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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 cholecystec-

tomy remains about 0.5%. The consequences of OBDI can

be devastating, with risks for major morbidity, costly medi-

cal care, liability risk, and even fatal outcomes.

The mostserious OBDIis a complete ducttransection for  which surgical treatment is obligatory. Complete obstruc-

tion 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 womanwas transferred to ourcare for man-

agement of a bile leak and jaundice after undergoing elec-tive laparoscopic cholecystectomy for symptomatic

cholelithiasis 10 days earlier. Endoscopic retrograde cholan-

giography revealed that several clips had beenplaced on the

bile duct, causing obstruction ( Fig. 1 ) that was confirmed by 

balloon occlusion cholangiography.

Laparotomy was performed the following day. Significant

inflammatory 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 confirmed leak

from the right hepatic duct ( Fig. 2 A) and also from the cys-

tic remnant from which clips had been removed. The com-

mon 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 re-

sidual bile leak and a persistent mild narrowing of the com-

mon hepatic duct ( Fig. 3 ) that was treated with a 10F stent.Balloon stricture dilations with placement of an increased

number of stents ( Fig. 4 A) were performed at 3-month in-

tervals. All stents were removed 10 months after the initial

stent placement. Cholangiography showed no residual

strictures ( Fig.4B). The patienthas 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

Figure 1. Complete bile duct obstruction (arrow) caused by clip place-

ment during cholecystectomy.

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successfully treated a partial bile duct obstruction caused

by a malpositioned cystic duct clip very near the com-

mon duct. Rarely, clips can be displaced by percutane-

ous2 or endoscopic3 means. Two groups were actually able to reestablish bile duct continuity after completetransection.4,5

 As long as ductal continuity remains intact, it is reason-

able to assume that endoscopic therapy will likely be

successful for treatment of residual bile duct leak or stric-

tures. Sequential stricture dilations followed by placement

of an increased number and size of plastic biliary stents dur-

ing ERCP has now become acceptable therapy for postoper-

ative 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 in-ternal drainage with an endoscopic stent. Second, the mul-

tidisciplinary team should be involved in all aspects of the

care plan. Third, the team should convey to the patient ad-

  vantages and disadvantages and expected outcomes per-

taining to morbidity and long-term success for bothsurgical and endoscopic treatment. It should be under-

stood that surgical treatment is considered the standard

of care for most complex OBDIs and that such surgeries

should be performed by experienced hepatobiliary sur-

geons at a referral center to optimize chances for best

long-term outcomes.

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 laparot-

omy. B, Narrowed common duct (arrow) at site of previous clip

placement.

Brief Report

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DISCLOSURE

  All authors disclosed no financial relationships rele-

vant to this publication.

 Abbreviation: OBDI, operative bile duct injury.

REFERENCES

1. Weber J, Adamek HE, Riemann JF. Endoscopic stent placement and clip

removal for common bile duct stricture after laparoscopic cholecystec-

omy. 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 percutane-

ous drainage and endoscopic stenting. Br J Surg 1993;80:1053-4.

4. Benner KG, Ivancev K, Porayko MK, Rosch J. Re-establishment of bil-

iary 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.

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.

Copyrightª 2009 by the American Society for Gastrointestinal Endoscopy

0016-5107/$36.00

doi:10.1016/j.gie.2008.07.029

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.

Brief Report

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