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Bile duct injuries were historically managed surgically, but with significant morbidity and mortality. Endoscopic intervention has replaced surgery in the majority of cases. The flow of bile is pressure dependent, and it will follow the path of least resistance. The objective of endoscopic therapy is to make the path to the duodenum that of lowest resistance. This requires stenting the sphincter of Oddi or sphincterotomy. The procedure reduces the leakage of bile and allows healing of the defect. Additionally, drainage of large fluid collections either surgically or percutaneously is important for prompt resolution of pain and prevention of infection.

The Bergman classification system is useful for grading severity and prognosticating response to therapy. Type A injuries are leaks from the cystic duct or the ducts of Luschka. They are typically mild and have a near-100% response rate to ERCP with sphincterotomy or stent placement (Figure 32-2). Type B lesions are high-grade leaks of the common bile duct or main hepatic ducts with or without stricturing. These may be amenable to endoscopic therapy, with a 71% response rate to stenting. Bridging the defect with the stent is important for resolution of type B defects. Type C injuries consist of strictures without leak. Endoscopic stent placement is now considered the standard of care for these lesions. Costamagna and others have shown that upsizing and the use of multiple stents are critical to success. Type D injuries are complete transections of the biliary system. Diagnosis is best made by MRCP, and surgical hepaticoje-junostomy is standard of care.

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Sandha GS, Bourke MJ, Haber GB. Endoscopic therapy for bile leak based on a new classification: results in 207 patients. Gastrointest Endosc. 2004;60:567-574. [PMID: 15472680]

Shah JN. Endoscopic treatment of bile leaks: current standards and recent innovations. Gastrointest Endosc. 2007;65:1069-1072. [PMID: 17531644]

Zyromski NJ, Lillemoe KD. Current management of biliary leaks. Adv Surg. 2006;40:21-46. [PMID: 17163093]

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