Mechanisms of major biliary injury during laparoscopic cholecystectomy

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.

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.

Helical CT cholangiography with three-dimensional volume rendering using an oral biliary contrast agent: feasibility of a novel technique

OBJECTIVE

We evaluated the feasibility and image quality of a new noninvasive biliary imaging technique: helical CT cholangiography with three-dimensional volume rendering using an oral biliary contrast agent.

SUBJECTS AND METHODS

Nineteen subjects including five healthy volunteers and 14 patients underwent helical CT cholangiography. Subjects ingested 6.0 g of iopanoic acid 6-10 hr before undergoing imaging. Axial data were used to construct three-dimensional volume-rendered cholangiograms. Two radiologists, an endoscopist, and a laparoscopic surgeon reviewed the images and evaluated overall image quality. In the 14 patients, findings from CT cholangiography were compared with those from ERCP, surgery, and intraoperative cholangiography.

RESULTS

All segments of the biliary tree were opacified in all volunteers except one, in whom the intrahepatic ducts were not opacified. Image quality was good to excellent in all volunteers. Anomalous cystic duct insertions were seen in two volunteers. Opacification of the biliary tree was rated as acceptable to excellent in nine patients and suboptimal in five. In five patients with good or excellent opacification, the biliary anatomy correlated with findings on intraoperative cholangiography or ERCP. CT cholangiography revealed additional conditions (gallbladder varices and acute pancreatitis) and variant anatomy in three patients.

CONCLUSION

Results of this pilot project suggest that obtaining CT cholangiograms using an oral biliary contrast agent is a feasible, noninvasive method for revealing biliary anatomy. However, visualization of the biliary tree was suboptimal in 36% of the patients, which represents a limitation of this technique.

Inflammatory conditions of the common bile duct

BACKGROUND

Inflammatory conditions of the biliary tree are infrequently reported with the exception of sclerosing cholangitis. These conditions, especially when affecting the common bile duct (CBD), can be mistaken for tumours; their existence should be considered in the differential diagnosis of biliary lesions and, in particular, biliary strictures. Few descriptions of inflammatory conditions exist in the published literature.

METHODS

A comprehensive search was undertaken of the last 20 years of published literature.

RESULTS

Potential aetiological factors include infection, infestation, traumatic bile duct injury, foreign body or gallstone reaction and the host inflammatory response.

CONCLUSIONS

These conditions typically mimic malignant tumours of the CBD but knowledge of the aforementioned processes might alter the surgical approach to biliary strictures (especially after previous cholecystectomy), with greater emphasis on surgical exploration.

Hospital credentialing and quality of care

The purpose of this study was to evaluate the impact of hospital credentialing standards on surgical outcomes for selected procedures. The study used hospital credentialing practices from a 1996 survey of North Carolina community hospitals, with surgical outcomes derived from a statewide database of inpatient surgical discharges in 1995. Hospital mortality, complications and elevated lengths of stay were used as outcome indicators in an analysis of 6 surgical procedures. Multivariate logit analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on outcomes, controlling for patient demographic characteristics, type of admission, severity of illness and hospital characteristics. Teaching hospitals adopted more stringent credentialing practices, with almost no difference between metropolitan and nonmetropolitan nonteaching facilities in their use of various credentialing policies. Surgical outcomes typically were not related to stringency of the hospital credentialing environment. Generally, the effect of specific practices was inconsistent (associated with improved outcomes for certain procedures and significantly worse outcomes for others) or counterintuitive (showing worse outcomes for selected surgical procedures where effects were statistically significant). More stringent hospital credentialing does not appear likely to improve patient outcomes.

Visual identification of the cystic duct-CBD junction during laparoscopic cholecystectomy (visual cholangiography): an additional step for prevention of CBD injuries

Despite advances in technical skills, common bile duct (CBD) injury during laparoscopic cholecystectomy is not an uncommon major complication. We describe a technical step that can be taken during the dissection of the triangle of Calot to allow the junction between the cystic duct and CBD to be clearly visualized. This is a safe and simple maneuver that mimics the one done in open surgery. Its routine application serves as an additional safety measure to prevent injury to the common bile duct.

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.

Acute Thermal Injury to the Canine Jejunal Free Flap: Electrocautery versus Ultrasonic Dissection

Electrocautery-induced thermal injury contributes to morbidity and mortality after laparoscopic surgery. Ultrasonic dissection is an alternative technique that may produce less thermal injury. We compared the amount of acute thermal injury caused to jejunal free flaps isolated with laparoscopic electrosurgical instruments with that caused by ultrasonic dissection (laparoscopic coagulating shears). Canine jejunal free flaps were isolated by electrocautery or laparosonic coagulating shears and remained viable on a vascular pedicle. After a period of ischemia and reperfusion, the flaps were resected to simulate harvesting and reimplantation. Thermal injury was observed at the site of dissection and was graded histologically. At the margin of the jejunal free flaps, the laparosonic coagulating shears produced less thermal injury (score, 2.2 at level 3) than the electrocautery grasping forceps (score, 3.7 at 35 W and 4.1 at 70 W). The laparosconic coagulating shears produced less thermal injury to a jejunal free flap than did electrocautery. Ultrasonic dissection is an alternative to the complications produced by electrocautery during laparoscopic dissection.

Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study

BACKGROUND

Previous studies suggest that laparoscopic cholecystectomy (LC) is associated with an increased risk of intraoperative injury involving the bile ducts, bowel, and vascular structures compared with open cholecystectomy (OC). Population-based studies are required to estimate the magnitude of the increased risk, to determine whether this is changing over time, and to identify ways by which this might be reduced.

METHODS

Suspected cases of intraoperative injury associated with cholecystectomy in Western Australia in the period 1988 to 1994 were identified from routinely collected hospital statistical records and lists of persons undergoing postoperative endoscopic retrograde cholangiopancreatography. The case records of suspect cases were reviewed to confirm the nature and site of injury. Ordinal logistic regression was used to estimate the risk of injury associated with LC compared with OC after adjusting for confounding factors.

RESULTS

After the introduction of LC in 1991, the proportion of all cholecystectomy cases with intraoperative injury increased from 0.67% in 1988-90 to 1.33% in 1993-94. Similar relative increases were observed in bile duct injuries, major bile leaks, and other injuries to bowel or vascular structures. Increases in intraoperative injury were observed in both LC and OC. After adjustment for age, gender, hospital type, severity of disease, intraoperative cholangiography, and calendar period, the odds ratio for intraoperative injury in LC compared with OC was 1.79. Operative cholangiography significantly reduced the risk of injury.

CONCLUSION

Operative cholangiography has a protective effect for complications of cholecystectomy. Compared with OC, LC carries a nearly twofold higher risk of major bile, vascular, and bowel complications. Further study is required to determine the extent to which potentially preventable factors contribute to this risk.

Implications of laparoscopic cholecystectomy for surgical residency training

BACKGROUND

Widespread adoption of minimal access techniques forced a generation of abdominal surgeons to re-learn many standard abdominal procedures. This threatened to reduce the pool of suitable "training" operations for surgical residents.

METHODS

Operator grade, duration of operation, acute/elective operation, conversion rate, complications, and postoperative stay were recorded prospectively on all laparoscopic cholecystectomies (LC) since 1992. This data was evaluated to determine how the introduction of LC affected residents' training.

RESULTS

The percentage of LCs performed by residents increased progressively to reach 58%. Operating time was longer for trainee surgeons, particularly for acute cases (145+/-50 minutes vs 111+/-54 minutes, p<0.05); however, conversion rate, incidence of complications, and postoperative stay were no different.

CONCLUSIONS

LC can be performed by surgical trainees with similar complication rates and outcomes as those of qualified surgeons. Once institutional experience has accumulated, this procedure can be integrated into residency training.

PLACE OF MINILAP CHOLECYSTECTOMY IN AN ERA OF LAPAROSCOPIC CHOLECYSTECTOMY

In view of surgical and economic factors of our country, minilap cholecystectomy can be performed as an alternative to the laparoscopic cholecystectomy and offers almost similar results as laparoscopic surgery. We compared the operation time, post-operative hospital stay and return to full activity and the results were encouraging. We hope that this article justifies its claim to orthodoxy in the coming years.

Laparoscopic cholecystectomy: a report on the community hospital experience in Hokkaido

We analyzed the outcome of 1408 patients who underwent laparoscopic cholecystectomy (LC) between February 1991 and October 1993 in affiliated community hospitals around Hokkaido, Japan. LC was performed for symptomatic gallstones (68%) and asymptomatic gallstones (29%) using the pneumoperitoneum (96%) or abdominal wall lift (4%) techniques. Intraoperative and postoperative complications occurred in 105 patients (10%), including bile duct injuries in 9 patients (0.9%). Conversion to open surgery or reoperation was required in 89 patients (8%) mainly because of unclear anatomy, difficulties with hemostasis, or bile duct injury. One patient died of congestive heart failure, resulting in a mortality rate of 0.07%. The patients were discharged after an average of 8 days, and returned to work after an average of 14 days. The complication and conversion rates were high; however, the incidences of reoperation, bile duct injuries, postoperative bile leaks, and deaths were low. In conclusion, LC was performed with acceptable safety in our community hospitals. The reason for this is most likely that conventional cholecystectomy was preferred to LC in difficult cases during this early period.

OUR FIRST HUNDRED LAPAROSCOPIC CHOLECYSTECTOMIES

Hundred patients with symptomatic gallstone disease underwent laparosopic cholecystectomy between June 1996 and August 1997. There were 78 females and 22 males, with a mean age of 46.2 (SD 17.8; range 21 to 85) years. The common presentations were right upper abdominal pain (n=66), acute cholecystitis (n=8) and history of jaundice (n=11). Sixteen patients underwent ERCP for suspected CBD stones. Endoscopic papillotomy and basketing cleared the CBD of all calculi in 12. Three patients required conversion to open cholecystectomy because of dense adhesions (n=2) and to control intraoperative haemorrhage (n=1). Mean operating time was 67.2 (SD 39.2; range 22 to 186) minutes. The mean requirement of analgesics was 2.8 (SD 1.3; range 2 to 5) doses and post-operative hospital stay was 1.6 (SD 1.4; range 1 to 7) days. All patients resumed normal activity within 14 days of operation and are well and satisfied with their operation at a median follow up of 8.6 months.

Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy

BACKGROUND

Bile leaks and bile duct strictures are major complications of cholecystectomy which increased in incidence after the introduction of laparoscopic surgery. The management and outcome of these complications following the introduction of laparoscopic cholecystectomy was reviewed.

METHODS

Eighteen patients of median age 45 (range 22-70) years were treated between January 1992 and December 1995. Six patients had a common hepatic duct (CHD) stricture, four following a failed previous repair. Nine patients had bile leaks from bile duct transection (four), cystic stump (four) or segment V duct (one). Two patients had partial bile duct damage with primary sutured repair at time of cholecystectomy. One patient had recurrent haemobilia from a hepatic artery pseudoaneurysm.

RESULTS

Cystic stump or segment V leaks were treated successfully by endoscopic stenting (median follow-up 42 months). Roux loop biliary reconstruction was carried out in nine patients: two CHD strictures, three of the four failed primary CHD repairs and four bile duct transections. All had normal liver function test results at median follow-up of 30 months. The two patients with partial duct injuries repaired at initial surgery required no further intervention. The right hepatic artery aneurysm was successfully embolized. There have been no deaths or major complications of endoscopic, radiological or surgical intervention.

CONCLUSION

Endoscopic stenting successfully treats cystic stump and segment V duct leaks. Duct strictures, including failed initial repairs and transections, have a good outcome with Roux-en-Y loop reconstruction.

Bile duct injury during laparoscopic cholecystectomy without operative cholangiography

BACKGROUND

The role of operative cholangiography in the prevention of bile duct injuries is controversial. A prospective audit of biliary injury is presented.

METHODS

Laparoscopic cholecystectomy without operative cholangiography was undertaken in a consecutive series of 1200 patients. All biliary injuries were recorded.

RESULTS

Meticulous dissection proved to be a reliable safeguard against injury to the right hepatic, common hepatic and common bile ducts. However, four accessory ducts were sacrificed and localized injury to the common hepatic or common bile duct occurred in three patients. These injuries would not have been prevented by operative cholangiography.

CONCLUSION

Operative cholangiography is not a prerequisite for the safe performance of laparoscopic cholecystectomy and cannot be relied upon to prevent all biliary injuries.

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.

Estudo anatômico das vias bilíferas extra-hepáticas no suíno. Comparação entre a dissecção convencional e por videolaparoscopia

Estudou-se no presente trabalho, através de dissecção de peças anatômicas constituidas de fígado e duodeno, a morfologia das vias bilíferas do suíno. Os animais foram separados em dois grupos iguais, sendo que o primeiro foi submetido a colecistectomia videolaparoscópica. O segundo grupo era constituído de suínos abatidos para consumo. Os animais do grupo da colecistectomia videolaparoscópica eram observados por um período curto de pós-operatório e depois abatidos para retirada de peças anatômicas, tendo sido realizado o estudo das vias bilíferas extra-hepáticas. No segundo grupo eram as peças retiradas após o abate dos animais, estas eram dissecadas, coradas com tinta guache e posteriormente submetidas a estudo radiológico com a injeção de Bário. Os dados obtidos foram analizados utilizando-se o teste de FISHER. Verificou-se que o ductus choledocus é constituído pela união do ductus cysticus e ductus hepaticus na grande maioria dos casos (84.3%). Verificou-se também que o ductus hepaticus é formado, em grande número dos casos, pela confluência do ductus principalis sinister e ductus principalis dexter. Os resultados encontrados permitem concluir que não existem diferenças significantes, no que se refere à conformação das vias bilíferas extra-hepáticas em ambos os grupos.

Chief resident experience with laparoscopic cholecystectomy

Resident competence in both open and laparoscopic cholecystectomy (LC) has been a concern among general surgeons. Laparoscopic surgery was late in coming at many surgical residency programs in the United States, and many residents have graduated with limited experience in LC. We are chief residents who were fortunate enough to start our training when LC was first introduced at our institution in 1990. This report summarizes our experience with LC in our chief year, during which we performed LC on 147 patients. The average operating time was 37 minutes (range, 12-82 minutes). Six patients (4%) required conversion to an open procedure. There were three complications (2 postoperative cystic duct leaks and 1 intraoperative common bile duct injury) for an overall complication rate of 2%. There was no mortality. It is our conclusion that graduating chief residents with 5 years' exposure to LC may perform the procedure with a complication rate comparable to that reported in the current literature. Insuring that graduating chief residents have adequate training in open cholecystectomy may become a more pressing issue in the near future.

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.

Operative cholangiography in laparoscopic cholecystectomy: Is it essential?

This study is to evaluate the need for preoperative cholangiography during laparoscopic cholecystectomy when endoscopic retrograde cholangiopancreatography (ERCP) is available. Over a period of four years, 1105 consecutive patients had laparoscopic cholecystectomy. All patients, in addition to their clinical assessment, had routine liver function tests (LFTs) and ultrasound (US) examination of the biliary tract. Preoperative ERCP was performed (diagnostic and/or therapeutic) in 107 (9.6%) of the patients. The indications for ERCP were one or more of the following: 1) abnormal liver function test, 74 patients; 2) jaundice, 37 patients; 3) common bile duct (CBD) stone seen in US, 36 patients, and/or CBD dilatation, 46 patients; and 4) pancreatitis, 20 patients. In 41 out of 107 (38%) patients, CBD stones were present and cleared endoscopically. Postoperative ERCP was necessary in eight patients: to remove retained stones in the CBD (two patients), to stop bile leak (two patients), and to investigate the persistent abnormal LFTs in the remaining patients. The number of patients who had evidence of retained CBD stone following laparoscopic cholecystectomy was only two. In both patients, endoscopic removal was successful. Therefore, it is clear that operative cholangiography in laparoscopic cholecystectomy is not essential if there is a reasonable facility for ERCP.

Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. McGill Gallstone Treatment Group

BACKGROUND

The management of bile leaks has evolved in the laparoscopic era. This study characterizes risk factors for their developmental and their clinical course and management.

METHODS

Data on a cohort of patients who developed bile leaks after cholecystectomy in the laparoscopic era were gathered prospectively and retrospectively from an ongoing surgical database and following a review of hospital charts.

RESULTS

Sixty-four patients (mean age 56 +/- 17.1 years, 72% women) were included over a 5-year study period. The incidence of leaks was 1.1% among patients entered in a laparoscopic cholecystectomy database. Intraoperative complications were encountered in 36%. Rates of intraoperative complication and conversion to open surgery were greater among patients who developed leaks (5.2% vs 0.6% and 33% vs 6.3%, respectively, p < 0.00001). Patients presented 5.3 +/- 4.2 days following surgery with abdominal pain (89%), fever (74%), and tenderness (81%). Ultrasound diagnosed a suspected leak in 73%, which ERCP showed as originating from the cystic duct stump in 77%. Biliary obstruction was noted in 20 (31%) patients (14 with stones). Treatments included percutaneous (13%), endoscopic (28%), primary or secondary operative procedures (14%), or a combination thereof (45%).

CONCLUSION

A complication at laparoscopic cholecystectomy increases the likelihood of a subsequent bile leak. Most patients present early with a patent cystic duct stump in the absence of biliary obstruction. Endoscopic therapy is successful in the majority of cases, but otherwise percutaneous or operative procedures may be needed.

Complications of laparoscopic cholecystectomy: the experience of a university-affiliated teaching hospital

BACKGROUND

In most published reports on laparoscopic cholecystectomy, the cases have been accrued from small community hospitals in a multicenter fashion. The purpose of this study was to compare the rate of complication following laparoscopic cholecystectomy performed at a single university-affiliated teaching hospital to those quoted in the literature.

STUDY DESIGN

A retrospective review of the first 1300 laparoscopic cholecystectomies performed at the Videoscopic Surgery Center at Pennsylvania Hospital from May 1990 through January 1994 was undertaken. Complications were classified as those related to creation of the initial pneumoperitoneum and those related to cholecystectomy.

RESULTS

A 3% conversion rate to open cholecystectomy (n = 40) was noted due to the presence of dense adhesions, gangrenous cholecystitis, or difficult anatomic relationships. There were 18 complications (1.4%) related to creation of the initial pneumoperitoneum and 14 complications (1.1%) related to cholecystectomy. Complications related to laparoscopy included bleeding from the abdominal wall (n = 2), trocar site hernia (n = 11), hollow viscus injury (n = 1), and wound infection (n = 4). Complications related to cholecystectomy included unanticipated retained CBD stone (n = 5), symptomatic bile leak (n = 6), hollow viscus injury (n = 1), intraabdominal abscess (n = 1), and a retained portion of gallbladder (n = 1). There were no perioperative deaths related to laparoscopic cholecystectomy, and the overall morbidity was 2.4%. Long-term follow-up revealed no cases of benign biliary strictures.

CONCLUSIONS

With attention to anatomy, technique, and meticulous dissection, laparoscopic cholecystectomy can be safely performed in a university-affiliated teaching hospital setting.

Inferolateral retraction reduces the risk of thermal injury to biliary structures

OBJECTIVES

Do various traction techniques significantly change the anatomic position during laparoscopic cholecystectomy?

METHODS

16 cadaveric liver specimens were dissected and measurements were taken between structures in the triangle of Calot. Measurements were taken while traction was placed on the infidubilum in the inferolateral, cephalad and anatomic positions. Thermal necrosis data was measured one week post-injury in a rat model for Non-contact Yag laser, Quartz, Sapphire tip, and electrocautery.

RESULTS

Inferolateral traction provided statistically significant increases in distance (P < 0.01) between the critical biliary structures. The increase in length by cephalad traction on the gallbladder was not statistically significant. Depth of necrosis for the devices were: cautery 1.03 mm, sapphire tip 0.63 mm, non-contact Yag laser 2.13 mm, and bare quartz tip laser 1.05 mm.

CONCLUSION

Inferolateral traction produced a statistically significant increase in distance between the critical biliary structures. This was not demonstrated with cephalad traction. We recommend avoiding thermal dissection in the Triangle of Calot due to the thermal devices necrosis depth in relation to the proximity of the biliary structures.

The cystic vein: the significance of a forgotten anatomic landmark

The cystic vein, a portion of biliary anatomy whose insignificance in open gallbladder surgery led to its being relegated to mythology, has been rediscovered by the magnified view of laparoscopic surgery. Its presence is an important anatomic feature that helps distinguish between cystic duct and common hepatic duct, thus diminishing the risk of inadvertent bile duct injury during laparoscopic cholecystectomy.

Postoperative complications of cholecystectomy in Victorian public hospitals

Cholecystectomies in Victorian public hospitals were evaluated by analysis of hospital morbidity data. The Victorian Inpatient Minimum Dataset (VIMD) contains data on postoperative complications from all cholecystectomies in Victorian public hospitals. Hospital separations associated with cholecystectomy were identified according to Australian national diagnosis-related groups and the procedures were grouped as open, laparoscopic or conversion from laparoscopic to open cholecystectomy (conversion). Postoperative complications were identified by ICD9-CM external-cause codes (E-codes) in the VIMD. The 35593 cholecystectomies performed between 1987-88 and 1993-94 were analysed. A further detailed analysis of all cholecystectomies performed in 1993 was based on logistic regression. This identified the adjusted odds (AOR) of occurrence of complications and included covariates of age, sex, admission type, diagnosis-related group and hospital identification code. The annual frequency of cholecystectomy increased after introduction of laparoscopic cholecystectomy in 1990, and was associated with an increase in rates of separations having adverse events, but laparoscopic cholecystectomy had the lowest rate (66.7 per 1000 separations). Adverse-event rates for open procedures increased to 157.5 per 1000 in 1993-94, and for conversions to 290.0 per 1000. Of 5627 cholecystectomies in 1993, 74.4 per cent were laparoscopic, 21.5 per cent open and 4.1 per cent conversions. Postoperative complications were more likely in males (AOR 1.67, 95 per cent confidence interval (CI) 1.38 to 2.04), in patients admitted as an emergency (1.27, CI 1.01 to 1.60), and in those having open cholecystectomies (2.25, 1.78 to 2.85) or conversions (4.29, 3.05 to 6.03). Analysis of the VIMD has provided information for the evaluation of cholecystectomy. The VIMD is a useful tool for monitoring postoperative complications and the quality of care in Victorian hospitals.

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.

Septic and other complications resulting from biliary stones placed in the abdominal cavity. Experimental study in rabbits

BACKGROUND

The aim of this experimental study is to assess the consequences of biliary stones placed in the abdominal cavity of rabbits.

METHODS

The animals were allocated to five groups. In group A a nonsterile gallstone was used. In group B animals with a nonsterile gallstone received preoperative chemoprophylaxis. In group C a sterile stone was placed in the abdomen. Group D served as control. In group E were animals with a nonsterile stone who had a prolonged follow-up period. Parameters studied postoperatively were temperature, white blood cell count, abscess formation, sepsis, peritonitis, adhesion formation, intestinal obstruction, and histological changes of the omentum enveloping the gallstones.

RESULTS

There was no statistically significant difference among the five groups concerning morbidity, mortality, or histological findings.

CONCLUSIONS

The prevalence of septic complications was higher among the four groups that received gallstones compared to the control group and thus an adverse effect of gallstone implantation can be suggested.

Has laparoscopic cholecystectomy changed patterns of practice and patient outcome in Ontario?

OBJECTIVE

To examine the effect of the introduction of laparoscopic cholecystectomy (LC) on patterns of practice (number of cholecystectomy procedures, case-mix and length of hospital stay) and patient outcomes in Ontario.

DESIGN

Cross-sectional population-based time trends using hospital discharge data.

SETTING

All acute care hospitals in Ontario where cholecystectomy was provided.

PATIENTS

All 119,821 Ontario residents who underwent cholecystectomy between 1989-90 and 1993-94. After exclusions (initial bile duct exploration, cancer, incidental cholecystectomy, or missing codes for age, sex or residence) 108,442 patients remained.

OUTCOME MEASURES

Number of cholecystectomy procedures, proportion of patients with acute or chronic gallstone disease, length of hospital stay, and rates of death, readmission, and bile duct injury and other in-hospital complications after cholecystectomy by year.

RESULTS

The number of cholecystectomy procedures increased by 30.4% between 1989-90 and 1993-94. The number of patients with chronic gallstone disease increased by 33.6%, and the number who underwent elective surgery increased by 48.3%. The proportion of procedures performed as LC increased from 1.0% in 1990-91 to 85.6% in 1993-94. Patients who received LC tended to be younger female patients with chronic gallstone disease with no coexisting conditions undergoing elective operations. The mean length of stay, adjusted for case-mix differences, was significantly lower in 1993-94 than in 1989-90 (2.6 days v. 7.5 days) (p < 0.05); the values for LC and open cholecystectomy in 1993-94 were 1.8 days and 7.3 days respectively. The decrease in the crude death rate over the study period (0.3% to 0.2%) was not significant (relative odds 1.10, 95% confidence interval [CI] 0.72 to 1.69). In 1993-94 the adjusted risk of readmission to hospital within 30 days was 1.38 (95% CI 1.19 to 1.58) as compared with 1989-90. Over the 5 years the rate of bile duct injuries tripled (0.3% in 1989-90 v. 0.9% in 1993-94). The adjusted risk of having at least one complication after cholecystectomy in 1993-94 was 1.90 (95% CI 1.75 to 2.07) as compared with 1989-90.

CONCLUSIONS

LC has had a substantial effect on the number of cholecystectomy procedures performed, the type of patient having the gallbladder removed and the length of hospital stay. Death rates are unchanged, but the odds of readmission and in-hospital complications are both increased. Future research should be directed toward determining the reasons for the overall increase in rates, developing methods to reduce bile duct injuries and identifying other relevant outcomes, such as patient satisfaction with the procedure.

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.

Laparoscopic-assisted and minilaparotomy approaches to colorectal diseases are similar in early outcome

OBJECTIVE

The purpose of this study was to compare laparoscopy with minilaparotomy approaches to colorectal diseases.

METHOD

Outcomes after minilaparotomy and laparoscopy were prospectively compared for a 12-month period.

RESULTS

Minilaparotomy was performed in 35 patients to achieve right colectomy (14), left colectomy (8), total colectomy (2), low anterior resection (6), abdomino-perineal resection (2), colostomy (1), and ileal resection (1). Laparoscopic techniques were used in 52 patients to perform right colectomy (20), left colectomy (11), low anterior resection (5), abdominoperineal resection (7), total colectomy (3), ileal resection (1), colostomy (3), transverse colectomy (1), and colostomy closure (1). Mean operative times were 69 minutes for minilaparotomy (range, 33-180) and 173 minutes for laparoscopy (range, 60-300). Mean incision lengths were 12 (range 8-18) cm and 8 (range, 0-25) cm; mean time to bowel movement was four (range, 1-7) days and 3.9 (range, 0-8) days; mean day of discharge was 6.9 (range 3-15) days, and 6 (range, 1-15) days postoperatively, respectively. Laparoscopy procedures were completed in 39 of 52 patients (75 percent); mean time to bowel movement was 3.5 (range, 0-6) days, and mean day of discharge was 5.3 (range, 1-14) days (P = <0.005).

CONCLUSION

The use of a small incision, whether by minilaparotomy or by laparoscopy, results in similar early return of function and discharge.

[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.

Laparoscopic cholecystectomy: the experience of community hospital

BACKGROUND

The practice of laparoscopic cholecystectomy in a community hospital is presented. The morbidity of the procedure is analysed and recommendations for improvement are made. Laparoscopic cholecystectomy was introduced into this 200 bed community hospital in October 1990. All five general surgeons accredited to the hospital agreed to participate in a quality assurance programme to determine the incidence of complications and to make recommendations for improvement.

METHODS

The records of all 534 patients having laparoscopic cholecystectomy between October 1990 and September 1993 were reviewed, and all complications recorded.

RESULTS

Of the 534 cases reviewed in the study 470 were considered uncomplicated and 64 patients experienced a total of 85 postoperative complications. The death of one patient was caused by a pulmonary embolus and another patient experienced a myocardial infarction. Twenty patients has postoperative atelectasis or pneumonia and urinary infection or retention occurred in seven. Complications of laparoscopic cholecystectomy requiring a conversion to open cholecystectomy occurred in eight patients, biliary complications occurred in 18 and 11 required re-operation.

CONCLUSIONS

Three areas of concern were identified. They were the incidence of major biliary injury (0.37% of all cases) and its management, the role of cholangiography, and the incidence and prophylaxis of deep venous thrombosis and pulmonary embolism. Recommendations for improvement in these areas were made.

Exposure for laparoscopic cholecystectomy dissection adversely alters biliary ductal anatomy

BACKGROUND

Exposure for open cholecystectomy entails lateral, caudal traction on the gallbladder infundibulum, which results in opening the angle between the cystic and hepatic ducts. Laparoscopic cholecystectomy (LC), as initially described, is done with cephalad traction on the gallbladder. We hypothesized LC exposure technique narrows the angle between the cystic and hepatic ducts, placing them at increased risk of injury.

METHODS

Twenty-three patients had routine LC. Cystic duct cholangiography (IOC) was done with a flexible 5-Fr catheter via a percutaneous introducer placed anterior to the gallbladder. Exposure of Calot's triangle was maintained with cephalad traction on the gallbladder fundus. IOC was repeated after allowing the organ to assume the anatomic position. The cholangiograms were inspected for significant differences, and the angle of the cystic to the hepatic duct (CDHD) was measured by a blinded radiologist.

RESULTS

The mean angle of the cystic to hepatic duct was 30 degrees +/- 19 degrees in the IOCs taken with cephalad traction on the gallbladder fundus vs 59 degrees +/- 22 degrees, P < 0.001, in the cholangiograms taken without traction. A filling defect at the cystic-hepatic duct junction was present in 39% of IOC taken with traction vs none without traction. The intrahepatic ducts were seen in all films without traction, whereas the intrahepatic ducts were not visualized in 13% of IOCs taken with traction.

CONCLUSIONS

From these data we conclude (1) extra-hepatic biliary ducts may be at increased risk of injury during LC because of the exposure technique and (2) imaging bile ducts in the anatomic position may convey misleading information about the relative location of important structures. Optimal exposure for dissection of Calot's triangle should utilize a second clamp on the infundibulum with lateral, caudal traction.

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.

Laparoscopic and open cholecystectomy outcomes in Medicare beneficiaries in member states of the Large State PRO Consortium

To determine the incidence of laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) and some of their possible outcomes (complications, mortality, 30-day readmission) in the general population of senior citizens, we examined Medicare claims data for beneficiaries 65 years and older in eight states. Billing data for all cholecystectomies (ICD9-CM 51.22, 51.23) performed on an inpatient basis in those states on Medicare beneficiaries age 65 and older during fiscal year 1992 were examined. The incidence of LC in each state ranged from 2.1 to 3.2/1,000, whereas the incidence of OC ranged from 2.2 to 3.5/1,000. Eleven and one-half percent of LC patients suffered at least one perioperative complications, as did 21.5% of OC patients. There was considerable interstate variation in complication rates. In-hospital mortality was about five times greater of OC (4.5%) than for LC (0.9%). Patients who underwent OC were more likely (9.2%) to be readmitted within 30 days than were LC patients (7.0%). LC seems to be at least as safe as OC in the elderly population. Analyzing Medicare claims data can be useful in uncovering geographic variations in cholecystectomy practice.

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.

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.