part of the liver), removing any fat and fibrous tissue from the hepatocystic triangle (an area between important ducts near the gallbladder), and confirming the identification of only two structures going into the gallbladder, namely the cystic duct and cystic artery.
Sometimes, local inflammation can cause scarring and distort the normal structure, which makes it look like the common bile duct arises directly from the gallbladder. In such complicated cases, there is a higher chance of injury to the bile duct and the need for more invasive procedures. If it is tough to use the CVS method in these situations, the surgeon might consider other options like a bailout cholecystostomy (making a new passage for bile to flow from the gallbladder), subtotal cholecystectomy (removing part of the gallbladder), or referring the patient to a specialist care center.
Fortunately, the chance of injuring the bile duct during a laparoscopic cholecystectomy is less than 1%, which makes it difficult to gather enough data to assess this risk statistically. However, smaller studies indicate that the CVS method is beneficial. SAGES, a professional organization focused on endoscopic surgery, has established a Safe Cholecystectomy program online to educate and promote the use of the CVS method; this aids in reducing accidental injuries, particularly when dealing with complicated gallbladder cases.
