Introduction
A postoperative biliary stricture is a serious complication due to a technical mishap in a cholecystectomy. It can be due to variations in the anatomy and vascular arrangement, local inflammation, and poor surgical expertise.
What Are Postoperative Biliary Strictures?
A postoperative biliary stricture is a serious complication due to a technical mishap in a cholecystectomy. It can be due to variations in the anatomy and vascular arrangement, local inflammation, and poor surgical expertise. A diagnosis between the procedure and the next can be difficult, but patients usually report back with obstructive symptoms within a few days. Unfortunately, there are also cases in the medical literature where the patient presents with a postoperative biliary stricture after a few years. Magnetic resonance cholangiography can be used as a test to determine the clinical scenario, provide details on the level of injury, and give an idea of how to manage the condition. Currently, endoscopic stenting is the first line of treatment generally practiced.
What Is a Biliary Stricture?
When a bile duct gets thinner or narrower, the condition is called biliary stricture (bile duct stricture). This is because the passage of bile from the liver to the small intestine becomes difficult when the bile duct narrows. This causes a problem in the digestion of food, especially fatty food. In addition, the accumulation of bile in the body can cause many problems. A mild amount of bile accumulation may be asymptomatic, but symptoms become more pronounced as the buildup increases.
What Are the Signs and Symptoms of Postoperative Biliary Stricture?
The patient may present signs and symptoms of postoperative biliary stricture immediately after the surgery, a few days after, or several months or even years after the procedure. Some patients present with biliary cutaneous fistulas (constant drainage of bile to structures other than those it usually does, often having communication with the biliary system) a few days after the surgery. Other symptoms shown can include:
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Jaundice (a yellowish discoloration of the skin and the white of the eye).
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Acute abdomen (the patient presents with sudden abdominal pain and nausea or vomiting).
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Sepsis (the body’s reaction to infection).
Injuries that manifest several weeks or months after surgery have fewer symptoms and frequently heal with the formation of a stricture. However, the patient may present with recurrent fever, which can indicate cholangitis (bile duct inflammation). Other symptoms can include weight loss and fatigue. Jaundice may not be present in a sectoral or lobular duct ligation (types of bile duct ligation or bile duct tying up).
How Are Postoperative Biliary Strictures Diagnosed?
1. If the condition shows up a few months or a few years after the surgery, a detailed case history can be taken to get knowledge on the previous surgeries done, if the patient had any history of sepsis after that surgery, etc.
2. Laboratory tests can reveal hyperbilirubinemia (an increase in the bilirubin in the blood) within a few days. Direct bilirubinemia (an unconjugated form of bilirubin formed as a part of the catabolism of hemoglobin) is usually found in cases of retained stones, the common bile duct, which was accidentally clipped, or biliary stenosis (accidental stricture of the bile duct). Leukocytosis (an increase in the white blood cell count) can also be seen. Hepatic transaminase, alkaline phosphatase, and gamma-glutamyl transpeptidase (enzymes tested for liver function tests) may be elevated in the case of a biliary obstruction (a blockage of the bile flow), while they may not be present in a biliary leak. However, the laboratory tests cannot indicate what exactly caused the biliary stricture.
3. Imaging studies are to be performed to know the anatomic location of the stricture. Ultrasonography(US) is the first diagnostic test or imaging test in a patient presenting with abdominal pain or other abdominal complaints post-biliary or pancreatic surgery. Ultrasonography is a fast, inexpensive, and non-invasive test to know the fluid collection, ductal dilatations, and a modification of the parenchyma. But it cannot distinguish a fluid collection as the collection of bile, a hematoma(a collection of blood), a seroma(a collection of a clear fluid usually near the surgical site), or a lymphocele ( collection of lymphatic fluid). Although it can show a dilatation in a bile duct or a pancreatic duct, it cannot be used to diagnose the exact cause of the stricture or the level of obstruction.
4. Magnetic resonance cholangiopancreatography (MRCP) is a useful diagnostic tool for viewing the pancreaticobiliary ducts and one of the most effective tools for finding biliary complications. Biliary dilatation and the level of obstruction can be detected accurately in most cases. Therefore, MRCP is the most viable alternative to endoscopic retrograde cholangiopancreatography (ERCP), a diagnostic tool to diagnose and treat problems of the liver, gallbladder, bile ducts, and pancreas, although it cannot be used therapeutically.
5. Computed tomography (CT) can be used to identify a biloma (an abnormal collection of bile in the extra biliary structures), pancreatic or liver abscesses, pancreatic necrosis, and atrophy or hypertrophy of the liver. However, CT should not be the first diagnosis for bile duct injuries, as it does not show the details of the biliary tree or ultrasonography.
6. Hepatobiliary scintigraphy with technetium 99-m labeled hepatic iminodiacetic acid (HIDA) is a safe, accurate, and noninvasive diagnostic tool for biliary leaks. It is more accurate and sensitive than a CT or an ultrasound. It can help in determining the clearance of bile across the strictures. It also enables the distinction between cholecystitis and cholangitis. However, HIDA cannot provide information on the level of obstruction or detect biliary dilatation. Hence, it is not commonly used as a first-line diagnostic tool.
7. Percutaneous transhepatic cholangiography (PCT) is the method of choice for most bile duct lesions, as it is an excellent diagnostic tool for showing the proximal biliary tree. Moreover, temporary therapeutic procedures can be done using this technique before going for a definitive approach.
How Are Postoperative Biliary Strictures Managed?
The management of the condition depends upon the extent of the injury, the presence of induced complications, and the risk to the patient of the surgical procedure. After a cholangiography, a definitive therapy along with surgical reconstruction or stenting can be planned. Previous cholangitis, an incomplete cholangiography, a repair within three weeks of injury, etc., can cause recurrent strictures.
Conclusion
A biliary stricture usually occurs as a result of iatrogenic injury following a cholecystectomy. The standard diagnosis for a post operative biliary stricture is a cholangiography. If not diagnosed and managed properly, it can cause complications like cholangitis and portal hypertension. All late biliary strictures might not require medical intervention. Some patients may remain asymptomatic, even if the injury is discovered by chance through liver function tests or abdominal ultrasonography.
