Bile Duct Injury Management (SAGES-AHPBA 2025)

Algorithm Steps

1. ▶

   Start

   Bile Duct Injury Suspected

   During or after cholecystectomy

   1. ◆

      Decision

      When Was Injury Recognized?

      Critical for management approach

      • INTRAOPERATIVE: Seen during surgery
      • EARLY POSTOP: Days 1-7
      • DELAYED: >7 days postop
      1. ●

         Action

         Intraoperative Recognition

         Best opportunity for repair

         • STOP - Do not attempt repair unless expert
         • Call hepatobiliary surgeon if available
         • Place drain near injury
         • Document injury location/extent
         • Obtain intraoperative cholangiogram
         • Consider conversion to open
         1. ●

            Action

            Strasberg Classification

            Classify injury type

            • TYPE A: Cystic duct leak or minor hepatic duct
            • TYPE B: Occlusion of aberrant RHD
            • TYPE C: Transection of aberrant RHD
            • TYPE D: Lateral injury to major duct
            • TYPE E1-E5: CHD/CBD transection
            • E1: >2cm from confluence
            • E2: <2cm from confluence
            • E3: At confluence
            • E4: Destruction of confluence
            • E5: Main hepatic duct + aberrant RHD
            1. ◆

               Decision

               Sepsis or Peritonitis?

               Urgent intervention needed

               1. ⚠

                  Warning

                  Urgent Source Control

                  Before definitive repair

                  • Percutaneous drainage of collections
                  • Antibiotics
                  • Resuscitation
                  • Do NOT attempt definitive repair in sepsis
                  • Wait 6-12 weeks for inflammation to settle
                  1. ◆

                     Decision

                     Type of Injury?

                     Guides management pathway

                     1. ●

                        Action

                        Type A: Cystic Duct/Minor Leak

                        Usually ERCP + stent

                        • ERCP with sphincterotomy ± stent
                        • Success rate: >90%
                        • Remove stent in 4-6 weeks
                        • If failed: PTC drainage
                        1. ●

                           Action

                           Post-Repair Care

                           Long-term follow-up essential

                           • LFTs monthly x 6, then q3mo x 2 years
                           • MRCP at 6-12 months
                           • Watch for stricture (10-20%)
                           • Cholangitis warrants urgent workup
                           1. ✓

                              Outcome

                              Outcomes

                              Prognosis and statistics

                              • Type A leak: >95% success with ERCP
                              • Type E repair: 80-90% good outcome at expert center
                              • Stricture rate: 10-20%
                              • Referral timing correlates with outcome
                     2. ●

                        Action

                        Type D: Lateral Injury

                        ERCP or surgical repair

                        • Small lateral injury: ERCP + stent
                        • Larger injury: May need surgical repair
                        • Primary repair over T-tube if >50%
                        1. ◆

                           Decision

                           Concomitant Vascular Injury?

                           Worsens prognosis significantly

                           1. ⚠

                              Warning

                              Vascular Injury Present

                              High morbidity, expert management

                              • Right hepatic artery: May need hepatectomy if ischemia
                              • Portal vein: Urgent repair needed
                              • Combined injury: Worst prognosis
                              • Consider transplant evaluation if extensive
                           2. ●

                              Action

                              Surgical Repair Principles

                              Roux-en-Y hepaticojejunostomy

                              • Healthy mucosa-to-mucosa anastomosis
                              • Roux limb 60-70cm
                              • Single-layer absorbable sutures
                              • External drain near anastomosis
                     3. ●

                        Action

                        Type E: Complete Transection

                        Requires surgical reconstruction

                        • REFER TO HEPATOBILIARY CENTER
                        • Roux-en-Y hepaticojejunostomy
                        • Timing: Early if no sepsis or delayed 6-12 weeks
                        • E3-E5 may need segment III approach
                        • Outcomes correlate with center volume
      2. ●

         Action

         Postoperative Workup

         If not recognized intraoperatively

         • Clinical signs: Pain, jaundice, fever, bilious drain
         • Labs: LFTs, bilirubin trending up
         • CT abdomen: Collection, biloma
         • MRCP: Delineate ductal anatomy
         • HIDA scan if subtle leak