Patients with a history of choledochal cysts are at increased risk of developing biliary cancer:
Patients with choledochal cysts have an increased risk of developing cancer anywhere in the biliary tree, but the incidence is highest in the gallbladder. Sclerosing cholangitis, anomalous pancreaticobiliary duct junction, and exposure to carcinogens (azotoluene, nitrosamines) also are associated with cancer of the gallbladder.
What percentage of bile duct injuries are identified intraoperatively?
Only about 25% of major bile duct injuries (common bile duct or hepatic duct) are recognized at the time of operation. Most commonly, intraoperative bile leakage, recognition of the correct anatomy, and an abnormal cholangiogram lead to the diagnosis of a bile duct injury.
The best initial test for a suspected postoperative bile leak includes:
Bile leak, most commonly from the cystic duct stump, a transected aberrant right hepatic duct, or a lateral injury to the main bile duct, usually presents with pain, fever, and a mild elevation of liver function tests. A CT scan or an ultrasound will show either a collection (biloma) in the gallbladder area or free fluid (bile) in the peritoneum.
What is the best initial management for an intraoperatively identified minor lateral injury to the common bile duct?
Lateral injury to the common bile duct or the common hepatic duct, recognized at the time of surgery, is best managed with a T-tube placement. If the injury is a small incision in the duct, the T tube may be placed through it as if it were a formal choledochotomy. In more extensive lateral injuries, the T tube should be placed through a separate choledochotomy and the injury closed over the T-tube end to minimize the risk of subsequent stricture formation.
After identification of a postoperative biliary stricture, what is the best initial management?
Patients with bile duct stricture from an injury or as a sequela of previous repair usually present with either progressive elevation of liver function tests or cholangitis. The initial management usually includes transhepatic biliary drainage catheter placement for decompression as well as for defining the anatomy and the location and the extent of the damage. These catheters will also serve as useful technical aids during subsequent biliary enteric anastomosis. An anastomosis is performed between the duct proximal to the injury and a Roux loop of jejunum. Balloon dilatation of a stricture usually requires multiple attempts and rarely provides adequate long-term relief. Self-expanding metal or plastic stents, placed either percutaneously or endoscopically across the stricture, can provide temporary drainage and, in the high-risk patient, permanent drainage of the biliary tree.