Surgical management of bile duct injuries following laparoscopic cholecystectomy: analysis and follow-up of 28 cases

BACKGROUND: Biliary tract lesions pose a dreaded complication of laparoscopic cholecystectomy. In a retrospective study we analyzed the clinical presentation, diagnostic and therapeutic management and outcome of 28 patients presenting with iatrogenic bile duct injuries. PATIENTS AND METHODS: Between 1994 and 2001 we treated 28 patients with bile duct lesions following laparoscopic cholecystectomy at our center. Operation notes and charts of all patients were reviewed systematically. A follow-up examination of each patient was performed after a median of 12 months (range 1-90). RESULTS: Twenty-two patients presented with major circumferential bile duct defect lesions. Less severe injuries (n=6) were two minor bile leaks, one bile duct stricture and three tangential lesions. Twenty-six patients were referred to our institution within 16 days (range 0-226 days). Six patients were treated by nonsurgical procedures: endoscopic stenting in four and percutaneous intervention in two. In one of the remaining patients a cystic duct leak was closed via laparotomy, and in 21 a hepaticojejunostomy was performed. Reconstruction of a hepaticojenunostomy was performed in two of these patients. Patients were dismissed from the hospital after a median of 13 days (range 4-156). Four patients presenting with generalized biliary peritonitis required prolonged intensive care. One or more episodes of cholangitis were seen in five patients during follow-up examinations. CONCLUSIONS: Major iatrogenic bile duct injuries are associated with high morbidity and prolonged hospitalization. Interdisciplinary cooperation and early referral to an experienced center is crucial in the management of patients suffering from this affliction. Cholangitis is a marked problem in the follow-up.     

预防腹腔镜胆囊切除术中胆管损伤的单中心经验

目的 探讨联合胆囊管解剖特点与围胆囊三角区分离预防腹腔镜胆囊切除术中胆管损伤的临床应用价值.方法 回顾分析西南医科大学附属中医医院肝胆外科2005年1月至2020年01月开展的9460例LC术的临床资料.结果 本组共开展9460例LC术,全组病例术中均无肝外主要胆管损伤.术后出现并发症18例,其中2005年1月至201...     

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.     

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.

     

Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy

BACKGROUND: Major bile duct injuries usually need operative repair and remain a challenge even for surgeons who specialize in hepatobiliary surgery. The purpose of this study was to evaluate management and short- and long-term outcomes of patients with major complications after cholecystectomy. METHODS: Data were analysed for 54 patients who underwent operation for major bile duct injuries after cholecystectomy between January 1990 and January 2002. Univariate and multivariate analyses were performed to identify risk factors for the development of biliary complications. RESULTS: Complete follow-up data were available for all 54 patients (median duration 61.9 (range 2.6-154.3) months). All underwent Roux-en-Y hepaticojejunostomy. Three patients (6 per cent) died from biliary tract complications during follow-up. Long-term biliary complications occurred in ten patients (19 per cent). Nine patients developed biliary stricture of whom five developed secondary biliary cirrhosis. A successful long-term result was achieved in 50 (93 per cent) of 54 patients, including those who required subsequent procedures. Biliary reconstruction in the presence of peritonitis (P = 0.002), combined vascular and bile duct injuries (P = 0.029), and injury at or above the level of the biliary bifurcation (P = 0.012) were significant independent predictors of poor outcome. CONCLUSION: Successful repair of bile duct injuries after cholecystectomy can be achieved in specialized hepatobiliary units.     

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.     

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.     

Outcome of surgery for bile duct injuries following laparoscopic cholecystectomy: Lahore General Hospital experience

The objective of this study was to describe the management and outcome of repair in patients who sustained bile duct injuries (BDI) following laparoscopic cholecystectomy (LC). This study was conducted in the department of surgery, Postgraduate Medical Institute/Lahore General Hospital, Lahore, over a period of 5 years from April 1999 to March 2004. Twelve patients of BDI following LC were managed during this period. Three out of 725 patients (0.4%) sustained BDI during LC in our own hospital, while 9 (75%) patients were referred from elsewhere. Strasberg type E accounted for majority of the injuries (66.6%). In 8 patients, Roux-en-Y hepaticojejunostomy was done. Excellent outcome after surgical reconstruction of BDI was noticed in 11(91%) patients.     

Bile duct injuries during laparoscopic cholecystectomy: management and outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux-en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux-en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.     

Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients

OBJECTIVE: A single institution retrospective analysis of 200 patients with major bile duct injuries was completed. Three patients died without surgery due to uncontrolled sepsis. One hundred seventy-five patients underwent surgical repair, with a 1.7% postoperative mortality and a complication rate of 42.9%. SUMMARY BACKGROUND DATA: The widespread application of laparoscopic cholecystectomy (LC) has led to a rise in the incidence of major bile duct injuries (BDI). Despite the frequency of these injuries and their complex management, the published literature contains few substantial reports regarding the perioperative management of BDI. METHODS: From January 1990 to April 2003, a prospective database of all patients with a BDI following LC was maintained. Patients' charts were retrospectively reviewed to analyze perioperative surgical management. RESULTS: Over 13 years, 200 patients were treated for a major BDI following LC. Patient demographics were notable for 150 women (75%) with a mean age of 45.5 years (median 44 years). One hundred eighty-eight sustained their BDI at an outside hospital. The mean interval from the time of BDI to referral was 29.1 weeks (median 3 weeks). One hundred nine patients (58%) were referred within 1 month of their injury for acute complications including bile leak, biloma, or jaundice. Twenty-five patients did not undergo a surgical repair at our institution. Three patients (1.5%) died after delayed referral before an attempt at repair due to uncontrolled sepsis. Twenty-two patients, having intact biliary-enteric continuity, underwent successful balloon dilatation of an anastomotic stricture. A total of 175 patients underwent definitive biliary reconstruction, including 172 hepaticojejunostomies (98%) and 3 end-to-end repairs. There were 3 deaths in the postoperative period (1.7%). Seventy-five patients (42.9%) sustained at least 1 postoperative complication. The most common complications were wound infection (8%), cholangitis (5.7%), and intraabdominal abscess/biloma (2.9%). Minor biliary stent complications occurred in 5.7% of patients. Early postoperative cholangiography revealed an anastomotic leak in 4.6% of patients and extravasation at the liver dome-stent exit site in 10.3% of patients. Postoperative interventions included percutaneous abscess drainage in 9 patients (5.1%) and new percutaneous transhepatic cholangiography and stent placement in 4 patients (2.3%). No patient required reoperation in the postoperative period. The mean postoperative length of stay was 9.5 days (median 9 days). The timing of operation (early, intermediate, delayed), presenting symptoms, and history of prior repair did not affect the incidence of the most common perioperative complications or length of postoperative hospital stay. CONCLUSIONS: This series represents the largest single institution experience reporting the perioperative management of BDI following LC. Although perioperative complications are frequent, nearly all can be managed nonoperatively. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.     

Major bile duct injuries after laparoscopic cholecystectomy: A tertiary center experience

Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Several series have described a 0.5% to 1.4% incidence of bile duct injuries during laparoscopic cholecystectomy. The aim of this study was to report on an institutional experience with the management of complex bile duct injuries and outcome after surgical repair. Data were collected prospectively from 40 patients with bile duct injuries referred for surgical treatment to our center between April {dy1998} and December 2003. Prior to referral, 35 patients (87.5%) underwent attempts at surgical reconstruction at the primary hospital. In77.5%of the patients, complex typeE1or typeE2BDIwas found. Concomitant with bile duct injury, seven patients had vascular injuries. Roux-en-Y hepaticojejunostomy was carried out in 33 patients. In two patients, Roux-en-Y hepaticojejunostomy and vascular reconstruction were necessary. Five patients, one with primary nondiagnosed Klatskin tumor, required right hepatectomy. Two patients, both with bile duct injuries and vascular damage, died postoperatively. Because of progressive liver insufficiency, one of them was listed for high-urgency liver transplantation but died prior to intervention. At the median follow-up of 589 days, 82.5% of the patients are in excellent general condition. Seven patients have signs of chronic cholangitis. Major bile duct injuries remain a significant cause of morbidity and even death after laparoscopic cholecystectomy. Because they present a considerable surgical challenge, early referral to an experienced hepatobiliary center is recommended.     

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。     

Late stage stenoses of bile ducts after iatrogenic bile duct injuries following cholecystectomy

INTRODUCTION: Iatrogenic bile duct injuries represent a severe complication after cholecystectomy. For the attending physician therapy and management of these injuries are a challenge. Inadequate and delayed treatment can lead to stenoses at a late stage, which can necessitate further surgical intervention. METHODS: In a study data of 74 patients, who were treated in our clinic for bile duct injuries following cholecystectomy, were analysed retrospectively. RESULTS: A total of 8 patients with late stage bile duct strictures following iatrogenic bile duct injury including the subsequent therapy could be identified. The data of these patients were analysed in respect of cause and strategies to prevent late stage stenoses. In 62 patients the bile duct injury occurred following laparoscopic and in 12 patients following open cholecystectomy. In 16 patients the injury was combined with a vascular lesion. The interval between primary intervention and definitive therapy was 11 days in 53 patients and 1-15 years in 21 patients. In 8 patients the reason for the re-operation after a long interval (1-15 years) was a late stage stenosis. A hepatico-jejunostomy was performed subsequently and during follow-up 5 / 8 patients were symptom-free; 7 patients were re-operated due to a stenosed primary biliodigestive anastomosis and 3 patients each due to atrophy of the right liver lobe and recurrent cholangitis. One patient complained of recurrent cholangitis and a further patient of symptoms due to adhesions. DISCUSSION: If treated inadequately bile duct injuries occurring during cholecystectomy can in the long-term lead to considerable problems such as recurrent cholangitis, late stage stenoses and even to secondary biliary cirrhosis. Therefore, a complex inter-disciplinary therapeutic concept aiming at timely treatment is necessary.     

The role of hepatic resection in the management of bile duct injuries following laparoscopic cholecystectomy

The creation of a specialized hepatobiliary surgery unit at our medical center has resulted in referral of 16 patients with bile duct complications following laparoscopic cholecystectomy over the last 18 months. No patient required conversion to open cholecystectomy. Although no injury was recognized at the time of surgery, 15 of 16 patients became symptomatic within the first 30 days. Two patients died from sepsis and multisystem organ failure after protracted hospital courses. Endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography determined diagnosis and level of injury. Six of seven patients with cystic duct leak underwent successful endoscopic stent placement and one patient sealed spontaneously after percutaneous drainage of a large biloma. Nine patients required surgery that included hepaticojejunostomy (five), T-tube insertion and drainage of abscess (two), or segmental hepatic resection (two). Timely recognition of bile duct complications following laparoscopic cholecystectomy is critical to a successful long-term outcome. Although the majority of cystic duct leaks can be managed with endoscopic stenting, patients with ductal injuries require hepaticojejunostomy. Segmental liver resection may serve an important role in the management of carefully selected patients with high intrahepatic injuries to avoid long-term transhepatic stenting and complications such as episodic cholangitis and late stricture formation.     

Advantages of multidisciplinary management of bile duct injuries occurring during cholecystectomy

BACKGROUND: The aim of the present study was to highlight the advantages of treatment of bile duct injury (BDI) occurring during cholecystectomy on the basis of a multidisciplinary cooperation of expert surgeons, radiologists, and endoscopists. METHODS: Sixty-six patients had major BDIs or short- or long-term failures of repair. BDI was diagnosed intraoperatively in 27 patients (40.9%) and postoperatively in 39 (59.1%) patients. Among referred patients, 30 had complications from bile leak, 15 from obstructive jaundice, and 20 from recurrent cholangitis. Two patients died from sepsis after delayed referral before repair was attempted. Eleven additional patients had minor BDIs with bile leak both with and without choleperitoneum. RESULTS: Of patients with major BDI, surgical repair was performed in 41 (64.1%). Postsurgical morbidity rate was 15.8%, and there was no mortality. The rate of excellent or good results after surgical repair was 78.0% (32 of 41 patients), and this increased to 87.8% (36 of 41 patients) by continuing treatment with stenting in postsurgical strictures. Biliary stenting alone was performed in 23 patients (35.9%), with excellent or good results in 17 (73.9%). More than 200 endoscopic and percutaneous procedures were performed for initial assessment, treatment of sepsis, nonsurgical repair, contribution to repair, and follow-up. Patients with minor BDIs underwent various combinations of surgical and endoscopic or percutaneous treatments, always with good results. CONCLUSIONS: A multidisciplinary approach was of paramount importance in many phases of treatment of BDI: initial assessment, treatment of secondary complications, resolution of sepsis, percutaneous stenting before surgical repair, dilatation of strictures after repair, final treatment in patients not repaired surgically, and follow-up.     

Benign bile duct stricture following cholecystectomy: critical factors in management

Seventy-eight patients with benign bile duct stricture following cholecystectomy were referred for further management over an 8-year period. The majority (58 per cent) had multiple operations before referral. On presentation 90 per cent of patients had abnormal liver function tests, 19.5 per cent a depressed serum albumin, 49 per cent a history of previous major infection, and 14 per cent associated liver disease and portal hypertension. Seventy-two patients (92 per cent) were operated upon: 63 by stricture repair alone, 4 by stricture repair and portal systemic anastomosis, and one by splenorenal anastomosis alone. Of the patients treated by stricture repair alone and no other procedure 90 per cent have a good result with a mean follow-up of 3.3 years, and an operative (30-day) mortality of 3.2 per cent. There were no postoperative deaths in 61 patients in whom stricture repair alone was performed by direct suture techniques, but in the presence of portal hypertension and liver disease the mortality was 27 per cent. Factors influencing a satisfactory stricture repair were the number of previous operations, site of stricture and type of repair. Factors influencing mortality were the number of previous operations, a history of major infection, the site of stricture, pre-operative serum albumin concentration, and the presence of liver disease and portal hypertension.