BRIEF REPORT

Bile duct obstruction after cholecystectomy caused by clips: undo what has been undone, then do what you normally do
Paul R. Tarnasky, MD, Jeffrey D. Linder, MD, Alejandro Mejia, MD, Richard Dickerman, MD, Rojan Jeyarajah, MD, Stephen S. Cheng, MD Dallas, Texas, USA

The overall frequency of operative bile duct injury (OBDI) has not substantially decreased, and the incidence of major bile duct injury during laparoscopic cholecystectomy remains about 0.5%. The consequences of OBDI can be devastating, with risks for major morbidity, costly medical care, liability risk, and even fatal outcomes. The most serious OBDI is a complete duct transection for which surgical treatment is obligatory. Complete obstruction caused by clips placed on the common duct has been considered a similar injury with regard to severity and its need for surgical therapy. We report a case that was treated by removing the clips at laparotomy followed by endoscopic stenting.

CASE REPORT
A 25-year-old woman was transferred to our care for management of a bile leak and jaundice after undergoing elective laparoscopic cholecystectomy for symptomatic cholelithiasis 10 days earlier. Endoscopic retrograde cholangiography revealed that several clips had been placed on the bile duct, causing obstruction (Fig. 1) that was conrmed by balloon occlusion cholangiography. Laparotomy was performed the following day. Signicant inammatory adhesions were encountered during blunt dissection. Clips were removed from the common duct near the bifurcation. There was no apparent cautery injury to the duct. A right hepatic duct laceration was noted that resulted in an approximately 1.5-cm gap and decreased duct diameter. The common hepatic duct was narrowed, but integrity appeared adequate, so it was elected to not proceed with hepaticojejunostomy. Repeat ERCP performed the next day conrmed leak from the right hepatic duct (Fig. 2A) and also from the cystic remnant from which clips had been removed. The common hepatic duct was patent with stenosis at the site of previous clip placement (Fig. 2B). A 7F 15-cm bile duct stent was placed to bridge the cystic and right hepatic duct leaks. Two months after cholecystectomy, ERCP showed no residual bile leak and a persistent mild narrowing of the comwww.giejournal.org

Figure 1. Complete bile duct obstruction (arrow) caused by clip placement during cholecystectomy.

mon hepatic duct (Fig. 3) that was treated with a 10F stent. Balloon stricture dilations with placement of an increased number of stents (Fig. 4A) were performed at 3-month intervals. All stents were removed 10 months after the initial stent placement. Cholangiography showed no residual strictures (Fig. 4B). The patient has remained asymptomatic with normal serum liver chemistries for more than 2 years since completing a course of endoscopic therapy.

DISCUSSION
Similar to our case, there are other reports of treating a major OBDI without surgical biliary bypass. Weber et al1
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Figure 3. Persistent mild narrowing (arrow) of common duct 2 months after operative bile duct injury.

Figure 2. A, Extravasation of contrast (arrow) from right hepatic duct demonstrated 1 day after bile duct clips were removed during laparotomy. B, Narrowed common duct (arrow) at site of previous clip placement.

successfully treated a partial bile duct obstruction caused by a malpositioned cystic duct clip very near the common duct. Rarely, clips can be displaced by percutaneous2 or endoscopic3 means. Two groups were actually able to reestablish bile duct continuity after complete transection.4,5 As long as ductal continuity remains intact, it is reasonable to assume that endoscopic therapy will likely be successful for treatment of residual bile duct leak or strictures. Sequential stricture dilations followed by placement of an increased number and size of plastic biliary stents during ERCP has now become acceptable therapy for postoperative biliary strictures. Several issues are to be considered before embarking on endoscopic treatment of bile duct obstruction caused by clips. First, the common duct must be intact to augment internal drainage with an endoscopic stent. Second, the multidisciplinary team should be involved in all aspects of the care plan. Third, the team should convey to the patient advantages and disadvantages and expected outcomes pertaining to morbidity and long-term success for both surgical and endoscopic treatment. It should be understood that surgical treatment is considered the standard of care for most complex OBDIs and that such surgeries should be performed by experienced hepatobiliary surgeons at a referral center to optimize chances for best long-term outcomes.
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Figure 4. A, Multiple plastic stents placed at ERCP to treat operative bile duct injury. B, Final cholangiogram after stent extractions after a course of endoscopic therapy.

DISCLOSURE All authors disclosed no nancial relationships relevant to this publication.

Abbreviation: OBDI, operative bile duct injury.

4. Benner KG, Ivancev K, Porayko MK, Rosch J. Re-establishment of biliary tract continuity by a combined ERCP and PTC approach after iatrogenic common bile duct ligation. Gastrointest Endosc 1992;38: 506-9. 5. Baron TH, Feitoza AB, Nagorney DM. Successful endoscopic treatment of a complete transection of the bile duct complicating laparoscopic cholecystectomy. Gastrointest Endosc 2003;57:765-9.

REFERENCES
1. Weber J, Adamek HE, Riemann JF. Endoscopic stent placement and clip removal for common bile duct stricture after laparoscopic cholecystecomy. Gastrointest Endosc 1992;38:181-2. 2. Wright TB, Bertino RB, Bishop AF, et al. Complications of laparoscopic cholecystectomy and their interventional radiologic management. Radiographics 1993;13:119-28. 3. Funnell IC, Bornman PC, Krige JEJ, et al. Complete common bile duct division at laparoscopic cholecystectomy: management by percutaneous drainage and endoscopic stenting. Br J Surg 1993;80:1053-4. Methodist Dallas Medical Center, Digestive Health Associates of Texas (P.R.T., J.D.L.), Methodist Dallas Liver Institute (A.M., S.S.C.), Surgical Associates of Dallas (R.D., R.J.), Dallas, Texas, USA. Reprint requests: Paul R. Tarnasky, MD, 221 W Colorado Blvd, Suite 630, Dallas, TX 75208. Copyright 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.07.029

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