bile duct obstruction after cholecystectomy
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BRIEF REPORT
Bile duct obstruction after cholecystectomy caused by clips: undo what has been undone, then do what you normally do
Paul R. Tarnasky, MD, Jeffrey D. Linder, MD, Alejandro Mejia, MD, Richard Dickerman, MD,Rojan Jeyarajah, MD, Stephen S. Cheng, MD
Dallas, Texas, USA
The overall frequency of operative bile duct injury
(OBDI) has not substantially decreased, and the incidence
of major bile duct injury during laparoscopic cholecystec-
tomy remains about 0.5%. The consequences of OBDI can
be devastating, with risks for major morbidity, costly medi-
cal care, liability risk, and even fatal outcomes.
The mostserious OBDIis a complete ducttransection for which surgical treatment is obligatory. Complete obstruc-
tion caused by clips placed on the common duct has been
considered a similar injury with regard to severity and its
need for surgical therapy. We report a case that was treated
by removing the clips at laparotomy followed by endoscopic
stenting.
CASE REPORT
A 25-year-old womanwas transferred to ourcare for man-
agement of a bile leak and jaundice after undergoing elec-tive laparoscopic cholecystectomy for symptomatic
cholelithiasis 10 days earlier. Endoscopic retrograde cholan-
giography revealed that several clips had beenplaced on the
bile duct, causing obstruction ( Fig. 1 ) that was confirmed by
balloon occlusion cholangiography.
Laparotomy was performed the following day. Significant
inflammatory adhesions were encountered during blunt
dissection. Clips were removed from the common duct
near the bifurcation. There was no apparent cautery injury
to the duct. A right hepatic duct laceration was noted that
resulted in an approximately 1.5-cm gap and decreased
duct diameter. The common hepatic duct was narrowed,but integrity appeared adequate, so it was elected to not
proceed with hepaticojejunostomy.
Repeat ERCP performed the next day confirmed leak
from the right hepatic duct ( Fig. 2 A) and also from the cys-
tic remnant from which clips had been removed. The com-
mon hepatic duct was patent with stenosis at the site of
previous clip placement ( Fig. 2B). A 7F 15-cm bile duct
stent was placed to bridge the cystic and right hepatic
duct leaks.
Two months after cholecystectomy, ERCP showed no re-
sidual bile leak and a persistent mild narrowing of the com-
mon hepatic duct ( Fig. 3 ) that was treated with a 10F stent.Balloon stricture dilations with placement of an increased
number of stents ( Fig. 4 A) were performed at 3-month in-
tervals. All stents were removed 10 months after the initial
stent placement. Cholangiography showed no residual
strictures ( Fig.4B). The patienthas remained asymptomatic
with normal serum liver chemistries for more than 2 years
since completing a course of endoscopic therapy.
DISCUSSION
Similar to our case, there are other reports of treating
a major OBDI without surgical biliary bypass. Weber et al1
Figure 1. Complete bile duct obstruction (arrow) caused by clip place-
ment during cholecystectomy.
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successfully treated a partial bile duct obstruction caused
by a malpositioned cystic duct clip very near the com-
mon duct. Rarely, clips can be displaced by percutane-
ous2 or endoscopic3 means. Two groups were actually able to reestablish bile duct continuity after completetransection.4,5
As long as ductal continuity remains intact, it is reason-
able to assume that endoscopic therapy will likely be
successful for treatment of residual bile duct leak or stric-
tures. Sequential stricture dilations followed by placement
of an increased number and size of plastic biliary stents dur-
ing ERCP has now become acceptable therapy for postoper-
ative biliary strictures.
Several issues are to be considered before embarking on
endoscopic treatment of bile duct obstruction caused by
clips. First, the common duct must be intact to augment in-ternal drainage with an endoscopic stent. Second, the mul-
tidisciplinary team should be involved in all aspects of the
care plan. Third, the team should convey to the patient ad-
vantages and disadvantages and expected outcomes per-
taining to morbidity and long-term success for bothsurgical and endoscopic treatment. It should be under-
stood that surgical treatment is considered the standard
of care for most complex OBDIs and that such surgeries
should be performed by experienced hepatobiliary sur-
geons at a referral center to optimize chances for best
long-term outcomes.
Figure 3. Persistent mild narrowing (arrow) of common duct 2 months
after operative bile duct injury.
Figure 2. A, Extravasation of contrast (arrow) from right hepatic duct
demonstrated 1 day after bile duct clips were removed during laparot-
omy. B, Narrowed common duct (arrow) at site of previous clip
placement.
Brief Report
e20 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 4 : 2009 www.giejournal.org
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DISCLOSURE
All authors disclosed no financial relationships rele-
vant to this publication.
Abbreviation: OBDI, operative bile duct injury.
REFERENCES
1. Weber J, Adamek HE, Riemann JF. Endoscopic stent placement and clip
removal for common bile duct stricture after laparoscopic cholecystec-
omy. Gastrointest Endosc 1992;38:181-2.
2. Wright TB, Bertino RB, Bishop AF, et al. Complications of laparoscopic
cholecystectomy and their interventional radiologic management.
Radiographics 1993;13:119-28.
3. Funnell IC, Bornman PC, Krige JEJ, et al. Complete common bile duct
division at laparoscopic cholecystectomy: management by percutane-
ous drainage and endoscopic stenting. Br J Surg 1993;80:1053-4.
4. Benner KG, Ivancev K, Porayko MK, Rosch J. Re-establishment of bil-
iary tract continuity by a combined ERCP and PTC approach after
iatrogenic common bile duct ligation. Gastrointest Endosc 1992;38:
506-9.
5. Baron TH, Feitoza AB, Nagorney DM. Successful endoscopic treatment
of a complete transection of the bile duct complicating laparoscopic
cholecystectomy. Gastrointest Endosc 2003;57:765-9.
Methodist Dallas Medical Center, Digestive Health Associates of Texas
(P.R.T., J.D.L.), Methodist Dallas Liver Institute (A.M., S.S.C.), Surgical
Associates of Dallas (R.D., R.J.), Dallas, Texas, USA.
Reprint requests: Paul R. Tarnasky, MD, 221 W Colorado Blvd, Suite 630,
Dallas, TX 75208.
Copyrightª 2009 by the American Society for Gastrointestinal Endoscopy
0016-5107/$36.00
doi:10.1016/j.gie.2008.07.029
Figure 4. A, Multiple plastic stents placed at ERCP to treat operative bile duct injury. B, Final cholangiogram after stent extractions after a course of
endoscopic therapy.
Brief Report
www.giejournal.org Volume 69, No. 4 : 2009GASTROINTESTINAL ENDOSCOPY e21
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