BENIGN BILIARY

STRICTURES

Moderator : Dr Chaitanya Krishna Kondabala

Senior Resident , Department of Surgery
CRH , Gangtok
Presenter : Dr Md Nazar Imam
DNB Resident , Department of Surgery
CRH , Gangtok
 INTRODUCTION
 A biliary stricture is an abnormal narrowing of the
common bile duct.

 A feared complication of many surgical and endoscopic

procedures.

 If improperly treated, it may lead to cholangitis, portal

hypertension & cirrhosis.

 Treatment of this disease is challenging as well as

rewarding, as most of the patients are in younger age
group.
 CAUSES
I. Congenital strictures
(a) Biliary atresia
II. Bile duct injuries
(a) Postoperative strictures
(i) Cholecystectomy or common bile duct exploration
(ii) Biliary-enteric anastomosis
(iii) Hepatic resection
(iv) Portocaval shunt
(v) Pancreatic surgery
(vi) Gastrectomy
(vii) Liver transplantation
(b) Strictures after blunt or penetrating trauma
(c) Strictures after endoscopic or percutaneous biliary intubation
III. Inflammatory strictures
a) Cholelithiasis or choledocholithiasis
b) Chronic pancreatitis
c) Chronic duodenal ulceration
d) Abscess or inflammation of liver or subhepatic space
e) Parasitic infection
f) Recurrent pyogenic cholangitis
IV. Primary sclerosing cholangitis
V. Radiation-induced stricture
VI. Papillary stenosis
 Incidence: Bile duct injuries are reported in 0.2 to 0.3 % of open cholecystectomy and 0.4 to
1.3% of laparoscopic cholecystectomy in larger studies. Actual incidence may be higher.

AUTHOR BDI incidence following OC BDI incidence following LC

McMahon, 1995 0.2 0.81

Strasberg, 1995 0.7 0.5
Shea, 1996 0.19-0.29 0.36-0.47
Targaroma, 1998 0.6 0.95
Lillemoe, 2000 0.3 0.4-0.6
Gazzaniga, 2001 0.0-0.5 0.07-0.95
Savar, 2004 0.18 0.21
Moore, 2004 0.2 0.4
Misra,2004 0.1-0.3 0.4-0.6
Gentileschi, 2004 0.0-0.7 0.1-1.1
Kaman, 2006 0.3 0.6

Jablonska, World J Gastroenterol 2009

Classification
BISMUTH CLASSIFICATION
IS BASED ON THE MOST DISTAL LEVEL AT WHICH HEALTHY BILIARY MUCOSA IS
AVAILABLE FOR ANASTOMOSIS DURING REPAIR OF BILIARY INJURY

TYPE CRITERIA

Low common hepatic duct stricture with a length of common hepatic duct stump of
1 > 2 cm

Proximal common hepatic duct stricture with hepatic duct stump < 2 cm
2

Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence
3 is preserved

Hilar stricture with involvement of confluence and loss of communication between

4 right and left hepatic duct

Involvement of an aberrant right sectorial duct alone or with concomitant stricture

5 of the common hepatic duct
STRASBERG CLASSIFICATION
STRATIFIES INJURIES FROM TYPE “A” TO “E”, WITH TYPE “E” INJURIES BEING
FURTHER SUBDIVIDED INTO E1 THROUGH E5 ACCORDING TO THE BISMUTH
CLASSIFICATION SYSTEM

TYPE CRITERIA
A Cystic duct leak or leak from small ducts in the
liver bed
B Occlusion of an aberrant right hepatic duct

C Transection without ligation of an aberrant right

hepatic duct
D Lateral injury to a major bile duct

E1 Transection > 2 cm from the hilum

E2 Transection < 2 cm from the hilum

E3 Transection in the hilum

E4 Separation of major ducts in the hilum

E5 Type C injury plus injury in the hilum

STEWART-WAY CLASSIFICATION

IS BASED PRIMARILY ON THE ANATOMIC PATTERN AND MECHANISM OF

A PARTICULAR INJURY, INCLUDING THE PRESENCE OF ASSOCIATED
VASCULAR INJURY
 Pathological effects of biliary
obstruction

Biliary High local

concentration inflammation
obstruction of bile salts
Pathological effects of biliary
obstruction (Contd.)
Fibrosis and
scarring Repeated
Biliary stasis cholangitis

Liver Secondary Biliary

atrophy cirrhosis and PHTN

Biliary fistula
 Clinical Presentation
Biliary colic
Obstructive Jaundice
Features of ascending cholangitis
- Charcot’s triad, Reynold’s pentad
Past history of cholecystectomy.
History suggestive of pancreatitis , trauma ,
radiation , alcohol abuse.
Overall only 10% of post-op. bile duct strictures are
recognized within 1st week and approx. 70% are
diagnosed within 6 months of original operation.
 Laboratory Tests
 Liver function tests usually show evidence of cholestasis
with fluctuating serum bilirubin level.

 When elevated, serum bilirubin is usually below 10 mg/dL,

unless secondary biliary cirrhosis has developed, or there is
complete cut off.

 Serum alkaline phosphatase is usually elevated.

 Serum aminotransferase levels can be normal or minimally

elevated except during episodes of cholangitis.

 If advanced liver disease exists, hepatic synthetic function

can be impaired, with lowered serum albumin and a
prolongation of prothrombin time.
Imaging Studies
 Ultrasound
 Study of choice for the
initial evaluation of
jaundice or symptoms
of biliary disease
 Will show dilated bile
ducts proximal to the
stricture CBD

 Information about PV

level of stenosis
 Contrast enhanced CT abdomen
CT helps in assessing any intra abdominal
collection.
 Definite level of bile duct stricture, dilated
intrahepatic radicals with cholangitic abscess.
 Vascular injury with liver atrophy-hypertrophy
complex.
Limited in evaluation of the type and extent of
biliary stricture.
 Magnetic Resonance
Cholangiopancreatography
Non-invasive method
Only diagnostic
Provides anatomic
information about
location and degree of
dilatation CBD
Delineate the
intrahepatic and PD

extrahepatic biliary tree

and pancreas
 Endoscopic Retrograde
Cholangiopancreatography
 Diagnostic and
therapeutic
 Invasive test using
endoscopy and
fluoroscopy to inject
contrast through the
ampulla and image the
biliary tree
 Used for dilatation of
the biliary stricture
 Percutaneous transhepatic
cholangiography

 Useful in intrahepatic
biliary disease

 In whom ERCP is not

technically feasible

 It will outline proximal

biliary tree, define stricture
and its location, allow
decompression of the
biliary tree
Hepatobiliary iminodiacetic acid
scan

 Helps in diagnosing biliary leaks.

 Provides functional assessment

of biliary stricture and
anastomosis leak.

 Suggests complete biliary

obstruction if small intestine is
not visualized in 60 minutes.

 Insensitive for detection of

biliary dilatation or cause of bile
duct obstruction.
 Operative Procedure
 The first surgical reconstruction (“end-to-side” Choledochoduodenostomy) of
iatrogenic bile duct injury was performed by Mayoin 1905.

 The first Roux-en-Y hepaticojejunostomy (HJ) was described by Monprofit in

1908.

 Dahl noted Roux en-Y HJ for surgical treatment of bile duct injury in 1909. In1969,
Smith created a mucosal graft anastomosis in the repair of the damaged proximal
bile duct.

 In 1954, Hepp and Couinaud described the hilar plate and long extrahepatic
course of the left hepatic duct.

 Restoration of bile flow is achieved by a bilio-enteric anastomosis. Rarely, when

the stricture is in pancreatic or immediate supra-duodenal CBD, a choledocho-
duodenostomy can also be constructed.

 Most often the reconstruction is by a Roux loop with hepaticojejunostomy.

 Surgery
(Biliary enteric anastomosis)
 Choledochoduodenostomy

Choledochojejunostomy

Roux-en-Y Hepaticojejunostomy (ideal)

 Successful bile duct enteric reconstruction is
dependent on several factors:
1. Adequate preoperative assessment of biliary anatomy
2. Exposure of proximal, healthy bile ducts with adequate
blood supply
3. The repair must include all injured/strictured ducts
to ensure adequate drainage of the entire liver, and
control of bile leakage.
4. Use of a healthy segment of intestine that can be
brought to the anastomosis without tension (most
often a Roux-en-Y jejunal limb)
5. Creation of a tension-free biliary mucosa-to-bowel
mucosa anastomosis
 Choledochoduodenostomy
 Commonly used for repair of the benign
strictures in the retropancreatic portion.

 Most successful in presence of dilated CBD

(>15 mm).

 For strictures in distal most part of CBD

 Maintains endoscopic access to the biliary

tree.

 The distal common bile duct is opened

longitudinally, as is the duodenum.
Interrupted sutures are placed between the
common bile duct and the duodenum.

 Concerns :
 bile reflux
 ascending cholangitis
 sump syndrome
Choledochojejunostomy
 Roux-en-Y Hepaticojejunostomy (ideal)
 It is the preferred method of surgical biliary
drainage in most instances, and is the standard
method of biliary reconstruction following bile
duct resection.

 Proper exposure of healthy well vascularised

proximal bile duct.

 Roux- en –Y Limb of jejunum >60 cm.

 The entire extrahepatic biliary tree has been

resected and the reconstruction done with a
Roux-en-Y limb of jejunum.

 This is an end-to-side anastomosis of the

common hepatic duct onto the jejunum.

 HEPP- COUINAUD APPROACH:

Hilar plate is dissected , left hepatic duct is
anastomosed to Roux jejunal loop with creation of
proximal ‘access loop’ for future endoscopic
approach.
THANKS