HPB Surgery, 1994, Vol. 8, pp. 101-105
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Non-Operative Management of a Common
Bile Duct Injury Sustained During
Cholecystectomy.in a Mo.rbidly Obese Patient.
(Non-Operative Repair of CBD Injury)
BOYD C. ASHDOWN*, PAUL V. SUHOCKI*, PAUL S. JOWELL and WILLIAM C. MEYERS
Departments of Radiology*, Medicine and Surgery,Duke University Medical Center, Durham, North Carolina 27710
A 29 year old morbidly obese patient suffered injury to his common bile duct during cholecystec-
tomy. Subsequent access to the biliary tree was obtained by using a long heavy gauge needle after
first opacifying the system with contrast injection through a nasobiliary tube. It is now twenty six
months after initial percutaneous biliary drainage placement and eighteen months after removal
of all biliary' access. The patient is asymptomatic and has normal liver function tests. This
technique can be useful in morbidly obese patients who are at increased risk from surgical repair
of biliary duct injuries.
KEY WORDS: Cholecystectomy laparoscopic cholecystectomy common bile duct injury
morbid obesity nasobiliary tube percutaneous biliary drainage
INTRODUCTION
Injury to the common bile duct during cholecystec-
tomy occurs in 0.1-0.2% of patients1'2'3. Due to the
increased surgical risk in the obese patient4'5, a non-
operative repair was performed.
The standard technique for percutaneous biliary
drainage was unacceptable due to the poor visualiz-
ation of the 22 gauge Chiba needle and the inability to
visualize the nondilated intrahepatic biliary radicals
with injection of contrat as the needle was retracted.
This modified technique involved placement of
a nasobiliary tube through which the biliary ,system
was opacified. Percutaneous access ofthe well visualiz-
ed intrahepatic ducts followed, with an 18 gauge trans-
lumbar aortography needle. The needle provided the
necessary length, rigidity and radiopacity for success-
fully accessing the biliary tree.
This case report emphasizes the importance
of a combined effort between the endoscopist and
Address correspondence to: Paul V. Suhocki, M.D., Department of
Radiology, Box 3808, Duke University Medical Center, Durham,
N.C. 27710, 919-681-2711.
interventional radiologist in the non-operative
treatment of a patient who was at significant risk of
complications related to surgery and general anes-
thesia.
CASE REPORT
The patient is a 19.7 kg., 29 year old caucasian male
(Figure 1) who underwent laparoscopic cholecystec-
tomy at an outside institution for symptomatic
cholelithiasis. Due to technical difficulty, the procedure
was converted to a standard open cholecystectomy.
Division ofthe common bile duct was detected prior to
surgical closure. An end to end choledochostomy was
performed and a #6 ureteral stent was left in the
common bile duct, extending to the skin surface. On
the second post-operative day, biliary drainage from
the common bile duct stent had ceased. A large amount
ofbile began to drain from the suture line as well as two
Jackson-Pratt drains (650cc per day). On the seventh
post-operative day, contrast was injected into the stent,
Which was seen to be no longer within the duct. It was
therefore removed.
101
102 BOYD C. ASHDOWN et al.
Figure Frontal view of morbidly obese male who sustained injury to the common bile duct during open cholecystectomy following
conversion from laparoscopic cholecystectomy.
The patient was transferred to our institution on the
ninth postoperative day. An initial ERCP demon-
strated a site of contrast extravasation in the mid
common bile duct (Figure 2). Attempts at retrograde
passage of a guidewire across the laceration were un-
successful. A 22 gauge Chiba needle could not be
visualized on the fluoroscope when pldced over the
patient's right upper quadrant. The 20 cm. long needle
was also felt to be too short and flexible to traverse the
large amount oftissue between the skin surface and bile
ducts. It was also suspected that contrast filling of
non-dilated ducts would be poorly visualized during
needle re.traction.
A nasobiliary tube was placed with its distal portion
passing through the common bile duct laceration .and
into the periductal space.
Contrast was then injected through the nasobiliary
tube, opacifying the biliary tree as well as the periductal
space at the-site of bile duct injury. An 18 gauge
translumbar aortography needle (Argon Medical,
Athens, Texas) was inserted into the opacified right
hepatic duct. A 0.035 inch angle tipped glidewire
(Medi-tech Boston Scientific Corporation, Watertown,
MA.)was advanced through the needle to the site ofthe
common bile duct injury where it entered the periduc-
tal space. The needle was removed and a 5F teflon
straight catheter (Universal Medical Instrument Cor-
poration, Ballston Spa, New York) was passed. The
catheter tip was lodged in the periductal space (Figure
3).
48 hours later a 0.035 in. Amplatz Super Stiffguide-
wire (Medi-tech Boston Scientific Corporation) was
passed through the 5F catheter. A 0.018 inch Ultra-
Select Nitinol guidewire, 80cm. long with an 8cm.
angled flexible tip (Microvena Corporation, Vadnais
Heights, MN) was directed across the injury site, into
the distal common bile duct and into the duodenum.
An 8F Ring Biliary drainage catheter (Cook) was
passed, with its distal arm positioned in the duodenum
(Figure 4). The catheter was placed to external drain-
age and output from the Jackson-Pratt drains ceased.
The patient was discharged for home on the fifth
post-procedure day with the biliary drainage tube to
external drainage. Contrast extravasation from the site
ofinjury was seen until 16 weeks following the drainage
procedure, at which time the catheter was converted to
internal drainage. Because of a stenosis seen at the site
of injury one month later, the common bile duct was
dilated with a 10mm diameter, 4cm long balloon
(Meadox Surgimed Inc., Oakland, NJ). A 14F Cope
biliary drainage catheter (Cook) was placed and left to
internal drainage. Two months later, the drainage
catheter was replaced with a 5F Multipurpose catheter
(Cook), the tip of which was positioned peripherally in
an intrahepatic duct. This was used as an emergency
access catheter while the patient was given a trial of
NON-OPERATIVE REPAIR OF CBD INJURY 103
Figure2 FRCP demonstrated extravasation of contrast (white
arrowheads)from the common bile duct (black arrows). Contrast has
traveled retrograde into the right intrahepatic ducts (black arrow-
heads).
internal drainage. The patient continued to do well and
the access catheter was removed 6 weeks later. The
patient remains asymptomatic, with normal liver func-
tion tests, at 18 months following catheter removal.
DISCUSSION
Injury to the common bile duct is the most common
complication ofcholecystectomy and can be difficult to
correct. Common bile duct injury occurs most fre-
quently during open cholecystectomy when it is mis-
taken for the cystic duct, resulting in resection ofpart of
the common bile duct and/or the common hepatic
duct6. The injury in this morbidly obese man occurred
during open cholecystectomy and consisted of simple
division of the common bile duct. The surgical pro-
cedure was difficult because of the patient's size, as was
subsequent radiologic management. Non-operative
treatment of the common bile duct injury was chosen
after transfer of this patient because it was felt safer
than an open repair. For obese patients, the mortality
associated with surgery has been reported as being as
high as 6%; this is felt to be caused by: 1) altered
respiratory and cardiovascular physiology making
maintenance of and recovery from general anesthesia
difficult, 2) protracted time of operation and 3) in-
creased post-operative incidence of wound infection,
deep venous thrombosis and pulmonary embolus''5.
This patient also seemed to have an intact biliary
system which was simply leaking and/or stenosed.
Opacification of the non-dilated biliary tree via
nasobiliary tube provided a target, the right hepatic
duct, for aiming the needle. This step also reduced the
risk of complications such as hepatic artery pseudo-
aneurysm, associated with multiple needle passes with
a large gauge needle. We were not sure that contrast
would travel retrograde through the injured duct, but
this step obviated the need for multiple blind needle
passes.
The first description of an 18 gauge used for per-.
cutaneous transhepatic cholangiography was in 19377
and in 1969 for biliary drainage8. The "skinny needle"
technique, using a 22 gauge needle, began in 19749. Our
aortography needle provided the length, rigidity and
radiopacity necessary for this patient. The needles
currently marketed for biliary drainage do not provide
all these features. The increased risk of hemorrhage
and bile peritonitis with an 18 gauge needle (as high as
25% lo)compared with the 5-7.9% rate with a 22
gauge needle11
prohibits its routine use.
A Wallstent was not placed for the benign stenosis
which developed 5 months post-procedure because of
the satisfactory anatomic and physiologic response to
balloon dilatation and the current lack of data on long
term patency of Wallstents. Further intervention can
be performed endoscopically in a retrograde fashion if
stenosis recurs.
Our patient sustained a common bile duct injury
following conversion from laparoscopic cholecystec-
tomy to open cholecystectomy. Technical difficulties
limited the laparoscopic approach. The laparoscopic
method is now considered the procedure of choice in
most patients requiring cholecystectomy12. It was first
described in 1989 by Dubois in France13, and in the
southern United States by Reddick14. Intraoperative
conversion of a laparoscopic to conventional open
cholecystectomy is a complication that occurs with an
incidence of 4.3 percent1. In a prospective analysis of
1,518 laparoscopic cholecystectomies, the Southern
104 BOYD C. ASHDOWN et al.
Figure 3 A nasobiliary tube is coiled in the stomach (closed arrowheads). The distal tip (closed arrows) has passed through the site ofCBD
injury and is coiled in the adjacent tissues. The tip ofthe percutaneouslypassed straightcatheter(open arrows)has also passed through the site
of injury and lies in the periductal tissues.
Figure 4 The nasobiliary tube has been removed. A Ring biliary drainage catheter has been passed into the duodenum. Contrast injection of
the catheter demonstrates extravasation (arrowheads) from the CBD.
Surgeons Club reported a 2.2 percent incidence of
CBD injury among the first 13 operations performed
by a surgeon, subsequently decreasing to 0.1 percent.
This is compared with a probable 0.1-0.2 percent bile
duct injury during conventional cholecystectomyTM 5.
As more surgeons perform laparoscopic cholecystec-
tomy, the interventional radiologist will be involved
more frequently in the management of common bile
NON-OPERATIVE REPAIR OF CBD INJURY 105
duct injuries. The laparoscopic biliary injury tends to
be more serious than the open one, and this technique
is unlikely to be applicable for permanent results.
However, the method described can be used for place-
ment oftubes in a number ofsuch cases in the morbidly
obese patient.
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