Is there a place for endoscopic management in post-cholecystectomy iatrogenic bile duct injuries?

Abstract

In this editorial we comment on the article by Emara et al published in the recent issue of the World Journal of Gastrointestinal Surgery. Previously, surgery was the primary treatment for bile duct injuries (BDI). The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures. Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years. Patient management, including the specific technique, is typically impacted by local knowledge and the kind and severity of the injury. Endoscopic therapy is a highly successful treatment for postoperative benign bile duct stenosis and offers superior long-term outcomes compared to surgical correction. Based on the damage features of BDI, therapeutic options include endoscopic duodenal papillary sphincterotomy, endoscopic nasobiliary drainage, and endoscopic biliary stent implantation.

Key Words: Post-cholecystectomy, Iatrogenic, Bile duct injuries, Endoscopic management, Benign bile duct stenosis

Core Tip: Post-cholecystectomy iatrogenic bile duct injuries (BDI) are not uncommon and hence deserve more attention. The treatment of BDI has evolved with the improvements in technology and minimally invasive procedure. Endoscopic treatment looks promising and effective treatment options for iatrogenic BDI.

INTRODUCTION

Post-cholecystectomy bile duct injury (BDI) is a serious complication caused by medical treatment that can lead to narrowing or leakage, significantly affecting quality of life and resulting in high healthcare expenses[1]. Laparoscopic cholecystectomy (LC) is the primary cause of injury in cases of BDI, responsible for around 80% of BDI cases[2]. Although the occurrence of LC-related BDI has decreased, the total number of cases remains significant due to the frequent performance of cholecystectomy[3]. Treating BDI promptly upon discovery is crucial to prevent complications such as biliary peritonitis, suppurative cholangitis, sepsis, secondary multiple organ dysfunction syndrome, and other catastrophic effects[4]. Previously, the primary therapy choices were surgical procedures. The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures[5]. Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years. For patients with BDI, the therapeutic strategies must be adapted not only to the type of injury, but also to the patient’s clinical conditions, taking into consideration the availability of resources and level of expertise of the treating team. Patient management is typically impacted by local knowledge, as well as the nature and degree of the injury.

ENDOSCOPIC SURGERY

Endoscopic surgery is mostly utilized for managing BDI following biliary tract surgery and is the primary treatment for moderate BDI biliary leakage[6]. Research indicates that biliary leakage caused by BDI can be effectively addressed in 78% to 100% of patients with endoscopic or radiographic intervention[7,8]. Based on the injury characteristics of BDI, treatment can involve endoscopic procedures including endoscopic duodenal papillary sphincterotomy, endoscopic nasobiliary drainage (ENBD), and endoscopic biliary stent implantation[9].

ENDOSCOPIC THERAPY FOR POSTOPERATIVE BENIGN BILE DUCT STENOSIS

Endoscopic therapy is an excellent treatment for postoperative benign bile duct stenosis (BBS) and provides superior long-term outcomes compared to surgical correction[10]. To tailor the optimal treatment method for each patient, it is essential to individualize each specific situation. The effectiveness rate of endoscopic therapy ranges from 60% to 90% in extensive investigations[11,12]. A study conducted on the long-term follow-up of postoperative treatment for BBS demonstrated that endoscopic treatment was deemed safer, effective, less intrusive, and reproducible[13]. Therefore, endoscopic retrograde cholangiopancreatography + ENBD was suggested as the optimal treatment for BBS. Full coverage self-expanding metal stents are now the primary treatment for BBS, surpassing plastic stents because to their notable benefits of increased safety and success rates, uncomplicated technology, and reduced need for endoscopic procedures[14,15]. Roux-en-Y hepaticojejunostomy should be considered in patients with significant bile duct resection or ischemia, provided that the surgical route is not restricted.

NEW TECHNOLOGIES IN ENDOSCOPIC THERAPY

Full coverage self-expanding stents should be the primary therapy option for individuals with BBS[16]. Traditional endoscopic or percutaneous interventional therapy may not be effective in achieving biliary drainage in severe BBS. New technologies, like small-diameter through-the-scope magnets (2.4 mm), have been created to enhance the success and effectiveness of endoscopic therapy. These magnets are simple to position and offer both safety and efficacy. Treating entire blockage of biliary connections following a whole liver transplant is highly effective[17]. Magnetic compression anastomosis relies on the fibrosis and necrosis of the constricted tissue. Endoscopists and interventional radiologists position magnets at opposite ends of a narrow area using endoscopic technology to create a magnetic force for bile duct anastomosis. Magnetic compression anastomosis has been proven effective and safe in multiple case reports and series[18]. Endoscopic ultrasound guided biliary drainage is a new device that offers the benefits of endoscopy and percutaneous methods without the need for a catheter[19].

STENT SIZE AND SPHINCTEROTOMY

The significance of stent size and sphincterotomy in decreasing the pressure gradient across the sphincter of Oddi is still a topic of debate. A bigger stent theoretically enhances biliary drainage. In a single randomized experiment, 7-Fr and 10-Fr stents were compared for their effectiveness in resolving bile leaks. The results indicated a slight tendency towards better resolution with the bigger 10-Fr stents, however this difference was not statistically significant. Furthermore, unresolved cases with 7-Fr stents were addressed by inserting a bigger stent[20]. The data does not provide conclusive evidence, although the current study did show a non-significant decrease in time to resolution when using bigger stents. There is less agreement on the effectiveness of sphincterotomy combined with stent placement in treating these patients. Avoiding a sphincterotomy when feasible reduces the risk of bleeding or perforation[21]. Sphincterotomy is linked to a rise in complication rates ranging from 7.3% to 9.8% and a death rate of up to 1.3%[22]. Sphincterotomy is contraindicated in patients with coagulopathy. Mavrogiannis et al[23] showed that sphincterotomy did not provide any extra advantage in resolving leaks. However, they and other authors propose that there might be an increased occurrence of pancreatitis in the absence of sphincterotomy[24,25].

CLINICAL IMPLICATIONS

Prevention is the most effective approach to treating diseases, like BDI. Therefore, it is crucial to have a thorough understanding of the risk factors associated with BDI. Effective management of BDI necessitates the cooperation of multidisciplinary teams, leveraging the unique strengths of each department, and taking into account various factors such as common BDI classification, patients’ liver function grade, comorbidities, multi-organ function, and infection control. This approach aims to develop a rational, comprehensive, and personalized treatment strategy to optimize patients’ clinical outcomes[26].

CONCLUSION

Previously, the primary therapy options for BDI were surgical procedures. The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures. Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years. Patient management is typically impacted by local knowledge, as well as the nature and degree of the injury. Endoscopic therapy is an excellent treatment for postoperative benign BBS and provides superior long-term outcomes compared to surgical correction. BDI damage characteristics can be treated with endoscopic procedures such endoscopic duodenal papillary sphincterotomy, ENBD, and endoscopic biliary stent implantation.