The most common presentation is jaundice. Associated symptoms may include pruritus, cholangitis, or less commonly, pain. If the patient has had biliary surgery, they may present with an acute abdomen or sepsis due to a biloma or biliary fistula.

In the absence of prior biliary surgery, stone disease should be suspected.

If a history of prior biliary surgery or instrumentation is present, a benign stricture should be suspected. Postoperative strictures present within the first 6 months in approximately 70% of patients. However, benign strictures can present years after biliary surgery.

In the absence of stone disease and prior biliary surgery, a malignant stricture should be suspected.

A complete history and physical examination is required to ensure the patient does not have evidence of infection or symptoms suggestive of metastatic disease. This assessment also should assess whether the patient is a candidate for major surgery.

A fundamental knowledge of biliary anatomy and the adjacent vascular structures is critical for success, both in deciding whether operative intervention is indicated, and if so, the type of procedure and an approach to ensure it is safe and effective. Biliary anomalies are frequent and should be expected; imaging studies should clearly define these structures and their relationship to each other. Hepatic vasculobiliary anatomic details are reviewed in Part 3, Chapter 15, Surgical Anatomy.

The aim of the diagnostic evaluation is to define the anatomy for restoration of biliary-enteric continuity in patients with benign strictures or plan appropriate palliative care in patients with malignant disease not amenable to curative resection. Magnetic resonance cholangiopancreatography (MRCP) is the initial diagnostic study of choice in patients with obstructive jaundice thought to be due to stone disease. Otherwise, magnetic resonance imaging (MRI) with intravenous contrast and MRCP is the initial study of choice for patients with obstructive jaundice due to a stricture (FIG 1). Ideally, it should be performed prior to any biliary interventions such as endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic cholangiography (PTC). However, most patients come for referral with prior invasive studies or biliary stents in place; these can make image interpretation challenging and/or lead to cholangitis in obstructed segments.

MRI/MRCP gives a detailed view of the biliary tract and the level or type of obstruction when a stricture is the cause (FIG 2). The vascular phases allow assessment of hepatic artery and portal vein involvement in the case of malignant processes and whether the hepatic arteries are intact and patent in cases of benign strictures related to prior biliary surgery. Finally, it allows for the assessment of direct hepatic involvement or metastatic disease.

When contrast for MRI cannot be given or the vascular anatomy is not adequately assessed, B-mode and Doppler ultrasonography (US) is highly accurate in assessing vascular patency and/or involvement.^1,2 It is important to note whether lobar atrophy is present, as this dictates treatment options.

ERC and PTC are supplementary techniques for defining the anatomy of the biliary tract and the extent of a stricture
when these are not clear from the MRCP. Either or both may be used to obtain a tissue diagnosis in unresectable patients or for stent placement to treat symptoms and/or for preoperative preparation. There is considerable debate as to which technique is optimal for treating hilar biliary strictures and this discussion is beyond the scope of this chapter.

To effectively relieve jaundice, approximately 30% of the functioning liver volume must be drained.³ The functioning and proposed drained volumes can be estimated using calculated liver volumes from preoperative cross-sectional imaging (computed tomography [CT] or MRI).⁴ Conversely, drainage of an atrophied hepatic lobe or segment is not effective.

Issues associated with repair of benign strictures are discussed separately from malignant strictures.

Intrahepatic biliary-enteric anastomoses are complex procedures that require experienced, multidisciplinary, hepatobiliary team care. If this is not available at your institution, the patient should be referred to an appropriate institution for definitive repair.

All procedures are done with 2.5× magnification using loupes. This allows for meticulous surgical technique and allows precise dissection and reconstruction.

It is important to establish a standardize approach for biliary-enteric anastomoses. Use this each time and the high intrahepatic anastomosis will be easier to perform.