Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography

Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P<0.001). Conversion of the LC to a laparotomy, often for repair of the injury, occurred more commonly in the group having a correctly interpreted IOC (P<0.001). Conversion resulted in detection of injuries sooner, resulting in fewer operative procedures to correct the injury (P<0.001). A transecting injury was prevented in at least seven patients when no visualization of the proximal biliary tree was documented by IOC. These partial ductal incisions were treated by t-tube placement. Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six. These data suggest routine IOC may offer significant potential advantages in the detection and subsequent correction of these injuries, as well as preventing extension of partial ductal incisions to complete ductal transections. Surgeons must be able to correctly interpret the IOC. Although routine IOC is suggested, careful dissection principles continue to be most important in the prevention of major extrahepatic bile duct injuries during LC.     

Biliary tract complications in laparoscopic cholecystectomy

Background: The higher risk of biliary tract injury is considered the most significant disadvantage of laparoscopic cholecystectomy. Methods: A national multicenter retrospective study was performed to determine the frequency, etiology, and treatment of biliary tract injuries between January 1, 1991, and December 31, 1994. Follow-up was by questionnaire. Results: Some 148 biliary tract complications were observed during 26,440 laparoscopic cholecystectomies. There was no significant correlation found between the number of LCs performed in one institute and the incidence of biliary tract injuries and postoperative bile leakage, but in the 2nd year of practice, the incidence of both complications decreased. In institutes with more conversions, more cases of bile leakage were also observed. A significant positive relationship was found between biliary tract injuries and postoperative bile leaks. There was no significant relationship between usage of intravenous and intraoperative cholangiography and ERCP. In univariant analysis of the type of injury, the primary treatment modality did not affect the outcome of injury or entail the necessity of reoperation. Obscure anatomy leads to significantly more main bile duct injuries. According to multivariant analysis, the outcome is significantly influenced unfavorably by the necessity of repeated interventions and advanced age. Conclusions: The definitely higher risk of bile duct injury mentioned in early studies was not confirmed. Received: 1 March 1996/Accepted: 26 November 1996     

Biliary tract complications following liver transplantation

INTRODUCTION: Biliary tract complications, which occur in 5.8% to 24.5% of adult liver transplant recipients, remain one of the most common problems following transplantation. The aim of this study was to evaluate these problems and analyze methods of treatment. MATERIAL AND METHODS: From 1989 to 2003, 36 (18.7%) among 193 patients who underwent orthotopic liver transplantations in our center developed biliary complications. Biliary strictures that developed in 18 cases (9.3%) were the most common complications. Clinical manifestations of strictures developed at 2 to 24 months after transplantation. Bile leaks occurred in 10 patients (5.2%), and were diagnosed in along the T-tube 4 cases and was not accompanied by any clinical manifestation. Bile leak to the peritoneum after T-tube removal occurred in 2 patients (1.1%). Solitary gallstone formation in one case (0.5%) was removed with the use of ECPW. One patient required retransplantation within 3 months after transplantation, because of the most severe complication-ischemic necrosis of biliary tract. RESULTS: Uneventful recovery was achieved in 34 patients in the analyzed group (94.4%). There was no case of recurrence during outpatient follow up. Two patients died in late follow-up of unrelated causes: namely, gastrointestinal bleeding due to a duodenal ulcer and multi-organ failure (MOF) due to a third severe episode of acute liver transplant rejection. CONCLUSIONS: Biliary complications remain an important problem in liver transplantation. Endoscopic and radiologic management are effective in the majority of cases. Surgical intervention is obligatory in selected cases.     

Management of bile duct injuries following laparoscopic cholecystectomy

INTRODUCTION: The aim of the present study is to analyse our experience in the treatment of bile duct injury following laparoscopic cholecystectomy and to propose an algorithm for the management. PATIENTS AND METHODS: From January 1990 to March 2002 175 patients with biliary tract injury sustained during laparoscopic cholecystectomy were treated at our institution. We divided the injuries into five basic types according to the mechanism, localisation and time of manifestation of the lesion. Risk factors affecting the outcome after operative repair were analysed by uni- and multivariate analysis. RESULTS: There were 46 patients with peripheral bile leak (Type A). Endoscopic treatment was successful in 92 %. 8 patients presented with an occlusion of the common bile duct (CBD) (Type B). Five of 6 patients with an incomplete occlusion of the CBD could be treated by endoscopic options. Of 52 patients that presented a lateral lesion of the CBD (Type C), endoscopic treatment was successful in 35 patients (67 %), but surgical treatment was necessary in 17 (33 %). 27 patients with a complete transsection of the CBD required surgical reconstruction. Endoscopic treatment was successful in 34 of 42 patients with a late stenosis of the CBD. 11 of 55 patients (20 %) developed postoperative biliary complications. Univariate analysis identified three factors to be significant predictors of outcome: 1. attempts of repair before referral, 2. combined bile duct and hepatic artery injury, 3. Reconstruction in a situation of peritonitis. After a median follow-up of 44.6 months (2-109) a successful outcome was obtained in 51 of 55 (93 %) patients, including those requiring a secondary procedure for recurrent stricture. CONCLUSIONS: Peripheral leakages, small lateral lesions and short stenosis usually can be treated endoscopically. Extended lateral injuries, complete CBD transsections and long stenoses require surgical therapy. For a successful therapy a specialized multidisciplinary team is crucial.     

Comparison of major bile duct injuries following laparoscopic cholecystectomy and open cholecystectomy

BACKGROUND: The mechanism and extent of major bile duct injuries following laparoscopic cholecystectomy differ from those of open cholecystectomy. METHODS: To identify differences in the demographic profile, timing of injury detection, management strategies and outcome, we undertook a retrospective review and analysis of our experience with 55 major bile duct injuries following both laparoscopic and open cholecystectomies over a period of 9 years. RESULTS: Thirty-one major bile duct injuries resulted from laparoscopic cholecystectomy (56%) and 24 of them were sustained after open cholecystectomy (44%). The median time of presentation was 7 days after laparoscopic cholecystectomy and 14 days following open cholecystectomy (P < 0.001). Twenty-eight (51%) patients had injuries recognized intraoperatively in both groups, of whom 18 patients underwent an attempt at primary repair before referral. All patients required subsequent surgical intervention. There were no differences in the clinical presentations between the two groups. However, serum alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase levels were significantly higher following open cholecystectomy (P < 0.05). There was no significant difference in the level of injury between the two groups. All patients underwent surgical repair in the form of a Roux-en-Y hepaticojejunostomy (including two revision hepaticojejunostomies in each group). Surgical outcome did not differ between the groups; however, better results were seen with Bismuth grades 1 and 2 strictures compared with Bismuth grades 3 and 4 strictures for both groups (P < 0.002). CONCLUSION: Major bile duct injuries following laparoscopic cholecystectomy present earlier and with lower levels of serum alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase. There does not appear to be a significant difference between the Bismuth-Strasberg grading of the strictures and the type of surgery carried out.     

Biliary tract injury in laparoscopic cholecystectomy: results of a single unit

Background: Laparoscopic cholecystectomy was introduced into Australia in early 1990. Its rapid increase in acceptance was, however, tempered by reports of an increased incidence of bile duct injury. The aim of this study was to report on the incidence of biliary tract injuries in a single unit, comment on the way they were managed and look at strategies to prevent them. Methods: A retrospective audit was conducted on laparoscopic cholecystectomies performed between January 1992 and March 2001. The data was collated from patient medical record files and yielded a total of 1216 procedures. Results: There were 899 women (74%) and 317 men (26%), with an age range of 13?92 years. Most of the procedures were performed on an elective (94%) rather than emergent basis (6%). There was one bile duct injury (0.09%) and seven bile leaks (0.63%). The single injury involved common bile duct obstruction by a misplaced clip and was successfully managed by chol­angio‐enteric bypass. Of the seven bile leaks, three were from the cystic duct stump, two from the gallbladder bed, and two were unidentified, settling conservatively. Of the five patients actively treated, two underwent therapeutic laparoscopy, two proceeded to laparotomy, and one was managed successfully by endoscopic stenting. Conclusions: Single‐centre studies such as this are important in ensuring that standards of surgery are maintained in a community setting.     

Evaluation of routine upper digestive tract endoscopy before laparoscopic cholecystectomy.

Endoscopy of the upper digestive tract was performed in 376 patients with symptomatic gallstone disease before elective laparoscopic cholecystectomy. Abnormalities were found in 60 patients (16.0 per cent); these included peptic ulcer (n = 14), gastric erosions (n = 15) and oesophagitis (n = 11). Thirty patients were treated medically and two by endoscopic polypectomy. In four patients endoscopy led to cancellation of cholecystectomy; in two the complaints have persisted. Statistical analysis of 28 variables showed few significant differences in symptoms between patients with normal and those with abnormal appearances at endoscopy. It is concluded that routine endoscopy before laparoscopic cholecystectomy is neither clinically useful nor cost effective in patients with symptomatic gallstone disease. This conclusion is related exclusively to patients with typical gallstone symptoms according to the definition used in this department.     

Electromyographic activity of the gastrointestinal tract following cholecystectomy

Electromyographic activity of the stomach and small bowel, both in the fasting and fed states, was evaluated in the postoperative period of 8 patients subjected to cholecystectomy. The migrating motor complex (MMC) was recorded on the first postoperative day in 5 patients, on the second day in 2, and on the third day in 1. Vomiting occurred in 1 patient in whom the MMC was recorded only on the third postoperative day. Feeding caused substitution of the MMC by the fed pattern in the stomach and small bowel in all patients. It is concluded from this study that gastric and small bowel motility is normal on the first 2 days of the postoperative period in most patients subjected to cholecystectomy.

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Resumen La actividad electromiográfica del estómago y del intestino delgado fue valorada en el estado de ayuno y después de haber ingerido 200 ml de leche durante el período postoperatorio en 8 mujeres sometidas a colecistectomia. El tracto gastrointestinal del ser humano exhibe 2 patrones característicos de motilidad, uno en el estado de ayuno, el complejo motor migratorio (CMM), y el que ocurre con la ingesta de alimentos, el patrón de alimentación. La ingesta de alimentos hace que el CMM sea sustituído por un patron no cíclico de picos intermitentes de potenciales que persisten durante todo el período postprandial, el denominado patrón de alimentación.El complejo motor migratorio normal fue registrado en el primer día postoperatorio en 5 pacientes, en el segundo día en 2, y en el tercer día en 1. Se presentó vómito en una paciente en quien el CMM fue registrado sólo hasta el tercer día postoperatorio. La alimentación causó la sustitución del CMM por el patrón de alimentación en el estómago y en el intestino delgado en la totalidad de las pacientes. La conclusión del presente estudio es que la motilidad del estómago y del intestino delgado es normal en los primeras 2 días de la fase postoperatoria en las mayoría de los pacientes sujetos a colecistectomía.

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Résumé L'activité électromyographique de l'estomac et de l'intestin grêle, et à jeun et avec aliments, a été évalueée en période postopératoire chez 8 patients ayant eu une cholécystectomie. Le complexe moteur migrateur (MMC) a été retrouvé le premier jour postopératoire chez 5 patients, le deuxième jour chez 2, et le troisième jour chez 1. Des vomissements se sont produits chez le patient chez qui le MMC a été retrouvé seulement au troisième jour postopératoire. Après l'alimentation, l'aspect électromyographique du MMC a été remplacé par un aspect postprandial chez tous les patients. Cette étude a permis de conclure que la motilité de l'estomac et de l'intestin grêle est normale les deux premiers jours de la période postopératoire chez la plupart des patients qui ont eu une cholécystectomie.

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Supported in part by FINEP grant no. 42.87.0752.00 and CNPq grant no. 40.1310-86.     

Management of bile duct injuries and strictures following cholecystectomy

During 7057 conventional cholecystectomies (1972–1991), 16 bile duct injuries occurred, amounting to a risk of 0.22%. A total of 1022 laparoscopic cholecystectomies were performed without such a complication since April 1990. In a retrospective study, 64 patients (16 of our patients and 48 referrals) with an injury or stricture due to conventional cholecystectomy were investigated. In 14 of our 16 patients the injury was recognized and immediately repaired with a good long-term result of 93%, including one successful repair of a subsequent stricture. Two cases of unrecognized injury were managed by nonoperative means. The group of 48 referred patients comprised 10 early postoperative complications (21%) and 38 strictures after an uneventful cholecystectomy. Of the 64 total patients, 10 (16%) underwent nonoperative treatment, and 54 required surgery. The mean follow-up period after surgery was 7.4 ±4.9 years. Most cases (93%) were repaired by bilioenteric anastomosis (i.e., foremost hepaticojejunostomy) with an 18% restricture rate. Including second and third repairs for restricture, a total of 60 operations (14 primary and 46 secondary reconstructions) were performed without hospital mortality. A good long-term result after stricture repair was achieved in 75% of the patients, whereas 17% had a poor outcome owing to restricture or death (10% had related mortality within 10 years). The other 8% had a moderate result due to recurrent cholangitis. Thus immediate repair of a bile duct injury offers the better chance of a favorable prognosis compared to secondary stricture repair.

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Resumen Se presentaron 16 lesiones de la vía biliar en 7.057 colecistectomías (1972–1991), lo cual significa un riesgo de 0.22%. Desde Abril de 1990 se han practicado 1.022 colecistectomías laparoscópicas sin que se haya prsentado tal complicación.En un estudio retrospectivo se estudiaron 64 pacientes con lesión o estenosis debido a colecistectomía convencional. En 14 de 16 la lesión fue reconocida y reparada inmediatamente con un buen resultado a largo plazo en 93%, incluyendo una exitosa reparación de una estrechez subsiguiente. Dos casos propios de lesión no reconocida fueron manejados por medios no operatorios. El grupo de 48 pacientes referidos estuvo conformado por 10 casos de complicaciones postoperatorias tempranas (21%) y 38 estrecheces luego de colecistectomía hecha sin complicaciones. Diez pacientes (16%) fueron tratados por medios no operatorios y 54 requirieron cirugía. El promedio de seguimiento después de la cirugía fue de 7.4 ±4.9 años. La mayoría de los casos (93%) fueron reparados mediante anastomosis bilioentérica, principalmente hepaticoyeyunostomía con una tasa de reestenosis de 18%. Incluyendo segundas y terceras reparaciones por estenosis, se realizaron 60 operaciones (14 reconstrucciones primarias y 46 secundarias) sin mortalidad hospitalaria. Se logró un buen resultado a largo plazo en 75% de los pacientes con reparaciones por estenosis y 17 pacientes exhibieron mal resultado, a juzgar por reestenosis o por muerte (10% mortalidad en 10 años). Por lo tanto, aparece obvio que la reparación inmediata de una lesión de la vía biliar ofrece la mejor oportunidad de un pronóstico favorable en comparación con la reparación secundaria de una estrechez.

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Résumé Parmi 7057 cholécystectomies traditionnelles réalisées entre 1972 et 1991, on a enregistré 16 lésions de la voie biliaire principale, ce qui représente un risque de 0.22%. Depuis le mois d'avril 1990, on a réalisé 1022 cholécystectomies sous coelioscopie, sans observer un seul de ces accidents. Nous avons analysé rétrospectivement les dossiers de 64 patients ayant une lésion ou une sténose secondaire à une cholécystectomie traditionnelle. Chez 14 de ces 16 observations personnelles, la lésion a été reconnue pendant l'intervention et a été réparée immédiatement avec un résultat à long terme satisfaisant chez 93% de ces patients; un de ces patients a dû être opéré deux fois. Chez deux patients ayant une lésion non reconnue pendant l'intervention, le traitement a été conservateur. Parmi les 48 patients vus en seconde main, il y avait 10 patients ayant une lésion récente, apparue dans les suites immédiates d'une intervention (21%) et 38 sténoses apparues dans les suites d'une cholécystectomie non compliquée. Seulement 10 patients (16%) ont été traités de facon conservatrice alors que 54 patients ont nécessité une réparation chirurgicale. Le suivi moyen a été de 7.4 ±4.9 ans. La plupart des cas (93%) ont été réparés par une anastomose bilio-intestinale, le plus souvent des anastomoses hépatico-jéjunales, avec un taux de resténose de 18%. En incluant les réparations secondaires et tertiaires, un total de 60 interventions (14 reconstructions primitives et 46 reconstructions secondaires) ont été pratiquées, sans aucune mortalité. Les résultats à long terme après réparation biliaire étaient considérés comme des succès chez 75% des patients, alors que 17% des patients ont eu des suites compliquées de resténose ou mort (10% de mortalité en 10 ans). Ainsi, la réparation immédiate des lésions de la voie biliaire offre un bien meilleur pronostic que les réparations secondaires.

     

腹腔镜胆囊切除术中肝外胆管损伤及处理

自１９９２年１月～１９９６年１月，１２５０例病人因胆囊结石或胆囊息肉样病变在本院施行ＬＣ，胆管损伤７例（０．５６％），损伤类型包括：（１）总胆管或总肝管横断各１例；（２）总肝管部分横断２例；（３）电凝损伤总肝管及右肝管各１例；（４）钛夹钳夹右肝管１例。本组处理方法为胆管修补、胆管对端吻合及空肠Ｒｏｕｘ－Ｙ吻合术。本文认为术者操作经验不足、不适当的止血操作、胆囊病变因素及解剖不清是导致胆管损伤的原因。胆管损伤最重要的仍然是术中发现及时处理，则预后良好。     

Biliary lesions after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the suitable treatment for symptomatic cholelithiasis, even if the incidence of biliary lesions following this procedure may be up to threefold higher than that of open cholecystectomy. We report our experience concerning the incidence, aetiopathogenesis, diagnosis and treatment of complications in a homogeneous group of laparoscopic cholecystectomies. In a total of 492 laparoscopic cholecystectomies only three bile duct lesions were observed (0.6%); they were classified according to Bismuth and re-assessed according to Strasberg. They consisted in two biliary leakages and one bile duct stricture. All patients were evaluated by full blood test, ultrasonography and endoscopic retrograde cholangiopancreatography. Endoscopic treatment was successful in the two patients with biliary leakage, while the patient with a stricture required surgical therapy. In conclusion, we suggest that a correct knowledge of the aetiopathogenesis together with a multidisciplinary approach to the diagnosis appear to be the best method for the detection, complete classification and most suitable treatment of symptomatic cholelithiasis.     

Biliary tract papillomatosis

Papillomatosis of the biliary tract is characterised by multicentric papillary lesions of intra and extrahepatic biliary epithelium. It's a rare benign neoplasm of the biliary tract that causes obstructive jaundice with a high rate of malignant transformation. We described a case of papillomatosis of the biliary tract in a woman of 75-years-old, who came to our observation with jaundice, pruritus and fever. The surgical treatment consisted of cholecystectomy, choledochotomy and positioning a definitive T-Tube. We described our experience and the evolution of this disease.     

Biliary fistula and bleeding after cholecystectomy

The authors analysed 303 cases of cholecystectomy performed in their hospital and found that there were 22 cases of biliary fistula (7.2%), subhepatic infection ensued in 3 (0.9%), and massive postoperative bleeding in 5 (1.7%) with two deaths. The histology of the gallbladder bed was studied under microscope in 60 bodies. It was found that the intact gallbladder bed, rich in collagenous, elastic, and reticular fibers was a strong fibromembranous lining adhering to the liver surface, with numerous small blood vessels, bile ductuli, and lymphangiomas going through it. Leaving the lining intact and through and through sutures of any bleeding spots during the process of cholecystectomy and routine drainage of the subhepatic space were suggested by the authors in order to prevent postoperative bile leakage and bleeding.