T f A

A B

FIGURE 4.16. Biliary stricture after cholecystectomy. (A) Film from a cholangiogram demonstrates a focal stricture in the proximal hepatic duct from injury at the time of cholecystectomy. (B) An ERCP from another patient showing a stricture in a similar location with proximal calculi.

complication. With the progression of fibrosis and scarring, luminal narrowing develops and an elevated alkaline phosphatase level ensues, followed by jaundice. Thermal injury from cautery or laser may also cause stricture formation. The usual presentation is 3 to 10 years after surgery. Surgical repair is often unsuccessful. The success rate is related to the level of stricture, the number of previous repairs, and the type of surgical reconstruction. The prognosis is worse for high strictures. Biliary strictures may be treated with balloon dilatation in some cases. The earlier the treatment is performed, the better is the prognosis. Stenting after balloon dilatation is controversial [34]. The long-term patency of biliary strictures treated with balloon dilatation is 65 to 75% which is comparable to the results of surgical repair [28,35].

Bile duct injuries are categorized according to the Bismuth classification (Fig. 4.17). Originally used to describe only the level of a stric-

Type III Type IV

Figure 4.17. Bismuth classification of bile duct stricture/injury.

Type III Type IV

Figure 4.17. Bismuth classification of bile duct stricture/injury.

ture, this classification is now commonly used to describe any biliary injury, including stricture, transection, tear, and ligation. Bismuth type I strictures involve the distal common bile duct in which the length of the duct proximal to the stricture is greater than 2 cm. In type II, the proximal duct is less than 2 cm. In type III there is a high hilar stricture, and in type IV the stricture extends to involve the bifurcation into the main left and right ducts. In patients with high ductal injuries PTC may be necessary to identify the proximal extent of the injury or stricture. The prognosis is poorer for high strictures (Bismuth III and IV). High injuries are usually inflicted during cholecystectomy (open or LC), while the low injuries usually occur during common duct exploration. Bismuth type II, III, and IV strictures require a hepatojejunostomy if surgical repair is necessary.

Choledocholithiasis

The incidence of choledocholithiasis in patients with gallstones is approximately 10 to 15%. In patients undergoing LC, common duct stones should generally be removed preoperatively by endoscopic means, since removal at the time of laparoscopic surgery is often difficult or not possible. Those at highest risk for the presence cho-ledocholithiasis are those with biliary dilatation (CBD >8 mm on sono-graphy) elevated bilirubin, or cholangitis. With modern ultrasound equipment and techniques, common duct stones can be identified in 70 to 90% of patients, depending on stone location. Common duct stones may be primary or secondary. Primary common duct stones are formed in the duct itself, whereas secondary stones are formed in the gallbladder and migrate into the common duct. Although an answer may not be found, it is important to try to determine whether stones are primary or secondary because the therapeutic implications may be different. In general, primary stones are softer, less well formed, and darker than retained stones [36]. Stasis is usually necessary for secondary stones to form, so it is necessary to perform a sphincteroplasty or choledochoduodenostomy on these patients in addition to stone removal.

Choledocholithiasis is considered to be a complication of cholecys-tectomy if not recognized at the time of surgery (Fig. 4.18). Approximately 2 to 5% of postcholecystectomy patients will develop symptoms due to choledocholithiasis, most of which are retained calculi. Symptoms may be immediate or delayed up to months or years after surgery. Choledocholithiasis is a common cause of jaundice after

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