Treatment of common bile duct injuries during laparoscopic cholecystectomy: endoscopic and surgical management

The increase of laparoscopic cholecystectomy has resulted in an increase of bile duct injuries. The purpose of this article is to define the types of injury, their occurrence and frequency, and their management by endoscopic and surgical techniques. Three investigations were included in the present study. 1. A 3-year retrospective study among 29 hospitals with 25,007 laparoscopic cholecystectomies. 2. An 8-year prospective study at our institution of 6488 patients. 3. A prospective endoscopic study of 94 patients with injuries and strictures of the common bile duct (CBD) after laparoscopic cholecystectomy. A special classification for bile duct injuries was developed. Among 25,007 patients from 29 hospitals, a total of 74 lesions were detected with an incidence of 0.29%. At our institution, 20 cases were seen (0.29%) with type I, II, and III injuries. The 94 cases managed by endoscopic procedure were submitted to endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, with placement of several stents 5 to 10 F during 8 months. The results of this procedure have been excellent to good in 76% of the cases up to 3 years of follow-up. According to our previous and present experience, bile duct injuries after laparoscopic procedure are two times higher than after open procedure. The best treatment is the prevention of these injuries by careful surgical technique. If they occur, the best moment to repair them is during surgery. If they are noticed after the operation, endoscopic or surgical procedures can be employed.     

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 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.     

腹腔镜胆囊切除术中胆管损伤的预防

目的总结腹腔镜胆囊切除术中胆管损伤的原因及其防治方法. 方法回顾分析1 000例腹腔镜胆囊切除术临床资料. 结果中转开腹手术15例(1.5%);并发症6例(0.6%),其中胆总管损伤3例,胃穿刺损伤1例,腹壁刺口出血1例,胆漏1例.无远期并发症. 结论胆道牵拉成角是胆管损伤最常见原因.     

胆囊切除术胆管损伤的原因分析与处理

目的探讨胆囊切除术导致胆管损伤的原因及损伤后的处理方式。方法对21例胆囊切除术引起胆管损伤的损伤原因及处理方式的临床资料进行回顾性分析。结果损伤原因主要有：（1）胆囊急性炎症期进行手术8例,（2）经验不足5例,（3）Calot三角结构不清3例和解剖变异3例,（4）术中出血导致损伤2例。在处理方式上,本组有3例在术中发现胆管损伤后即时进行修复,12例在术后14d内修复,均取得良好的效果。另外6例在损伤后15d-95d之间进行修复,其中4例恢复良好,1例术后存在慢性胆管炎,死亡1例。绝大部分17例的病例采用胆管空肠Roux-en-Y吻合术,恢复良好15例。结论胆囊切除术导致的胆管损伤应由有经验的肝胆外科专科医生进行修复．早期修复是可行的,胆管空肠吻合术是首选的手术方式。     

Delayed presentation of bile duct injuries after laparoscopic cholecystectomy

Bile duct injury is a serious complication of laparoscopic cholecystectomy, with 50% of bile duct injuries showing a delayed presentation. We experienced four patients (one male and three female) with bile duct injuries after laparoscopic cholecystectomy performed and referred by a local practitioner. The patients' ages ranged from 34 to 63 years. Symptoms included abdominal pain, anorexia, jaundice, ascites, ileus, fever, and tarry stool. Ductal injuries were a result of electrocautery burn in two patients and biliary strictures were due to malapplication of endoclips in the remaining two. The observed bile duct injuries, confirmed by ultrasonography, computed tomography (CT) scanning, and cholangiographic studies, were successfully treated by choledochotomy with a silastic T-tube stent. To avoid bile duct injuries, laparoscopic cholecystectomy should be performed by a well trained and experienced hepatobiliary surgeon, who should ensure accurate identification of the anatomical structures of Calot's triangle, careful dissection and management of intraoperative bleeding, and a lower threshold for conversion to open surgery.     

Management of major bile duct injuries after laparoscopic cholecystectomy

Background: The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of major bile duct injuries (MBDI) after laparoscopic cholecystectomy (LC).Methods: We performed a retrospective analysis of 27 patients who were treated between January 1995 and December 2002 for MBDI after LC at a single unit in a tertiary center. Major bile duct injury was defined according to the Strasberg classification. All patients underwent magnetic resonance cholangiography (MRC), percutaneous transhepatic cholangiography (PTC), or endoscopic retrograde cholangiopancreatography (ERCP) to delineate the biliary anatomy and assess the level of injury. On the basis of the cholangiographic findings, all patients underwent Roux-en-Y hepaticojejunostomy after a waiting period of 8-12 weeks.Results: A total of 29 hepaticojejunostomies were performed in 27 patients. Seventeen patients (63%) presented with biliary fistula and ascites; 10 (27%) presented with obstructive jaundice. In 14 patients (52%) the MBDI was identified during the LC. Twenty patients (74%) had undergone one or more procedure before referral. Eight patients (30%) had E1, five patients (18.5%) had E2, nine patients (33%) had E3, and five pattients (18.5%) had E4 injury. Two patients had early anastomotic stricture, for which redo hepaticojejunostomy with access loop was performed.Conclusions: Major bile duct injury after LC commonly presents with biliary fistula and ascites. High-injuries are common after LC. Hepaticojejunostomy repair yields excellent results in these cases.Presented at the First European Endoscopic Surgery Week, at the annual meeting of the European Association for Endoscopic Surgery (EAES), Glasgow, Scotland 15–18 June 2003     

腹腔镜胆囊切除术中胆管损伤的调查分析

目的 调查分析腹腔镜胆囊切除术(LC)中引起胆管损伤的原因和损伤后的处理方法.方法 对广东省内10家大型三甲医院所发生的和收治外院转入的LC胆管损伤病例进行调查,获得自1993年10月至2007年11月发生的LC胆管损伤病例110例,对病例数据进行统计学分析.结果 110例LC胆管损伤病例中,在该10家大型医院内发生者58例(52.7%),而在外院损伤后转入者52例(47.3%).损伤原因包括:(1)经验不足(48.2%);(2)胆囊急性炎症期进行手术(20.0%);(3)Calot 三角结构不清(15.5%)和解剖变异(11.8%);(4)术中出血导致损伤(4.5%).损伤部位主要在胆总管和肝总管.106例接受且H管修复手术或内镜下放置胆管支架,术后恢复良好率达95.3%,病死率为0.9%,有3.8%的病例手术后仍有胆管炎发作.有63例患者采用胆管空肠吻合手术治疗,术后恢复良好率达93.7%;修复手术在损伤后30 d内实施的占63.2%;83.0%的病例一次手术修复成功.结论 经验不足和解剖不清等主观因素是LC术中胆管损伤的主要原因;LC术中胆管损伤的修复需要由有胆管修复经验的肝胆外科医牛进行,及时转诊可以使患者获得良好的疗效.早期进行修复是可行的.     

Managing bile duct injury during and after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now the treatment of choice for gallstones, but there has been concern that bile leakage after a laparoscopic cholecystectomy is more frequent than after an open cholecystectomy. We have experienced 16 patients with bile duct injury after a laparoscopic cholecystectomy. Five patients had a circumferential injurury to the major bile duct, and we employed a converted open technique for biliary reconstruction. The other 11 patients had partial injurury to the major bile duct, and we performed laparoscopic restoration; all 11 of these patients received endoscopic retrograde cholangiography (ERC) on the day after the operation and stenting for biliary decompression and drainage. No complications were identified and the duration of hospitalization in these patients was significantly shorter than in those who had the converted procedure. If intraoperative cholangiography is performed routinely, the presence and form of bile duct injury can be clearly identified, and the decision to restore the site of injury or to convert to the open technique for biliary reconstruction can be made immediately. Received for publication on May 26, 1998; accepted on Aug. 28, 1998     

Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy (LC) is associated with an increased incidence of bile duct injuries when compared with the open surgical technique. Long-term results of repaired injuries and hepatic damage associated with chronic biliary obstruction are lacking. METHODS: From Aug 1, 1991 until Dec 1, 1999, there were 27 patients referred for management of complex biliary injuries that occurred during LC. Patients underwent percutaneous transhepatic cholangiography and placement of transhepatic catheters with computed tomography-guided biloma drainage when indicated. On the basis of the cholangiography findings, patients underwent Roux-en-Y hepaticojejunostomy (HJ) and liver biopsy or were treated with nonsurgical interventions. RESULTS: Twenty-one of 27 patients (77. 8%) underwent HJ, and 16 of these 21 patients (76.2%) also underwent hepatic biopsy. In 1 patient, a recurrent stricture developed at 20 months after the initial repair; and, in a second patient, an episode of cholangitis developed in the postoperative period with the transhepatic catheters in place. Five of 16 patients (31.2%) demonstrated marked hepatic fibrosis with 4 (25%) of these patients showing evidence of evolving cirrhosis at the time of HJ. CONCLUSIONS: In this series with 55 months of follow-up, HJ repair of LC injuries was associated with an initial 95.2% success rate and an ultimate success rate of 100%. Despite this, delayed referral, averaging 12 months, was associated with significant hepatic injury in 5 of 16 (31.3%) patients who underwent biopsy.     

Trends in bile duct injuries from laparoscopic cholecystectomy

Bile duct injuries are a serious complication of cholecystectomy Laparoscopic cholecystectomies (LC) were originally associated with an increased incidence of injuries Patients referred to a tertiary center were reviewed to assess the trends in the number, presentation, and management Seventy-three patients were referred over a 6-year period with a maximum of 17 patients referred in 1992, but the number has not declined substantially over time The persistent number of referrals is a consequence of ongoing injuries One third of injuries were diagnosed at LC, and the use of cholangiography has not mcreased The number of cystic duct leaks has not decreased and they represent 25% of all cases The level of injury has remained unchanged with Bismuth types I and II in 3 7% and types III and IV in 38% Excluding patients with cystic duct leaks, 58% were referred after a failed ductal repair Definitive treatment with biliary stenting was successful in 37%, and 34 patients (47%) required a bihary-entenc anastomosis Complications occurred in 18 patients (25%) including seven with postoperative stricture or cholangins No biliary reoperations have been performed at a mean follow-up of 36 months Presented at the 1997 Americas Hepato-Pancreato-Biliary Congress, Miami, Fla, February 20–23, 1997     

Management of main bile duct injuries that occur during laparoscopic cholecystectomy

The introduction of laparoscopic cholecystectomy in surgical practice resulted with an increased incidence of bile duct injuries and required new classification systems. This article presents six cases of major bile duct injuries that occurred in our first 1,000 laparoscopic cholecystectomies. Four female and two male patients (ages, 36-71 years) were detected to have major bile duct injuries. Laparoscopic dissection was difficult because of acute inflammation in four patients and fibrosis in two patients. These six cases were between laparoscopic cholecystectomies 26 and 377 performed by the operating surgeons. Three of the patients had type E2 injury according to the Strasberg classification: one detected intraoperatively and the other two postoperatively. All were treated with Roux-en-Y hepaticojejunostomy. The other three patients had type D injuries: two realized intraoperatively and one postoperatively. Two of these injuries were repaired primarily over a T-tube. The remaining patient, whose injury was realized intraoperatively, underwent nasobiliary drainage postoperatively. Only one patient had a complication associated with a trocar injury to the liver parenchima during the first operation. A hepatic abscess and external biliary fistula developed, which were treated conservatively. At this writing, all the patients are well and without problems after 2.5 to 6 years of follow-up evaluation. Difficulties in laparoscopic dissection because of severe inflammation or fibrosis resulted in injuries to our patients. We can underscore the fact that experience may not always protect from complications, and that conversion to laparotomy might have prevented some of these injuries. Patients with a minor injury and a controlled leak can be treated by a combination of surgical and endoscopic or radiologic techniques. The treatment plan must be individualized for every patient, depending on the injury type, presentation, and condition of the patient.     

Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life

OBJECTIVE: To assess the quality of life (QOL) of patients after surgical reconstruction of a major bile duct injury from laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: The incidence of bile duct injuries has increased dramatically since the introduction and widespread use of LC. Previous reports show that at long-term follow-up, most patients surgically repaired will have a successful outcome as measured by standard clinical parameters. However, there is a general impression that these patients have an impaired QOL. Data addressing QOL of these patients are limited. METHODS: A standard QOL questionnaire was sent to 89 patients after successful surgical repair of a major bile duct injury from a LC treated at the Johns Hopkins Hospital between 1990 and 2000. The instrument consisted of 30 items on a visual analog scale categorized into physical (15 items), psychological (10 items), and social (5 items) domains. The same questionnaire was sent to age- and sex-matched healthy controls (n = 100) and to patients who underwent uncomplicated LC (n = 100). An additional portion of the questionnaire inquired about outcome measures and legal action undertaken by patients. RESULTS: Overall QOL scores for bile duct injury patients in the three domains (physical, psychological, and social) were 76%, 77%, and 75%, respectively. QOL scores were comparable to those of patients undergoing uncomplicated LC and healthy controls in the physical and social domains but were significantly different in the psychological domain. Presenting symptoms, prior repair, level of injury, number of stents, length of postoperative stenting, and length of follow-up did not influence QOL scores. Repaired patients reported similar rates of abdominal pain, change in bowel habits, use of pain medications, and recent symptoms of fever or chills as LC controls. Thirty-one percent of responding bile duct injury patients reported having sought legal recourse for their injury. All QOL domain scores were significantly lower in the patients who pursued a lawsuit versus those who did not. CONCLUSIONS: This study provides formal data evaluating QOL after surgical repair of major bile duct injuries from LC. Although there was a significant difference in the QOL as evaluated from a psychological dimension, bile duct injury patients reported QOL scores in the physical and social domains comparable to those of control patients. The decreased QOL assessment in the psychological dimension may be attributable to the prolonged, complicated, and unexpected nature of these injuries. The presence of a lawsuit appears to be associated with a poorer QOL assessment.     

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.     

Common bile duct injuries during laparoscopic cholecystectomy that result in litigation

Background: Iatrogenic common bile duct injury is the worst complication of laparoscopic cholecystectomy. The goal of this study is to increase awareness of the problem and educate surgeons about the consequences of these injuries. Methods: A total of 46 bile duct injuries were analyzed by review of medical records, cholangiograms, videotapes, and surgeon statements. All cases were involved in malpractice litigation. Results: All types of injuries were represented. There were 15 transections, 11 excisions, 6 lacerations, 8 clip impingements, 3 burns, 2 bile leaks, and 1 cystic duct leak. In all, 72% of these injuries occurred in elective cases in which there was no acute inflammation. Cholangiograms were performed in 16 cases, but they were misinterpreted in 11 of them. Injury type and severity was similar in patients with and without cholangiography. A total of 80% of these injuries were not detected at the initial surgery. The average delay in diagnosis was 10 days. Complications were worse in patients with delayed diagnosis. Primary surgeons had less successful outcomes from repairs than referral surgeons (27% versus 79%). In 86% of cases, litigation was resolved in favor of plaintiffs by settlement or verdicts. The average award was $214,000. Conclusions: Factors that predispose to lawsuits include treatment failures in immediately recognized injuries, complications that result from delays in diagnosis, and misinterpretation of abnormal cholangiograms. Injury prevention can be improved by increased awareness of common mistakes. Improved cholangiographic technique and interpretation should decrease injury severity, delays in diagnosis, and subsequent morbidity.     

Outcome of 49 repairs of bile duct injuries after laparoscopic cholecystectomy

Treatment of bile duct injuries after laparoscopic cholecystectomy is still under discussion. The aim of this study was to evaluate the results of end-to-end or biliodigestive anastomosis for various types of bile duct injury. Patient charts of 49 (0.81%) classified bile duct injuries from a national survey of 6076 laparoscopic cholecystectomies in The Netherlands were analyzed. The median follow-up after repair was 183 days (range 14–570 days). Statistical analysis showed that an end-to-end anastomosis was preferred by the surgeons for less severe bile duct injuries and a biliodigestive repair for more severe injuries. Three patients died owing to a delayed detected bile duct injury. Twelve bile duct strictures occurred after repair, leading to a stricture rate of 25%. The time elapsed between repair and occurrence of a stricture was 134 days (range 13–270 days). The type of repair or the severity of the bile duct injury did not determine the outcome of the repair. Histologically proved cholecystitis predisposed a stricture at the repair site. It was concluded that treatment of bile duct injuries is associated with a high stricture rate at the repair site of the anastomosis. End-to-end anastomosis is mostly successful for the less severe injury detected during laparoscopic cholecystectomy. For all other cases this repair can at least be considered a temporary internal drainage procedure. The biliodigestive anastomosis can best be considered a delayed repair after a drainage procedure has resolved the local inflammatory status.

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Resumen El tratamiento de las lesiones de la vía biliar durante la colecistectomía laparoscópica es todavía motivo de discusión. El propósito del presente estudio fue comparar los resultados de la anastomosis término-terminal con la anastomosis biliodigestiva en el manejo de los diferentes tipos de lesiones de la vía biliar. Se revisaron las historias de 49 (0.81%) lesiones biliares en un estudio nacional sobre 6.0076 colecistectomías laparoscópicas practicadas en los Países Bajos. El seguimiento medio luego de la reparación fue de 183 días (rango 14–570). El análisis estadístico demostró que la anastomosis término-terminal fue el método preferido por los cirujanos para el manejo de las lesiones menos severas y que la reparación mediante anastomosis biliodigestiva due el de preferencia para las lesiones más graves. Tres pacientes murieron a consecuencia de una lesión no detectada de la vía biliar. Se presentaron 12 estrecheces luego de la reparación, lo bilial significó una tasa de estenosis de 25%. El período transcurrido entre la reparación y la aparición de la estrechez fue de 134 dias (rango 13–270). El tipo de reparación y de gravedad de la lesión de la vía biliar no determinó el resultado final de la reparación. La comprobación histológica de colecistitis apareció como un factor predisponente de estrechez a nivel del sitio de la reparación. Conclusión: El tratamiento de las lesiones de la vía biliar está asociado con una elevada tasa de estenosis en el sitio de reparación de la anastomosis. La anastomosis término-terminal es el procedimiento más exitoso en las lesiones menos graves que sean detectadas durante la colectistectomía laparoscópica. En todos los demás casos, este tipo de reparación debe ser considerado por lo menos como un procedimiento temporal de drenaje interno. La anastomosis biliodigestiva debe ser considerada como una forma tardía de reparación una vez que un procedimiento de drenaje haya resuelto el estado inflamatorio.

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Résumé Le traitement des lésions de la voie biliaire après cholécystectomie laparoscopique reste discuté. Le but de cette étude a été d'évaluer les résultats de l'anastomose termino-terminale ou biliodigestive pour différentes lésions biliaires. Les dossiers de 49 patients (0.81%) parmi 6079 chlécystectomies en Hollande ont été analysés. La médiane de suivi après réparation a été de 183 (14–570) jours. L'analyse statistique a montré que l'anastomose termino-terminale a été préférée pour les lésions peu graves, alors que l'anastomose biliodigestive a été le traitement de choix pour les lésions plus graves. Trois patients sont décédés en rapport avec une lésion de la voie biliaire détectée avec retard. Douze sténoses ont été observées après réparation (25%) avec un délai d'apparition moyen de 134 (13–270) jours. Le type et la gravité de la lésion n'influençaient pas l'évolution finale. La cholécystite prouvée histologiquement était un facteur prédisposant de sténose. En conclusion, le traitement des lésions de la voie biliaire est associée à un taux de sténose élevé à l'endroit de la lésion. Une anatomose termino-terminale est suffisante en cas de lésion mineure, détectée pendant la cholécystectomie laparoscopique. Dans les autres cas, cette modalité peut être une solution de drainage transitoire mais une anastomose biliodigestive est le meilleur traitement après résolution de l'inflammation locale.

     

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 and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy

BACKGROUND: Recent collective reviews have described the management and outcome of bile duct injuries during laparoscopic cholecystectomy. However, few have reported on the clinical significance of concomitant right hepatic arterial injuries. This study was conducted to examine the correlation of combined bile duct and vascular injuries and to evaluate the impact of these injuries on patient morbidity. 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-en-Y hepaticojejunostomy was performed. Eleven patients had a concomitant vascular injury. Arterial reconstruction was performed in addition to Roux-en-Y hepaticojejunostomy in 2 patients. Eight patients underwent other surgical procedures and were not included in the statistical analysis. To evaluate the impact of vascular injuries, univariate and multivariate analysis was performed. RESULTS: The rate of postoperative biliary complications was 21.7% for all patients. Univariate and multivariate analysis identified 2 risk factors for the development of biliary complications after reconstructive surgery: (1) combined bile duct and hepatic arterial injuries (6 of 11 patients [54.5%] vs 4 of 35 patients [11.4%]; P=.006) and (2) surgical repair in active peritonitis (8 of 13 patients [61.5%] vs 2 of 33 [6.1%]; P <.001). In the other, late referred patients with concomitant right hepatic arterial injury, the distal part of the artery was not exposable. After a median follow-up time of 44.6 months (range, 2 to 143.5 months) a successful outcome was achieved in 42 of 46 patients (91.3%), which included the patients who required additional endoscopic or surgical treatment after primary reconstruction. CONCLUSIONS: The outcome of bile duct reconstruction is worse in patients with concomitant arterial injuries. We therefore recommend the assessment of patients with major bile duct injuries for additional vascular injuries. Further studies are needed to evaluate the importance of hepatic arterial revascularization in early recognized injuries to the long-term outcome of bile duct reconstructions.     

Bile duct injuries during laparoscopic cholecystectomy

Surgical Endoscopy -