Bile duct resection and reconstruction

INTRODUCTION — Even with the rising popularity of endoscopic and interventional radiology techniques to divert or restore biliary flow [1-3], operative bile duct resection and reconstruction (BDRR) remains a common procedure. Approximately 67,000 patient admissions for BDRR were recorded by the Nationwide Inpatient Sample Discharge database from 2004 to 2011, with an average of over 8000 patients per year [4].

Surgical aspects of BDRR, including preoperative preparation, techniques, and postoperative management, as well as outcomes, will be discussed here. The management of common bile duct stone and bile duct injury, and surgical treatment of cholangiocarcinoma, are covered elsewhere. (See "Surgical common bile duct exploration" and "Repair of common bile duct injuries" and "Surgical resection of localized cholangiocarcinoma".)

INDICATIONS — Bile duct resection and reconstruction (BDRR) is performed for a variety of indications, including benign and malignant tumors; complications from biliary and gallbladder disease or surgery; and, more rarely, traumatic, infectious, or inflammatory processes involving the biliary tree. In a large retrospective study of 67,160 patients who underwent BDRR, 2.5 percent of procedures were performed for congenital anomalies, 37.4 percent for malignant neoplasms, 2.3 percent for benign neoplasms, 9.9 percent for biliary injuries, and 47.9 percent for other nonmalignant diseases [4]. These indications, including malignant disease, are presenting with increasing incidence [5].

Malignant tumors — BDRR can be performed for various forms of cancer, including cholangiocarcinoma (extrahepatic and intrahepatic), hepatocellular carcinoma, and metastatic disease to the liver or the porta hepatis (rare). Intrahepatic cholangiocarcinomas and tumors at the biliary bifurcation may require concomitant liver resection with BDRR. Pancreatic cancer or periampullary cancers involving the distal common bile duct are generally treated with pancreaticoduodenectomy (Whipple operation). (See "Surgical resection of localized cholangiocarcinoma" and "Surgical resection of hepatocellular carcinoma" and "Surgical resection of lesions of the head of the pancreas".)

Benign tumors — BDRR can also be performed to excise premalignant tissue or correct aberrant bile flow that may predispose to inflammation and subsequent dysplasia or cancer. Examples of benign lesions that can be removed with BDRR include choledochocele (image 1), which carries a lifetime cancer risk of 30 percent [6-11], sclerosing cholangitis [12], and ampullary lesions such as adenomatous polyps and carcinoma in situ [13,14]. (See "Biliary cysts" and "Primary sclerosing cholangitis in adults: Management" and "Ampullary adenomas: Management".)

Complicated biliary disease — The majority of BDRRs are performed for benign biliary disease, such as complications of cholelithiasis or choledocholithiasis, and iatrogenic injury after endoscopy, cholecystectomy, or other gastrointestinal procedures [4,15-25]. (See "Surgical common bile duct exploration" and "Repair of common bile duct injuries" and "Complications of laparoscopic cholecystectomy".)

PREOPERATIVE PREPARATION — Prior to bile duct resection and reconstruction (BDRR), precise localization of the target lesion and biliary decompression for obstructing lesions are required by endoscopic or radiologic means.

Localization — The first step in imaging should include abdominal ultrasound, which can help establish the level of biliary obstruction. Conventional computed tomography (CT) can be used to assess for extrahepatic, metastatic, and perihilar adenopathy, although high-resolution CT and/or magnetic resonance imaging (MRI) are recommended for acute assessment of the tumor and determination of resectability [26].

Decompression — The best approach depends on whether the lesion is accessible to endoscopy.

●Endoscopically accessible lesions – For endoscopically accessible lesions, endoscopic retrograde cholangiopancreatography (ERCP) with endobiliary stent placement and/or endoscopic ultrasound (EUS) are the preferred methods of securing the diagnosis and providing temporary relief of biliary obstruction prior to BDRR [27]. In patients with lesions suspicious for cholangiocarcinoma, it is crucial to perform all imaging before biliary drainage because ascertainment of resectability is more challenging after endoscopic stent placement.

●Endoscopically inaccessible lesions – When ERCP/EUS is not available, or when lesions are endoscopically inaccessible, radiographic imaging with interventional radiologic placement of percutaneous transhepatic cholangiocatheter or cholangioscopy [28] can also relieve biliary obstruction prior to BDRR (image 2 and image 3).

Biopsy — For patients eligible for surgery, biopsy should be limited to selected cases due to the risk of tumor seeding and tract recurrence [29]. In addition, it is often difficult to obtain pathologic confirmation, and in most cases, patients are offered surgical therapy based on clinical suspicion and radiologic evidence.

Staging laparoscopy — For some malignant disease, such as hilar cholangiocarcinoma, patients may benefit from a staging laparoscopy in detection of occult extrahepatic disease [30,31].

SURGICAL TECHNIQUES

Incision — For open bile duct resection and reconstruction (BDRR), an upper midline or a right subcostal incision with left or xiphoid extension can be utilized. For laparoscopic procedures, the standard laparoscopic or robotic-assisted laparoscopic approaches to the right upper quadrant can be adopted.

Exposure — A wide Kocher maneuver is performed to expose the duodenum and is continued cephalad to expose the right side of the porta hepatis. A plastic endobiliary stent or a percutaneous transhepatic cholangiocatheter placed preoperatively can aid in identification of the bile duct and the ampulla of Vater.

The gallbladder, if intact, is removed from the gallbladder fossa but left attached to the bile duct specimen by the cystic duct for anatomic identification and for adherence to principles of oncologic resection (in malignant cases). Alternatively, if there is no stent in the bile duct, the gallbladder can be removed and a cholangiocatheter passed down the cystic duct to the bile duct and into the duodenum for easier identification of the ampulla of Vater (for distal bile duct or ampullary lesions).

Resection — The resection techniques vary based upon the location of the lesion. Ampullary lesions are typically resected transduodenally. More proximal lesions such as mid-bile-duct lesions are typically removed by a segmental bile duct excision with or without concomitant liver or pancreatic resection, depending on the margin status of the biliary resection.

Ampullary resection — Ampullary resection is usually performed to remove ampullary tumors and rarely performed for ampullary strictures. With the duodenum intact, the ampulla of Vater is first searched for by intraoperative ultrasound or by palpation of a tumor or a biliary stent. If the ampulla can be located in this fashion, the duodenum is opened transversely to minimize narrowing of the lumen after closure. If the ampulla cannot be located prior to duodenotomy, a longitudinal incision on the duodenum allows for extension cephalad or caudad as necessary until the ampulla is found.

In patients with ampullary tumors, normal mucosa surrounding the tumor is identified and marked circumferentially using electrocautery with a gross margin of 3 mm. Fine (5-0) absorbable sutures can be placed circumferentially around the tumor for traction and to mark the "staying" duodenum. The tumor is then excised using electrocautery, along with full-thickness resection of the ampulla around the biliary stent. As dissection deepens, more sutures are placed circumferentially, until the structures of the bile duct and pancreatic duct become clearly identified and divided (figure 1).

The specimen is removed, after which orifices of the biliary and pancreatic duct are reimplanted in the back wall of the duodenum with interrupted 5-0 sutures (figure 2). Secretin, which induces pancreatic secretion, can be used when necessary to identify the pancreatic duct. Careful identification of the pancreatic duct as well as the bile duct is necessary to avoid postoperative pancreatic duct obstruction, which can cause potentially fatal pancreatitis. A 5 French pediatric feeding tube can be used as a stent to protect the pancreatic duct orifice during reimplantation [32].

Midportion bile duct resection — Mid-bile-duct resection is typically performed for potential bile duct cancers.

For tumors or lesions in the middle portion of the bile duct that do not grossly involve the hepatic bifurcation cephalad or the pancreas caudad, the surgeon should be able to identify uninvolved bile duct superior and inferior to the area of interest. In addition, the surgeon should also identify the common hepatic artery (generally to the patient's left of the bile duct) and the portal vein (posterior to the bile duct and common hepatic artery) (figure 3). The right hepatic artery generally passes posteriorly, but occasionally passes anteriorly, to the bile duct just above the cystic duct insertion and is susceptible to injury (figure 4). The use of intraoperative ultrasound for arterial and venous identification, as well as tumor assessment, can help guide surgical dissection.

The bile duct is first transected inferiorly, so a frozen section of the inferior margin can be sent while the surgeon continues to dissect the bile duct and surrounding tissues off the portal vein and hepatic artery. For known or suspected malignant tumors, the nodal contents of the porta hepatis should be removed with the specimen en bloc or as a separate specimen. Subsequently, the specimen is divided at its superior margin, which is also sent for a frozen section.

If margins return positive or suspicious for cancer, the surgeon must decide if additional tissue can be removed safely. If the inferior margin is positive, a pancreatic resection (ie, a Whipple procedure) may be required; if the superior margin is positive, the hepatic bifurcation of the biliary tree may need to be resected with or without a hepatic resection, following which separate left and right hepatic reconstructions are required.

Perihilar resection — Proximal bile duct lesions close to or at the hepatic bifurcation are termed perihilar lesions. Most perihilar lesions are malignant (eg, Klatskin tumor). Resection techniques of perihilar cholangiocarcinoma are discussed in another topic. (See "Surgical resection of localized cholangiocarcinoma", section on 'Perihilar cholangiocarcinoma'.)

Intraoperative frozen section analysis — Intraoperative frozen section analyses are carried out on the resection margins to ensure complete resection. One should divide the bile duct sharply as cautery artifact can interfere with pathology evaluation. In addition, the presence of biliary obstruction can also cause pathology to be equivocal during frozen section analyses.

Lymphadenectomy — For malignant tumors, lymph node dissection should be performed. However, there is no clear consensus on the extent of lymphadenectomy [33].

Reconstruction — Following resection, bile duct reconstruction is typically accomplished by a Roux-en-Y biliary-enteric anastomosis, sometimes by anastomosing multiple bile ducts to the Roux limb. In patients with potentially devascularized high bile duct injuries, the Rodney Smith reconstruction is preferred. Direct end-to-end anastomosis of the extrahepatic bile duct is rarely successful because of stricturing. Choledochoduodenostomy, the direct anastomosis of the bile duct to the duodenum, was more widely utilized in the past and maintains the gastrointestinal tract in its native position with one anastomosis. However, the presence of inflammation in the duodenum and porta hepatis may make tension-free anastomosis difficult, and reflux cholangitis can occur [34].

Routine reconstruction — The gold standard for bile duct reconstruction is the Roux-en-Y anastomosis (choledochojejunostomy or hepaticojejunostomy) (figure 5). In most patients whose bile duct has been transected, the anastomosis is performed superior to the takeoff of the cystic duct because of a better blood supply. In rare patients whose bile duct is left in continuity, a side-to-end biliary-enteric anastomosis can be fashioned at the most accessible level of the bile duct.

Special reconstruction — The standard Roux-en-Y hepaticojejunostomy technique can be varied to accommodate special patient groups who require BDRR.

Multiduct reconstruction — In patients who have bile duct injuries from cholecystectomy or trauma, multiple biliary ducts may be injured. Each orifice will need to be anastomosed with the Roux limb, or the patient will suffer from biliary obstruction of the attendant liver segment(s). For patients with multiple duct injuries, preoperative placement of percutaneous transhepatic catheters into all obstructed ducts by interventional radiology can be critical. In the operating room, these catheters can be manipulated into the operative field for identification of the injured ducts.

Hilar duct reconstruction — Patients who sustain traumatic or iatrogenic injuries to the biliary tree can sometimes sustain a concomitant vascular injury to the right hepatic artery, which eliminates arterial blood supply to the hilar bile ducts. As a result, healing of a standard hepaticojejunal anastomosis is prevented. The Rodney Smith reconstruction is a sutureless technique for reconstruction of hilar bile ducts with a jejunal mucosal graft [35]. It utilizes one or more indwelling interventional radiology catheters that are secured to the Roux limb to deliver a vascularized sleeve of jejunal mucosa into contact with epithelium of the bile duct. Postoperatively, the liver bed, bile ducts, and jejunal Roux limb are allowed to adhere by fibrosis and scar formation, thereby completing the reconstruction. Postoperatively, catheter cholangiograms are obtained to confirm anastomotic patency before the catheters are gradually pulled back and eventually removed several months after the procedure (figure 6).

Minimally invasive approach — The minimally invasive approach was initially used primarily for palliative bypass of unresectable periampullary cancers to offer patients a decreased length of stay and preserve their quality of life. It was also been used in transduodenal resection of ampullary tumors with pancreatic and biliary duct reimplantation (picture 1 and picture 2).

Surgeons are increasingly performing BDRR using minimally invasive methods, including laparoscopic, robotic, and hybrid techniques [36-42]. These have been identified as safe alternatives to open procedures with comparable outcomes [43-45].

The minimally invasive approach is now more routinely used for all indications, including reoperative biliary reconstruction (ie, biliary reconstruction after cholecystectomy with biliary and/or arterial injury) and biliary reconstruction after gastric bypass surgery [46-49].

POSTOPERATIVE MANAGEMENT

Nasogastric tube — After bile duct resection and reconstruction (BDRR), nasogastric suction is sometimes continued for one to two days.

Drains — Most surgeons place surgical drains after BDRR, especially after the duodenum has been entered (eg, ampullary resection). A single large-bore closed-suction drain (eg, 19 French Blake) is generally sufficient and can be removed several days after the operation if there is no evidence of biliary or enteric leak.

Output from surgical drains can be checked for fluid amylase level if there is any concern for a pancreatic or duodenal leak. Bile leaks are generally obvious by the color of the effluent. Most leaks are self-limited and subside within one to two weeks. Large-volume leaks may require total parenteral nutrition (TPN) and potentially bile refeeding, if enteric nutrition is desired. (See "Surgical resection of lesions of the head of the pancreas", section on 'Pancreatic fistula'.)

Postoperative biliary access — In patients who undergo primary repair of biliary injuries, placement of a T-tube across the area of repair allows access to the biliary tree by interventional radiology in case of stricture or leak (figure 7). However, direct end-to-end reconstruction of the extrahepatic, extrapancreatic bile duct is rarely successful in cases of injury or complications of gallstone disease and is contraindicated in cases of tumor.

Another approach that can also provide postoperative percutaneous access to the biliary tree is to tack the Roux limb of a hepaticojejunostomy to the abdominal wall and mark the spot with large clips. When necessary, the biliary tree can then be accessed radiologically or endoscopically through the Roux limb.

OUTCOMES — Perioperative mortality and morbidity rates are 4.2 and 32 percent, respectively, after bile duct resection and reconstruction (BDRR) for all causes according to an analysis of the Nationwide Inpatient Sample Discharges database (2004 to 2011) [4].

Mortality — Reported perioperative mortalities after BDRR for benign and malignant diseases were 0 to 5 percent [18,50-54] and 5.6 to 8.6 percent [51,55], respectively.

For many complex surgical procedures, there is an inverse relation between hospital volume of surgical procedures and surgical mortality [56,57]. Although BDRR is considered a complex hepatobiliary procedure, a substantial proportion of BDRR procedures, especially those for benign indications, are performed at low-volume centers with fewer than 10 cases per year [4]. Transferring a stable patient who requires BDRR from a low- to a high-volume center should be encouraged and may optimize patient outcomes.

Morbidity — BDRR for benign disease is associated with reported perioperative morbidity rates of 13 to 49 percent [52-54].

Early complications — The most common perioperative complications after BDRR are infection (13 percent) and bleeding (5 percent) [4]. Bile leak is another early complication of BDRR and has been reported in 3.7 percent of biliary-enteric anastomoses [58].

Late complications — The most common late complication of BDRR is bile duct stricture formation, reported at a rate of 10 to 30 percent [59,60]. Patients who develop post-BDRR stricture are susceptible to biliary sepsis and cholangitis, which may require urgent percutaneous transhepatic cholangiography to decompress. (See "Approach to the patient with postoperative jaundice", section on 'Biliary strictures'.)

Patients with incompletely bypassed biliary systems may develop atrophy of the affected segments with need for further procedures, including abscess drainage and/or hepatic resection.

Patients undergoing bile duct resection for tumor may develop recurrence. As an example, cholangiocarcinoma has a dismal prognosis and is likely to recur both locally and systemically. Ampullary adenomas can recur after open or minimally invasive transduodenal resection, especially in the setting of a positive margin. Patients with recurrent ampullary adenomas may require a pancreaticoduodenostomy operation for cure. (See "Surgical resection of localized cholangiocarcinoma", section on 'Recurrence'.)

SUMMARY AND RECOMMENDATIONS

●Indications – Bile duct resection and reconstruction is performed for a variety of indications, including benign and malignant tumors; complications from biliary and gallbladder disease or surgery; and other traumatic, infectious, or inflammatory processes involving the biliary tree. (See 'Indications' above.)

●Preoperative preparation – Careful preoperative planning, which may include magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatogram (ERCP), and/or interventional radiology transhepatic biliary drain placement, is critical to operative success. (See 'Preoperative preparation' above.)

●Resection techniques – Bile duct resection techniques vary based upon the location of the lesion. Ampullary lesions are typically resected transduodenally. More proximal lesions such as mid- or hilar bile duct lesions are typically removed by a segmental bile duct excision with or without concomitant liver or pancreatic resection, depending upon the margin status of the biliary resection. (See 'Resection' above.)

●Reconstruction techniques – Bile duct reconstruction is typically accomplished by a Roux-en-Y biliary-enteric anastomosis, sometimes by anastomosing multiple bile ducts to the Roux limb. In patients with devascularized hilar duct injuries, the use of a jejunal mucosal graft (ie, the Rodney Smith reconstruction) may be beneficial. Direct end-to-end anastomosis of the extrahepatic bile duct is rarely successful. (See 'Reconstruction' above.)

●Minimally invasive approaches – Minimally invasive bile duct resection and reconstruction is more routinely performed as an alternative to the open approach for all indications with comparable outcomes. (See 'Minimally invasive approach' above.)

●Outcomes – Bile duct resection and reconstruction procedures are associated with a perioperative mortality and morbidity rate of 4.2 and 32 percent, respectively. The most common early complications are bleeding and infection; potential late complications include stricture, liver atrophy, and disease recurrence. (See 'Outcomes' above.)