Management of major biliary complications after laparoscopic cholecystectomy

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.

Repair of bile duct injuries with Gore-Tex vascular grafts: experimental study in dogs

Bile duct injury is the most feared complication related to biliary tract operations. The goal of this investigation was to offer an alternative treatment that might prevent this complication. Twelve mongrel dogs, thin-walled FEP-ringed Gore-Tex vascular grafts, and Gore-Tex sutures were used in this study. The dogs were randomized into three groups of four according to the length of time of graft implantation: group 1 = 1 month; group 2 = 2 months; and group 3 = 3 months. During the first part of the study, a biliary injury was induced by ligating the middle choledocus after performing a conventional cholecystectomy. During the second part of the study, biliodigestive and biliobiliary anastomosis were performed using Gore-Tex vascular grafts prior to resection of the stenotic area. Initially, an increase in serum bilirubin and alkaline phosphatase levels was noted. Two weeks later, after implantation of the grafts, these values returned to normal. Thin-walled FEP-ringed Gore-Tex vascular grafts were found to be useful in the repair of bile duct injuries, especially in complete transections of the common bile duct. The ductility and flexibility of the material allows any type of anastomosis to be performed, especially when bile duct-gut anastomosis is technically difficult.

How do bile duct injuries sustained during laparoscopic cholecystectomy differ from those during open cholecystectomy?

BACKGROUND AND PURPOSE

Bile duct injuries sustained during laparoscopic cholecystectomy differ from those of open cholecystectomy. The authors conducted a retrospective analysis of their experience with 124 major bile duct injuries to identify these differences.

PATIENTS AND METHODS

Biliary injury in 83 patients (67%) was sustained during open cholecystectomy, while in 41 patients (33%), it occurred during laparoscopic cholecystectomy. Intraoperative recognition was possible in 21 patients (25%) in the former group and in 14 patients (34%) in the latter (P < 0.05).

RESULTS

The median time of presentation after laparoscopic cholecystectomy was 37 days v 240 days after open cholecystectomy (P < 0.001). Twenty-eight patients presented with external biliary fistulae in both groups. Spontaneous closure of these fistulae occurred in 21 patients (75%) in the open cholecystectomy group and in only 10 patients (36%) in the laparoscopic group (P < 0.01). Bismuth type III or IV injuries were the commonest type in the laparoscopic cholecystectomy group (N = 25; 61%) while Bismuth type I or II were the usual injuries in open cholecystectomy (N = 57; 69%) (P < 0.01). After hepaticojejunostomy, over a mean follow-up period of 3.4 years, stenosis of the hepaticojejunostomy was seen in two patients in both groups.

CONCLUSION

Compared with open cholecystectomy, biliary injuries sustained during laparoscopic cholecystectomy are more likely to present earlier, are more often associated with persistent bile leaks, and are usually high injuries. However, the results of surgical repair do not appear to be different in these two groups.

Bile Duct Injury following Laparoscopic Cholecystectomy: A Cause for Continued Concern

Previous reports suggest that bile duct injuries sustained during laparoscopic cholecystectomy (lap chole) are frequently severe and related to cautery and high clip ligation. We performed a review of patients who sustained bile duct injury from lap chole since 1990 and assessed time to injury recognition, time to referral, Bismuth classification, initial and subsequent repairs, rate of recurrence, and length of follow-up. Seventy-four patients [median age 44 years, 58 of 74 female (78%)] were referred with a bile duct injury after lap chole. The level of injury was evenly divided between the bile duct bifurcation and the common hepatic duct: Bismuth III, IV, and V (40 of 74, 54%) versus Bismuth I and II (34 of 74,46%). Concomitant hepatic arterial injury was identified in nine (12%) patients. Patients referred early after bile duct injury and requiring operative intervention underwent hepaticojejunostomy at a median of 2 days after referral. After surgical reconstruction at our center there has been an overall success rate of 89 per cent with no need for reintervention. Six (10%) of these patients have required one additional balloon dilatation at a mean follow-up of >24 months. One (2%) patient underwent biliary-enteric revision in follow-up. In patients with bile duct injury, stricture repair without delay was successful in the majority of patients treated in this series. Only one of 64 patients reconstructed at our center has required reoperation; six others have required a single balloon dilatation with subsequent good or excellent results. The majority of patients treated with operative repair at an experienced center can expect good long-term results with rare need for reintervention.

Biliary complications associated with laparoscopic cholecystectomy--an analysis of common misconceptions

BACKGROUND

Several views are expressed by surgeons on biliary complications following laparoscopic cholecystectomy as follow: most are caused by trainees; complications occur in the presence of difficult anatomy/pathology; injuries occur more proximally than at open cholecystectomy; most injuries are recognised immediately and most can be managed non-operatively. The aim of our study was to determine if these views are substantiated in clinical practice.

METHODS

The mode of presentation, management and outcome of thirty-two patients referred to a hepatobiliary unit over a seven year period were analysed.

RESULTS

In 72% of cases the initial operator was a consultant. Five of the 32 complications (16%) occurred in the presence of difficult anatomy/pathology. Two patients had proximal biliary tree injuries, the only mortalities (two) occurring in this group. Only 41% of injuries were detected immediately; 87% required surgical intervention, hepaticojejunostomy being the most common procedure performed (75%).

CONCLUSION

Our study shows that the majority of bile duct injuries are not caused by trainees, do not occur because of unusual anatomy/pathology, do not occur in the proximal biliary tree and are not recognised at the time of operation. Most injuries ultimately require major reconstructive surgery for definitive management.

Postoperative bile duct strictures: management and outcome in the 1990s

OBJECTIVE

To describe the management and outcome after surgical reconstruction of 156 patients with postoperative bile duct strictures managed in the 1990s.

SUMMARY BACKGROUND DATA

The management of postoperative bile duct strictures and major bile duct injuries remains a challenge for even the most skilled biliary tract surgeon. The 1990s saw a dramatic increase in the incidence of bile duct strictures and injuries from the introduction and widespread use of laparoscopic cholecystectomy. Although the management of these injuries and short-term outcome have been reported, long-term follow-up is limited.

METHODS

Data were collected prospectively on 156 patients treated at the Johns Hopkins Hospital with major bile duct injuries or postoperative bile duct strictures between January 1990 and December 1999. With the exception of bile duct injuries discovered and repaired during surgery, all patients underwent preoperative percutaneous transhepatic cholangiography and placement of transhepatic biliary catheters before surgical repair. Follow-up was conducted by medical record review or telephone interview during January 2000.

RESULTS

Of the 156 patients undergoing surgical reconstruction, 142 had completed treatment with a mean follow-up of 57.5 months. Two patients died of reasons unrelated to biliary tract disease before the completion of treatment. Twelve patients (7.9%) had not completed treatment and still had biliary stents in place at the time of this report. Of patients who had completed treatment, 90. 8% were considered to have a successful outcome without the need for follow-up invasive, diagnos tic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture after laparoscopic cholecystectomy had a better overall outcome than patients whose postoperative stricture developed after other types of surgery. Presenting symptoms, number of stents, interval to referral, prior repair, and length of postoperative stenting were not significant predictors of outcome. Overall, a successful outcome, without the need for biliary stents, was obtained in 98% of patients, including those requiring a secondary procedure for recurrent stricture.

CONCLUSIONS

Major bile duct injuries and postoperative bile duct strictures remain a considerable surgical challenge. Management with preoperative cholangiography to delineate the anatomy and placement of percutaneous biliary catheters, followed by surgical reconstruction with a Roux-en-Y hepaticojejunostomy, is associated with a successful outcome in up to 98% of patients.

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.

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 segmental hepatic duct can be particularly difficult to diagnose in that results of endoscopic 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 cholecystectomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopic 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 segmental 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 follow-up 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 injury 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 endoscopic retrograde cholangiogram. Management begins with percutaneous access of the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy.

Antiperistaltic Roux-en-Y Biliary-Enteric Bypass after Bile Duct Injury: A Technical Error in Reconstruction

Bilioenteric reconstruction using a Roux limb of jejunum is a well-established surgical option for the reconstruction of the proximal bile duct. Previous studies discussing short- and long-term complications of biliary-enteric anastomosis have focused on technical aspects, such as the use of anastomotic stenting or the level of the biliary tree used. We report two cases of previously unreported complications after hepaticojejunostomy that resulted from a technical error in constructing the Roux limb. Within a 3-month period, two patients were referred to our institution with recurrent cholangitis after biliary reconstruction for injuries sustained during laparoscopic cholecystectomy. Reexploration disclosed major technical flaws in the construction of the Roux limb used for biliary drainage. Antiperistaltic limbs had been constructed in both patients: one from the distal ileum and one from the conventional location in the jejunum. In both cases, isoperistaltic reconstruction of the Roux limbs resolved the recurrent cholangitis. Cholangitis after biliary-enteric bypass can arise from a variety of etiologies and lead to anastomotic narrowing or ineffective drainage of the biliary tree. Review of the literature failed to disclose reports of technically flawed Roux limb construction as a cause of cholangitis. We present these cases to highlight the devastating consequences of antiperistaltic construction of the Roux limb. We hope that by publishing the role of this avoidable error in recurrent cholangitis after biliary-enteric bypass we may help prevent its future occurrence.

Biliary leaks: treatment by means of percutaneous transhepatic biliary drainage

PURPOSE

To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks.

MATERIALS AND METHODS

Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect.

RESULTS

In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma.

CONCLUSION

Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.

Value of magnetic resonance cholangiopancreatography in demonstrating major bile duct injuries following laparoscopic cholecystectomy

BACKGROUND

Conventionally, recognition of bile duct injuries after laparoscopic cholecystectomy largely relies on endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). However, these invasive procedures are not without risk. Preliminary experience with use of magnetic resonance cholangiopancreatography (MRCP) to identify these injuries is reported.

METHODS

The medical records of five patients who had undergone laparoscopic cholecystectomy and had suspected major bile duct injuries were reviewed. All five patients underwent MRCP, followed by conventional cholangiography: either ERCP or PTC, or both. The findings of MRCP and conventional cholangiography were compared.

RESULTS

Four patients had proven bile duct injuries. The remaining patient had gallstones dislodged into the common bile duct (CBD) during laparoscopic cholecystectomy, which presented as transient jaundice mimicking a bile duct injury. The MRCP images were of higher diagnostic value than conventional cholangiographic images in four patients with frank bile duct injury. For these patients, ERCP showed only the cut-off sign of the CBD, and PTC was needed to visualize the upper biliary system. MRCP, however, demonstrated the entire biliary system proximal and distal to the amputated or stenotic sites simultaneously. In the remaining patient with dislodged gallstones, the two techniques yielded similar diagnostic information.

CONCLUSION

This preliminary study suggests that MRCP is an ideal diagnostic test whenever bile duct injury following laparoscopic cholecystectomy is suspected.

Improvement in the management of bile duct injuries?

BACKGROUND

Previous studies have suggested that improvements in diagnostic workup and treatment of bile duct injuries (BDI) sustained during laparoscopic cholecystectomy can be expected as experience increases with the laparoscopic procedure. Many published articles reported that early diagnosis, proper classification, and optimal timing of treatment of BDI increase the likelihood of successful treatment. This study determined whether diagnosis and management of BDI have improved over the years.

STUDY DESIGN

Between June 1990 and November 1996, 106 patients were diagnosed and treated in the Amsterdam Academic Medical Center for BDI sustained during laparoscopic cholecystectomy. Detailed information was obtained about peroperative findings, time interval from laparoscopic cholecystectomy to symptoms, and interval from symptoms to diagnosis. Bile duct injuries were classified into four types. Two patient groups were compared: BDI patients diagnosed from 1990 until 1994 ("learning phase") and patients diagnosed from 1995 until 1996.

RESULTS

Bile duct injuries combined with bile leakage were diagnosed significantly earlier in the second period after the learning phase. The percentages of injuries diagnosed peroperatively, "blind laparotomies," and suboptimal timed hepaticojejunostomies were not different between the groups.

CONCLUSIONS

Except for earlier diagnosis of BDI in the later period than in previous years, there appeared to be no significant improvement in diagnostic workup and management during the past 2 years.

Derivação hepaticojejunal sem sutura: uma alternativa para reconstituição da via biliar

A lesão das vias biliares foi observada em dois pacientes submetidos à colecistectomia videolaparoscópica e convencional. Para reconstituição da via biliar foi aplicada a técnica hepaticojejunostomia em Y-de-Roux com a introdução dao segmento proximal do ducto hepático comum, apoiada por um catéter perdido na luz da alça exclusa, sem sutura. O grau das lesões segundo a classificação de Bismuth tomou a técnica exeqüível. No período de nov/94 a fev/97 os casos evoluíram clinicamente assintomáticos e com exames laboratoriais dentro dos padrões de normalidade. O controle ultra-sonográfico demonstra a presença do catéter simulando o colédoco. A boa evolução dos casos não nos autoriza a conclusões definitivas. A facilidade técnica e a baixa morbidade no pós-operatório nos motivaram a escrever este artigo.

Laparoscopic biliary injury: more than a learning curve problem

BACKGROUND

The increase in the incidence of iatrogenic injury to the extrahepatic biliary tree that has been documented since the introduction of laparoscopic cholecystectomy (LC) has been explained as a 'learning curve' problem. The early New Zealand experience has been published and the present study was undertaken to determine whether there had been any change in the incidence, nature and management of laparoscopic biliary injuries (LBI) after further experience with LC.

METHODS

A nationwide audit was undertaken in 1995 by two confidential postal questionnaires: to all active general surgeons (n=184, response rate 60%), and to all endoscopists performing endoscopic retrograde cholangiopancreatography (ERCP) (n=18, response rate 100%).

RESULTS

The total number of LBI was 21, compared with 41 for 1991-92. The site and nature of the injuries were similar for the two survey periods. More of the injuries appeared to be diagnosed after the operation and prior to discharge (25% vs 47%). Calculating the national incidence of LBI was not possible without complete reporting, but in the subset of surgeons responsible for the LBI there was no apparent decrease in the incidence of all LBI (2.8% vs 2.9%), those requiring active re-intervention (2.4% vs 2.7%) and major duct injury (1.1% vs 0.7%), despite a significant increase in the surgeons' prior experience with LC (20% vs 61% of surgeons had performed more than 100 LC). There were some concerning trends in management: a less frequent use of ERCP in patients with LBI diagnosed after surgery (76% vs 65%) and a higher proportion of patients with minor injuries managed by re-operation (26% vs 50%).

CONCLUSIONS

The present study indicates that iatrogenic biliary injury is a persistent problem in New Zealand, despite increasing experience with LC, and suggests the need for more intensive scrutiny of operative technique and training. There is scope to manage more patients with minor duct injuries conservatively.

Suspected biliary complications after laparoscopic and open cholecystectomy leading to endoscopic cholangiography: a retrospective comparison

To study how suspected postoperative biliary complications are influenced by surgical technique, we compared clinical profiles of 63 patients referred for ERCP after open (OC) and laparoscopic cholecystectomy (LC) over a four-year period. ERCP was not performed for postoperative pain alone and only six (9.5%) studies were normal. Referrals after LC were younger (mean 39.1 vs 53.6 years, P < 0.001) and ERCP was requested earlier (mean 71.6 vs 2360 days, P < 0.001) in the postoperative course. Choledocholithiasis (CDL) alone, the most common finding, was successfully managed with a single ERCP in 97.2% of cases. CDL after LC occurred in younger patients (35.5 vs 58.9 years, P < 0.01) who presented earlier (mean 98.6 days vs 5.1 years, P < 0.01), without biliary ductal dilatation (P < 0.01). Although CDL after LC was associated with higher ALT and bilirubin levels than after OC, the difference was not statistically significant. Cystic duct leaks (LC: six patients, OC: four patients) were typically associated with CDL after OC and 90% resolved with endoscopic therapy. Biliary ligation (four cases) was managed successfully with choledochojejunostomy. We conclude that findings at ERCP for suspected biliary obstruction or injury after OC or LC are similar and usually can be endoscopically managed. After LC, referrals currently are younger, present much earlier, and retained stones are less likely to be associated with ductal dilatation than after OC.

Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis.

METHODS

63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group).

FINDINGS

The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0.0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2-5] vs 6 [5-8] days; p=0.0063). Mean length of sick leave was shorter in the LC group (13.9 vs 30.1 days; 95% CI for difference 10.9-21.7).

INTERPRETATION

Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.

The consequences of a major bile duct injury during laparoscopic cholecystectomy

Bile duct injury is perhaps the most feared complication of laparoscopic cholecystectomy. The focus of this study was on the immediate and short-term outcome of patients who have undergone repair of major bile duct injuries with respect to hospital stay, perioperative interventions, and reoperations. The records of patients who underwent surgery at three academic hospitals in Philadelphia (Hospital of the University of Pennsylvania, Thomas Jefferson University Hospital, and Graduate Hospital) from 1990 to 1995 for repair of a major biliary injury following laparoscopic cholecystectomy were reviewed. A major biliary injury was defined as any disruption (including ligation, avulsion, or resection) of the extrahepatic biliary system. Small biliary leaks not requiring surgery were excluded. Thirty-two patients sustained major bile duct injuries. The injury was recognized immediately in 10 patients. The remaining 22 patients had pain (59%), jaundice (50%), and/or fever (32%) as the symptom heralding the injury. Bismuth classification was as follows: 13% of patients were class I, 63% were class II, 7% were class III, 7% were class IV, and 10% were class V. Biliary reconstruction included a Roux-en-Y hepaticojejunostomy in 30 patients and two were primary repairs. There was one postoperative death from multiorgan system failure. The mean length of hospital stay after repair was 17 +/- 8 days. Over a mean follow-up period of 11.5 +/- 10.5 months, 11 patients (38%) required 19 emergency readmissions, most commonly for cholangitis. Five patients (17%) required postoperative balloon dilatation for biliary stricture. At follow-up 18 patients (62.0%) remain asymptomatic with normal liver function, eight (28%) are experiencing episodic cholangitis, and three (10%) are asymptomatic with persistently elevated liver function values. The consequences of a major biliary tract injury following laparoscopic cholecystectomy include a complex operative repair resulting in a lengthy postoperative stay with an increased risk of death, an excessive number of perioperative diagnostic and therapeutic studies, frequent readmissions (often as emergencies), and a lifelong risk of restricture. The "cost" to these patients remains enormous.

A multidisciplinary approach to major bile duct injury following laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Many series describing the management of major bile duct injuries after laparoscopic cholecystectomy have been reported with satisfactory short-term results. However, the information of their prognosis with sufficient time-period follow-up is sparse.

METHODS

Sixteen consecutive patients with major bile duct injury following laparoscopic cholecystectomy were retrospectively reviewed, including six common bile duct transections, four bile duct perforations, and six hilar strictures but without perforation. With respect to the level of bile duct injuries, there were the following based on Bismuth's classification: type 1 in six patients, type 2 in five patients, type 3 in three patients, type 4 in one patient, and type 5 in one patient. All patients received surgical management, interventional radiology and endoscopic treatment. The time periods of follow-up ranged from 37 to 72 months (mean, 52 months). The final results were rated as being excellent, good, fair, or poor, based on the criteria of symptoms, biochemical data, and radiology.

RESULTS

There was no procedure-related mortality. Ten of the 16 patients had either excellent or good results, two had fair results, and four had poor results. Of the latter four, the patients had been classified as Bismuth type 1, 3, 4, and 5, respectively, and all sustained a failed initial surgical repair.

CONCLUSIONS

Using a multidisciplinary approach, 12 (75%) of the 16 patients attained a promising result through a long-term follow-up, while those with the higher biliary stricture and with an unsuccessful initial surgical repair had a disappointing outcome.

Benign post-operative bile duct strictures

The vast majority of post-operative bile duct strictures occur following cholecystectomy, these injuries having been seen at an increased frequency since the introduction of laparoscopic cholecystectomy. Bile duct injuries usually present early in the post-operative period, obstructive jaundice or evidence of a bile leak being the most common mode of presentation. In patients presenting with a post-operative bile duct stricture months to years after surgery, cholangitis is the most common symptom. The 'gold standard' for the diagnosis of bile duct strictures is cholangiography. Percutaneous transhepatic cholangiography is generally more valuable than endoscopic retrograde cholangiography in that it defines the anatomy of the proximal biliary tree that is to be used in surgical reconstruction. The most commonly employed surgical procedure with the best overall results for the treatment of bile duct stricture is a Roux-en-Y hepaticojejunostomy. The results of the surgical repair of bile duct strictures are excellent, long-term success rates being in excess of 80% in most series. Recent data have suggested that, at intermediate follow-up of approximately 3 years, an excellent outcome can be obtained following repair of bile duct injuries after laparoscopic cholecystectomy. Percutaneous and endoscopic techniques for the dilatation of bile duct strictures can be useful adjuncts to the management of bile duct strictures if the anatomical situation and clinical scenario favour this approach. In selected patients, the results of both endoscopic and percutaneous dilatation are comparable to those of surgical reconstruction.

Bile duct imaging and injury: a regional audit of laparoscopic cholecystectomy

BACKGROUND

The aim of the present study was to report details of practice with respect to bile duct imaging and bile duct injury.

METHODS

A prospective audit of laparoscopic cholecystectomy (LC) was undertaken in the Otago region from the introduction of LC in 1991 through to December 1995. The audit includes all procedures done by all surgeons in public and private hospitals over the period without exclusion.

RESULTS

Laparoscopic cholecystectomy was attempted in 929 patients and completed laparoscopically in 832 (89.6%). Intraoperative cholangiography (IOC) was undertaken with increasing frequency over the study period, from 5.9% in 1991 to 32.2% in 1995. The overall IOC rate for individual surgeons varied from 4.5 to 47.6%. The use of peri-operative endoscopic retrograde cholangiopancreatography (ERCP) increased with the introduction of LC but has plateaued at approximately 6%. A total of 15.4% of patients with one or more clinical indicators of choledocholithiasis underwent LC without any form of bile duct imaging. Eight main bile duct injuries (0.86%) and a further 18 bile leaks occurred (total bile duct injury rate 2.8%). Intra-operative cholangiography was attempted (unsuccessfully) in only one patient with main duct injury, although five of the eight injuries were recognized intra-operatively.

CONCLUSION

This prospective regional audit demonstrates a gradual return to the use of IOC, a modest but stable reliance on peri-operative ERCP, and a higher than expected rate of bile-duct injury.

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.

Post-cholecystectomy external biliary fistula

BACKGROUND

External biliary fistula (EBF) following bile duct injury is a serious complication of cholecystectomy.

METHODS

From January 1989 to December 1994, 37 patients with post-cholecystectomy external biliary fistula were seen at this centre. There were 14 partial, 22 complete and one sub-vesical duct of Luschka injury. Sixteen patients had a controlled EBF at presentation; 10 patients had intra-abdominal collections and seven patients presented with peritonitis.

RESULTS

A staged approach to the management of these patients was adopted in which the initial management aimed at creating a 'controlled' fistula. This approach comprised conservative treatment (n = 9), percutaneous catheter drainage of intra-abdominal collections (n = 10), biliary drainage (n = 6), and surgical intervention (n = 7). One patient died because of progressive liver failure in spite of intensive management. Definitive management comprised the surgical repair of biliary strictures wherever indicated, after waiting for the acute problems to settle.

CONCLUSIONS

By adopting a staged approach along with a judicious use of endoscopy, radiology and surgery that were based on clinical circumstances, it was possible to achieve satisfactory results for this otherwise distressing condition.

Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster

OBJECTIVE

This study was designed to evaluate the total costs associated with repair of laparoscopic cholecystectomy (LC)-related bile duct injuries.

SUMMARY BACKGROUND DATA

The popularity of LC with both patients and surgeons is such that this procedure now exceeds open cholecystectomy by a ratio of approximately 4 to 10:1. However, costs associated with LC-related injuries, particularly regarding treatment patterns, have up to now not been explored fully.

METHODS

The complete hospital and interventional radiology (IR) billing records for 49 patients who have completed treatment for laparoscopic cholecystectomy-related bile duct injuries were divided into 8 categories. These records were totaled for comparison of costs between patient groups that experienced different injuries and treatment patterns.

RESULTS

Patients with LC-related bile duct injuries were billed a mean of $51,411 for all care related to repair of their bile duct injury. Patients incurred an average of 32 days of inpatient hospitalization and 10 outpatient care days. Postoperative treatment included long-term chronic biliary intubation averaging 378 days. Two patients (4%) died as a result of their LC-related complications. Patients with bile duct injuries that were recognized immediately at the time of the initial surgery ultimately experienced a total cost for their repair and hospitalization of 43% to 83% less than for patients in whom recognition of the injury was delayed (p < 0.019 to 0.070). In addition, the total hospitalization and outpatient care days was reduced by as much as 76% with early recognition of an iatrogenic injury.

CONCLUSIONS

Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.

Radiological findings in biliary fistula and gallstone ileus

PURPOSE

Biliary fistula and gallstone ileus are rarely found. The diagnosis is difficult and may be delayed until operation. We reviewed the radiological findings in a retrospective material.

MATERIAL AND METHODS

The cases of 16 patients treated for biliary fistula were analyzed with respect to findings at imaging. Ten patients had a spontaneous fistula. Nine of them had an internal bilioduodenal fistula and one had an external fistula with stones passing through a subcutaneous abscess. Five patients also had gallstone ileus and one patient a rare gastric outlet obstruction caused by a gallstone (Bouveret's syndrome). Six patients had an iatrogenic fistula. One of them had internal bile ascites and 5 an external fistula, one of which was a biliocystic fistula resulting from attempted hepatic cyst sclerotherapy.

RESULTS

Various imaging modalities were used and there was often a delay in the diagnosis. Imaging did not show the fistula itself in any of the spontaneous cases. However, a nonvisualized or shrunken gallbladder seen at US often coexisted in these cases. CT yielded the diagnosis in one case of gallstone ileus, and a Gastrografin meal yielded it in the case of Bouveret's syndrome. Fistulography and cholangiography provided a correct diagnosis of fistula in all cases of iatrogenic biliocutaneous fistulas.

CONCLUSION

Patients with biliary fistula usually undergo examinations with nonspecific results. The imaging findings could be more specific if the possibility of this diagnosis were remembered.

Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group

The rapid introduction of laparoscopic cholecystectomy has been associated with an apparently increased incidence of bile duct injury which has provoked worldwide concern. The true incidence and mechanism of iatrogenic ductal injury during the development of this procedure remain unclear. To assess this, the introduction of laparoscopic cholecystectomy in the West of Scotland has been audited prospectively over a 5-year period. All cases of biliary ductal injury have been independently reviewed. Some 48 surgeons undertaking laparoscopic cholecystectomy in 19 hospitals submitted prospective data between September 1990 and September 1995. A total of 5913 laparoscopic cholecystectomies were attempted with 98.3 per cent completion of data collection. During this period 37 laparoscopic bile duct injuries occurred. The annual incidence peaked at 0.8 per cent and has fallen to 0.4 per cent in the final year of audit. Injuries occurred after a median personal experience of 51 (range 3-247) laparoscopic cholecystectomies in 22 surgeons. Major bile duct injuries occurred in 20 of 37 patients, giving an incidence of 0.3 per cent. Five mechanisms for laparoscopic ductal injury were identified, including tenting, confluence and diathermy injuries as well as the classical and variant classical types. Ductal injuries were discovered at operation in 18 patients with consequent repair giving a good clinical outcome in 17. Contributory factors (severe inflammation, aberrant anatomy and poor visualization) were present in only 13 of 37 cases. This audit suggests that, at least in the introductory period, laparoscopic cholecystectomy is associated with an overall bile duct injury rate higher than that reported previously after open cholecystectomy, although the incidence of major ductal injury is similar. The late downward trend in bile duct injury, however, suggests there may be a prolonged learning curve for this procedure. Improved understanding of the mechanism of injury may lead to yet further reductions in this complication.

Long-term follow-up after bilioenteric anastomosis for benign bile duct stricture

OBJECTIVE

The authors provide a prospective evaluation of long-term results after bilioenteric anastomoses for benign biliary stricture.

SUMMARY BACKGROUND DATA

With the advent of laparoscopic techniques, the frequency of bile duct injury after operation has increased. Reports on the operative management of these injuries have not provided long-term follow-up. Over a similar period, reports of both endoscopic and invasive radiographic methods as primary treatment for bile duct stricture have compared success rates to antiquated surgical reports.

METHODS

A protocol whereby preoperative radiographic (e.g., cholangiogram, computed tomographic scan, ultrasound), biochemical (e.g., alkaline phosphatase, and total bilirubin), and clinical evaluation was combined with ongoing postoperative evaluation and follow-up at approximately 6-month intervals. A total of 111 patients were evaluated from 1985 to 1995. Patients were categorized in three groups: 1) those with postoperative injuries during open and laparoscopic gallbladder surgery (31 patients), 2) those undergoing operation for pain associated with chronic pancreatitis who have distal common bile duct stenoses (64 patients), and 3) those with nonchronic pancreatitis-associated benign bile duct strictures (16 patients).

RESULTS

Mean follow-up was 60 months. Overall preoperative alkaline phosphatase was 640 units/L with a range of 280 to 1860 units/L. All patients had abnormally elevated alkaline phosphatase. Only 3 of 111 patients have had mild persistent elevation after operation. Clinical jaundice, present in 49 of 111 patients, was resolved uniformly by operative decompression. Total bilirubin was elevated abnormally in 56 of 111 patients and also was uniformly corrected by operation.

CONCLUSIONS

These data support the careful combined use of endoscopy, invasive radiology, and surgery in the management of benign strictures of the biliary tree. These data further suggest a success rate for surgical management that, over long-term follow-up, appears to exceed that found using alternative measures. Alternative methods should measure their success rates against success rates currently achieved by operative management.

Treatment of bile duct lesions after laparoscopic cholecystectomy

From January 1990 to June 1994, 53 patients who sustained bile duct injuries during laparoscopic cholecystectomy were treated at the Amsterdam Academic Medical Centre. There were 16 men and 37 women with a mean age of 47 years. Follow up was established in all patients for a median of 17 months. Four types of ductal injury were identified. Type A (18 patients) had leakage from cystic ducts or peripheral hepatic radicles, type B (11 patients) had major bile duct leakage, type C (nine patients) had an isolated ductal stricture, and type D (15 patients) had complete transection of the bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) established the diagnosis in all type A, B, and C lesions. In type D lesions percutaneous cholangiography was required to delineate the proximal extent of the injury. Initial treatment (until resolution of symptoms and discharge from hospital) comprised endoscopy in 36 patients and surgery in 26 patients. Endoscopic treatment was possible and successful in 16 of 18 of type A lesions, five of seven of type B lesions, and three of nine of type C lesions. Most failures resulted from inability to pass strictures or leaks at the initial endoscopy. During initial treatment additional surgery was required in seven patients. Fourteen patients underwent percutaneous or surgical drainage of bile collections, or both. After endoscopic treatment early complications occurred in three patients, with a fatal outcome in two (not related to the endoscopic therapy). During follow up six patients developed late complications. All 15 patients with complete transection and four patients with major bile duct leakage were initially treated surgically. During initial treatment additional endoscopy was required in two patients. Early complications occurred in eight patients. During follow up seven patients developed stenosis of the anastomosis or bile duct. Reconstructive surgery in the early postoperative phase was associated with more complications than elective reconstructive surgery. Most type A and B bile duct injuries after laparoscopic cholecystectomy (80%) can be treated endoscopically. In patients with more severe ductal injury (type C and D) reconstructive surgery is eventually required in 70%. Multidisciplinary approach to these lesions is advocated and algorithms for treatment are proposed.

[Injuries of the extrahepatic bile ducts. Clinical aspects, diagnosis and therapy]

From 1990 to 1995, 27 patients with biliary injuries were treated at the Department of General Surgery of Münster University Hospitals. All lesions occurred during cholecystectomy, either via laparoscopy (n = 17) or via laparotomy (n = 10). Ten patients were male and 17 female. The mean age was 51.2 years. In all cases a preoperative ERCP was performed. Based on the ERCP status a new classification was developed taking into account the type and location of the injury, as well as the opportunity for endoscopic treatment. Twenty-two patients underwent surgical bile duct reconstructions (12 hepaticojejunostomies, 3 choledochojejunostomies, 7 direct reconstructions). In five cases endoscopic therapy alone was successful. The perioperative mortality was 7.4% (2/27). Three of the surviving 25 had to be readmitted for recurrent cholangitis. Only 15 feel well without any limitations on everyday activities.

Low insertion of hepatic segmental duct VII-VIII is an important cause of major biliary injury or misdiagnosis

BACKGROUND

The importance of variant anatomy is only mentioned generally in most articles in this era of laparoscopic cholecystectomy. We report a series of 14 patients in whom a seemingly low insertion of hepatic segmental duct VII-VIII was clinically important.

METHODS

The patients were managed at Duke University Medical Center. Two intraoperative videotapes of injury were reviewed.

RESULTS

Three categories of patients were identified: 6 patients who had injury in association with another major injury to the biliary system, 7 patients who had an isolated VII-VIII system injury, and 1 patient with a Klatskin tumor in whom the unobstructed variant duct was stented. After appropriate evaluation, all patients were successfully treated. Several lawsuits resulted, even when the injury was seemingly minor. Symptoms developed in all patients who filed lawsuits, but none in those who did not.

CONCLUSION

Appreciation of the VII-VIII biliary variant can lead to avoidance of injury or to a successful repair. The injury can easily occur despite "normal" cholangiography. Successful clinical outcome does not necessarily correlate with freedom from lawsuits.

Intraoperative trans-gallbladder cholangiography intended to delineate bile duct anatomy

Intraoperative cholangiography has been recommended to lower the incidence and severity of biliary tract injury during laparoscopic cholecystectomy. However a literature review of common bile duct (CBD) injuries does not appear to support this concept. Most cystic duct cholangiographies disclose the injury after the fact. This study was designed to compare the technical difficulties and complications of laparoscopic cholecystectomy in three groups of patients: Group 1 underwent intraoperative cholangiography through the gallbladder (n = 288), group 2 underwent intraoperative cholangiography through the cystic duct (n = 162), and group 3 did not undergo cholangiography (n = 227). Cholecystectomies were defined as "difficult" if there was a need to convert to open procedure in the absence of an accidental complication, or if estimated blood loss was over 100 ml, and/or if operating time was over 2 h. Difficult cholecystectomies were encountered in 34% of patients in group 2 and 28.2% of patients in group 3, but in only 7.6% of patients in group 1. Technical complications (bleeding, bile leak, common bile duct injury, retained common bile duct stones, false positive choledocholithiasis, pancreatitis, and trocar injuries) occurred in 11.7% of cases in group 2, 4.4% in group 3, and in only 1.4% of group 1. Intraoperative cholangiography performed through the gallbladder before any dissection was initiated significantly facilitated the operation and helped decrease the incidence of technical complications.

Bile leakage following laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is now the treatment of choice for gallstones, but there has been concern that bile leakage with LC is more frequent than after open cholecystectomy (OC). We have analyzed our experience of this complication with regard to both its incidence and management. From a consecutive series of 500 LC, in which both operative cholangiography and drainage of the gallbladder bed were routine, bile leakage was identified in ten patients (2%). There was no bile duct injury. Nine of the ten patients presented with bile in the drain within 24 h of operation and one patient presented 1 week after operation with a subphrenic collection. Of the ten patients, five settled spontaneously. Of the five remaining patients, two needed laparotomy--one for a subphrenic collection not responding to percutaneous drainage and one for biliary peritonitis. One patient was treated by relaparoscopy and suture of a duct of Luschka and one patient had successful percutaneous drainage of an infected collection; the fifth patient who presented with a late subphrenic collection of bile was shown at endoscopic retrograde cholangiopancreatography (ERCP) to have a cystic duct stump leak and was treated with an endoscopic stent. Bile leakage is seen more frequently after LC than OC for reasons that are currently unclear. We believe that the use of routine gallbladder bed drainage is justified for this reason alone. The majority of bile leaks settle either spontaneously or with minimally invasive intervention.

A new technique for reconstruction of the common bile duct after severe injury by laparoscopic cholecystectomy

Laparoscopic cholecystectomy involves a higher incidence of severe common bile duct injury than did open cholecystectomy. The severe injuries most often result from technical problems and inadequate exposure. Reconstruction of the bile duct is then possible provided that an immediate diagnosis is made and an appropriate surgical technique is applied. The report focuses on a new method of reconstruction of the common bile duct by interposition of a small jejunal conduit. The procedure was performed in five patients with severe bile duct injury (Bismuth class 3-4) that occurred during laparoscopic cholecystectomy. The outcome after follow-up periods of 9 months to more than 2 years is promising. This method of reconstruction is therefore recommended for severe forms of bile duct injury.

Immediate laparoscopic cholecystectomy as definitive therapy for acute cholecystitis

The objective of this study was to determine the safety and efficacy of immediate laparoscopic cholecystectomy in the management of acute calculous cholecystitis. A prospective data collection was performed on all patients admitted to one surgical service over a 2-year period. The patients were managed by a uniform protocol consisting of (1) preoperative ERCP when common duct stones were suspected; (2) operation within 24 h of diagnosis; and (3) selective operative cholangiography. Previous surgery was not a contraindication to inclusion. The setting was an urban teaching hospital. There were 52 patients, 34 females and 18 males. Nineteen had undergone previous abdominal surgery. Five patients had preoperative ERCP and five had intraoperative cholangiography. The patients underwent laparoscopic cholecystectomy 0.8 +/- 0.4 days postadmission. Four (7.7%) were converted to open cholecystectomy. Fifty-eight percent had spillage of bile and/or stones. Patients went home 2.3 +/- 1.6 days postoperatively. There were no deaths and two complications: a subhepatic biloma and a superficial wound infection. Follow-up of all patients has revealed no late complications. We conclude: (1) Immediate laparoscopic cholecystectomy is safe and effective for acute cholecystitis even when complicated by previous surgery, inflammatory adhesions, and gangrene. (2) Intraoperative spillage of bile and stones does not lead to an increase in early complications. (3) Cholangiography is needed only when clinically indicated. (4) Laparoscopic cholecystectomy should be the treatment of choice for patients admitted for acute cholecystitis.

Benign biliary strictures: repair and outcome with a contemporary approach

BACKGROUND

The Hepp-Couinaud technique is an innovative approach for repair of proximal biliary strictures. We have used this method selectively for bile duct reconstruction since 1982. Our aim was to analyze our experience with the surgical repair of benign biliary strictures in the decade since the Hepp-Couinaud technique has become an integral component of our surgical management strategy.

METHODS

Seventy-two patients undergoing surgical repair of benign biliary stricture between 1983 and 1992 were reviewed retrospectively. A grading system on clinical symptoms, results of liver function studies, and need for reintervention was used to assess outcome.

RESULTS

For the 27 patients with noniatrogenic strictures, followed up a mean of 3.9 years, excellent or good results (grade A or B) were obtained in 88.9%. For the 45 patients with iatrogenic strictures, followed up a mean of 4.6 years, 86.7% were categorized as grade A or B. The cumulative probability of anastomotic failure was significantly less for the 21 patients in whom the Hepp-Couinaud method was used when compared with the 24 patients in whom it was not (p = 0.032). Outcome was not influenced by age, time delay from injury to reconstruction, preoperative stenting, the number of previous repairs, or the duration of postoperative stenting.

CONCLUSIONS

Surgical reconstruction affords excellent or good results for the vast majority of patients with benign biliary strictures. For proximal iatrogenic strictures superior anastomotic durability is achieved with the Hepp-Couinaud technique.

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.

Intraoperative cholangiography is not essential to avoid duct injuries during laparoscopic cholecystectomy

BACKGROUND

Whether or not to perform intraoperative cholangiography (IOC) with laparoscopic cholecystectomy is controversial. The decision to perform IOC should depend on the individual surgeon's preference for the management of choledocholithiasis.

PATIENTS AND METHODS

An initial experience of 525 patients undergoing laparoscopic cholecystectomy done without IOC is reviewed.

RESULTS

Suspected or proven choledocholithiasis was managed by endoscopic retrograde cholangiography with sphincterotomy if necessary. There were no bile duct injuries or bile leaks, and 9% (47) of patients underwent endoscopic investigation or treatment. There have been no secondary operations for duct stones.

CONCLUSION

We think that the use of IOC to avoid bile duct injuries is not essential, and that the key to avoiding such injuries is meticulous demonstration of anatomic detail at operation. We have been satisfied with selective use of endoscopic cholangiography and sphincterotomy for the management of choledocholithiasis.

Bile duct injury and bile leakage in laparoscopic cholecystectomy

The introduction of laparoscopic cholecystectomy has been associated with an increased incidence of bile duct injury. This review presents the incidence of bile duct injury in reported series and examines the role of the learning curve and other contributing factors. There is good evidence to suggest that, with adequate training and experience, the incidence of biliary injury can be reduced to a level comparable to that of open cholecystectomy. Continued audit is required to ensure that the low complication rates achieved in selected centres with wide experience are reproduced by the surgical community in general.

Complications of laparoscopy and thoracoscopy

Laparoscopy was first performed at the turn of the century, but it was not until the introduction of laparoscopic cholecystectomy that the procedure became widely adopted by general surgeons. Since then, traditional open procedures, including cholecystectomy, exploratory laparotomy, colectomy, hernia repair, and appendectomy, are being widely performed laparoscopically. The advantages of laparoscopic surgery, including less postoperative pain due to smaller surgical incisions, shorter hospital stay, quicker return to preoperative activity, and superior cosmesis, resulted in widespread popularity with both surgeons and patients. In certain situations, the traditional method may be superior to the laparoscopic approach, as may be the case with laparoscopic hernia repair. It is difficult to justify converting a local, extraperitoneal, 45-minute, outpatient inguinal hernia repair in a virgin groin into a general anesthetic, transperitoneal, 2-hour plus, possibly inpatient laparoscopic procedure with the implantation of mesh. However, data may indicate that this operation does indeed have benefits. We must, therefore, carefully study such new operations. With the advent of a new surgical procedure, both surgeons and anesthesiologists must be familiar with the various complications unique to this technique. If recognized early, potentially life-threatening complications, including gas embolization and tension pneumothorax, can be corrected.

Corrective treatment and anatomic considerations for laparoscopic cholecystectomy injuries

BACKGROUND

Complete reports of biliary and vascular injuries after laparoscopic cholecystectomy are rare.

STUDY DESIGN

Fifteen patients with complex laparoscopic cholecystectomy injuries underwent corrective operations. The injuries consisted of 14 bile duct injuries and one large laceration of a cirrhotic liver. Five of the bile duct injuries were accompanied by inadvertent occlusion of the right hepatic artery, and one was further complicated by portal vein occlusion. One hepatic artery occlusion and one portal vein occlusion were successfully reconstructed. Two patients with arterial occlusion required right hepatic lobectomy. Corrective biliary operations consisted of common hepaticojejunostomy (seven cases), right and left hepaticojejunostomies (one case), right anterior and left hepaticojejunostomies (two cases), right hepaticojejunostomy (one case), right posterior hepaticojejunostomy (one case), and left hepaticojejunostomy after right lobectomy (two cases).

RESULTS

Except for a patient with a severe laceration of a cirrhotic liver who died as a result of hepatic failure, the remaining 14 patients are alive and well with normal hepatic function tests at six and 37 months after corrective operations.

CONCLUSIONS

A knowledge of anatomy is critical to the prevention of injuries to the hepatobiliary tree and related structures during laparoscopic cholecystectomy.

Early laparoscopic biliary injury: experience in New Zealand

Data on the incidence, nature and management of early laparoscopic biliary injury up to January 1993 were obtained by a postal questionnaire sent to all New Zealand general surgeons (n = 214; response rate 71 percent) and to all endoscopists who perform endoscopic retrograde cholangiography (n = 16; response rate 100 percent). A total of 41 injuries (surgeons' survey, 22; endoscopists' survey, 19) occurred in an estimated 4000 laparoscopic cholecystectomies; 16 involved the common bile and hepatic ducts, and 25 the cystic and segment V ducts. Operative cholangiography was performed in one patient. The diagnosis of injury was made after operation in 31 of 41 patients and after discharge in 21. Conservative management was undertaken in only 19 patients. This prospective audit documents an increase in the incidence of early biliary injury after the introduction of laparoscopic cholecystectomy in New Zealand. The results highlight the need for further study to determine the best way to ensure early and accurate diagnosis of biliary injury and to define optimal conservative and operative management.