Bile Duct Injury After Laparoscopic Intraoperative Cholangioscopy

CASE REPORT

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES, Professor of Medicine, Department of Gastroenterology, Virginia Tech Carilion School of Medicine

Final Diagnosis

Bile duct injury with associated bile leak and choledocholithiasis, managed with endoscopic retrograde cholangiopancreatography and self-expanding metal stent placement.

Patient Demographics

A 45-year-old patient.

Clinical History

The patient was admitted with acute cholecystitis and underwent emergent laparoscopic cholecystectomy. During intraoperative cholangiogram, multiple stones were visualized within the bile duct. A direct laparoscopic intraoperative cholangioscopy was performed (panel B) revealing multiple stones, some of which were impacted within the bile duct. Spy Glas cholangioscopy-lithotripsy was performed. The bile duct subsequently appeared damaged and swollen. An intraoperative cholangiogram revealed a large bile leak (panel D).

Endoscopic Findings

1. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a significant bile leak (E, yellow arrow).
2. A rounded filling defect, consistent with a bile stone, was observed within the bile duct near the area of the injury (F, yellow arrow).
3. The wire was seen exiting through the bile duct injury (panel E, green arrow).

Endoscopic Technique

1. ERCP was performed following the discovery of a bile duct injury.
2. A wire was manipulated past the stone and the bile leak into the proximal common bile duct and left hepatic system (panel F)
3. An 8 mm diameter, 60 mm long self-expanding metal stent (Viabil) was inserted into the common bile duct, bridging the bile duct injury (G, F, yellow oval).
4. An occlusion cholangiogram through the stent confirmed resolution of the bile leak (H).
5. A plastic stent was placed through the metal stent to maintain patency and prevent occlusion from proximal stones. This also aimed to prevent a stone-induced valve mechanism effect.
6. The patient is scheduled for stent removal in approximately six months. If bile leak persists, a new stent will be inserted.

Discussion

This case highlights a rare but significant complication of laparoscopic intraoperative cholangioscopy for choledocholithiasis: bile duct injury and subsequent bile leak. The immediate recognition and endoscopic management of this complication are crucial for patient outcomes. The use of a self-expanding metal stent provided immediate sealing of the bile leak, while the placement of an additional plastic stent addressed the concern of continued obstruction from residual stones. The decision to prioritize bile leak sealing over complete stone extraction during the initial ERCP was appropriate given the acuity of the injury and the technical challenges posed by the inflamed duct. Subsequent follow-up for stent removal and potential further stone management is essential.

Key Learning Points

1. Bile duct injury is a potential complication of advanced endoscopic procedures such as intraoperative cholangioscopy and lithotripsy.
2. Endoscopic retrograde cholangiopancreatography is an effective method for the diagnosis and management of bile duct injuries and bile leaks.
3. Self-expanding metal stents can effectively seal bile duct injuries and leaks.
4. Consideration should be given to placing a plastic stent within a metal stent to maintain patency and prevent occlusion from residual stones or debris.
5. Long-term follow-up is essential to ensure resolution of the injury and to manage any remaining biliary pathology.

References

1. Cotton PB, et al. Endoscopic management of bile duct injuries. Gastrointest Endosc. 2007;65(6):830-836.
2. Singhal D, et al. Endoscopic treatment of bile leaks. Curr Opin Gastroenterol. 2013;29(5):540-545.
3. Davids PH, et al. Bile duct strictures after laparoscopic cholecystectomy: a new challenge for the endoscopist. Gut. 1993;34(9):1260-1262.