Common bile duct injuries during laparoscopic cholecystectomy that result in litigation

Magnetic Resonance Cholangiography Diagnosing Post-cholecystectomy Biliary Injuries

OBJECTIVE

This study aimed to determine the diagnostic performance of contrasted magnetic resonance cholangiography for detecting bile duct lesions following cholecystectomy.

MATERIALS AND METHODS

A retrospective case series study was conducted that included patients over 18 years of age with suspected bile duct injury after cholecystectomy, who underwent contrasted magnetic resonance cholangiography, and who also had endoscopic retrograde cholangiopancreatography, surgery, or subsequent clinical follow-up. The images were interpreted by two radiologists who assigned the type of lesion according to the Strasberg classification. Qualitative variables were represented by frequencies and proportions, while quantitative variables were described using measures of central tendency and dispersion. Sensitivity, specificity, and predictive values were assessed, along with interobserver variability, using the kappa index.

RESULTS

We included 20 patients with a median age of 51.5 years (interquartile range: 35), and 14 (70%) were women. In all 20 patients, lesions were identified on magnetic resonance cholangiography, of which 19 were confirmed with the gold standard for a positive predictive value of 100% (hepatobiliary-specific contrast agents) and 92% (extracellular contrast). The most frequent lesions were Strasberg E2 and E4 in five patients each. The kappa index was 1 in determining the presence or absence of bile duct injury and 0.9 in the Strasberg classification.

CONCLUSION

Contrasted magnetic resonance cholangiography is a method with high positive predictive value and almost perfect interobserver agreement for diagnosing bile duct lesions after cholecystectomy.

Online calculators for predicting the risk of anastomotic stricture after hepaticojejunostomy for bile duct injury after cholecystectomy: a multicenter retrospective study

BACKGROUND

Anastomotic stricture is a common underlying cause of long-term morbidity after hepaticojejunostomy (HJ) for bile duct injury (BDI) following cholecystectomy. However, there are no methods for predicting stricture risk. This study was aimed at establishing two online calculators for predicting anastomotic stricture occurrence (ASO) and stricture-free survival (SFS) in this patient population.

METHODS

The clinicopathological characteristics and follow-up information of patients who underwent HJ for BDI after cholecystectomy from a multi-institutional database were reviewed. Univariate and multivariate analyses of the risk factors of ASO and SFS were performed in the training cohort. Two nomogram-based online calculators were developed and validated by internal bootstrapping resamples ( n =1000) and an external cohort.

RESULTS

Among 220 screened patients, 41 (18.64%) experienced anastomotic strictures after a median follow-up of 110.7 months. Using multivariate analysis, four variables, including previous repair, sepsis, HJ phase, and bile duct fistula, were identified as independent risk factors associated with both ASO and SFS. Two nomogram models and their corresponding online calculators were subsequently developed. In the training cohort, the novel calculators achieved concordance indices ( C -indices) of 0.841 and 0.763 in predicting ASO and SFS, respectively, much higher than those of the above variables. The predictive accuracy of the resulting models was also good in the internal ( C -indices: 0.867 and 0.821) and external ( C -indices: 0.852 and 0.823) validation cohorts.

CONCLUSIONS

The two easy-to-use online calculators demonstrated optimal predictive performance for identifying patients at high risk for ASO and with dismal SFS. The estimation of individual risks will help guide decision-making and long-term personalized surveillance.

Subtotal cholecystectomy: is it a safe option for difficult gall bladders?

INTRODUCTION

Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC.

METHODS

We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study.

RESULTS

A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC.

CONCLUSIONS

STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.

Major iatrogenic bile duct injury during elective cholecystectomy: a Czech population register-based study

PURPOSE

Bile duct injury (BDI) remains the most serious complication following cholecystectomy. However, the actual incidence of BDI in the Czech Republic remains unknown. Hence, we aimed to identify the incidence of major BDI requiring operative reconstruction after elective cholecystectomy in our region despite the prevailing modern 4 K Ultra HD laparoscopy and Critical View of Safety (CVS) standards implemented in daily surgical practice among the Czech population.

METHODS

In the absence of a specific registry for BDI, we analysed data from The Czech National Patient Register of Reimbursed Healthcare Services, where all procedures are mandatorily recorded. We investigated 76,345 patients who were enrolled for at least a year and underwent elective cholecystectomy during the period from 2018-2021. In this cohort, we examined the incidence of major BDI following the reconstruction of the biliary tract and other complications.

RESULTS

A total of 76,345 elective cholecystectomies were performed during the study period, and 186 major BDIs were registered (0.24%). Most elective cholecystectomies were performed laparoscopically (84.7%), with the remaining open (15.3%). The incidence of BDI was higher in the open surgery group (150 BDI/11700 cases/1.28%) than in laparoscopic cholecystectomy (36 BDI/64645 cases/0.06%). Furthermore, the total hospital stays with BDI after reconstruction was 13.6 days. However, the majority of laparoscopic elective cholecystectomies (57,914, 89.6%) were safe and standard procedures with no complications.

CONCLUSION

Our study corroborates the findings of previous nationwide studies. Therefore, though laparoscopic cholecystectomy is reliable, the risks of BDI cannot be eliminated.

Determinants, Costs, and Consequences of Common Bile Duct Injury Requiring Operative Repair Among Privately Insured Individuals in the United States, 2003-2020

Objective

Characterize the determinants, all-cause mortality risk, and healthcare costs associated with common bile duct injury (CBDI) following cholecystectomy in a contemporary patient population.

Background

Retrospective cohort study using nationwide patient-level commercial and Medicare Advantage claims data, 2003-2019. Beneficiaries ≥18 years who underwent cholecystectomy were identified using Current Procedure Terminology (CPT) codes. CBDI was defined by a second surgical procedure for repair within one year of cholecystectomy.

Methods

We estimated the association of common surgical indications and comorbidities with risk of CBDI using logistic regression; the association between CBDI and all-cause mortality using Cox proportional hazards regression; and calculated average healthcare costs associated with CBDI repair.

Results

Among 769,782 individuals with cholecystectomy, we identified 894 with CBDI (0.1%). CBDI was inversely associated with biliary colic (odds ratio [OR] = 0.82; 95% confidence interval [CI]: 0.71-0.94) and obesity (OR = 0.70, 95% CI: 0.59-0.84), but positively associated with pancreas disease (OR = 2.16, 95% CI: 1.92-2.43) and chronic liver disease (OR = 1.25, 95% CI: 1.05-1.49). In fully adjusted Cox models, CBDI was associated with increased all-cause mortality risk (hazard ratio = 1.57, 95% CI: 1.38-1.79). The same-day CBDI repair was associated with the lowest mean overall costs, with the highest mean overall costs for repair within 1 to 3 months.

Conclusions

In this retrospective cohort study, calculated rates of CBDI are substantially lower than in prior large studies, perhaps reflecting quality-improvement initiatives over the past two decades. Yet, CBDI remains associated with increased all-cause mortality risks and significant healthcare costs. Patient-level characteristics may be important determinants of CBDI and warrant ongoing examination in future research.

Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements

Background. To define what type of injuries are more frequently related to medicolegal claims and civil action judgments. Methods. We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries. Results. The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a “poor” visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries. Conclusions. During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.

Tactics and techniques of choledochal sanation after papillotomy

Сholelithiasis ranks third in terms of the prevalence of diseases among the adult population. A complication such as choledocholithiasis occurs in up to 33% of patients with gallstone disease. Despite the improvement in treatment methods and the use of “gold” standards, the number of complicated forms of cholelithiasis has no tendency to decrease. Timely resolution of choledocholithiasis by a correctly chosen technique helps to reduce complications and increases the frequency of favorable outcomes of the disease, returning patients to social activity.

That is why it is important to know and, if possible, to use various methods of rehabilitation of the common bile duct when performing modern endoscopic transpapillary interventions.

Comparison of indocyanine green dye fluorescent cholangiography with intra-operative cholangiography in laparoscopic cholecystectomy: a meta-analysis

OBJECTIVE

To compare indocyanine green dye fluorescence cholangiography (ICG-FC) with intra-operative cholangiography (IOC) in minimal access cholecystectomy for visualization of the extrahepatic biliary tree.

BACKGROUND

Although studies have shown that ICG-FC is safe, feasible, and comparable to IOC to visualize the extrahepatic biliary tree, there is no comparative review.

METHODS

We searched The Embase, PubMed, Cochrane Library, and Web of Science databases up to 8 April 2020 for all studies comparing ICG-FC with IOC in patients undergoing minimal access cholecystectomy. The primary outcomes were percentage visualization of the cystic duct (CD), common bile duct (CBD), CD-CBD junction, and the common hepatic duct (CHD). We used RevMan v5.3 software to analyze the data.

RESULTS

Seven studies including 481 patients were included. Five studies, comprising 275 patients reported higher CD (RR = 0.90, p = 0.12, 95% CI 0.79-1.03, I² = 74%) and CBD visualization rates (RR = 0.82, p = 0.09, 95% CI 0.65-1.03, I² = 87%) by ICG-FC. Four studies, comprising 223 patients, reported higher CD-CBD junction visualization rates using ICG-FC compared to IOC (RR = 0.68, p = 0.06, 95% CI = 0.45-1.02, I² = 94%). Four studies, comprising 210 patients, reported higher CHD visualization rates using ICG-FC compared to IOC (RR = 0.58, p = 0.03, 95% CI 0.35-0.93, I² = 91%).

CONCLUSION

ICG-FC is safe, and it improves visualization of CHD.

Iatrogenic Biliary Injury during Cholecystectomy: Critical Review of a Historical Case and Its Political Consequences

Biliary injuries during cholecystectomy represent serious adverse events that can have a profound impact on the patient's quality of life and on the surgeon's well-being and career. Sometimes, they can have an unexpectedly disastrous effect on the whole community, as demonstrated by the case of Anthony Eden, former foreign secretary and prime minister of Britain in the 1950s. Mr. Eden, later Lord Avon, had been suffering from biliary symptoms for a while when he had his cholecystectomy performed on April 12, 1953. On post-op day 1, a bile leak was evident, possibly due to a complete transection of the common bile duct. After a first reoperation to drain a bile collection, the definitive repair was performed in Boston by Dr. Cattell on June 10, 1953, with a loop hepatico-jejunostomy. Unfortunately, the bilioenteric anastomosis became gradually narrow, causing recurrent cholangitis, and Mr. Eden started a symptomatic treatment with pethidine, barbiturate, and amphetamine. These could have affected his perception of reality and his political judgement during the Suez Canal Crisis and, other than being the ultimate reason for 3,000+ war casualties, might have caused a Third World War. The historical and clinical implications of this case are thoroughly discussed.

Effectiveness of near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary study

INTRODUCTION

Bile duct injury represents the most serious complication of LC, with an incidence of 0.3-0.7% resulting in a significant impact on quality-of-life, overall survival, and frequent medico-legal litigations. Near-infrared fluorescent cholangiography (NIRF-C) represents a novel intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. The role of routine use of pre-operative magnetic resonance cholangio-pancreatography (MRCP) to better clarify the biliary anatomy before laparoscopic cholecystectomy is still a matter of debate. The primary aim of this study was to evaluate the effectiveness of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in comparison with pre-operative MRCP.

METHODS

Data from 26 consecutive patients with symptomatic cholelithiasis or chronic cholecystitis, who underwent elective laparoscopic cholecystectomy with intra-operative fluorescent cholangiography and pre-operative MRCP examination between January 2018 and May 2018, were analyzed. Three selected features of the cystic duct-common hepatic duct anatomy were identified and analyzed by the two different imaging methods: insertion of cystic duct, cystic duct-common hepatic duct junction, and cystic duct course.

RESULTS

Fluorescent cholangiography was performed successfully in all twenty-six patients undergoing elective laparoscopic cholecystectomy. The visualization of cystic duct was reported in 23 out of 26 cases, showing an overall diagnostic accuracy of 86.9%. The level of insertion, course, and wall implantation of cystic duct were achieved by NIRF-C with diagnostic accuracy values of 65.2%, 78.3%, and 91.3%, respectively in comparison with MRCP data. No bile duct injuries were reported.

CONCLUSION

Fluorescent cholangiography can be considered a useful imaging diagnostic tool comparable to MRCP for detailed intra-operative visualization of the cystic duct-common hepatic duct anatomy during elective laparoscopic cholecystectomies.

Laparoscopic versus open surgery for the management of post-cholecystectomy benign biliary strictures

BACKGROUND AND AIM

Surgical management by a bilioenteric anastomosis is the standard for the repair of post-cholecystectomy benign biliary strictures (BBS). This is traditionally done as an open operation. There are a few reports describing the procedure by a laparoscopic technique. The aim of the present study was to describe our experience of laparoscopic bilio-enteric anastomosis [Roux-en-Y hepaticojejunostomy (LRYHJ)/laparoscopic hepaticoduodenostomy (LHD)] in the management of post-cholecystectomy BBS and compare the outcomes with our patients operated by the open approach.

METHODS

Retrospective analysis of prospective data of post-cholecystectomy BBS patients treated by laparoscopic bilio-enteric anastomosis. The outcomes were compared with patients who underwent an open repair.

RESULTS

Between January 2016 and February 2019, 63 patients underwent surgery for post-cholecystectomy BBS. Twenty-nine patients who underwent laparoscopic bilio-enteric anastomosis (LRYHJ-13, LHD-16) were compared with 34 patients who underwent an open repair. The median age (40 vs 39) years, type of index surgery [laparoscopic cholecystectomy (13 vs 15), laparoscopic converted to open cholecystectomy (10 vs 16), and open cholecystectomy (6 vs 3)], type of injury low stricture (7 vs 5) and high stricture (22 vs 29), preoperative biliary fistula (23 vs 30), and time from injury to repair (6 vs 7 months) were similar in the 2 groups. The median duration of surgery was also similar (210 vs 200 min, p = 0.937); however, the median intraoperative blood loss (50 mL vs 200 mL, p = 0.001), time to resume oral diet (2 vs 4 days p = 0.023),** and median duration of postoperative hospital stay (6 vs 8 days, p = 0.001) were significantly less in the laparoscopy group. Overall morbidity rate (within 30 days post-surgery) was significantly higher in the open repair group (38% vs 20%). In a subgroup analysis of the laparoscopic repair group, the operative time in patients who underwent an LHD was significantly less than LRYHJ (190 vs 230 min, p = 0.034). The other parameters like the mean intraoperative blood loss, time to initiate oral diet, duration of postoperative hospital stay, and incidence of postoperative bile leak were similar. Patients undergoing open repair had a median follow-up of 26 months with two developing anastomotic stenosis and those undergoing laparoscopic repair had a median follow-up for 9 months with one developing anastomotic stenosis.

CONCLUSION

Laparoscopic surgery for post-cholecystectomy BBS with an LRYHJ or LHD is feasible and safe and compares favourably with the open approach.

Reliable reconstruction of the complex high-location bile duct injury: a novel hepaticojejunostomy

BACKGROUND

This study aimed to propose a novel surgical reconstruction technique for complex high-location bile duct injury (CHBDI).

METHODS

There were eight patients with CHBDI underwent the novel hepaticojejunostomy between Feb 2015 and Feb 2017. Seven patients underwent a primary operation and found CHBDI postoperatively in the inferior hospitals referred to our center. And four of them had received hepaticojejunostomy, but the results were not satisfying. One patient (No.8) with radiographically diagnosed hilar cholangiocarcinoma came to our center for surgical treatment and underwent the novel hepaticojejunostomy technique because CHBDI was found in operation. Perioperative and follow-up data of these patients were retrospectively reviewed.

RESULTS

The mean age was 47.6 ± 10.7 years, and there was four female. The mean range of time between the injury and the repair operation in our center was 6.3 ± 4.8 months. All repair operations using the novel hepaticojejunostomy technique in our center were successfully performed. No postoperative complications, including biliary fistula, restenosis, peritonitis, and postoperative cholangitis was observed. Besides, no evidence of biliary stenosis or biliary complications happened during the follow-up (median 28 months).

CONCLUSIONS

The novel hepaticojejunostomy is a reliable and convenient technique for surgical repair of multiple biliary ductal openings like CHBDI.

[Management of bile duct injuries]

Bile duct injuries can occur after abdominal trauma, postoperatively after cholecystectomy, liver resection or liver transplantation and also as a complication of endoscopic retrograde cholangiopancreatography (ERCP). The clinical appearance of bile duct injuries is highly variable and depends primarily on the underlying cause. In addition to the high perioperative morbidity, following successful initial complication management, bile duct injuries can lead to significant long-term complications. The treatment requires close interdisciplinary cooperation between surgery, interventional gastroenterology and interventional radiology. The treatment of bile duct injuries depends primarily on the time of diagnosis (intraoperative/postoperative) as well as the extent of the injury and is discussed in this review.

Early Surgical Repair of Bile Duct Injuries following Laparoscopic Cholecystectomy: The Sooner the Better

Background  We aimed to investigate the outcomes of the immediate surgical repair of bile duct injuries (BDIs) following laparoscopic cholecystectomy. Materials and Methods  Between January 2012 and May 2017, patients, who underwent immediate surgical repair (within 72 hours) for postcholecystectomy BDI, by the same surgical team expert in hepatobiliary surgery, were enrolled into the study. Data collection included demographics, type of BDI according to the Strasberg classification, time to diagnosis, surgical procedures, and outcome. Results  There were 13 patients with a mean age of 43 ± 12 years. Classification of BDIs were as follows: type E in six patients (46%), type D in three patients (23%), type C in two (15%), and types B and A in one patient each (7.6%). Mean time to diagnosis was 22 ± 15 hours. Surgical procedures included Roux-en-Y hepaticojejunostomy for all six patients with type-E injury, primary repair of common bile duct for three patients with type-D injury, and primary suturing of the fistula orifice was performed in two cases with type-C injury. Other two patients with type-B and -A injury underwent removal of clips which were placed on common bile duct during index operation and replacing of clips on cystic duct where stump bile leakage was observed probably due to dislodging of clips, respectively. Mean hospital stay was 6.6 ± 3 days. Morbidity with a rate of 30% ( n  = 4) was observed during a median follow-up period of 35 months (range: 6-56 months). Mortality was nil. Conclusion  Immediate surgical repair of postcholecystectomy BDIs in selected patients leads to promising outcome.

A comprehensive evaluation of the long-term economic impact of major bile duct injury

BACKGROUND

Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI.

METHOD

Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes.

RESULTS

Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates.

CONCLUSION

Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.

Robotic-assisted repair of iatrogenic common bile duct injury after laparoscopic cholecystectomy: Surgical technique and outcomes

BACKGROUND

Bile duct injury after cholecystectomy can be a life-threatening complication. Use of robotic approach to manage a complex biliary injury is in an early phase.

METHODS

We have performed an analysis of our prospectively maintained database that included 12 patients who underwent robotic-assisted repair of bile duct injury after laparoscopic cholecystectomy between 2014 and 2017.

RESULTS

All patients underwent robotic biliary repair within 2 weeks after primary injury. No conversion to open surgery was necessary, the estimated mean blood loss was 252 mL, and the mean operative time was 260 minutes. The mean length of stay was 9.4 days. The 30-day complication events were a subhepatic abscess and a recurrent episode of cholangitis. One patient underwent the reoperation. The mortality was null.

CONCLUSION

Robotic-assisted bile duct injury repair seems to be safe and feasible. It offers promising results, thus potentially capable of modifying the management of biliary injury.

Iatrogenic bile duct injury: impact and management challenges

Iatrogenic bile duct injuries (BDIs) after laparoscopic cholecystectomy, being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery with a significant impact on patient's quality of life. The primary aim of this review was to discuss the classification of BDIs, the proposed methods to prevent biliary lesions, the associated risk factors, and the management challenges depending on the timing of recognition of the injury, its extension, the patient's clinical condition, and the availability of experienced hepatobiliary surgeons. Early recognition of BDI is of paramount importance and limiting the diagnosis delay is crucial for an optimal postoperative outcome. The therapeutic management depends on the type and gravity of the biliary lesion, and includes endoscopic, radiologic, and surgical approaches.

Management of iatrogenic bile duct injuries: Multiple logistic regression analysis of predictive factors affecting morbidity and mortality

OBJECTIVE

Iatrogenic bile duct injuries remain a challenge for the surgeons to overcome. The predictive factors affecting morbidity and mortality are important for determining the best management modality.

MATERIAL AND METHODS

The patients who referred to Ege University Faculty of Medicine after laparoscopy associated iatrogenic bile duct injury are grouped according to Strasberg-Bismuth classification system. The type and number of prior attempts, concomitant complications, and treatment modalities are analyzed using the SPSS version 18 (IBM, Chicago, IL, USA). The variables with p<0.10 were considered for univariate analysis and then evaluated for predictive factors by forward Logistic Regression method using multiple logistic regression analysis.

RESULTS

According to the analysis of 105 patients who were referred during 2004-2014, the type and number of prior attempts are considered predictive factors in sepsis. In multiple logistic regression analysis, abscess formation, concomitant vascular injury, and serum bilirubin level are significantly effective in predicting mortality.

CONCLUSION

The management of iatrogenic bile duct injuries should be carefully planned with a multidisciplinary approach. The predictive factors affecting morbidity and mortality are important in determining the best modality for managing iatrogenic bile duct injuries. Abscess formation, vascular injury, and serum bilirubin level are the potential risk factors. Therefore, we can strongly recommend immediate assessment of patients for prompt diagnosis and referring to an HPB center, to avoid further injuries.

Surgeons opinions of legal practice in bile duct injury following cholecystectomy

INTRODUCTION

Litigation for bile duct injury following laparoscopic cholecystectomy places financial strain on the health service, causes significant patient morbidity and adversely affects the patient and surgeon. Claimants argue that the injury itself is evidence of negligence.

METHODS

A questionnaire addressing views on BDI causation was sent to members of AUGIS working in the National Health Service, UK. Response themes and responses were compared between groups of surgeons.

RESULTS

Of 117 respondents, 45% experienced BDI and 22% had medicolegal experience. 47% of respondents identified factors outside the surgeons control as being relevant to BDI. Those that had experienced BDI from their own surgery were less likely to identify surgeon/systems errors as the primary cause for BDI than those that had not (34% vs 74%, p < 0.001). Medicolegal expert surgeons were more likely to report that substandard technique should be presumed (50% vs 19%, p = 0.002), however, 25% of medicolegal experts indicated that not all BDIs caused by their own surgery could have been avoided.

CONCLUSION

A significant number of experienced surgeons indicated that BDI following LC should not be assumed to result from surgeon negligence or institutional failure. This suggests that negligence should not be inferred from the act of BDI alone.

Bile Duct Injury after Cholecystectomy: Surgical Therapy

BACKGROUND

Iatrogenic bile duct injuries (IBDI) after laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery. The most important aspect regarding this issue is the prevention of IBDI during index cholecystectomy. Once it occurs, early and accurate diagnosis of IBDI is very important for surgeons and gastroenterologists, because unidentified IBDI may result in severe complications such as hepatic failure and death. Laboratory tests, radiological imaging, and endoscopy play an important role in the diagnosis of biliary injuries.

METHODS

This review summarizes and discusses the current literature on the management of IBDI after LC from a surgical point of view.

RESULTS AND CONCLUSION

In general, endoscopic techniques are recommended for the initial diagnosis and treatment of IBDI and are important to classify them correctly. In patients with complete dissection or obstruction of the bile duct, surgical management remains the only feasible option. Different surgical reconstructions are performed in patients with IBDI. According to the available literature, Roux-en-Y hepaticojejunostomy is the most frequent surgical reconstruction and is recommended by most authors. Long-term results are most important in the assessment of effectiveness of IBDI treatment. Apart from that, adequate diagnosis and treatment of IBDI may avoid many serious complications and improve the quality of life of our patients.

Magnetic resonance cholangiopancreatography evaluation of intrahepatic bile duct variations with updated classification

PURPOSE

Preoperative detection of intrahepatic bile duct (IHBD) variations is essential to reduce surgical morbidity and mortality rates. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive and reliable method for demonstrating the normal IHBD anatomy and its variations. This retrospective study aimed to identify and classify novel variations, except those already reported in the literature, using MRCP.

METHODS

MRCP examinations, which were conducted in two different centers in the last five years, were retrospectively evaluated. IHBD variations were recorded with respect to the Yoshida classification. In addition, newly detected variations that were not included in this classification were identified and classified.

RESULTS

MRCP examinations of 2624 patients were screened, and 2143 were determined to be eligible for evaluation. Of 2143 patients, 987 were males (average age, 54±18 years) and 1156 were females (mean age, 57±17 years). In this study, 10 novel variations that were not included in the Yoshida classification were identified in 14 patients.

CONCLUSION

MRCP is an effective, reliable, and noninvasive imaging method for evaluating the IHBD anatomy and its variations. Novel variations described in this study may help to better understand the biliary anatomy.

Role of Liver Transplantation in Bilio-Vascular Liver Injury After Cholecystectomy

BACKGROUND

The aim of this study was to report 2 cases of liver transplantation (LT) for iatrogenic bile-vascular injury (BVI) sustained during cholecystectomy and to review the literature for LT after cholecystectomy.

METHODS

Between March 2001 and July 2013, within our institution, 12 patients were treated after cholecystectomy, 3 of 12 received LT, 1 for acute de-compensation in a cirrhotic patient and 2 after iatrogenic lesions.

RESULTS

The majority of iatrogenic injury occurred during video-laparocholecystectomy (63,6%; 7/11). Three patients of 12 (25%) received LT: the first patient developed acute de-compensation in chronic and after liver failure. The second patient developed recurrent cholangitis and secondary biliary cirrhosis. The third patient had undergone emergency hepatectomy because of bleeding and subsequent total hepatectomy with porto-caval shunt. Five of 12 (42%) patients were treated with bilio-digestive anastomosis: 1 patient with direct repair on T-tube; 2 patients (17%) with arterial vascular lesion requiring surgical treatment; and 1 patient treated with medical therapy. No deaths occurred. The post-operative morbidity included 1 re-intervention, 3 recurrent cholangitis, 1 anastomotic biliary stricture, 1 anastomotic bile leak, and cholestasis in 3 patients. The overall hospital stays were higher after LT. Median follow-up was 8.25 years (range, 2-14).

CONCLUSIONS

The management of iatrogenic injury during cholecystectomy depends on the time of recognition, extent of injury, experience of the surgeon, and the patient's general condition. If safe repair is possible, BVI should be treated promptly, otherwise all patients should be treated in an experienced center.

[Unusual evolution of a complex bile duct injury after a laparoscopic cholecystectomy]

Depuis l'avènement de la chirurgie coelioscopique de la lithiase biliaire le nombre de plaies des voies biliaires a sensiblement augmenté dans la littérature en rapport avec la courbe d'apprentissage des opérateurs. Les plaies méconnues peuvent avoir des conséquences immédiates dramatiques et évoluer vers la péritonite biliaire. Ailleurs la réparation des fistules biliaires externes au stade de dilatation des voies biliaires nécessite une anastomose bilio digestive ou des résections hépatiques réglées.

A Promising Method for Repairing Low-Level Biliary Strictures After Cholecystectomy

The purpose of this study is to introduce and evaluate a new technique of repairing bile ducts by the tubular gastric wall with a vascularized pedicle. Both the end-to-end bile duct repair and Roux-en-Y hepatoenterostomy have limitations in the treatment of benign bile duct strictures after cholecystectomy. There are no other good choices to manage these cases, especially the bile duct transection injuries or partly missing common bile duct or hepatic duct. Eleven patients with partly missing common bile ducts in the Chinese People's Liberation Army General Hospital between January 2007 and December 2012 were retrospectively analyzed. The study comprised 8 females and 3 males, whose age ranged from 29 to 56 years. All patients underwent successful bile duct repair. The time of operations ranged from 210 minutes to 240 minutes. The maximal blood loss was less than 220 ml. There was no perioperative mortality and no case of gastric fistula. Postoperative complications occurred in 3 patients, including wound infection, bile leakage, and erosive gastritis. All complications were cured by conservative treatment. The mean follow-up time was 42 months. One patient was classified as Terblanche's grade II and 10 patients were classified as Terblanche's grade I. The observations indicate that this technique is a feasible and effective choice to manage low level biliary stricture after cholecystectomy, especially suitable to repair bile duct transection injuries or partly missing common bile duct or hepatic duct.

Major bile duct injury requiring operative reconstruction after laparoscopic cholecystectomy: a follow-on study

BACKGROUND

Bile duct injury (BDI) after laparoscopic cholecystectomy (LC) has significant cost impact and is a significant source of morbidity and mortality. We undertook a population-based assessment of the national experience with BDI between 2001 and 2011 and compared this to our report for the prior decade.

METHODS

Using the nationwide inpatient sample (NIS) for 2001-2011, we identified patients who underwent LC or partial cholecystectomy, with and without biliary reconstruction. Data were analyzed using methods that accounted for the hierarchical, stratified random sampling of the NIS. Both univariate modeling and multivariate modeling were performed.

RESULTS

LCs increased from 71.1 % in 2001 to 79.0 % in 2011 (p < 0.0001). Annual mortality decreased from 0.56 to 0.38 % (p = 0.002). In 2001, 0.11 % of LCs were associated with biliary reconstruction versus 0.09 % in 2011 (p = 0.15) with rates ranging from 0.08 to 0.12 %. The need for reconstruction was associated with an average in-hospital mortality rate of 4.4 %. Mortality rates from LC remained consistent across the study period (average mortality, 0.10 %, p = 0.57). Under multivariate analysis, admission to rural or urban non-teaching centers was associated with a decreased rate of injury; the majority of major BDIs were admitted from clinic or outpatient settings. These results are consistent with results from the prior decade. Neither emergent admission nor race was associated with increased odds of BDI, and this differs from our prior analysis.

CONCLUSION

LC continued to increase in utilization between 2001 and 2011. Although rates of BDI have decreased, the need for reconstruction continues to be associated with a significant mortality. In addition, mortality related to biliary reconstruction is also higher than previously published series and may reflect the complexity of managing biliary injury as well as the higher likelihood of these patients having comorbid conditions.

Iatrogenic biliary injuries: multidisciplinary management in a major tertiary referral center

Background. Iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. Better outcomes of such injuries have been shown in cases managed in a specialized center. Objective. To evaluate biliary injuries management in major referral hepatobiliary center. Patients & Methods. Four hundred seventy-two consecutive patients with postcholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist, and radiologist) at major Hepatobiliary Center in Egypt over 10-year period using endoscopy in 232 patients, percutaneous techniques in 42 patients, and surgery in 198 patients. Results. Endoscopy was very successful initial treatment of 232 patients (49%) with mild/moderate biliary leakage (68%) and biliary stricture (47%) with increased success by addition of percutaneous (Rendezvous technique) in 18 patients (3.8%). However, surgery was needed in 198 patients (42%) for major duct transection, ligation, major leakage, and massive stricture. Surgery was urgent in 62 patients and elective in 136 patients. Hepaticojejunostomy was done in most of cases with transanastomotic stents. There was one mortality after surgery due to biliary sepsis and postoperative stricture in 3 cases (1.5%) treated with percutaneous dilation and stenting. Conclusion. Management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging early referral to highly specialized hepatobiliary center.

Analysis of risk factors for postoperative complication of repair of bile duct injury after laparoscopic cholecystectomy

BACKGROUND

Bile duct injury (BDI) after laparoscopic cholecystectomy (LC-BDI) is still a major problem. However, despite the many improvements in clinical management of patients undergoing repair, postoperative complications remain frequent and factors that increase the susceptibility to such adverse events remain unknown.

AIM

To report on a large experience with laparoscopic cholecystectomy-associated bile duct injuries (LC-BDIs) and define predictive factors associated with postoperative complication.

METHODS

A retrospective medical record review of 94 patients referred for the surgical management of major BDIs to our center during a 12-year period between January 1, 1998, and December 31, 2010, was performed. Univariate statistical analysis and multivariate analysis were used to identify risk factors for postoperative complications. A nomogram was developed to predict postoperative complication, given associated risk factors, and bootstrap validation was performed.

RESULTS

In univariate analysis, there is no factor significantly associated with short-term complication. There was a statistically significant relationship between type of repair and the risk of biliary strictures (p = 0.012). Other factors significantly associated with late biliary strictures were sepsis (p = 0.007) and bile leak (p = 0.003). In multivariate analysis, bile leak (p = 0.005), sepsis (p = 0.03), and type of repair (p = 0.028) were independently and significantly associated with long-term complication. The resulting nomogram demonstrated good accuracy in predicting long-term complication, with a bootstrap-corrected concordance index 0.7905.

CONCLUSIONS

Our results suggest that missed injuries that result in sepsis or bile leak as well as high injuries that require hepaticojejunostomy will result in a higher stricture rate after repair.

Subtotal Cholecystectomy and Open Total Cholecystectomy: Alternatives in Complicated Cholecystitis

Subtotal cholecystectomy (SC) is an alternative to open total cholecystectomy (OTC) when variable anatomy or other intraoperative findings preclude safe dissection of Calot's triangle. The objective of this study was to compare the outcomes between SC and OTC in patients with complicated cholecystitis, cases that could not be completed with the original surgical approach and required intraoperative conversion to either SC or OTC. All cases of cholecystectomy converted to SC or OTC from January 2008 to December 2012 were retrospectively identified. Preoperative laboratory values, imaging studies, and clinical demographics were compared between the two groups. The outcome variables analyzed included hospital and intensive care unit length of stay as well as intraoperative complications. In this study, 214 cases of complicated cholecystitis were analyzed; 63 SC and 151 laparoscopic converted to OTC. From the SC group, 46 (73%) were converted to open, 12 (19%) were primary open, and five (8%) were done laparoscopically. There were no statistically significant differences in demographics, preoperative serologic markers, or intraoperative findings ( P > 0.05). Five (3.3%) common bile duct (CBD) injuries occurred in the OTC group, whereas none occurred in the SC group. Overall there were 23 (15.2%) complications in the OTC group and nine (14.3%) in the SC group. The aggregate severe complication rate (CBD injury, vascular injury, gastrointestinal injury) was significantly higher in the OTC group (0.0 to 7.9%, P = 0.036). In conclusion, SC may be considered as a safe alternative in complicated cholecystitis.

Iatrogenic biliary injuries: identification, classification, and management

Because it offers several advantages over open cholecystectomy, laparoscopic cholecystectomy has largely replaced open cholecystectomy for the management of symptomatic gallstone disease. The only potential disadvantage is a higher incidence of major bile duct injury. Although prevention of these biliary injuries is ideal, when they do occur, early identification and appropriate treatment are critical to improving the outcomes of patients suffering a major bile duct injury. This report delineates the key factors in classification (and its relationship to mechanism and management), identification (intraoperative and postoperative), and management principles of these bile duct injuries.

Clipless minilaparoscopic cholecystectomy: a study of 1,096 cases

PURPOSE

Low conversion rate, high safety, and good cosmetic result with less medical cost are chased by all laparoscopic surgeons. We used general laparoscopic instruments and combined with absorbable thread trying to perform a clipless minilaparoscopic cholecystectomy for benign gallbladder patients and got all the above-mentioned results.

SUBJECTS AND METHODS

From January 2008 to February 2011, 1096 minilaparoscopic cholecystectomies were performed for patients with uncomplicated or complicated benign gallbladder disease by our treatment team. The three-port technique with the help of an electrocautery hook, forceps, and suction was applied for laparoscopy cholecystectomy, and the cystic duct and vessels were ligated by absorbable thread rather than hemostasis clips and Harmonic(®) scalpels (Ethicon, Cincinnati, OH). The operative time, blood loss, subhepatic drain, conversion rate, drainage time, and hospital stay were reviewed and statistically analyzed.

RESULTS

Our conversion rate was 0.18%, which was much lower than those reported by many studies. The mean operating time was 28 minutes (range, 11-70 minutes). Mean blood loss was 12 mL (range, 5-200 mL). A subhepatic drain was placed in 63 patients, with a mean drainage time of 1.7 days (range, 1-6 days). The mean postoperative hospital stay was 2.5 days (range, 2-7 days). No postoperative bleeding, biliary leakage, intraabdominal infection, umbilical site infection, umbilical incision herniation, biliary duct or bowel injury, or mortality occurred.

CONCLUSIONS

Minilaparoscopic cholecystectomy using absorbable thread instead of clips and Harmonic scalpels offers a safe, effective, and economical surgical alternative for benign gallbladder patients.

Sonographic assessment of a suspected biloma: A case report and review of the literature

A biloma is a rare disease characterized by an abnormal intra- or extrahepatic bile collection due to a traumatic or spontaneous rupture of the biliary system. Laboratory findings are nonspecific. The diagnosis is usually suspected on the basis of a typical history (right upper quadrant abdominal pain, chills, fever and recent abdominal trauma or surgery) and is confirmed by detection of typical radiologic features. We report the case of a patient with a history of previous cholecystectomy for lithiasis who presented with clinical symptoms and laboratory data suggestive of acute pancreatitis. Imaging studies also revealed the presence of a chronic and asymptomatic biloma, which could be mistaken for a pseudocyst. The atypical location and ultrasound findings suggested an alternative diagnosis. We therefore reviewed the known literature for bilomas, focusing on the role of ultrasonography, which can reveal some typical aspects, such as location and imaging features. We conclude that ultrasound plays a key role in the assessment of a suspected biloma in patients with appropriate history and clinical features and provides valuable diagnostic clues even in the absence of these.

Prompt Repair of Post Cholecystectomy Bile Duct Transection Recognized Intraoperatively and Referred Early: Experience from a Tertiary Care Teaching Unit

Postcholecystectomy bile duct injuries are a cause of significant morbidity and occasional mortality. Intraoperative recognition and repair of complete biliary transection with hepaticojejunostomy is the recommended treatment; however, it is possible only in few patients as either the injury is not recognized intraoperatively or the center is not geared up to perform an urgent hepaticojejunostomy in these patients with a nondilated duct. Retrospective analysis of data from a tertiary care referral center over a period of 10 years from January 2000 to December 2009 to report the feasibility and outcomes of prompt repair was done (defined as repair within 72 h of index operation) of postcholecystectomy bile duct injury. Ten patients of postcholecystectomy bile duct injury detected intraoperatively and referred early underwent prompt repair. All patients had a complete transection of the bile duct (type of injuries as per Strasberg classification: Type E V: 1, Type E III: 5, Type E II: 3 and Type E I: 1). The mean duration between injury and bile duct repair in the form of Roux-en-Y hepaticojejunostomy (RYHJ) was 22.7 (range 5-42) hours. The mean diameter of the anastomosis was 1.63 (range1-2.1) cm, and the anastomosis was stented in 7 patients. The mean duration of surgery was 4.6 +1.7 h. One patient developed bile leak on the first postoperative day, which settled by day 5. The mean duration of hospital stay was 5.1 (range 4-8) days. With a mean follow-up of 42 (range 24-110) months, all patients had excellent (70 %) or good outcome (30 %). Prompt RYHJ (within first 72 h) for postcholecystectomy biliary transection is an effective treatment and potentially limits the morbidity to the patient.

Visibility enhancement of common bile duct for laparoscopic cholecystectomy by vivid fiber-optic indication: a porcine experiment trial

Bile duct injury (BDI) is the most serious iatrogenic complication during laparoscopic cholecystectomy (LC) and occurs easily in inexperienced surgeons since the position of common bile duct (CBD) and its related ductal junctions are hard to precisely identify in the hepatic anatomy during surgery. BDI can be devastating, leading to chronic morbidity, high mortality, and prolonged hospitalization. In addition, it is the most frequent injury resulting in litigation and the most likely injury associated with a successful medical malpractice claim against surgeons. This study introduces a novel method for conveniently and rapidly indicating the anatomical location of CBD during LC by the direct fiber-optic illumination of 532-nm diode-pumped solid state laser through a microstructured plastic optical fiber to avoid the wrong identification of CBD and the injury from mistakenly cutting the CBD that can lead to permanent and even life threatening consequences. Six porcine were used for preliminary intra-CBD illumination experiments via laparotomy and direct duodenal incision to insert the invented CBD illumination laser catheter with nonharmful but satisfactory visual optical density.

Cholecystectomy-related bile duct and vasculobiliary injuries

Background

Combined vasculobiliary injury is a serious complication of cholecystectomy. This study examined medium- to long-term outcomes after such injury.

Methods

Patients referred to this institution with Strasberg type E bile duct injuries were identified from a prospectively maintained database (1990–2010). Long-term outcomes were evaluated by chart review.

Results

Sixty-three patients were referred with bile duct injury alone (45 patients) or vasculobiliary injury (18). Thirty patients (48 per cent) had septic complications before transfer. Twenty-six patients (41 per cent) had long-term biliary complications over a median follow-up of 96 (range 12–245) months. Nine patients (3 with bile duct injury, 6 with vasculobiliary injury) required further interventions after a median of 22 (8–38) months; five required biliary surgical revision and four percutaneous dilatation of biliary strictures. Vasculobiliary injury and injury-related sepsis were independent risk factors for treatment failure: hazard ratio 7·79 (95 per cent confidence interval 2·80 to 21·70; P &lt; 0·001) and 4·82 (1·69 to 13·68; P = 0·003) respectively.

Conclusion

Outcome following bile duct injury repair was worse in patients with concomitant vasculobiliary injury and/or sepsis.

Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating?

Laparoscopic cholecystectomy is now one of the most frequently performed abdominal surgical procedures in the world. The most common major complication is bile duct injury, which can have catastrophic repercussions for patients and it has been suggested that intraoperative cholangiography may reduce the rate of bile duct injury. Whether this procedure should be performed routinely is still an active subject of debate. We discuss the available evidence and likely implications for the future.

Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients

BACKGROUND

Whether to routinely or selectively use intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has been a controversial issue for many years. Many authors maintain that IOC decreases the rate of biliary complications such as bile duct injuries, biliary leak, and missed common bile duct (CBD) stones. However, in contrast to these claims, many centers have opted to perform LC without IOC. In this retrospective study, the results of a series of 1,100 LCs, all of which involved major biliary complications and which were performed without the use of IOC, were reviewed.

METHODS

Data from 1,100 selected patients (728 females and 372 males) undergoing LC without the use of IOC from January 2003 to November 2011 were analyzed. One hundred and seventy LCs were performed by young surgeons during the learning curve, and 930 by surgeons with over 10 years of experience. Two techniques were used to create pneumoperitoneum: the Veress technique in 319 cases (29%) and the Hasson technique in the remaining 781 cases (71%). Patients with a suspicion of CBD stones were excluded from the study.

RESULTS

Two CBD injuries (0.18%) and three biliary leaks (0.27%) were detected among this group. Thirty-three patients (3%) needed conversion to open cholecystectomy. Missed CBD stones were reported in 4 cases (0.36%). There was no postoperative mortality.

CONCLUSION

LC can be performed safely without the use of IOC and with acceptable low rates of biliary complications. An accurate preoperative evaluation of clinical risk factors, precise operative procedures, and conversion to an open approach in doubtful cases are important measures which must be taken to prevent CBD injury.