Bile duct injuries 12 years after the introduction of laparoscopic cholecystectomy

Factors influencing the occurrence of biliary stricture above the confluence in major bile ducts injuries: Analysis of a case series

Background

bile duct injury is a complication that occurs mainly after cholecystectomy. Outcomes of biliary repair surgery are worse when the stricture level is above the biliary confluence.

Method

A single centred retrospective study was carried out on patients operated in our department for biliary stricture after a major bile duct injury over the period from January 2010 to May 2018. Only patients operated for biliary stricture were included. This study aimed to determine the independent factors influencing the occurrence of a stricture above de biliary confluence. Univariate and multivariate binary regression was used for data analysis.

Results

Fifty-three patients were included, they were 43 women and 10 men, sex-ratio was 0.23. Thirty-one patients had Grade E3-E4-E5 stricture (58,5%), and patients who had a failure of a previous repair surgery accounted for 36% (n = 19) of our patients.After univariate and multivariate analysis, only laparoscopic cholecystectomy (OR = 7.58, CI = [1.47-38, 91], P = 0.015) and failure of anterior biliary repair surgery (OR = 7, 12, CI = [1.29-39.42], P = 0.025) were independent factors associated with more frequent occurrence of biliary strictures above the confluence.

Conclusion

Failure of biliary repair surgery makes the pre-existing biliary stricture progress and compromises subsequent surgery's outcomes. It is important to refer all cases of bile duct injury to specialized centers to increase the chances of success of the first biliary repair surgery.

Difficult iatrogenic bile duct injuries following different types of upper abdominal surgery: report of three cases and review of literature

Background

Iatrogenic bile duct injuries (BDIs) are mostly associated with laparoscopic cholecystectomy but may also occur following gastroduodenal surgery or liver resection. Delayed diagnosis of type of injury with an ongoing biliary leak as well as the management in a non-specialized general surgical units are still the main factors affecting the outcome.

Case presentation

Herein we present three types of BDIs (Bismuth type I, IV and V) following three different types of upper abdominal surgery, ie. Billroth II gastric resection, laparoscopic cholecystectomy and left hepatectomy. All of them were complex injuries with complete bile duct transections necessitating surgical treatment. All were also very difficult to treat mainly because of a delayed diagnosis of type of injury, associated biliary leak and as a consequence severe inflammatory changes within the liver hilum. The treatment was carried out in our specialist hepatobiliary unit and first focused on infection and inflammation control with adequate biliary drainage. This was followed by a delayed surgical repair with the technique which had to be tailored to the type of injury in each case.

Conclusion

We emphasize that staged and individualized treatment strategy is often necessary in case of a delayed diagnosis of complex BDIs presenting with a biliary leak, inflammatory intraabdominal changes and infection. Referral of such patients to expert hepatobiliary centres is crucial for the outcome.

Iatrogenic, blunt, and penetrating trauma to the biliary tract

Iatrogenic and traumatic bile leaks are uncommon. However, given the overall increase in number of hepatobiliary surgeries and the paradigm shift toward nonoperative management of patients with liver trauma, they have become more prevalent in recent years. Imaging is essential to establishing early diagnosis and guiding treatment as the clinical signs and symptoms of bile leaks are nonspecific, and a delay in recognition of bile leaks portends a high morbidity and mortality rate. Findings suspicious for a bile leak at computed tomography or ultrasonography include free or contained peri- or intrahepatic low density fluid in the setting of recent trauma or hepatobiliary surgery. Hepatobiliary scintigraphy and magnetic resonance cholangiopancreatography (MRCP) with hepatobiliary contrast agents can be used to detect active or contained bile leak. MRCP with hepatobiliary contrast agents has the unique ability to reveal the exact location of bile leak, which often governs whether endoscopic management or surgical management is warranted. Percutaneous transhepatic cholangiography and fluoroscopy via an indwelling catheter that is placed either percutaneously or surgically are useful modalities to guide percutaneous transhepatic biliary drain placement which can provide biliary drainage and/or diversion in the setting of traumatic biliary injury. Surgical treatment of a bile duct injury with Roux-en-Y hepaticojejunostomy is warranted if definitive treatment cannot be accomplished through percutaneous or endoscopic means.

Iatrogenic bile duct injury with loss of confluence

AIM: To describe our experience concerning the surgical treatment of Strasberg E-4 (Bismuth IV) bile duct injuries.

METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo (median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study.

RESULTS: Patients were divided in three groups: G1 (n = 21): Construction of neoconfluence + Roux-en-Y hepatojejunostomy. G2 (n = 26): Roux-en-Y portoenterostomy. G3 (n = 6): Double (right and left) Roux-en-Y hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation.

CONCLUSION: Loss of confluence represents a surgical challenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis (neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.

Quality of life in bile duct injury: 1-, 5-, and 10-year outcomes after surgical repair

BACKGROUND

Quality of life after bile duct injury is a relevant health issue besides physician-oriented outcomes. A prospective study was performed to explore short- and long-term outcomes after surgical repair.

METHOD

We studied a cohort of patients with Strasberg E injuries who underwent Roux-en-Y jejunal anastomosis from 1990 to 2008. The Short Form Health Survey (SF-36) was selected as the appropriate quality of life assessment instrument. Two groups were comprised: Group I included patients with 10-year follow-up after surgery. Group II included patients operated during 2008 with preoperative 1- and 5-year questionnaires.

RESULTS

Group I patients (N = 41) were operated from 1990 to 2003 and Group II (N = 44) during 2008. There is a significant improvement in quality of life after the first year of repair in all domains. Readmissions (48 vs 25 %; p < 0.01), colangitis (46 vs 14 %; p < 0.001), and hepatojejunal redo (26 vs. 4 %; p < 0.0001) were less frequent in Group II. No differences in quality of life summary scores were found between Group I and II.

CONCLUSIONS

Quality of life improves significantly after the first year of surgical repair, reaching a plateau at 5 years. No correlation exists with physician-centered outcomes.

Management of iatrogenic bile duct injuries: role of the interventional radiologist

Bile duct injuries are infrequent but potentially devastating complications of biliary tract surgery and have become more common since the introduction of laparoscopic cholecystectomy. The successful management of these injuries depends on the injury type, the timing of its recognition, the presence of complicating factors, the condition of the patient, and the availability of an experienced hepatobiliary surgeon. Bile duct injuries may lead to bile leakage, intraabdominal abscesses, cholangitis, and secondary biliary cirrhosis due to chronic strictures. Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. Imaging options include cholescintigraphy, ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter. Depending on the type of injury, management may include endoscopic, percutaneous, and open surgical interventions. Percutaneous intervention is performed for biloma and abscess drainage, transhepatic biliary drainage, U-tube placement, dilation of bile duct strictures and stent placement to maintain ductal patency, and management of complications from previous percutaneous interventions. Endoscopic and percutaneous interventional procedures may be performed for definitive treatment or as adjuncts to definitive surgical repair. In patients who are eligible for surgery, surgical biliary tract reconstruction is the best treatment option for most major bile duct injuries. When reconstruction is performed by an experienced hepatobiliary surgeon, an excellent long-term outcome can be achieved, particularly if percutaneous interventions are performed as needed preoperatively to optimize the patient's condition and postoperatively to manage complications.

Can residents safely and efficiently be taught single incision laparoscopic cholecystectomy?

OBJECTIVE

Single incision laparoscopic cholecystectomy (SILC) has recently emerged as an option for selected patients undergoing gallbladder removal. While SILC appears safe when performed by experienced surgeons under controlled conditions, there are no studies evaluating the SILC learning curve for incorporation into resident education and the effect on OR efficiency.

DESIGN, SETTING, AND PARTICIPANTS

Chief residents were taught and evaluated by a single attending surgeon facile with SILC techniques. Residents were transitioned from assistants to primary surgeon during their clinical rotation. Outcomes data were prospectively tabulated compared with data from standard laparoscopic SLC and attending surgeon SILC outcomes. The setting was an academic, tertiary care teaching hospital. Participants were chief residents rotating on hepatobiliary surgery service. Residents previously had demonstrated mastery of basic laparoscopic surgical techniques.

RESULTS

Seven chief residents were evaluated with a total of 49 SILCs with a mean of 7 (range 5-12) SILCS/resident. Five conversions to SLC occurred, all within the first 3 SILCs performed by the resident as operative surgeon. Mean blood loss was 30 mL. Median length of stay was <1 day. Average length of operation increased after the first 2 cases, reflecting the transition of the attending surgeon from primary surgeon to assistant role. By the fifth case, operative times returned to the attending surgeon SILC baseline and historical operative times for SLC at our institution. Factors associated with longer-length of surgery were increasing BMI and presence of acute or chronic cholecystitis, choledocholithiasis, and use of intraoperative cholangiogram. Five postoperative complications occurred and were not associated with position along the resident's learning curve. One death occurred due to metastatic laryngeal cancer within 30 days of SILC.

CONCLUSIONS

Residents can safely be taught the techniques of SILC with minimal disruption to operating room efficiency. Residents already proficient in the use of standard laparoscopic techniques transition to SILC quickly with a short learning curve and proper instruction.

Does increased experience with laparoscopic cholecystectomy yield more complex bile duct injuries?

BACKGROUND

Two decades since the advent of laparoscopic cholecystectomy, the rate of bile duct injuries still remains higher than in the open cholecystectomy era.

METHODS

The rate and complexity of bile duct injuries was evaluated in 83,449 patients who underwent laparoscopic cholecystectomy between 1995 and 2008 in the Kaiser Permanente Northern California system. Fifty-six surgeons who performed a laparoscopic cholecystectomy in the past were surveyed to determine factors that predispose to bile duct injuries.

RESULTS

The overall incidence of bile duct injuries was .10%; 59.5% of the 84 injuries were cystic duct leaks. Incidence varied slightly from .10% (1995-1998) to .08% (1999-2003) and .12% (2004-2008). There was a trend toward more proximal injuries (injury <2 cm from the bifurcation: 14.3% to 44.4% to 50.0% of major injuries). The misinterpretation of anatomy was cited by 92.9% of surgeons as the primary cause of bile duct injuries; 70.9% cited a lack of experience as a contributing factor.

CONCLUSIONS

Laparoscopic cholecystectomy has an overall low risk of bile duct injuries; the rate remains constant, but injury complexity may have increased over time.

Differential diagnosis of upper gastrointestinal bleeding proximal to the ligament of Trietz

Upper gastrointestinal bleeding (UGIB) is an important medical problem for patients and the medical system. The causes of UGIB are varied and their accurate identification guides appropriate management. The major cause of UGIB is peptic ulcer disease, for which Helicobacter pylori and nonsteroidal antiinflammatory drug use are major risk factors. Lesser causes include Dieulafoy lesion, gastric antral vascular ectasia, hemobilia, aortoenteric fistulas, and upper gastrointestinal tumors. Awareness of causes and management of UGIB should allow physicians to treat their patients more effectively.

Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding

Over the past two decades, transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications, such as peptic ulcer bleeding, malignant disease, hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding. Transcatheter interventions include the following: selective embolization of the feeding artery, sandwich coil occlusion of the gastroduodenal artery, blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery. Transcatheter embolization is a fast, safe and effective, minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract. This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.

Single Incision Laparoscopic Cholecystectomy Using a “Two-Port” Technique Is Safe and Feasible: Experience in 101 Consecutive Patients

Single incision laparoscopic cholecystectomy (SILC) is a new minimally-invasive technique that has recently been developed to address several disease processes of the gallbladder. However, the safety and feasibility of this technique are still being evaluated. Utilizing a “two-port” technique with transabdominal suture retraction and a rigorous adherence to the critical view of safety, we evaluated our experience in a prospectively maintained database and compared this with standard laparoscopic cholecystectomy (SLC) over the same period. SILC was completed successfully in 87 per cent of patients. Operative times were found to be similar between SLC and SILC (75 and 76 minutes, respectively; P = 0.12). Operative blood loss, hospital stay, and short-term complications were not statistically different between SILC and SLC. Cholangiograms, obtained on a selective basis, were performed in 19 per cent of SILCs. No bile duct injuries occurred during SILC or SLC. Although our aggregate number is not enough to accurately assess the rate or safety of bile duct injuries, SILC seems to be safe and feasible when evaluating other metrics and does not seem to interfere with operative efficiency compared with SLC.

The learning curve of laparoendoscopic single-site (LESS) cholecystectomy: definable, short, and safe

BACKGROUND

The applications of laparoendoscopic single-site (LESS) surgery, including cholecystectomy, are occurring quickly, although little is generally known about issues associated with the learning curve of this new technique including operative time, conversion rates, and safety.

STUDY DESIGN

We prospectively followed all patients undergoing LESS cholecystectomy, and compared operations undertaken at our institutions in cohorts of 25 patients with respect to operative times, conversion rates, and complications.

RESULTS

One-hundred fifty patients of mean age 46 years underwent LESS cholecystectomy. No significant differences in operative times were demonstrable between any of the 25-patient cohorts operated on at our institution. A significant reduction in operative times (p < 0.001) after completion of 75 LESS procedures was, however, identified with the experience of a single surgeon. No significant reduction in the number of procedures requiring an additional trocar(s) or conversion to open operations was observed after completion of 25 LESS cholecystectomies. Complication rates were low, and not significantly different between any 25-patient cohorts.

CONCLUSIONS

For surgeons proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency. Operative complications and conversions were infrequent and unchanged across successive 25-patient cohorts, and were similar to those reported for multi-incision laparoscopic cholecystectomy after the learning curve.

15 years of litigation following laparoscopic cholecystectomy in England

OBJECTIVE

We aimed to analyze trends in litigation following laparoscopic cholecystectomy (LC) in England and compare our findings with data from the United States.

BACKGROUND

Several studies from the United States have highlighted the medico-legal repercussions of complications following LC. In 2007-2008, litigation claims cost the National Health Service in England over 660 million Great British Pounds (GBP) (1.1 billion USD). Despite this, there has been little examination of litigation following LC in England.

METHODS

Data from the National Health Service Litigation Authority on clinical negligence claims between 1995 and 2009 following LC were obtained and analyzed.

RESULTS

Four hundred eighteen claims were made of which 303 were settled. One hundred ninety-eight (65%) were found to be in the claimants favor for a total cost of 20.4 million GBP (33.4 million USD). Litigation claims have leveled since 2001. Operator error was the most likely cause to result in a claim and the only cause associated with a successful claim (P = 0.023). A delay in the recognition of complications was the second most common reason for initiation of a claim. Bile duct injury was the most frequent injury resulting in litigation and the most likely injury associated with a successful claim (P < 0.001). The average payout for a successful claim was 102,827 GBP/168,337 USD. Findings from US studies were similar, although the magnitude of payouts was 4 times higher.

CONCLUSION

Strategies that minimize bile duct injury and speed up recognition of injuries should be adopted to reduce the litigation burden and improve patient care.

Iatrogenic bile duct injury during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has largely replaced open cholecystectomy as the standard of care for gallbladder excision. A major disadvantage of this trend has been the increased incidence of bile duct injuries, which, while uncommon, are significantly higher with laparoscopic cholecystectomy. Most injuries are not recognized at the time of surgery and present in a delayed fashion, leading to significant patient morbidity and a negative impact on the quality of life of patients. Treatment is governed by the time of presentation and the nature of the bile duct injury incurred and requires a multidisciplinary approach. Radiologists play a key role in management, with diagnosis of complications, accurate depiction of the biliary injury, and facilitating or providing definitive therapy depending on the type of injury.

Voluntary and involuntary ligature of the bile duct in iatrogenic injuries: a nonadvisable approach

BACKGROUND

Bile duct injuries related to laparoscopic and/or open cholecystectomy are a frequent finding and require surgical treatment. Complete obstruction is due to either intentionally or unintentionally placed ligatures or clips. The intentional application is usually performed to "facilitate identification of the duct by bile duct dilation." Considering that we are a national referral center for such injuries, we decided to analyze our cases of voluntary and involuntary duct ligation after iatrogenic bile duct injury.

METHODS

We reviewed the files of patients with voluntary or involuntary bile duct ligation. Results of preoperative evaluation of the ducts, operative treatment, and postoperative results were analyzed.

RESULTS

A total of 413 patients were included. Forty-five patients presented with complete obstruction. In 15 cases, the ligature was intentional, and in 30 cases, occlusion was involuntary. Bile duct dilation (>10 mm) was demonstrated in one case of voluntary (6%) and three cases of involuntary ligations (10%). The remaining cases in both groups had no duct dilation and developed necrosis at the blinded duct and leakage proximal to the ligature, with different degrees of bilioperitoneum and/or biloma. In all cases, a Roux-en-Y hepatojejunostomy was performed.

CONCLUSION

Bile duct ligature produces dilation in a very small number of patients (less than 10%) and usually produces necrosis of the blinded stump with subsequent bile leakage. Placement of a subhepatic drain and transference of the patient to a qualified center for reconstruction is the best approach if the primary surgeon is not able to do the repair.

[Anatomic variants of the biliary tree with MR Cholangiography: feasibility and surgical applications]

PURPOSE

To assess the usefulness of MR Cholangiography for evaluation of anatomic variants of the biliary tree before biliary surgery.

MATERIALS AND METHODS

Our study group consisted of 45 consecutive patients (29 males, 16 females; mean age 57 years), who were referred for MR evaluation of malignant (n=26) and benign (n=19) cholangiopancreatic diseases. MR Cholangiography studies were independently reviewed by two radiologists.

RESULTS

Anatomic variants of the biliary tree were observed in 9 patients (20%); 6 variants involved the biliary confluence and 4 the cystic duct (one patient had both). Anatomic variants involved principally the right posterior duct: 1 (2,2%) drainage of right posterior duct into left hepatic duct; 2 (4,4%) triple confluence of right posterior duct, right anterior duct, and left hepatic duct, and 3 (6,6%) aberrant drainage of right posterior duct into common hepatic duct. Observed cystic duct anomalies included: 2 (7,44%) low insertion of the cystic duct into the common hepatic duct and 3 (11,1%) medial insertion of the cystic duct into the common hepatic duct.

CONCLUSION

MR Cholangiography accurately shows anatomic variants of the biliary tree. Noninvasive preoperative evaluation of the biliary anatomy may be important for the detection of anatomic variants that may increase the complexity of hepatic surgical procedures and biliary interventions.

[Iatrogenic biliary injuries during cholecystectomy]

AIM OF THE STUDY

To analyze our experience with biliary injuries during cholecystectomy in order to determine associated risk factors, morbidity, and results after reconstruction.

PATIENTS AND METHODS

Review of the series of patients referred to our department for biliary injury during cholecystectomy over a 9-year period. Items regarding the type of lesion, risk factors, management, morbidity, and late results were recorded.

RESULTS

Fifteen patients were referred to our department for bile duct injury during cholecystectomy between 1997 and 2005 (14 by laparoscopy and four by laparotomy; nine women and nine men). The main surgical indication was biliary colic (n=8). Three patients were operated on in an emergency setting (for acute cholecystitis). In nine patients the gallbladder wall was inflammatory. Intraoperative cholangiography was performed in nine patients, but revealed just one injury. Lateral injury to the bile duct was the most frequent type of lesion. In nine patients, the injury was detected intraoperatively and a biliary drainage was left in place; five of them had a synchronic repair and three required later reconstruction. Nine patients had a delayed identification of biliary injury; six of them required a biliodigestive anastomosis. Two patients died, three had several episodes of acute cholangitis after reconstruction and two presented incisional hernia.

CONCLUSION

An inflammatory environment is the main risk factor for biliary injury during cholecystectomy. Bile duct injury is more frequent with laparoscopic cholecystectomy but can also occur with an open approach. Intraoperative cholangiography does not prevent biliary injuries nor detect them accurately. Biliary drainage can reduce morbidity for intraoperatively detected injuries and may be a sensitive approach for the surgeon with no hepatobiliary experience. Morbidity is increased in patients with delayed identification of the injury.

Intrahepatic repair of bile duct injuries. A comparative study

INTRODUCTION

The frequency of bile duct injuries associated to cholecystectomy remains constant (0.3-0.6%). A multidisciplinary approach (endoscopical, radiological, and surgical) is necessary to optimize the outcome of the patient. Surgery is indicated when complete section of the duct is identified (Strasberg's E injuries) requiring a bilioenteric anastomosis as treatment. Nowadays, the most frequent technique used for reconstruction is a Roux-en-Y hepatojejunostomy. Long-term results of reconstruction are related to several technical and anatomic factors, but an ischemic duct (with subsequent scarring) plays a mayor role. In this paper, we report the results of biliary reconstructions comparing the extrahepatic-probably ischemic -- to intrahepatic -- non ischemic -- repairs.

METHODS

We reviewed the files of patients referred to our hospital (third-level teaching hospital) for bile duct repair after iatrogenic injury from 1990 to July 2006. Injury classification, time lapse since injury, surgical repair technique, and long-term follow-up were noted. In all cases, a Roux-en-Y hepatojejunostomy was done. Partial resection of segment IV was performed in 136 patients to obtain noninflamed, nonscarred, nonischemic biliary ducts with the purpose of reaching the confluence and achieving a high-quality bilioenteric anastomosis. An anastomosis at the level of the confluence was attempted in 293 patients (in 198 the confluence was preserved and in 95 it was lost). In the remaining 80 patients, a low bilioenteric anastomosis was done at the level of the common hepatic duct. We compared intrahepatic (198) and extrahepatic (80) repairs.

RESULTS

A total of 405 cases (88 males, 317 females) were identified, with a mean age of 42 years (range 17-75). All of the injuries were classified as Strasberg E1, E2, E3, E5 (less frequent); those with E4 classification (separated ducts) were excluded. In all cases, the confluence was preserved (N = 293). Thirty-two cases were repaired minutes to hours after the injury occurred. The remaining 373 patients arrived weeks after the injury. In 198 cases, an intrahepatic repair was done, including the 136 in which resection of segments IV and V was part of the surgery. In the remaining 80 cases (operated between 1990 and 1997), an extrahepatic repair was done at the level of the common hepatic duct where the surgeon found a healthy duct. Twelve (15%) of the 80 cases with extrahepatic anastomosis required a new intervention (surgical or radiological), compared to only 8 of the 198 (3%) that had an intrahepatic anastomosis (P = 0.00062). Good results were obtained in 85% and 97% of the cases with extrahepatic anastomosis and intrahepatic anastomosis, respectively. Both groups had a reintervention rate of 7% (20/278).

CONCLUSIONS

An intrahepatic anastomosis requires finding nonscarred, nonischemic ducts, thus allowing a safe and high-quality anastomosis with significantly better results when compared to the low-level anastomosis group.

Complex bile duct injuries: management

Laparoscopic cholecystectomy is the present treatment of choice for patients with gallbladder stones, despite its being associated with a higher incidence of biliary injuries compared with the open procedure. Injuries occurring during the laparoscopic approach seem to be more complex. A complex biliary injury is a disease that is difficult to diagnose and treat. We considered complex injuries: 1) injuries that involve the confluence; 2) injuries in which repair attempts have failed; 3) any bile duct injury associated with a vascular injury; 4) or any biliary injury in association with portal hypertension or secondary biliary cirrhosis. The present review is an evaluation of our experience in the treatment of these complex biliary injuries and an analysis of the international literature on the management of patients.

Long-term results of a primary end-to-end anastomosis in peroperative detected bile duct injury

The management of a bile duct injury detected during laparoscopic cholecystectomy is still under discussion. An end-to-end anastomosis (with or without T-tube drainage) in peroperative detected bile duct injury has been reported to be associated with stricture formation of the anastomosis area and recurrent jaundice. Between 1991 and 2005, 56 of a total of 500 bile duct injury patients were referred for treating complications after a primary end-to-end anastomosis. After referral, 43 (77%) patients were initially treated endoscopically or by percutaneous transhepatic stent placement (n = 3; 5%). After a mean follow-up of 7 +/- 3.3 years, 37 patients (66%) were successfully treated with dilatation and endoscopically placed stents. One patient died due to a treatment-related complication. A total of 18 patients (32%) underwent a hepaticojejunostomy. Postoperative complications occurred in three patients (5%) without hospital mortality. These data confirm that end-to-end anastomosis might be considered as a primary treatment for peroperative detected transection of the bile duct without extensive tissue loss. Complications (stricture or leakage) can be adequately managed by endoscopic or percutaneous drainage the majority of patients (66%) and reconstructive surgery after complicated end-to-end anastomosis is a procedure with relative low morbidity and no mortality.

Early versus late repair of bile duct injuries

Biliary injuries associated with laparoscopic cholecystectomy occur at a constant rate of 0.3% to 0.6%. The spectrum of injures ranges from small leaks of bile to complete section of the main ducts requiring bilioenteric reconstruction. The goal of biliary reconstruction is to obtain a high-quality bilioenteric anastomosis that will not malfunction for a long time. No prospective, controlled, randomized trial (evidence level 1) has been conducted that shows whether an early repair is better than a late one. The timing of the operative procedure should be individualized. A complete examination of the patient should be performed to identify the type of injury and coexistent comorbidities. For septic patients and those with multiple organ dysfunction syndrome, the repair should be delayed. Maneuvers to drain the bile ducts can be performed to relieve jaundice and cholangitis in these patients. For these cases, the surgery should be delayed. If a stable patient is found, without comorbidities, the operation can be scheduled earlier. Subhepatic drains should not be left for a long period because of the risk for intestinal fistulization. If needed, they should be changed for transhepatic stents. High-quality bilioenteric anastomoses are performed with fine absorbable sutures for healthy ducts (nonscarred, noninflamed, nonischemic) in a wide opening, with anastomosis of a (tension-free) defunctionalized jejunal limb. Individualization of the patient is the best rule.

Bile duct injuries: management of late complications

BACKGROUND

Laparoscopic cholecystectomy is the treatment of choice for gallbladder stones. In the current study, this approach was associated with a higher incidence of biliary injuries. The authors evaluate their experience treating complex biliary injuries and analyze the literature.

METHODS

In a 15-year period, 169 patients with bile duct injuries (BDIs) resulting from open and laparoscopic cholecystectomies were treated. The patients were retrospectively evaluated through their records. Biliary injury and associated lesions were evaluated with imaging studies. Surgical management included therapeutic endoscopy, percutaneous interventions, hepaticojejunostomy, liver resection, and liver transplantation. Postoperative outcome was recorded. Survival analysis was performed with G-Stat and NCSS programs using the Kaplan-Meier method.

RESULTS

Of the 169 patients treated for BDIs, 148 were referred from other centers. The injuries included 115 lesions resulting from open cholecystectomy and 54 lesions resulting from laparoscopic cholecystectomy. A total of 110 patients (65%) fulfilled the criteria for complex injuries, 11 of whom met more than one criteria. Injuries resulting from laparoscopic and open cholecystectomies were complex in 87.5% and 72% of the patients, respectively. The procedures used were percutaneous transhepatic biliary drainage for 30 patients, hepaticojejunostomy for 96 patients, rehepaticojejunostomy for 16 patients, hepatic resection for 9 patients, and liver transplantation projected for 18 patients. Hepaticojejunostomy was effective for 85% of the patients. The mean follow-up period was 77.8 months (range, 4-168 months). The mortality rate for noncomplex BDI was 0%, as compared with the mortality rate of 7.2% (8/110) for complex BDI. Mortality after hepatic resection was nil, and morbidity was 33.3%. The actuarial survival rate for liver transplantation at 1 year was 91.7%.

CONCLUSIONS

Complex BDIs after laparoscopic cholecystectomy are potentially life-threatening complications. In this study, late complications of complex BDIs appeared when there was a delay in referral or the patient received multiple procedures. On occasion, hepatic resections and liver transplantation proved to be the only definitive treatments with good long-term outcomes and quality of life.

Chirurgische Behandlung benigner Läsionen und Strikturen der Gallenwege

Benign strictures of the biliary ducts are treated surgically in 90% of cases. Usually they are caused by trauma to the choledochous duct during gallbladder operations. Younger patients are frequently affected and, particularly if the strictures go untreated, can suffer from secondary complications such as cholangitis or secondary biliary cirrhosis with the serious dangers of portal hypertension and even hepatic failure and death. Although immediate treatment by end-to-end anastomosis has sometimes been described, this method is reasonable only for smooth cuts to the choledochous duct. Good long-term results have been achieved in 86% of cases with Roux-en-Y hepaticojejunostomy. In general, the best way to avoid complications is the all-important surgical maxim of correct indication for the primary operation. The best course is to limit the decision for surgery to symptomatic gallstones.

Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is the preferred treatment of symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC is used to show cystic ducts that are not seen by MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with nonvisualized cystic ducts by MRC. To our knowledge, this is the first study of visualization of cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.

Nonvariceal upper gastrointestinal bleeding: epidemiology and diagnosis

Nonvariceal upper gastrointestinal bleeding remains an important cause of patient morbidity, mortality, and use of considerable health care resources. An early and accurate diagnosis is critical for guiding appropriate management and facilitating patient care. This article reviews the most recent epidemiologic data on acute nonvariceal upper gastrointestinal bleeding and outlines important aspects of making the diagnosis.

[Biliary-enteric anastomosis malfunction: retrospective study of 20 surgical cases. Review of literature]

INTRODUCTION

This retrospective study of 20 procedures for malfunction of a biliary-enteric anastomosis include 7 choledochoduodenal anastomosis (CD) and 13 choledocho- or hepaticojejunal anastomosis (HJ).

METHODS AND RESULTS

The malfunctions were revealed by angiocholitis (N=16) jaundice (N=4) acute abdominal syndrome (N=1). Among the 7 CD, the median waiting period before reoperation has been 14 years, the procedures were justified by a biliary disorder in 5 cases (1stricture, 4 stones or food obstruction) or by a duodenal stricture (2 cases). The CD have been converted into HJ. The operative mortality was null, the morbidity rate was of 14%. A recurrence of angiocholite occurred in the long-term followed-up. About HJ, the waiting time before reoperations was 6 years and 9 months, the procedures were justified by anastomotic anastomosis stricture (7) calculi without stricture (4) Roux-en-Y limb anomalies (2). Two Roux-en-Y limbs have been lengthened. The anastomoses have been redone when necessary. The side-to-side HJ were converted in end-to-side HJ. The operative mortality was null, the morbidity rate of 8%. In the long term followed-up, 2 stenosis recurrence and 1 lithiase recurrence occurred.

CONCLUSIONS

Malfunctions of biliodigestives anastomosis are revealed by angiocholitis that can lead to secondary biliary cirrhosis. The complications treatment of CD is easy and effective. The complications evolution of HJ depends of initial pathology.

Bile duct replacement using an autologous femoral vein graft: an experimental study. Preliminary results

The repair of common bile duct injuries is a complex procedure with a significant rate of postoperative morbidity and mortality. The aim of this study was to demonstrate the usefulness of the autologous vein graft in replacement of the bile duct. Twelve male Sprague-Dawley rats weighing 350+/-550 g were used in the study and were divided at random into two groups: the control group (60) and the experimental group in which a 3-mm segment of the bile duct was resected and the biliary tract was replaced by a segment of vein aided by stent (G1). Both groups were subdivided into pairs of rats to study at 30, 60, and 120 days. All of the animals underwent radioisotope cholangiography, a repeat laparotomy, and blood tests for further pathologic study. The clinical evaluation and biochemical nuclear medicine and pathologic studies showed no evidence of cholestasis. The histologic study of the graft showed replacement of the endothelium by biliary-appearing epithelium. The use of an autologous vein graft with a supporting stent proves to be a feasible and alternative procedure for bile duct reconstruction. Further experimental studies should be carried out to validate these findings so they can be implemented in clinical cases.

The era of ultrasonography during laparoscopic cholecystectomy

BACKGROUND

The use of ultrasound cholangiography during cholecystectomy has been well described. This study was undertaken to assess the use of the umbilical port exclusively for ultrasound and to assess its employment on the use of fluoroscopy resources. In addition, we also looked at the increased use of ultrasound from 2000 to 2004.

METHODS

The use of imaging techniques during all cholecystectomies was analyzed from January 2000 to July 2001 for one surgeon and compared with that surgeon's present use from January 2004 to June 2004. Patient demographics, intraoperative finding, and postoperative results were reviewed.

RESULTS

During the first study period, ultrasound was used in 29% of 189 laparoscopic cholecystectomies. During 2004, ultrasound was used in 77% of 66 laparoscopic cholecystectomies. Throughout both periods, fluoroscopy was only used during 6 laparoscopic common bile duct explorations (2.4% of all cases). There were no false-positive or -negative ultrasounds, and there were no bile duct injuries.

CONCLUSIONS

As experience with ultrasound cholangiography increases, there is little indication for fluoroscopic cholangiography except for rare questions concerning anatomy and during therapeutic maneuvers for common bile duct stones.

[Bile duct injuries at laparoscopic cholecystectomy: early repair results]

STUDY AIM

To compare the early repair results in bile duct injuries at laparoscopic cholecystectomy to a later repair and so the early reconstruction by an end-to-end anastomosis to a Roux-en-Y bypass.

PATIENTS AND METHOD

From 1990 to 2003, twelve patients were treated for bile duct injury, not diagnosed at the time of cholecystectomy and had an early repair within 30 days after the cholecystectomy. They had either a duct to duct anastomosis or a Roux-en-Y bypass at the time of the reconstruction.

RESULTS

The level of the injury was Bismuth II (N=7), III (N=1), IV (N=2) and V (N=1) referral to Bismuth classification and one isolated right sectoral duct injury. Four patients had an duct to duct anastomosis and eight an hepaticojejunostomy at a median of 15.3 days after cholecystectomy. With one patient lost to follow up, the overall success rate in this series was 81.8% after reconstruction with a mean 40 months follow up. The reconstruction by an end to end anastomosis was successful in 100% of patients (with a mean 31.2 months follow up) and in 71.4% of patients after a Roux-en-Y biliary reconstruction (with a mean 45 months follow up).

CONCLUSION

Good results may be performed, by an early repair in bile duct injuries at laparoscopic cholecystectomy, either by an duct to duct anastomosis or a Roux-en-Y bypass.

Iatrogenic intestinal injury concomitant to iatrogenic bile duct injury: the second component

OBJECTIVE

Bile duct injuries have a frequency of 0.1% to 0.3% even in the most experienced centers. Complex biliary lesions usually require a bilioenteric anastomosis, achieving good long-term results in 80% to 90% of the cases. Besides injuries to the abdominal contents during laparoscopy (by trocars or electrocautery), intestinal complications associated with reconstruction attempts can be observed. We analyzed the concomitant intestinal complications in 251 patients with iatrogenic biliary injuries reconstructed over this 12-year period.

METHODS

A retrospective review of patients with biliary tract reconstruction after iatrogenic injury in a tertiary academic health-care center was done. All patients with concomitant intestinal injury were included; type of operation and postoperative outcome were analyzed.

RESULTS

Among 251 patients, 35 cases had a concomitant intestinal injury. The most common site of fistulization was the duodenum (18 cases, 50%); 9 cases were associated with long-term subhepatic drains (more than three weeks), and the other 9 cases were associated with a dehiscent hepatoduodenostomy. Faulty Roux-en-Y reconstruction was observed in 5 cases. In 5 cases, fistulization of the jejunum and ileum, secondary to drain placement, was documented, as well as 3 cases with colonic injuries. Two patients had a dehisced Roux-en-Y anastomosis. One had a bilioenteric omega type ileal anastomosis, and 1 had a hepatoileal anastomosis without omega reconstruction. Primary repair of the duodenum with resection of the affected intestinal or colonic segment was done at the same time of biliary repair without related morbidity.

CONCLUSIONS

Concomitant gastrointestinal injures were found with an incidence of 15% in our series. The most common site of fistulization is the duodenum. In half of the patients, it was secondary to a dehiscent hepatoduodenostomy, whereas in the other, it was caused by long-term subhepatic drains. Besides faulty Roux-en-Y reconstruction, fistulization was related with long-term drains. Primary repair and resection of the affected segment of jejunum, ileum, and colon can be done during the same operative stage of biliary reconstruction, without significant correlated mortality.