Endoscopic approaches to common bile duct injuries.

Operative injury of the biliary tree is not a new complication of cholecystectomy but has become increasingly more visible during the emergence of the laparoscopic approach. Optimal treatment of such problems depends upon early recognition and strategic planning of a therapeutic approach. ERCP has become increasingly important in identifying bile leaks and their source after cholecystectomy. A high index of suspicion is mandatory in patients complaining of discomfort several days after surgery, and liberal use of CT or ultrasound imaging helps identify bile leaks before peritonitis is severe. Once bile leaks or ductal injury are suspected, ERCP should be performed to confirm the leak, identify its site and cause, and help define a therapeutic plan. In minor leaks, endoscopic diversion by sphincterotomy or stenting provides a rapid solution. In more significant injuries where ductal integrity is intact, endoscopic dilatation and stenting may play a role in closing leaks and resolving strictures while averting surgery. Where injury is severe, ERCP, often combined with transhepatic cholangiography, helps to rapidly assess the extent of injury and plan a strategy for operative repair.