Prognostic factors in the treatment of the bile duct injuries and strictures

To describe the prognostic factors after surgical reconstruction data. were collected prospectively on 60 patients treated at the Scientific Center of Surgery named after M.Topchubashov and N5 City Hospital with major bile duct injuries and postoperative bile duct strictures between 2000 and 2009. Of the 60 patients 21 had bile duct injuries, other 39 had postoperative strictures. In 15 of 53 patients with iatrogenic injury of bile ducts trauma was recognized and repaired intraoperatively. In 22 patients was early, in 16 patients delayed recognition of bile duct injury. Most of patients had undergone a choledocho (8) or hepaticojejunostomy (33) by Roux. External drainage of bile ducts was performed in 24 patients. Of the 60 patients undergoing surgical reconstruction, 47 hud completed treatment. Of patients who had completed treatment, 82,9% were considered to have a successful outcome (24 patients excellent, 15 patients - good results) without the need for follow-up invasive, diagnostic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture-without external drainage had a better overall outcome (92,9% successful outcome) than patients with drainage of bile ducts (68,4% successful outcome). Number of stents and length of postoperative stenting also were significant predictors of outcome. Type of operation (laparoscopic or open cholecystectomy) had nd significant influence on outcome. At the same time a successful outcome, without the need for biliary stents, was obtained in 87,5% of patients after laparoscopic cholecystectomy versus 71,8% after open cholecystectomy.     

Percutaneous management of bile duct strictures and injuries associated with laparoscopic cholecystectomy: a decade of experience

BACKGROUND: The 1990s were associated with a dramatic increase in bile duct injuries with the widespread use of laparoscopic cholecystectomy (LC). Interventional radiology has an integral role in diagnosing and managing these injuries. Definitive percutaneous management with balloon dilatation might be possible in select patients with intact biliary-enteric continuity, but longterm data are limited. STUDY DESIGN: Data were collected prospectively on 51 consecutive patients with major bile duct stricture or injury associated with LC, treated with percutaneous management, January 1, 1990, to December 31, 1999. Percutaneous transhepatic cholangiography and biliary catheter placement were followed by balloon dilatation and stenting. Outcomes were assessed with direct patient contact or hospital records. RESULTS: All patients completed treatment, and 50 (98%) were stent free at mean followup of 76 months. The success rate of percutaneous management was 58.8%, without need for subsequent intervention. Presenting symptoms, level of injury, and number of stents or dilatations did not predict outcomes. Percutaneous treatment was more likely to fail in patients stented for less than 4 months (p < 0.001). Operative repair at Hopkins before percutaneous management was predictive of a successful outcome (p < 0.05). Including subsequent operations or percutaneous management, successful outcomes were achieved in 98% of patients. CONCLUSIONS: Major bile duct injuries after LC remain a clinical challenge. Although surgical reconstruction is the treatment cornerstone, selected patients with biliary-enteric continuity can achieve successful long-term results with definitive percutaneous management. The combination of percutaneous management and surgical reconstruction results in successful outcomes in virtually all patients.     

腹腔镜胆囊切除术后胆管损伤围手术期处理

目的探讨腹腔镜胆囊切除术后胆管损伤围手术期的处理方法。方法分析我院1989年1月至2005年6月收治的38例腹腔镜胆囊切除术后胆管损伤的临床资料,结合随访结果总结有关围手术期处理方面的经验。结果38例胆道重建包括胆肠吻合术29例和对端吻合及胆管修补术9例,术后均放置胆道支撑管;术后发生胆瘘5例（13．15％）,切口感染4例（10．52％）,腹腔积液3例（7．89％）。胆道引流管3～4周内拔除31例;5～6周拔除7例。随诊6个月～15年,平均93个月,33例（86．84％）手术效果良好,5例（13．16％）术后吻合口狭窄,其中3例再次手术治愈,2例经十二指肠镜介入球囊扩张好转。结论胆管损伤宜术中及时发现和合理的处理;胆管损伤导致严重腹腔感染应尽早探查引流择期再行胆道重建术;胆道重建术后吻合口再狭窄处理前须获得满意的影像学检查结果;是否胆管重建术后常规放置支撑管和通过介入方法行胆管扩张治疗胆道狭窄的疗效有待进一步研究。     

Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management.

OBJECTIVE: The authors provide the results of follow-up evaluation after combined surgical and radiologic management of 89 patients with major bile duct injuries during laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: The incidence and mechanism of injury of major bile duct injuries during laparoscopic cholecystectomy has been clearly defined. Furthermore, a number of series have described the management of these injuries by surgical, endoscopic, and radiologic techniques with excellent short-term results. Long-term follow-up data, however, are lacking in the management of these injuries. METHODS: Data were collected prospectively on 89 patients treated at a single institution with major bile duct injuries after laparoscopic cholecystectomy managed between July 1, 1990, and July 1, 1996. Patients referred with injuries underwent early percutaneous transhepatic cholangiography and biliary drainage. Based on the cholangiographic appearance and clinical situation, patients were managed by either percutaneous balloon dilatation or surgical reconstruction with a Roux-en-Y hepaticojejunostomy with transanastomotic stenting. Follow-up was obtained by personal interview during October 1996. RESULTS: Two patients died without an attempt at definitive therapy. Both deaths were caused by sepsis and multisystem organ failure present at the time of transfer to the authors' institution. The remaining 87 patients were managed initially by either balloon dilatation (N = 28) or surgical reconstruction (N = 59). Ten patients have not completed treatment and still have biliary stents in place. Evaluation of 25 patients completing treatment after balloon dilatation (mean follow-up, 27.8 months) showed a success rate of 64%. Evaluation of 52 patients completing treatment after surgical reconstruction (mean follow-up, 33.4 months) showed a success rate of 92%. All failures were managed successfully by either surgical reconstruction or balloon dilatation. CONCLUSIONS: Major bile duct injuries can be managed successfully by combined surgical and radiologic techniques. This series provides, for the first time, significant follow-up on a large number of patients with overall success rates of 64% after balloon dilatation and 92% after surgical reconstruction. The combination of surgery and balloon dilatation resulted in a successful outcome in 100% of patients treated.     

医源性胆管损伤的原因及处理(附66例报告)

目的探讨胆管损伤和狭窄的防治方法。方法回顾性分析６６例胆囊切除（或伴）胆总管探查术发生胆管损伤及狭窄的原因和治疗。结果１３例胆管损伤在术中发现并立即修复,其中１２例手术治愈,１例术后发生胆管狭窄。５３例胆管狭窄或胆漏在术后被诊断,其中４例行胆管对端吻合（术后均复发狭窄）;４４例行胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合,３６例治愈;５例吻合口狭窄经再手术治愈。８例死亡（死于胆漏感染５例,胆汁性肝硬化３例）。结论胆管损伤若能术中发现并妥善修复常可避免发生狭窄。胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合治疗胆管狭窄可取得较好疗效。     

Treatment of recurrent bile duct stricture after primary reconstruction for laparoscopic cholecystectomy-induced injury

Laparoscopic cholecystectomy (LC) has been accepted as a primary treatment modality for various benign gallbladder diseases. However, bile duct injury has occurred in a non-negligible proportion of patients who undergo LC. The outcome of primary reconstruction for LC-induced major bile duct injuries is usually favorable, but a small proportion of patients revealed serious biliary stricture during follow-up. We described the experience on the treatment for such delayed-onset bile duct strictures that occurred in 5 patients. One patient showed biliary strictures 6 months after primary hepaticojejunostomy, which were successfully treated with radiologic intervention. Other 4 patients underwent right lobectomy and redo hepaticojejunostomy 4 to 16 months after primary biliary reconstruction. No recurrent biliary stricture occurred during mean follow-up of 40 months. In conclusion, prolonged surveillance over 5 years seems necessary for the detection of delayed-onset biliary stricture after primary biliary reconstruction. Delayed-onset bile duct stricture should be treated on the case-by-case basis, with radiologic intervention or radical biliary reconstruction combined with liver resection.     

Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases

BACKGROUND: Bile duct injuries in combination with major vascular injuries may cause serious morbidity and may even require liver resection in some cases. We present two case studies of patients requiring right hepatic lobectomy after bile duct and right hepatic artery injury during laparoscopic cholecystectomy. PATIENTS: Two patients sustained combined major bile duct and hepatic artery injury during laparoscopic cholecystectomy. Surgical management consisted of immediate hepaticojejunostomy with reconstruction of the artery in one patient and hepaticojejunostomy alone in the other patient. In both cases the initial postoperative course was uncomplicated. RESULTS: After 4 and 6 months both patients suffered recurrent cholangitis due to anastomotic stricture. Both developed secondary biliary cirrhosis and required right hepatic lobectomy with left hepaticojejunostomy. The patients remain well 31 months and 4.5 years after surgery. CONCLUSIONS: The outcome of bile duct reconstruction may be worse in the presence of combined biliary and vascular injuries than in patients with an intact blood supply of the bile ducts. We recommend arterial reconstruction when possible in early recognized injuries to prevent late strictures. Short-term follow-up is most important for early recognition of postoperative strictures and to avoid further complications such as secondary biliary cirrhosis.     

Surgical treatment of bile duct injuries following laparoscopic cholecystectomy. Does the concomitant hepatic arterial injury influence the long-term outcome?

BACKGROUND: Bile duct injuries are the most dreaded complication associated with laparoscopic cholecystectomy. Recent collective reviews have outlined the management of bile duct injuries, but only few have reported on the significance of concomitant injuries of the right hepatic artery. This study was conducted to compare the outcome of patients with isolated bile duct injuries and patients with additional vascular injuries. PATIENTS AND METHODS: From January 1990 to February 2002, a total of 54 patients with bile duct injuries during laparoscopic cholecystectomy were surgically treated in our institution. In 46 patients a Roux-Y hepaticojejunostomy was performed. Eight patients underwent other surgical procedures and were not included in the statistical analysis. 11 patients had a concomitant vascular injury. Multivariate analysis was performed to evaluate the impact of vascular injuries. RESULTS: The rate of postoperative biliary complications was 21.7 % for all patients. Patients with combined bile duct and hepatic arterial injuries had a higher risk for the development of a biliary complication (6 of 11 patients (54.5 %) versus 4 of 35 patients (11.4 %); p = 0.006). After a median follow-up time of 61 months (range, 2-164 months) a successful overall outcome was achieved in 42 of 46 patients (91.3 %), which included the patients who required additional endoscopic or surgical treatment after primary reconstruction. The long-term outcome was successful in 9 of 11 patients (81.8 %) with combined bile duct and hepatic arterial injuries and in 33 of 35 patients (94.3 %) with solitary bile duct injury. CONCLUSION: The outcome of patients with combined bile duct and arterial injuries is worse than in patients with isolated bile duct injuries. We therefore recommend the evaluation of patients with major bile duct injuries for additional vascular injuries. Vascular reconstruction should be performed when ever possible in early recognised injuries to prevent late complications.     

Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction

Biliary strictures after living donor liver transplantation (LDLT) with duct-to-duct (D-D) reconstruction are associated with postoperative morbidity and mortality. The aims of this study were to evaluate the long-term outcomes of endoscopic deployment of plastic stents, and to investigate factors associated with the stent deployment failure. Between April 2001 and May 2007, 96 patients received LDLT with D-D reconstruction at Okayama University Hospital. Among them, 41 patients (43%) had anastomotic biliary strictures, and all were referred first for endoscopic retrograde cholangiography (ERC). When deployment was unsuccessful, a percutaneous transhepatic procedure was employed. Successful stent deployment was achieved in 35 out of total 41 patients (85%) by both procedures. Among the 35 patients, 28 had their stents removed as a result of strictures resolution. Eight patients underwent ERC and repeated stent deployment as a result of recurrence of the strictures. Finally, 21 out of 41 (51%) patients with biliary stricture were completely treated by endoscopic therapy during the observation period (median 873 days: range 77–2060). By multivariate analysis, biliary leakage was associated with stent deployment failure. Endoscopic deployment of plastic stents is a first-line therapy for patients with biliary stricture after LDLT.     

Postoperative bile duct strictures

Bile duct strictures are an uncommon but serious complication of primary operations on the gallbladder or biliary tree. Most strictures occur as a result of injury to the bile duct during cholecystectomy. In addition, strictures can occur at the site of previous biliary anastomoses for reconstruction of the biliary tree. Most patients with benign bile duct strictures present soon after their initial operation; however, in some cases, presentation is delayed for years. Cholangiography is essential for defining the anatomy of the biliary tree prior to management. In many cases, nonoperative biliary drainage is useful to treat sepsis and biliary fistulas. A number of alternatives exist for elective repair of bile duct strictures. Experience would suggest, however, that a choledochojejunostomy or hepaticojejunostomy performed through a Roux-en-Y limb of jejunum is the preferable management in most cases. Postoperative biliary stenting may be valuable in optimizing the results. Nonoperative management by percutaneous transhepatic or endoscopic balloon dilatation has been reported to be successful in a number of small series. Long-term results are limited, however. Comparative data suggest that surgical repair for benign postoperative strictures is associated with fewer long-term problems and with similar overall morbidity and costs.     

Management of bile duct strictures. An evolving strategy.

In an effort to determine the role of interventional radiologic and endoscopic techniques in the management of benign biliary strictures, a retrospective analysis was carried out on 194 consecutive patients with bile duct strictures treated at UCLA between 1955 and 1990. Patients were classified as group 1 (1955 through 1979; n = 138) or group 2 (1980 through 1989; n = 56). Follow-up was for a minimum of 24 months and was in excess of 3 years in 179 patients (92%). Although the incidence of recurrent strictures was similar in the two groups (21% and 23%), the reoperation rate was significantly lower (P less than .02) in group 2 (6%) than in group 1 (21%). Percutaneous transhepatic biliary dilatation, used in 20 patients in group 2, was successful in 13 (93%) of 14 patients with anastomotic strictures and three (50%) of six patients with primary strictures (P less than .05). We conclude that surgical reconstruction remains the standard therapy for patients with primary bile duct strictures. Percutaneous transhepatic biliary dilatation has limited usefulness for these patients, but may be more appropriate for those with anastomotic strictures.     

Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies

BACKGROUND: Major bile duct injuries remain a potentially devastating complication after laparoscopic cholecystectomy. A retrospective review was conducted of patients who underwent a biliary-enteric reconstruction of a biliary injury to assess their long-term outcome. METHODS: Retrospective review of bile duct injury database from January 1990 to December 2005. RESULTS: A total of 144 patients were treated for bile duct injury, and 84 (58%) required a biliary-enteric reconstruction. Stratification by Bismuth-Strasberg injury level revealed E1 or E2 in 23, E3 in 33, E4 in 17, E5 in 1, and B+C in 10. Forty-four (52%) were operated within 7 days of laparoscopic cholecystectomy, the remainder operated at a median of 79 days after referral. Early or late mortality occurred in 3 (4%). At a mean follow-up of 67 months, 9 patients (11%) developed a biliary stricture presented at a median of 13 months after bile duct repair. Level of injury was very important in predicting a postoperative biliary stricture: E4 (35%) versus E3 (9%; P = .023), and E4 versus E1, E2 B+C (0%; P = .001). More strictures occurred in patients operated within 7 days of laparoscopic cholecystectomy (19%) versus delayed repair (8%; P = .053). Overall, 90% of patients are alive and nonstented; 5 patients have chronic liver disease (1 on the waiting list for liver transplant). Nonbiliary complications occurred in 15 patients; the total morbidity was 40%. CONCLUSIONS: Bile duct injuries that require a biliary-enteric repair are commonly associated with long-term complications. Level of injury and likely timing of repair predict risk of postoperative stricture.     

Isolated right segmental hepatic duct injury: A diagnostic and therapeutic challenge

Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmentai hepatic duct can be particularly difficult to diagnose in that results of endoscopie retrograde cholangiography (ERC) are usually interpreted as ‘normal’ with no leaks demonstrated. The aim of this study was to describe a single institution’s experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a laparoscopic cholccystcctomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopie retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmentai biliary system, with placement of a percutaneous transhepatic stent. After the biliary leak was controlled, all patients underwent Roux-en-Y hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67%) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89%) of the nine patients are asymptomatic, with a mean followup of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental hepatic ductal inlury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopie retrograde cholangiogram. Management begins with percutaneous access or the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy. Presented at the Fortieth Annual Meeting of The Society tor Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures.

OBJECTIVE: The authors review the treatment and outcome of patients with benign bile duct strictures who underwent biliary enteric repair. SUMMARY BACKGROUND DATA: The authors conducted a retrospective review of all clinical records of patients referred for treatment of benign bile duct strictures caused by surgery, trauma, or common bile duct lithiasis or choledochal cyst. The authors performed univariate and multivariate analyses of clinical and pathologic factors in relation to patient outcome and survivals. METHODS: Eighty-four patients with documented benign bile duct strictures underwent hepaticojejunostomy, choledochojejunostomy, and intrahepatic cholangiojejunostomy during a 15-year period (January 1975 to December 1989). Morbidity, mortality, and patient survival rates were measured. RESULTS: Early and late outcomes correlated neither with demographic and clinical features at presentation nor with etiologic or pathologic characteristics of the stricture. Best results correlated with high biliary enteric anastomoses and degree of common bile duct dilatation independently of bile duct stricture location. CONCLUSIONS: High biliary enteric anastomosis provides a safe, durable, and highly effective solution to the problem of benign strictures of the bile duct. Transanastomotic tube stenting is unnecessary. Endoscopic and percutaneous transhepatic dilatation seems more appropriate for the treatment of patients in poor condition and those with anastomotic strictures.     

Endoscopic treatment of biliary complications after right-lobe living-donor liver transplantation with duct-to-duct biliary anastomosis

BACKGROUND/PURPOSE: The aims of this study were to characterize the features of the biliary complications that occur after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis, and to evaluate the efficacy of treating biliary complications endoscopically. METHODS: The records of 273 consecutive patients who underwent RL-LDLT with duct-to-duct biliary anastomosis from July 1999 through July 2005 at Kyoto University Hospital were reviewed to determine the overall incidence of postoperative biliary complications and the outcome of endoscopic repair of those complications. RESULTS: Biliary complications occurred in 93 (34.1%) of the patients. These complications were: 80 biliary strictures (75 anastomotic and 5 nonanastomotic) and 16 biliary leakages (5 patients with biliary leakage also had a biliary stricture); most (72%) of the anastomotic strictures were complex (i.e., fork-shaped or trident-shaped). The strictures and leakages were repaired by the endoscopic placement of multiple inside stents above the sphincter of Oddi, and by nasobiliary drainage, respectively. The procedure was successful in repairing 51 (68.0%) of the anastomotic strictures and 8 (50.0%) of the biliary leakages. CONCLUSIONS: Endoscopic stenting of the bile ducts is efficacious in treating biliary complications related to RL-LDLT with duct-to-duct biliary anastomosis and the stenting should be attempted before surgical revision of strictures and leakages.     

Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma

Extrahepatic bile duct traumatic injuries are extremely rare and their treatment is difficult and with several controversies. The aim of this study was to offer some more clinical information on their surgical repair and outcome. We present seven patients with extrahepatic biliary tract lesions after blunt abdominal trauma, (isolated gallbladder lesions were excluded) four males and three females from 23 to 51 years of age (mean age 35.1 years). All patients had suffered high-energy blunt abdominal trauma and presented associated injuries, mostly liver trauma and lung contusions. Six gallbladder lesions and six common bile duct injures were identified; a right hepatic duct laceration and a left hepatic duct transection were also present. Injuries were treated either with primary repair or with duct-jejunal anastomoses with Roux-en-Y reconstruction. Principal complications were postoperative anastomotic leakage (1 case) and recurrent cholangitis (3 cases) with or without stricture. Not-diagnosed injuries caused substantial morbidity. We prefer and recommend the use of primary repair in partial ruptures with no significant tissue loss and biliary-enteric anastomoses in large injuries and complete transections because they offer the best long-term drainage with less risk of stricture formation than end-to-end anastomoses. We defend the use of long duration (6 to 9 months) transanastomotic stents.     

Results of surgical treatment of benign strictures of extrahepatic bile ducts

The main reason of benign biliary strictures is the traumatic bile duct injuries during laparoscopic or open cholecystectomy. Although there are growing possibilities of interventional endoscopic treatment of such pathology the definitive operative drainage is in many cases the therapy of choice. There were analyzed the short- and long-term results of surgical reconstruction in 160 patients with of benign strictures of hepaticocholedochus. Complication rate was 12,5%, mortality 2,5%. Median follow-up period was 53,6+/-51,3 month, good and satisfactory long-term results were observed in 76%. There were revealed two factors, predicting poor outcome: biliary fistula (R=0,31; p=0,0053) and reoperations (R=0,309; small er, Cyrillic=0,0058). Conclusion: biliodigestive anastomosis is method of choice for treatment of benign biliary strictures of hepaticocholedochus. Hepaticojejunostomy with Roux-en-jejunal limb is more preferable variant of reconstruction for treatment of benign biliary strictures of HC. Good long-term results can be achieved in most part of the patients. In patient with not wide bile ducts and in technically difficult cases transhepatic biliary drainage is acceptable.     

Chirurgie und interventionelle Techniken bei Gallenwegserkrankungen Kombiniertes Vorgehen oder konkurrierende Verfahren?

Bile duct stones, benign lesions of the bile duct, and malignant stenoses are principal entities requiring an interdisciplinary approach to diagnosis and treatment. There are unequivocal indications for surgical and interventional approaches. In many situations sparse data do not allow for clear-cut recommendations, which leads to a competition of surgical and interventional modes of treatment. In cholecystocholedocholithiasis, therapeutic splitting--endoscopic stone extraction and laparoscopic cholecystectomy--is at present the preferred strategy. The laparoscopic approach, including common bile duct exploration, may prove advantageous in the future. Emergency situations caused by choledocholithiasis--purulent cholangitis and biliary pancreatitis--require interventional treatment. For bile duct injuries with biliary leakage and treatment of short strictures, transpapillary or transhepatic prostheses may be adequate. In extended strictures or bile duct defects, surgical repair is required. In malignant stenoses, surgical treatment provides the longest survival. If operability is excluded, an interventional approach offers substantial palliation. The results of the different forms of stents and prostheses are comparable.     

Percutaneous transhepatic management of complex biliary problems.

A series of 27 patients with complex biliary problems secondary to previous biliary operations is presented. The patients are divided into two groups: (1) patients with acute perioperative biliary problems; all had biliary leak with abscess, biliary cutaneous fistula, and/or stricture following cholecystectomy or common duct exploration and (2) patients with chronic postoperative biliary problems; all had previous repair of biliary stricture or injuries with late stricture formation. Early management of all patients included placement of a percutaneous biliary stent. Abscesses were drained operatively, and biliary leaks or fistulas were allowed to close spontaneously. Jaundice and cholangitis were allowed to resolve. Following stabilization, management of stricture, if present, was addressed. Eight acute patients had strictures, of which four were partial and three were dilated percutaneously. Four were complete and required operative repair. All 12 chronic patients had strictures, of which six were partial and successfully managed with percutaneous dilatation. Four patients also had common duct stones which were successfully crushed percutaneously. The authors conclude that percutaneous transhepatic drainage offers significant advantages in the early stabilization and treatment of patients with complex biliary problems, and that partial strictures of the biliary tree may be managed successfully by percutaneous dilatation.     

Bile duct stricture in an infant with gastroschisis treated by percutaneous transhepatic drainage, biliary stenting, and balloon dilation

A newborn twin with an antenatal diagnosis of gastroschisis underwent staged repair of the abdominal wall defect. She developed multiple fistulae due to ischemic bowel and then abdominal wall dehiscence requiring additional surgical interventions. Obstructive jaundice, first evident at 3 weeks of age, became progressively severe. A stricture of the common bile duct was diagnosed by percutaneous transhepatic cholangiography. The stricture was treated by percutaneous biliary drainage, biliary stenting, and balloon dilation of the common bile duct. These procedures, commonly used in adults for biliary decompression, may be useful alternatives to surgical intervention in infants and children with obstructive jaundice due to bile duct stricture.