BILE DUCT STRICTURES, INJURIES, AND SURGERY
What is a bile duct stricture?
A bile duct stricture is a narrowing of the bile duct. A narrowed bile duct prevents the bile from draining into the intestine. The bile then backs up in the liver and spills over into the blood causing obstructive jaundice (yellow discoloration of the skin and eyes).
What are the causes of bile duct stricture?
There are many causes for biliary stricture. These causes can be benign (non-cancerous) or cancerous. Cancerous bile duct strictures are caused by bile duct cancer and pancreatic cancer. Benign (non-cancerous) bile duct strictures may develop from chronic pancreatitis, injury to the bile duct after a laparoscopic cholecystectomy and a variety of infective causes that are uncommon in the United States. The most common cause for a benign bile duct stricture is trauma to the bile duct during a laparoscopic cholecystectomy for gallstone disease. It is estimated that approximately 0.1% to 1% of gallbladder operations may lead to injury to the bile duct with subsequent development of a bile duct stricture. In addition to injury to the bile duct, injury to the hepatic artery (the blood vessel that supplies blood to the liver) is commonly associated with a bile duct injury.
How does bile duct injury from laparoscopic cholecystectomy develop?
Patients with bile duct injury after a laparoscopic cholecystectomy can present with the injury soon after the cholecystectomy or many weeks to months after the injury. Patients who present early usually present with leakage of bile into the abdominal cavity. Some of the symptoms that are associated with this include persistent pain and discomfort and feeling of illness after the laparoscopic cholecystectomy. Patients recover rapidly after laparoscopic cholecystectomy and the majority of patients are back to their pre-surgery state within ten days to two weeks. Patients who continue to complain of symptoms and are not improving and should be evaluated for possible bile duct injury from laparoscopic cholecystectomy. Often patients will develop fevers and jaundice. Patients who develop delayed symtoms from a bile duct stricture usually have scarring of the bile duct from the injury. These patients typically present with dilatation of their bile duct above the point of injury. At the point of injury the scarring gives rise to narrowing so that bile cannot go through. The bile then spills over into their blood and they typically present with jaundice.
Treatment of bile duct injuries
Early detection of bile duct injuries is important and with appropriate treatment patients generally do well. The principles of treatment of bile duct injury include:
- Treat all infections: Treatment of all infection and sepsis that may typically develop from leakage of bile or due to blockage of bile.
- Repair to healthy bile duct: To repair a injured bile duct a segment of small intestine is brought up to the bile duct and the bile duct is then sutured (sewed) to the intestine. For long term healing and for good results a normal uninjured bile duct away from the site of the injury should be used. This may be difficult to accomplish in high (close to the liver) bile duct injuries.
- Location of injury determines type of procedure and results: the type of repair performed to the bile duct depends on the level of the injury. For patients who have low injuries to their bile duct finding an area of normal bile duct above the site of the injury and suturing that area to the intestine is easily accomplished for the repair. In patients whose injury is high up in the bile duct close to the liver, the repair is much more complex since finding a segment of normal bile duct above the injury may be extremely difficult. In addition to this in patients who have an associated injury to their blood vessels, the diminished blood flow to the bile duct may jeopardize the healing process after the repair.
Treatment of bile duct injuries in a specialized center
Patients with bile duct injury often require complex operations that may range from a simple repair for a low bile duct injury to a complex repair to small ducts with possible need for removal of part of their liver tissue for injuries high up in the bile duct close to the liver. Such surgeries should be performed by surgeons trained in heaptobiliary and transplant surgery such as those at Canyon Surgical Associates.