1. Biliary stricture
Guide : Dr M K Chouhan
Professor and HOD of surgery
Dr SNMC,JODHPUR
Candidate-Dr Sumer

2. Biliary stricture

3. definition
A biliary stricture is an abnormal narrowing of
the bile duct, the tube that moves bile (A
substance that helps in digestion) from the
liver to the small intestine

4. Anatomy of biliary tree

5. Pathological effects of biliary
obstruction
Biliary
obstruction
High local
concentratio
n of bile salts
inflammatio
n

6. Pathological effects of biliary
obstruction
Fibrosis
and
scarring
Biliary fistula
Biliary
stasis
Liver
atrophy
Repeated
cholangitis
Biliary cirrhosis and
PHTN

7. Causes of benign stricture
I. Congenital strictures
Biliary atresia
II. Bile duct injuries
A. Postoperative strictures
(1) Cholecystectomy or common bile duct
exploration (accounting 80% of nonmalignant stricture)
(2) Biliary-enteric anastomosis
(3) Hepatic resection
(4) Portocaval shunt
(5) Pancreatic surgery
(6) Gastrectomy
(7) Liver transplantation
B. Stricture after blunt or penetrating trauma

8. Causes of benign stricture
C. Strictures after endoscopic or percutaneous
biliary intubation
III. Inflammatory strictures
A. Cholelithiasis or choledocholithiasis
B. Chronic pancreatitis
C. Chronic duodenal ulceration
D. Abscess or inflammation of liver or subhepatic
space
E. Parasitic infection
F. Recurrent pyogenic cholangitis (Oriental
cholangiohepatitis)
IV. Primary sclerosing cholangitis
V. Radiation-induced stricture

9. Causes of malignant stricture
 Primary tumors
1. Cholangiocarcinoma
2. GB Cancer
3. Pancreatic
adenocarcinoma
4. Ampullary carcinoma
5. Hepatoma
6. Gastric carcinoma
Metastatic tumors
1. pancreatic
adenocarcinoma
2. Colon cancer
3. Breast cancer
4. Lung cancer
5. Melanoma
6. Ovarian cancer

10. Bile duct injury at
cholecystectomy
 Incidence
1.open cholecystectomy 0.1 -0.2%
2.lap cholecystectomy 0.4 -1.3%
 80% of benign strictures occurs following
injury during a cholecystectomy.
 A major factor is surgeons inexperience-
learning curve effect

11. causes
 Anatomic variations
 Technical factors
 Pathologic factors

12. Anatomic variations
(failure to recognize abnormal anatomy
&anomalies)

13. Technical factors
 Experience of surgeon
 Improper assistance
 Extensive dissection
 Excess use of cautery
 Misplacement of clips
 Excess traction on gall bladder
 Subvesical duct of luschka in 1-2 % patients
 CBD Exploration-use of metal bougies
 Attempts to achieve hemostasis

14. Pathologic factors
Acute cholecystitis
inflammation leads to edema in the porta
hepatis and calots triangle—distortion of
anatomy
Chronic cholecystitis
chronic inflammation leads to fibrosis,
adherence, contracted fibrotic gall bladder,
cholecystocholedochal fistula
(partial cholecystectomy, cholecystostomy, and
cholecystocholedochoduodenostomy are
options)

15. Laparoscopicspecific
- Classification of Causes of Laparoscopic Biliary
Injuries
1. Misidentification of the bile ducts as the cystic duct
a. Misidentification of the common bile duct as the cystic
duct
b. Misidentification of an aberrant right sectoral hepatic
duct as the cystic duct
2.Technical causes
a. Failure to occlude the cystic duct securely
b. Plane of dissection away from gallbladder wall into the
liver bed
c. Injudicious use of electrocautery for dissection or
bleeding control
d. Excessive traction on cystic duct with tenting upward of
common hepatic duct
e. Injudicious use of clips to control bleeding
f. Improper techniques of ductal exploration

16. Laparoscopicspecific
Proper exposure –maximum cephalad traction on
fundus with concomitant lateral traction on
infundibulum

17. Location&classification

18. Bismuth`s classification

19. Strasberg`s classification

20. Strasberg`s classification

21. Hannover`s classification

22. Clinical presentation

23. Clinical presentation

24. investigations

33. cholangioscopy

34. Benign Malignant Benign

39. Surgical treatment of BDI
Recognized at operation
 Immediate open conversion and repair by an
experienced surgeon
 If competent help unavailable, put a drain &
should be referred to a specialist center
 End to end repair overT- tube
 Roux –en –Y hepaticojejunostomy
 (silk sutures should be avoided for all biliary
reconstructions, because they can act as
nidus for stone formation)

40. Surgical treatment of BDI
Recognized in immediate postoperative period
 Avoid early reoperation
 Bile leak from cystic duct, subvesical duct of
luschka or from noncircumferential laceration
with no distal obstruction to bile flow may
close spontaneously (1to 3 weeks)
 Endoscopic sphincterotomy with stenting-
hasten closure
 For severe lacerations and complete
transactions –delayed approach is best
(timing of surgical intervention 4-10 weeks)

41. Surgical treatment of BDI
injury presenting at an interval
 Presented as late bile duct stenosis and
stricture
 Consider nonoperative biliary drainage
procedures
 Consider surgery if no resolution in 12 -24
months
 Almost always requires Roux –en –Y
hepaticojejunostomy

46. end t

47. Roux-en-Y Hepaticojejunostomy
Common method of repair of bile duct injury
Proper exposure of healthy ,well vascularised
proximal bile duct
Roux- en –Y Limb of jejunum >60 cm
Mucosa to mucosa tension free anastomosis
Side to side or end to side
hepaticojejunostomy using left hepatic duct

65. •Factors associated with poor outcome
after surgery
 Proximal stricture (Bismuth type 3 and 4)
 Multiple prior attempts at repair
 Portal hypertension
 Hepatic parenchymal disease (cirrhosis or hepatic fibrosis)
 End-to-end biliary anastomosis
 Surgeon inexperience
 Intrahepatic or multiple strictures
 Concurrent cholangitis or hepatic abscess
 Intrahepatic stones
 External or internal biliary fistula
 Intra-abdominal abscess or bile collection
 Hepatic lobar atrophy
 Advanced age or poor general health
 Many authors have advocated the use of anasto

67. Prevention is the
best treatment of
biliary strictures.

68. Thanks