Begin typing your search above and press return to search.
Volume: 16 Issue: 6 December 2018


Repair of Bile Duct Injury With Autologous Vein Graft and Stent

Objectives: We investigated the effects of autologous vein transplant on bile duct injury repair, through observation of the hepatic and biliary system tissue morphology changes and animal survival after bile duct injury repair.

Materials and Methods: Rabbits were equally divided into groups. Group A had cholecystectomy and common bile duct resection (length of 0.5 cm), transplant of an autologous vein (length of 0.5 cm), and stent implant. Group B had cholecystectomy and common bile duct resection (length of 1.0 cm), transplant of an autologous vein (length of 1.0 cm), and stent implant. The third group (group C) had cholecystectomy only.

Results: Two rabbits died in group A and group B; all experimental animals from group C survived. Regarding liver biochemical indexes at preoperative week 1, at postoperative month 1, and at postoperative month 3, we found no significant differences (paired t test, P > .05). Liver biochemical indexes between groups were also not significantly different (P > .05). At month 3, postoperative liver pathology of experimental animals showed no significant changes and no cholestasis; biliary epithelial cells were seen in the transplant vascular.

Conclusions: We conclude that autologous vein graft can effectively repair bile duct injury for a short coloboma.

Key words : Bile duct resection, Biliary repair, Cholecystectomy, Experimental study


Bile duct injury (BDI) is one of the most serious complications in biliary tract surgery, which can be indicated after trauma, for biliary neoplasms, and for cancer that has infiltrated into the bile duct. Severe bile duct injury can lead to repeated biliary infection, biliary stricture, biliary cirrhosis, liver failure, and even death. Laparoscopic cholecystectomy (LC) has become the standard surgical treatment for gallstone disease and is one of the most routinely performed abdominal procedures by general surgeons. Despite the known benefits of a mini-invasive surgical approach, treatment and prevention of BDI are still challenging because, in most cases, BDI represents a serious problem and can have late complications.1 The incidence of BDI seems to have decreased compared with earlier periods.2 However, several studies have shown a persistently higher rate and complexity of BDI when LC is performed compared with the open procedure (0.3% to 0.6% vs 0.2%).3-6 However, the incidence of BDI in the LC were reported to be different in some retrospective studies.7-9 To date, the best management strategy in terms of timing of repair remains controversial.10-12 Most authors agree that intraoperative recognition of BDI with immediate repair by specialized hepato­pancreatobiliary surgeons offers the best results.13

In recent years, different materials and methods have been reported for BDI repair, with each having different effects. Our study investigated autologous vein graft for repair of BDI using an animal model.

Materials and Methods

This study was carried out in strict accordance with the recommendations in the Guide for the Care and Use of Laboratory Animals of the National Institutes of Health. The animal use protocol has been reviewed and approved by the Institutional Animal Care and Use Committee (IACUC) of Nanchang University.

A total of 24 healthy adult male rabbits (age 4-6 mo) weighing 3 ± 0.5 kg were supplied by the experimental animal center of the Medical School of Nanchang University.

Experiment groups
Rabbits were randomly divided into 3 groups, of 8 rabbits each. Group A had cholecystectomy and common bile duct resection (length of 0.5 cm), transplant of a 0.5-cm rabbit ear margin vein, and implant of a 1.5-cm silicone tube as a stent. Group B had cholecystectomy and common bile duct resection (length of 1.0 cm), transplant of a 1.0-cm rabbit ear margin vein, and implant of a 1.5-cm silicone tube as a stent. Group C had simple cholecystectomy only as an experimental comparison.

Surgical procedure
Under general anesthesia, the rabbit ear vein (0.5-1.0 cm in length according to the requirements of the experimental group) was removed, washed and soaked in physiologic saline solution, and placed in a 1.5-cm silicone stent tube. The silicone tube was bevel shaped at the 2 ends. Resection of the common bile duct was conducted according to the experiment requirements of length. The stent was implanted using 8-0 suture with continuous suturing at the 2 ends. Dry sterile gauze was used to check for bile leakage. We covered the transplant blood vessels with the greater omentum by suturing and fixing the omentum. After the surgical area was washed, we placed a silicone drainage tube next to the bile duct and below the liver; this was externally fixed using 1-0 full thickness silk to suture to the abdominal wall and 0 silk to suture the skin and subcutaneous tissue. Group C had simple cholecystectomy with ends sutured.

Postoperative observation and treatment
After surgery, all experimental rabbits received 0.3 g/day of intravenous ceftriaxone sodium for 3 consecutive days. Experimental rabbits were dissected after death. Observation of bile leakage and collection of intraperitoneal fluid were included as routine examination. Animals that were still alive at postoperative month 3 received air embolization. We opened the abdominal cavity to observe the physiologic and pathologic changes around the surgical site, removed blood vessels (including those involving the upper and lower bile ducts), and collected liver tissue to view pathologic changes after hematoxylin and eosin staining. We collected fasting venous blood from experimental animals during preoperative week 1, postoperative month 1, and postoperative month 3. Liver biochemical tests included measurement of alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, albumin, and alkaline phosphatase.

Statistical analyses
All data are reported as means ± standard deviation and were analyzed with SPSS software (SPSS: An IBM Company, version 20.0, IBM Corporation, Armonk, NY, USA). Paired t tests were used to compare between groups, with one-sample t test used for comparisons within each group. P < .05 was considered to be statistically significant.


Animal survival
One rabbit died of bile leakage and bile peritonitis on postoperative day 3 in group A; another rabbit died of bile leakage, bile peritonitis, and intra-abdominal suppurative infection on postoperative day 4 (intra-abdominal large bile and showing pus moss; this rabbit had fever on preoperative day 1). In group B, 2 rabbits died, one of bile leakage and bile peritonitis in the peritoneal cavity on postoperative day 2 (copious yellow-green liquid in the peritoneal cavity) and one of bile leak and intra-abdominal infection on postoperative day 3 (intra-abdominal turbid yellow-green liquid with stench). All remaining animals survived to 3 months after surgery.

Liver biochemical indexes
All surviving experimental animals had liver biochemical indexes measured on preoperative week 1, at postoperative month 1, and at postoperative month 3. Results are summarized in Tables 1-2-3. Within groups, results at different time points by paired t test were not significant (P > .05). Between groups, results were also not statistically significant (P > .05). No significant changes in liver biochemical indexes were shown preoperatively and post­operatively (Tables 1-2-3).

We observed the specimens’ general forms, the transplanted vascular tissues, and the liver tissue pathologic changes after hematoxylin and eosin staining. Rabbit livers showed no obvious changes. We observed large tissue adhered in the peritoneal cavity and operative region without obvious hyperemia and edema. We also observed anastomotic scarring, smooth mucosa, no anastomotic stenosis, omentum majus, and vascular healing in the repaired area, with little blood permeating from blood capillaries after greater omentum stripping.

With microscopic examination, we observed simple columnar epithelium over the transplanted vascular, a large amount of fibrous tissue in the outer vascular cavity close to the anastomotic with hyperplasia of epithelial cells, goblet cells, and glands compared with normal bile duct pathology (Figure 1C and 1D). Our postoperative examination showed clear liver tissue structure and liver without cholestasis, a phenomenon shown in diseased liver compared with normal liver tissue pathology (Figure 1A and 1B).


Iatrogenic injury accounts for most bile duct injuries; however, the development of LC to replace traditional laparotomy and its gradually popularization has brought good outcomes to patients. This procedure has also brought a greater risk of BDI, with an incidence rate of 0.3% to 0.6% by LC.14 A literature review had reported some severe complications of bile duct injury, such as bile leakage, bile duct stricture, biliary cirrhosis, and even liver failure without other treatment options but liver transplant and combined with liver vascular injury need liver resection.15 These complications can have serious consequences, such as decreased quality of life, a heavy economic burden, and even death.16,17

End-to-end anastomosis of the bile duct and jejunum Roux-en-Y anastomosis have been widely used for biliary repair. The most commonly used method now is the hepatic duct and jejunum Roux-en-Y anastomosis. Postoperatively, these procedures can lead to intestinal content reflux, peptic ulcers, anastomotic stricture, repeated biliary infection, high calculi recurrence rate, and even cholangiocarcinoma.18,19 Because use of the hepatic duct and jejunum Roux-en-Y anastomosis changes the normal biliary physiology, including disuse of Oddi sphincter function, patients can have higher rates of reflux cholangitis and biliary infection. An interrupted jejunum can also prevent intestinal smooth muscle depolarization, causing jejunum peristalsis function disorder. These changes can affect quality of life; long-term regurgitation-stimulated anastomosis can also lead to cancer.20 Maintaining the function of the Oddi sphincter could prevent various complications caused by regurgitation. We used end-to-end anastomosis for less or no biliary tissue defects. Some studies have shown that end-to-end anastomosis has a good effect, with some patients who have biliary strictures achieving good curative effects by endoscopic treatment.21-24 Regarding avoidance of biliary defects, there must be fully dissociated ligaments around the liver, duodenum, and head of pancreas to ensure the anastomosis without tension. However, damaged blood vessels surrounding the bile duct frequently dissociate, affecting anastomotic healing.

Both biologic materials and artificial materials are being used to repair BDI, to restore the physical channel, and to prevent reflux in patients who have unobstructed lower bile ducts and normal function of the Oddi sphincter. Our experiment used autologous vein end-to-end anastomosis, not only directly reducing the tension of anastomosis and reducing the damage of dissociated ligaments around the liver, the duodenum, and the head of pancreas, but also keeping biliary normal physiology and maintaining normal function of the Oddi sphincter.

Tang and associates used the gallbladder wall to repair the injured bile duct in 21 patients with choledocholith. Patients showed no postoperative complications, and the normal function of the gallbladder was preserved. However, this procedure requires a normal gallbladder, without inflammation, edema, or fibrosis. Patients with cholecystectomy were unable to have this procedure.25 Crema and Trentini and associates used the proximal jejunum and mesenteric vascular for BDI repair. After 6 weeks, complete integration was noted between the bile duct mucosa, tube, and duodenum.26,27 Ebata and associates used the pedicled omentum for cholangioplasty. After 5 weeks, histologically, ordinary biliary epithelium overlaid the surface of the grafted omentum, showing that the omentum can obviously accelerate the healing of the bile duct. The patient has remained well at 3-year follow-up.28 Helmy and associates used the stomach wall, based on a vascularized pedicle with the right gastroepiploic vessels, to repair a biliary defect. Histologic evidence of healing was shown.29 With nonbiologic materials, Nakashima and associates designed a new artificial bile duct consisting of collagen sponge and polypropylene mesh for biliary defects. After 2 weeks, the experimental dogs showed similarly normal bile duct structures.30

Vascular tissue structure has a certain tension like the bile duct and has the advantages of rich materials, simple and convenient for collection. In addition, the vascular tissue has clear structure layers compared with the gastrointestinal serosa layer, which is too thick and difficult for anastomosis. Our experiment used the rabbit ear vein and placement of a silicone tube as biliary stent for BDI repair, which covered the greater omentum, increasing the blood supplied and strengthening the anastomosis area’s anti-infection ability. Our results showed that experimental animal groups had the same survival rate. In addition, liver biochemical indexes at preoperative week 1, postoperative month 1, and postoperative month 3 were not significantly different (paired t test; P > .05). Results were also not significant between groups (P > .05). After the surgical procedure, animals had a high survival rate, good bile duct continuity, unobstructed bile duct, and histologically vascular endothelial cell dif­ferentiated bile duct. The use of blood vessels for BDI repair of a short bile duct coloboma is feasible.

Four animals died as a result of bile leakage and peritonitis, which we thought were related to the experimental conditions. During the dissociation procedure of the bile duct, many blood vessels on the surface of the bile duct were damaged. It is also important that the stent is compatible with bile duct size. A big stent forced into the bile duct may cause high tension in the bile duct wall high, causing ischemia and affecting anastomotic healing and perhaps leading to bile duct necrosis and operation failure. A small stent could result in poor external drainage and increased biliary pressure, leading to anastomosis ischemia or even anastomosis burst because of the high pressure. A small-diameter stent also can become shifted and deformed.


An autologous vein graft can effectively repair a BDI for a short coloboma. However, our experimental follow-up was short, necessitating further research of long-term effects.


  1. de Santibanes E, Palavecino M, Ardiles V, Pekolj J. Bile duct injuries: management of late complications. Surg Endosc. 2006;20(11):1648-1653.
    CrossRef - PubMed
  2. Fischer JE. Is damage to the common bile duct during laparoscopic cholecystectomy an inherent risk of the operation? Am J Surg. 2009;197(6):829-832.
    CrossRef - PubMed
  3. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180(1):101-125.
  4. Sicklick JK, Camp MS, Lillemoe KD, et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005;241(5):786-795.
  5. Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford). 2011;13(1):1-14.
    CrossRef - PubMed
  6. Pulitano C, Parks RW, Ireland H, Wigmore SJ, Garden OJ. Impact of concomitant arterial injury on the outcome of laparoscopic bile duct injury. Am J Surg. 2011;201(2):238-244.
    CrossRef - PubMed
  7. Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg. 1993;165(1):9-14.
    CrossRef - PubMed
  8. Shea JA, Healey MJ, Berlin JA, et al. Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. Ann Surg. 1996;224(5):609-620.
    CrossRef - PubMed
  9. Newman L, 3rd, Newman C, Baird DR, et al. An institutional review of the management of choledocholithiasis in 1616 patients undergoing laparoscopic cholecystectomy. Am Surg. 1994;60(4):273-277.
  10. Stewart L, Way LW. Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes. HPB (Oxford). 2009;11(6):516-522.
    CrossRef - PubMed
  11. Sahajpal AK, Chow SC, Dixon E, Greig PD, Gallinger S, Wei AC. Bile duct injuries associated with laparoscopic cholecystectomy: timing of repair and long-term outcomes. Arch Surg. 2010;145(8):757-763.
    CrossRef - PubMed
  12. Perera MT, Silva MA, Hegab B, et al. Specialist early and immediate repair of post-laparoscopic cholecystectomy bile duct injuries is associated with an improved long-term outcome. Ann Surg. 2011;253(3):553-560.
    CrossRef - PubMed
  13. Silva MA, Coldham C, Mayer AD, Bramhall SR, Buckels JA, Mirza DF. Specialist outreach service for on-table repair of iatrogenic bile duct injuries--a new kind of 'travelling surgeon'. Ann R Coll Surg Engl. 2008;90(3):243-246.
    CrossRef - PubMed
  14. Machado NO. Biliary complications postlaparoscopic cholecystectomy: mechanism, preventive measures, and approach to management: a review. Diagn Ther Endosc. 2011;2011:967017.
    CrossRef - PubMed
  15. Truant S, Boleslawski E, Lebuffe G, Sergent G, Pruvot FR. Hepatic resection for post-cholecystectomy bile duct injuries: a literature review. HPB (Oxford). 2010;12(5):334-341.
    CrossRef - PubMed
  16. Cannon RM, Brock G, Buell JF. A novel classification system to address financial impact and referral decisions for bile duct injury in laparoscopic cholecystectomy. HPB Surg. 2011;2011:371245.
    CrossRef - PubMed
  17. Andersson R, Eriksson K, Blind PJ, Tingstedt B. Iatrogenic bile duct injury--a cost analysis. HPB (Oxford). 2008;10(6):416-419.
    CrossRef - PubMed
  18. Ismail A, Ramsis R, Sherif A, Thabet A, El-Ghor H, Selim A. Use of human amniotic stem cells for common bile duct reconstruction: vascularized support of a free amnion graft. Med Sci Monit. 2009;15(9):BR243-247.
  19. Bettschart V, Clayton RA, Parks RW, Garden OJ, Bellamy CO. Cholangiocarcinoma arising after biliary-enteric drainage procedures for benign disease. Gut. 2002;51(1):128-129.
    CrossRef - PubMed
  20. de Reuver PR, Grossmann I, Busch OR, Obertop H, van Gulik TM, Gouma DJ. Referral pattern and timing of repair are risk factors for complications after reconstructive surgery for bile duct injury. Ann Surg. 2007;245(5):763-770.
    CrossRef - PubMed
  21. de Reuver PR, Busch OR, Rauws EA, Lameris JS, van Gulik TM, Gouma DJ. Long-term results of a primary end-to-end anastomosis in peroperative detected bile duct injury. J Gastrointest Surg. 2007;11(3):296-302.
    CrossRef - PubMed
  22. Abdel-Raouf A, Hamdy E, El-Hanafy E, El-Ebidy G. Endoscopic management of postoperative bile duct injuries: a single center experience. Saudi J Gastroenterol. 2010;16(1):19-24.
    CrossRef - PubMed
  23. Vellody R, Willatt JM, Arabi M, Cwikiel WB. Temporary placement of stent grafts in postsurgical benign biliary strictures: a single center experience. Korean J Radiol. 2011;12(6):708-713.
    CrossRef - PubMed
  24. Boerma D, Rauws EA, Keulemans YC, et al. Impaired quality of life 5 years after bile duct injury during laparoscopic cholecystectomy: a prospective analysis. Ann Surg. 2001;234(6):750-757.
    CrossRef - PubMed
  25. Tang LJ, Tian FZ, Cai ZH. Cholecysto-choledochostomy plus construction of subcutaneous cholecystic tunnel in treatment of choledocholith. Hepatobiliary Pancreat Dis Int. 2003;2(1):114-116.
  26. Crema E, Trentini EA, Llanos JC. Proposal of a new technique for bile duct reconstruction after iatrogenic injury: study in dogs and review of the literature. Acta Cir Bras. 2007;22(3):162-167.
    CrossRef - PubMed
  27. Trentini EA, Crema E, Llanos JC, Lerco MM, Magna LA, Leonardi LS. Biliary tract reconstruction using jejunal tube: an experimental study in dogs. Hepatobiliary Pancreat Dis Int. 2009;8(2):179-185.
  28. Ebata T, Takagi K, Nagino M. Hilar cholangioplasty using omentum for ductal defect in biliobiliary fistula. J Hepatobiliary Pancreat Sci. 2011;18(3):458-462.
    CrossRef - PubMed
  29. Helmy AA, Hamad MA, Aly AM, et al. Novel technique for biliary reconstruction using an isolated gastric tube with a vascularized pedicle: a live animal experimental study and the first clinical case. Ann Surg Innov Res. 2011;5:8.
    CrossRef - PubMed
  30. Nakashima S, Nakamura T, Miyagawa K, et al. In situ tissue engineering of the bile duct using polypropylene mesh-collagen tubes. Int J Artif Organs. 2007;30(1):75-85.

Volume : 16
Issue : 6
Pages : 696 - 700
DOI : 10.6002/ect.2016.0309

PDF VIEW [130] KB.

From the 1Department of General Surgery, Medical School of Nanchang University, Nanchang, China; the 2Department of General Surgery, Sanming First Hospital, Sanming, China; the 3Department of Vascular Surgery, the First Affiliated Hospital of Nanchang University, Nanchang, China; and the 4School of Medicine, Shandong University, Jinan, China
Acknowledgements: Bin Xie and Haiping Luo are equal first authors. All authors have no conflicts of interest regarding this paper and no sources of funding to declare.
Corresponding author: Qiang Liu, Department of Vascular Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Street, Nanchang 330006, China
Phone: +86 791 88692523