Management of bile duct injuries and strictures following cholecystectomy

Early Versus Delayed Surgical Repair and Referral for Patients With Bile Duct Injury: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study was to systematically review and meta-analyze the available evidence regarding the association between timing of repair or referral and clinical outcomes in bile duct injury (BDI).

BACKGROUND

Surgical repair is recommended for patients with complex BDI following laparoscopic cholecystectomy. However, consensus on the timing of surgery or referral to a specialist is lacking.

METHODS

We searched PubMed, Embase, Cochrane Library, and Scopus for eligible studies. The coprimary outcomes were repair failure in follow-up and postoperative complications. We pooled odds ratios (ORs) using random-effects models.

RESULTS

We included 32 studies. The rate of repair failure was significantly higher for early versus delayed repair [OR 1.65, 95% confidence interval (CI) 1.14-2.37, P= 0.007], lower for early versus delayed referral (OR 0.28, 95% CI 0.17-0.45, P < 0.001), but did not differ substantially for on-table versus postcholecystectomy repair (OR 2.06, 95% CI 0.89-4.73, P = 0.09). Regarding postoperative complications, early referral outperformed delayed referral (OR 0.24, 95% CI 0.09-0.68, P= 0.007); however, we found no significant differences between early and delayed repair (OR 1.34, 95% CI 0.96-1.87, P= 0.08), or between on-table and postcholecystectomy repair (OR 1.13, 95% CI 0.42-3.07, P= 0.81). At the cutoff time point of 6 weeks, early repair was associated with increased rates of repair failure (OR 4.03; P < 0.001), postoperative complications (OR 2.18; P < 0.001), and biliary stricture (OR 6.23; P < 0.001).

CONCLUSIONS

Among patients with BDI, early referral and delayed repair appear to confer favorable outcomes.

Management of post-cholecystectomy benign bile duct strictures: review

Cholecystectomy is one of the common surgical procedure performed across the world and bile duct injury is a dreaded complication. The present review addresses the classification of injuries, preoperative preparation and evaluation of these patients and appropriate timing of surgery. A detailed preoperative evaluation combined with a meticulous wide anastomosis by experienced surgeons is the key in achieving long term success. Vascular injuries and its consequences on repair and outcome is also reviewed. Long term results of surgical repair and quality of life in these patients are excellent.

Iatrogenic bile duct injuries in kashmir valley

Cholecystectomy is one of the commonest operations performed throughout the world and bile duct injury is the worst complication of this procedure. In a prospective and retrospective study 25 patients were seen in a tertiary care hospital over a period of 10 years. 72% of patients were referred from other hospitals. 48% of patients presented within one month of injury. Pain was the commonest presentation (92%) followed by jaundice (80%). Liver functions were deranged in 70% of patients, USG revealed biliary dilatation in 69.6% of patients. ERCP was done in 16 patients and revealed cut off of the common hepatic duct in 43.8% of patients. Intraoperative findings revealed adhesions in 96% of patients. 48% of patients had bile duct stricture. Roux-en-Y hepaticojejunostomy was the commonest procedure performed. All patients showed improvement in liver function after surgery. Wound infection was the commonest complication seen in 32% patients. 3 patients died in our series.

Two decades of percutaneous transjejunal biliary intervention for benign biliary disease: a review of the intervention nature and complications

Objective

To assess outcomes of percutaneous transjejunal biliary intervention (PTJBI) in terms of success and effectiveness in patients with a Roux-en-Y hepaticojejunostomy for benign biliary strictures and stones.

Methods

Clinical and radiographic records of 63 patients with a Roux-en-Y choledochojejunostomy or hepaticojejunostomy for benign disease who underwent at least one PTJBI between 1986 and 2007 were reviewed. Effectiveness was determined by successful access rate, rates of stricture dilatation and/or stone extraction, morbidity, complications and hospitalisation.

Results

PTJBI was attempted 494 times. Successful access to the Roux-en-Y was accomplished in 93% of interventions. After access to the Roux-en-Y was granted, all strictures were effectively dilated. Ninety-seven percent of extraction attempts of intrahepatic calculi were successful. The median number of interventions per patient was five. The median interval between interventions was 51.5 weeks (range 2.7–1,279.6 weeks). The early complication rate was 3%. Morbidity, measured in terms of cholangitis episodes was 14%, in 25 out of 63 patients. Mean hospitalisation was 4.1 nights per year.

Conclusion

PTJBI is safe and effective in treating benign biliary strictures and/or calculi. High success rates and short hospitalisation periods, together with few complications make it a well-accepted and integral part of managing complex biliary problems.

Multidisciplinary approaches for management of postcholecystectomy problems (surgery, endoscopy, and percutaneous approaches)

PURPOSE

A prospective study to evaluate the postcholecystectomy problem management.

PATIENTS AND METHODS

From March 2005 to April 2007, 210 patients were managed using surgery, endoscopy, and percutaneous approaches.

RESULTS

Endoscopy was therapeutic in 183 cases [stones (81), stricture (55), leakage (35)], and only diagnostic in 24 cases. Percutaneous approaches were carried out in 34 cases as diagnostic in 19 cases, stenting in 2 cases, and combined with endoscopy in 13 cases. Surgery was carried out in 40 cases either urgent in 10 cases (4.8%), or planned in 30 cases (14.3%), for peritoneal lavage in 7 cases, choledocholithotomy in 8 cases, undo ligation and T-tube drainage in 5 cases, common bile duct repair splinted by T tube in 3 cases, choledochoduodenostomy in 1 case, and Roux-en-Y choledochojejunostomy in 18 cases.

CONCLUSIONS

Endoscopy is effective and safe not only for diagnostic but also for therapeutic approaches, especially when combined with percutaneous approaches that help in failure cases, but surgery remains as the gold standard treatment not only for the cases, which failed to be treated by less invasive approaches, but also in cases that are mandatory to be explored as peritonitis.

Asian race/ethnicity as a risk factor for bile duct injury during cholecystectomy

Iatrogenic bile duct injury (BDI) is an uncommon but serious complication of cholecystectomy, with identified risk factors of acute cholecystitis, male sex, older age, and aberrant biliary anatomy. The Nationwide Inpatient Sample (1998-2006) was queried for cholecystectomy performed on hospital day 0 or 1. Bile duct injury repair procedure codes were used as a surrogate for BDI. We identified 377,424 patients who underwent cholecystectomy, with 1124 BDIs (0.3%). On multivariate logistic regression analysis, Asian race/ethnicity was a significant risk factor for BDI (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.59-3.23; P < .001). This persisted for laparoscopic (OR, 2.62; 95% CI, 1.28-5.39; P = .009) and open (2.21; 1.59-3.07; P < .001) cholecystectomies. No other race/ethnicity was identified as a risk factor for BDI. We report a new finding that Asian race/ethnicity is a significant risk factor for BDI in laparoscopic and open cholecystectomies.

Endoscopic management of postoperative bile duct injuries: a single center experience

BACKGROUND/AIM

Biliary endoscopic procedures may be less invasive than surgery for management of postoperative bile duct injuries (POBDI). This retrospective work presents the experience of a single referral center during a period of 14 years in endoscopic management of POBDI.

MATERIALS AND METHODS

Between 1994 (March) and 2008 (May), ERCP had been performed on 277 patients suspected to have POBDI. Patients shown to have complete transaction of bile duct were prepared for definitive surgery. For patients with simple biliary leak, sphincterotomy was performed with stenting. Pneumatic dilatation and stenting were done on patients with biliary stricture and preserved ductal continuity. ERCP was repeated every 3 months till the site of narrowing disappeared.

RESULTS

The mean age was 45.3 years, 162 (58.5%) were females. The most common previous surgery was cholecystectomy (open, [N=119] 44%, and laparoscopic, [N=77] 28%). ERCP failed in 17 patients (6.1%). For successfully cannulated cases (N=260, 93.9%), the type of bile duct injury diagnosed at ERCP was completely ligated CBD (N=31/260 , 11.9%). Bile leakage was detected in (N=167/260, 64.2%) all patients with endoscopic sphincterotomy and stent insertion, the leak stopped in all of them. Biliary stricture was diagnosed in 33/260 patients (12.7%) and 17 of them had repeated balloon dilatation with stenting while the remaining had surgical correction. The success rate of endoscopic therapy for biliary strictures was 82%. Cholangiogram was normal in 29 patients (11.2%).

CONCLUSIONS

Endoscopic therapy is safe and effective in the management of postoperative bile duct leak. For postoperative bile ductal strictures, ERCP is a less favorable option.

Liver transplantation: the last measure in the treatment of bile duct injuries

BACKGROUND

Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI.

METHODS

Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan-Meier test.

RESULTS

Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24-152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively.

CONCLUSION

Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.

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.

Recurrent bile duct stricture: causes and long-term results of surgical management

BACKGROUND/PURPOSE

The management of recurrent bile duct strictures is a challenge for surgeons. This study reports the experience of revision surgery in patients referred following the failure of primary repair, and compares the outcome with that in patients who underwent management of recurrent stricture following primary repair at our institution.

METHODS

Over a period of 15 years, 300 patients with postcholecystectomy benign biliary stricture underwent surgical repair at our institution; 36 patients (12%) were referred after a failed primary repair.

RESULTS

In 25 (69%) patients, the primary repairs were done at peripheral hospitals. Twelve (33%) had had an early repair, at the time of cholecystectomy while 24 (67%) had a delayed repair at a later date; 83% and 67% of the patients who had undergone early and delayed repair, respectively, had not had a preoperative cholangiogram. Primary repairs performed were a bilioenteric anastomosis (22; 61%) or an end-to-end bile duct repair (14; 39%). Twenty-seven (75%) patients presented within 90 days after the primary repair, and the median interval to recurrent symptoms was 45 days (range, 1 day to 6.1 years). The median delay in referral after the development of symptoms of restricture was 175 days (range, 30 days to 22 years). Twenty-three (64%) patients had high strictures (Bismuth types III-V). All patients underwent a Roux-en-Y hepaticojejunostomy. At a median follow-up of 37 months (range, 12-144 months), 33 of 35 evaluable patients (94%) with recurrent stricture had an excellent/good outcome compared to 223 of 242 evaluable patients (92%) who had had their primary repair at our institution. Ten (4%) patients had a poor result following primary repair at our center. There was a significant difference in the stricture repair-to-recurrence interval between those patients referred to us with recurrent strictures and those who failed after primary repair at our institution (median interval, 1.5 vs 20 months; P = 0.001)

CONCLUSIONS

Patients referred with recurrent strictures had had their primary repair at peripheral settings; the failures were technical, presenting early (median, 1.5 months) with recurrent symptoms, compared to findings in patients with recurrent strictures following primary repair at our center. The long-term outcome following the repair of the primary and the recurrent strictures was no different in our experience.

[Relaparoscopy as an alternative to laparotomy for laparoscopic complications]

In the field of visceral surgery, complications requiring reintervention following laparoscopy are currently most likely to be approached with conventional laparotomy. However, relaparoscopy has the theoretical advantage of maintaining the reduced morbidity allowed by the first procedure. Essential to the success of relaparoscopy is a clear understanding of the various specific complications. Should the surgeon decide on relaparoscopy, then prompt action is of central importance. Following laparoscopic cholecystectomy, it is fundamentally technically possible through renewed laparoscopy to treat not only subhepatic abscesses but also smaller lesions of the bile duct, for example from the gall bladder fossa. Revision of complications following fundoplication is technically very demanding and should be performed only by those most experienced in the techniques of laparoscopy. In contrast to interventional drainage, relaparoscopy of abscesses following laparoscopic appendectomy has the theoretical advantage of allowing recognition and treatment of the causes, for example in the case of appendicular stump insufficiency. Relapses very shortly after endoscopic surgery of inguinal herniae result from erroneous technique and may be corrected endoscopically in most cases. Complications following colon surgery have so far been dealt with using open surgery for technical reasons and also for patient safety. Given the uncertainty in the literature, patient safety must be paramount, when deciding on which technique is best to employ, particularly in cases of haemorrhage.

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.

Bile Duct Injuries at Laparoscopic Cholecystectomy: A Single-Institution Prospective Study. Acute Cholecystitis Indicates an Increased Risk

During the last decade laparoscopic cholecystectomy (LC) has become established as the gold standard. The drawbacks in the form of bile duct (BD) injuries have also come into focus. We present the results of a prospective, consecutive series of 1568 patients with reference to BD injuries regarding risks, management, and preventive measures. The significant complications of all patients operated upon with LC between October 1999 and December 2003 were recorded prospectively. BD injuries were classified according to Strasberg into types A-E. Transected major BDs, injuries of type E, were regarded as "major" injuries and types A, B, C, and D were "minor" injuries. Major BDs were transected in five patients (0.3%), three of whom had acute cholecystitis. In the two patients operated on electively, the BD injuries were detected postoperatively, while they were detected intraoperatively when the operation was performed of necessity. The BDs were all reconstructed with a Roux-en-Y hepaticojejunostomy. Two patients had anastomotic strictures. Minor BD injuries were encountered in 19 patients (1.2%). The 13 patients with leakage from the cystic duct or gallbladder bed, injury type A, were treated by endoscopic (ERC) stenting without sequelae. Five patients sustained a lateral BD injury, type D; they were treated with a simple suture over a T-tube (at LC) or endoscopically (ERC) without further problems. A transected aberrant right hepatic BD, type C injury, was due to its small-caliber sutured. Minor BD injuries could be managed at the primary hospital if the endoscopic expertise were at hand. Acute cholecystitis seems to be a risk factor for BD injuries.

Das Inspektionsstoma nach komplexen Rekonstruktionen an den zentralen Gallengängen

INTRODUCTION

A modified Roux-en-Y hepaticojejunostomy that allows postoperative endoscopic access was first described in 1984. We report our experience with this operative procedure.

METHODS

After complicated bile duct resection, reconstruction was performed as a modified Roux-en-Y hepaticojejunostomy, with the 20 cm afferent limb brought up as in terminal jejunostomy in the right upper abdominal quadrant. Postoperative follow-up consisted of endoscopic and radiologic control of the biliary tree every 3 months for 1 year; ileostomy resection was performed 1 year later if the postoperative course was undisturbed.

RESULTS

From March 1995 to February 2002, we performed this operation in 17 patients (mean age 56 years). The endoscopic and radiologic (cholangiography) diagnostic procedures--every 3 months postoperatively--were uneventful.

CONCLUSIONS

The modified Roux-en-Y hepaticojejunostomy described here permits good control and intervention in complicated surgery for bile duct lesions, tumor resection with unclear resectional margins, and recurrent intrahepatic stone formation.

Management of major bile duct injuries after laparoscopic cholecystectomy

BACKGROUND

The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of major bile duct injuries (MBDI) after laparoscopic cholecystectomy (LC).

METHODS

We performed a retrospective analysis of 27 patients who were treated between January 1995 and December 2002 for MBDI after LC at a single unit in a tertiary center. Major bile duct injury was defined according to the Strasberg classification. All patients underwent magnetic resonance cholangiography (MRC), percutaneous transhepatic cholangiography (PTC), or endoscopic retrograde cholangiopancreatography (ERCP) to delineate the biliary anatomy and assess the level of injury. On the basis of the cholangiographic findings, all patients underwent Roux-en-Y hepaticojejunostomy after a waiting period of 8-12 weeks.

RESULTS

A total of 29 hepaticojejunostomies were performed in 27 patients. Seventeen patients (63%) presented with biliary fistula and ascites; 10 (27%) presented with obstructive jaundice. In 14 patients (52%) the MBDI was identified during the LC. Twenty patients (74%) had undergone one or more procedure before referral. Eight patients (30%) had E1, five patients (18.5%) had E2, nine patients (33%) had E3, and five patients (18.5%) had E4 injury. Two patients had early anastomotic stricture, for which redo hepaticojejunostomy with access loop was performed.

CONCLUSIONS

Major bile duct injury after LC commonly presents with biliary fistula and ascites. High-injuries are common after LC. Hepaticojejunostomy repair yields excellent results in these cases.

Laparoscopic cholecystectomy: early and late complications and their treatment

Laparoscopic cholecystectomy gained wide acceptance as treatment of choice for gallstone disease and cholecystitis. With this new technique, not only did the new era of minimal invasive surgery begin, but also the spectrum of complications changed. Laparoscopy-related complications such as access injuries and procedure-related problems are discussed in our article. Typical mishaps are reviewed according to the literature. Set-up of the pneumoperitoneum (morbidity up to 0.2%); bleeding-from trocar sites and vascular injury (mortality up to 0.2%); biliary leaks and bile duct injuries are the main topics in this article (still on a level of 0.2%-0.8%). Aetiology, diagnosis and treatment are discussed, and an overview of the most cited classifications of bile duct injuries is summarised graphically. Finally, bowel injuries as a specific complication in laparoscopy are discussed (incidence up to 0.87%).

CONCLUSION

Careful selection of patients, the knowledge of typical procedure-related complications, and their best treatment are the key points for a safe laparosopic cholecystectomy.

Percutaneous transhepatic cholangioscopic treatment of patients with benign bilio-enteric anastomotic strictures

BACKGROUND

Percutaneous transhepatic cholangioscopy is a nonoperative method for accessing bilio-enteric anastomotic strictures that cannot be reached via the transpapillary route. This study evaluated the immediate and long-term results of treatment via percutaneous transhepatic cholangioscopy of patients with benign bilio-enteric anastomotic strictures.

METHODS

A retrospective analysis was conducted of 21 patients who, between October 1994 and March 2001, had undergone percutaneous transhepatic cholangioscopy for bilio-enteric anastomotic strictures. Follow-up ranged from 12 to 79 months (mean 33.3 months).

RESULTS

The initial technical success rate was 100%, and the short-term morbidity and mortality rates were, respectively, 14.3% and 0%. However, strictures recurred in 8 patients (38.1%) at a mean of 17.1 months (range 2-38 months). The success rate exclusive of patients with recurrent strictures was 61.9%, and the overall success rate was 81.0% when the procedures were repeated. The long-term morbidity rate was 38.1%, but most complications resolved with conservative treatment. In 17 patients (81.0%), strictures were complicated by biliary stones, and these were successfully treated via percutaneous transhepatic cholangioscopy (stone removal rate 94.1%, recurrence rate 37.5%).

CONCLUSIONS

Percutaneous transhepatic cholangioscopy-based treatment of patients with benign bilio-enteric anastomotic strictures is safe and effective. This minimally invasive method frequently can be used as a substitute for surgery.

Current management of postoperative complications and benign biliary strictures

Postoperative complications after surgery of the biliary tract are usually amenable to endoscopic treatment. Such complications are most frequent after laparoscopic cholecystectomy. Bile leaks and bile duct strictures are the two main biliary injuries. Bile leaks are usually detected during the early postoperative period and can be treated by endoscopic drainage of the biliary tree (endoscopic sphincterotomy with or without nasobiliary drain). Postoperative biliary strictures are usually identified months or years after surgery. Endoscopic placement of an increasing number of plastic stents can achieve morphologic disappearance of the stricture and persistent dilation on long-term follow-up in most cases.

An endoscopic approach to the management of surgical bile duct injuries: nine years' experience

BACKGROUND

The evaluation of the endoscopic treatment of surgical bile duct injuries, especially in the management of post-operative strictures, remains controversial.

AIM

The aim of this study was to evaluate the feasibility of using endoscopic management from a study of the clinical reports of two of the main endoscopy units in Sicily.

PATIENTS AND METHODS

A total of 137 consecutive patients were selected. There were 85 simple biliary fistulas: 64 from the cystic duct stump; 19 from the gall bladder bed; and two from intra-hepatic bile ducts. There were 52 biliary lesions: 15 complete transections; 12 incomplete lesions of the common bile duct with six associated strictures; five complete or incomplete sections of the right antero-medial duct; and 20 incomplete strictures (without leak).

RESULTS

The success rate was 96.3% for simple biliary fistulas. Endoscopic therapy was feasible only in 40.6% of lesions of the common bile duct or the right antero-medial duct (13/32), but with 100% success. In the case of strictures (with or without associated leak), there was a good outcome in 88.2% of patients who completed the therapeutic procedure.

CONCLUSIONS

Endoscopic management of simple biliary fistulas and incomplete lesions of the common bile duct is the preferred approach. If continued for 12-24 months, with the placement of three or more 10F stents, the management of stenoses is guaranteed to yield good results.

Biliary-enteric transanastomotic stenting with Intestofix

BACKGROUND

Biliary-enteric transanastomotic stenting is useful under adverse local conditions or when small-calibre bile ducts are encountered.

METHODS

A commercially available feeding jejunostomy kit, Intestofix, was inserted transjejunally through the blind loop of a Roux-en-Y hepatico-jejunostomy.

CONCLUSIONS

The stent splinted the anastomosis to reduce biliary leaks and may help to prevent subsequent stricture formation.

Using contrast-enhanced MR cholangiography with IV mangafodipir trisodium (Teslascan) to evaluate bile duct leaks after cholecystectomy: a prospective study of 11 patients

OBJECTIVE

The purpose of our study was to determine whether contrast-enhanced MR cholangiography using IV mangafodipir trisodium can accurately detect the presence and location of bile duct leaks in patients who have undergone cholecystectomy.

SUBJECTS AND METHODS

Our study group included 11 patients with suspected bile duct leaks after cholecystectomy. Axial single-shot fast spin-echo and gradient-echo images were acquired in all patients before and 1-2 hr after IV administration of mangafodipir trisodium. The contrast-enhanced MR cholangiograms were evaluated for image quality, degree of ductal or small bowel opacification, and the presence and location of bile duct leaks, strictures, and stones. MR cholangiograms were correlated with conventional contrast-enhanced cholangiograms obtained in all patients, including endoscopic retrograde cholangiography (n = 10) and percutaneous transhepatic cholangiography (n = 1).

RESULTS

Excretion of mangafodipir trisodium was noted in the intrahepatic and extrahepatic bile ducts in all patients from 1 to 2 hr after IV administration. Bile ducts and fluid collections that contained excreted mangafodipir trisodium showed increased signal intensity on gradient-echo sequences and decreased signal intensity on single-shot fast spin-echo sequences. Conventional contrast-enhanced cholangiography showed the presence of bile duct leaks in six patients and the absence of bile duct leaks in five patients, with false-negative findings in one patient and false-positive findings in one patient for bile duct leak (sensitivity, 86%; specificity, 83%).

CONCLUSION

Contrast-enhanced MR cholangiography with IV mangafodipir trisodium can successfully detect the presence and location of bile duct leaks in patients suspected of having such leaks after undergoing cholecystectomy. More research is necessary before acceptance of this examination as routine in the workup of these patients.

Impaired quality of life 5 years after bile duct injury during laparoscopic cholecystectomy: a prospective analysis

OBJECTIVE

To assess the impact of bile duct injury (BDI) sustained during laparoscopic cholecystectomy on physical and mental quality of life (QOL).

SUMMARY BACKGROUND DATA

The incidence of BDI during laparoscopic cholecystectomy has decreased but remains as high as 1.4%. Data on the long-term outcome of treatment in these patients are scarce, and QOL after BDI is unknown.

METHODS

One hundred six consecutive patients (75 women, median age 44 +/- 14 years) were referred between 1990 and 1996 for treatment of BDI sustained during laparoscopic cholecystectomy. Outcome was evaluated according to the type of treatment used (endoscopic or surgical) and the type of injury. Objective outcome (interventions, hospital admissions, laboratory data) was evaluated, a questionnaire was filled out, and a QOL survey was performed (using the SF-36). Risk factors for a worse outcome were calculated.

RESULTS

Median follow-up time was 70 months (range 37-110). The objective outcome of endoscopic treatment (n = 69) was excellent (94%). The result of surgical treatment (n = 31) depended on the timing of reconstruction (overall success 84%; in case of delayed hepaticojejunostomy 94%). Five patients underwent interventional radiology with a good outcome. Despite this excellent objective outcome, QOL appeared to be both physically and mentally reduced compared with controls (P <.05) and was not dependent on the type of treatment used or the severity of the injury. The duration of the treatment was independently prognostic for a worse mental QOL.

CONCLUSIONS

Despite the excellent functional outcome after repair, the occurrence of a BDI has a great impact on the patient's physical and mental QOL, even at long-term follow-up.

Pericholecystic adhesions in single v multiple gallstones and their consequences for laparoscopic cholecystectomy

BACKGROUND

Adhesions are amongst the common reasons for open conversion of laparoscopic cholecystectomy. It is not clear whether this problem is more common with single or multiple gallstones.

PATIENTS AND METHODS

The clinical records of 110 patients with chronic cholelithiasis harboring multiple stones in the gallbladder (multiple stone group; MSG) and 45 patients with single stones in the gallbladder (SSG) undergoing laparoscopic cholecystectomy were analyzed for differences in the clinical presentation and outcome with special reference to the incidence of pericholecystic adhesions, size of the stones, and their implications for conversion and complications.

RESULTS

Patients in the SSG had a significantly higher incidence of dense pericholecystic adhesions in the region of the porta hepatis (P = 0.003). Eleven patients in the SSG (24.4%) were converted to open cholecystectomy. Dense pericholecystic adhesions around the porta hepatis alone contributed to nine of these conversions (81.8%). The size of the stones was significantly greater (P < 0.001) in those patients of the SSG who required conversion to open cholecystectomy. Thirteen patients of the MSG (11.8%) required conversion to open cholecystectomy. Dense pericholecystic adhesions alone contributed to conversion in four cases (30.7%), and the size of the gallstones was not significantly different (P = 0.981) in patients with or without conversion to open cholecystectomy. There was no difference in the clinical presentation or complications in the two groups of patients.

CONCLUSION

Dense adhesions in the porta hepatis are significantly more common in patients with single stones and are the most common reason for open conversion.

Long-term follow-up after biliary stent placement for postoperative bile duct stenosis

BACKGROUND

The outcome of temporary biliary stent placement for postoperative bile duct stenosis was retrospectively evaluated with the main aim of assessing long-term complications after stent removal.

METHODS

ERCP was performed between 1981 and 1991 in 74 patients with postoperative bile duct stenoses. Two 10F stents were inserted for a maximum of 12 months with stent exchange every 3 months to avoid cholangitis caused by clogging.

RESULTS

Stent insertion failed in 11 patients with complete and 4 patients with incomplete biliary obstruction. Early complications occurred in 14 patients (19%) including 2 deaths. Therefore 57 patients were included in the stent phase of the study. In 10 patients the referring physician did not adhere to the treatment protocol, and nonelective stent exchange for jaundice and/or cholangitis was necessary in 7 (70%). Of the 47 patients treated according to protocol, complications developed in 40% during the period with stents in situ. Stents were eventually removed in 44 patients who were subsequently followed for a median of 9.1 years. Late complications developed in 15 patients (34%) including recurrent stenosis in 9 (20%). All cases of recurrent stenosis occurred within 2 years of stent removal.

CONCLUSIONS

Endoscopic treatment is feasible in 80% of patients who undergo an ERCP for postoperative bile duct stenosis. After stent insertion and during the time with stents in situ, complications occur at a significant rate but are usually mild or reflect the patient's underlying condition. After stent removal, recurrent stenosis develops in 20% of patients within 2 years of stent removal. Endoscopic treatment should be the initial management of choice for postoperative bile duct stenosis.

Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents

BACKGROUND

Endoscopic dilation with stents has been proposed as an alternative to hepaticojejunostomy for management of postoperative biliary strictures. Good long-term results with double 10F plastic stent insertion for 1 year have been reported in 74% to 90% of cases. This is a review of our experience with a more aggressive approach.

METHODS

The technique, short-term results, and long-term results of placement of increasing numbers of stents until complete disappearance of the biliary stricture are reported. At each exchange, the maximum possible number of stents in relation to the tightness of the stricture and diameter of the bile duct were inserted. All stents were removed at the end of treatment.

RESULTS

The records of 45 of 55 patients with postoperative biliary strictures treated in this manner and observed consecutively were reviewed retrospectively. By intention-to-treat analysis the success rate was 89% (40/45). Early complications developed in 4 (9%) patients (3 cholangitis, 1 pancreatitis) and stent occlusion that required early exchange occurred in 8 (18%) patients. There was 1 death caused by a stroke 2 months after a stent exchange. Forty-two patients completed the protocol (mean number of stents 3.2 +/- 1.3; range 1-6). Mean duration of treatment was 12.1 +/- 5.3 months (range 2-24 months). Two patients died of unrelated causes during follow-up. Among the remaining 40 patients there was no recurrence of symptoms caused by relapsing biliary stricture at a mean follow-up of 48.8 months (range 2-11.3 years). One patient sustained 2 episodes of cholangitis but without stricture recurrence.

CONCLUSIONS

This more aggressive approach to endoscopic treatment with stents may improve long-term results for patients with postoperative biliary strictures.

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

BACKGROUND AND PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic bile duct injuries: spectrum at a tertiary-care center

BACKGROUND AND PURPOSE

Laparoscopic cholecystectomy (LC) is associated with a higher incidence of bile duct injury than is open cholecystectomy. We reviewed our experiences with the management of laparoscopic bile duct injuries.

PATIENTS AND METHODS

From October 1992 through August 1998, 34 patients with bile duct injuries (BDI) following LC were seen. The presentation, type of injury (Strasberg classification), management, and outcome were analyzed in these patients.

RESULTS

Of the 16 patients who sustained injury at our center (type A [N = 9], D [N = 5], and E1 [N = 2]), in 14, the injury was detected during LC, and two patients manifested with postoperative bile leak. All patients had an excellent outcome at a median follow-up of 5.5 (range 1.9-8.0) years. Of the 18 patients who sustained injury elsewhere (type C [N = 1], D [N = 2], E [N = 14; 6 with external biliary fistula (EBF) and 8 with benign biliary stricture (BBS)], and not known [1]), 9 had EBF, 1 had biliary peritonitis, and 8 had BBS at the time of presentation. Of these 18 patients, 4 underwent early repair of the BDI before referral (repair over a T-tube [N = 2] and Roux-Y hepaticojejunostomy [N = 2]). Three of them developed restricture. One patient was referred to us within 12 hours of injury and had a successful repair over a T-tube. Two patients with early repair for lateral injury had an excellent outcome. Eleven patients with BBS underwent repair with an excellent (N = 10) or fair (N = 1) outcome at a median follow-up of 5.0 (2.0-6.2) years. Three patients were lost to follow-up.

CONCLUSION

The spectrum of injuries sustained at LC at a tertiary-care center is different from that in the community hospitals. Missed injuries and attempts at repair in inexperienced hands result in serious sequelae of stricture formation and long-term morbidity.

A case of recurrent cholangitis after bile duct injury during laparoscopic cholecystectomy: value of scintigraphy with Tc-99m GSA and hepatobiliary scintigraphy for indication of lobectomy

A 39-year-old woman with acute cholecystitis and gallstones underwent laparoscopic cholecystectomy. She suffered from recurrent episodes of cholangitis due to injury of the major bile ducts during laparoscopic cholecystectomy. Hepatobiliary scintigraphy with Tc-99m Sn-N-pyridoxyl-5-methyltryptophan was performed. Although normal bile excretion was found from the left hepatic duct to the percutaneous transhepatic biliary drainage (PTBD) tube, excretion from the right hepatic lobe was prolonged. Scintigraphy with Tc-99m diethylenetriaminepentaacetic acid-galactosyl human serum albumin demonstrated atrophy of the right hepatic lobe and enlargement of the left hepatic lobe. Cholangiography via the PTBD tube revealed complete obstruction of the left hepatico-jejunal anastomosis and could not enhance the right intrahepatic bile duct. A right hepatic lobectomy was performed because of the atrophy, glissonitis and the absence of an appropriate bile duct for reconstruction. Postoperatively she was active and exhibited no evidence of recurrent cholangitis.

Cirurgia videolaparoscópica nas doenças biliopancreáticas

Com a experiência adquirida na cirurgia da vesícula biliar, a videocirurgia está sendo indicada cada vez mais em outras doenças. Decorridos 15 anos da primeira cirurgia, os autores avaliam os resultados e analisam as perspectivas deste procedimento nas doenças biliopancreáticas. Seguem a proposta que divide este procedimento em procedimentos de rotina, avaliação e desenvolvimento. Nas doenças da vesícula biliar, a colecistectomia laparoscópica é considerada padrão ouro, levando vantagem em todos os itens sobre a laparotômica, excluídas as lesões da via biliar e o vazamento biliar pelo coto cístico. Enfatizam situações especiais: da colecistite aguda, da colecistectomia durante a gravidez, da vesícula em porcelana e do câncer da vesícula. Comentam as perspectivas da videocirurgia nas complicações da colecistectomia laparoscópica. No tratamento da coledocolitíase, consideram o procedimento como em avaliação pela falta de ensaios clínicos prospectivos randomizados com grupo controle comparáveis e acompanhados por prazo de tempo maior. Nas doenças do pâncreas, a videocirurgia é um procedimento em desenvolvimento, com exceção da pancreatite aguda biliar não complicada, que se beneficia com a colecistectomia laparoscópica. O mesmo ocorre com as cirurgias de derivação para desobstrução da via biliar. Embora factíveis dentro dos princípios da cirurgia convencional, faltam estudos comparativos com outras técnicas existentes analisando eficácia e efetividade.

The Role of Hepatic Resection in the Management of Bile Duct Injuries following Laparoscopic Cholecystectomy

The creation of a specialized hepatobiliary surgery unit at our medical center has resulted in referral of 16 patients with bile duct complications following laparoscopic cholecystectomy over the last 18 months. No patient required conversion to open cholecystectomy. Although no injury was recognized at the time of surgery, 15 of 16 patients became symptomatic within the first 30 days. Two patients died from sepsis and multisystem organ failure after protracted hospital courses. Endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography determined diagnosis and level of injury. Six of seven patients with cystic duct leak underwent successful endoscopic stent placement and one patient sealed spontaneously after percutaneous drainage of a large biloma. Nine patients required surgery that included hepaticojejunostomy (five), T-tube insertion and drainage of abscess (two), or segmental hepatic resection (two). Timely recognition of bile duct complications following laparoscopic cholecystectomy is critical to a successful long-term outcome. Although the majority of cystic duct leaks can be managed with endoscopic stenting, patients with ductal injuries require hepaticojejunostomy. Segmental liver resection may serve an important role in the management of carefully selected patients with high intrahepatic injuries to avoid long-term transhepatic stenting and complications such as episodic cholangitis and late stricture formation.

Laparoscopic biliary injury: more than a learning curve problem

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term results of hepaticojejunostomy for benign lesions of the bile ducts

BACKGROUND

Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared.

METHODS

A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation.

RESULTS

Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition.

CONCLUSIONS

Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.

Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis

OBJECTIVE

The purpose of this study was to perform a meta-analysis of large laparoscopic cholecystectomy case-series and compare results concerning complications, particularly bile duct injury, to those reported in open cholecystectomy case-series.

SUMMARY BACKGROUND DATA

Since the introduction of laparoscopic cholecystectomy in the United States, hundreds of reports about the technique have been published, many including statements about the advantages of laparoscopic cholecystectomy compared with those of open cholecystectomy. There is an unevenness in scope and quality of the studies. Nevertheless, enough data have accumulated from large series to permit analyses of data regarding some of the most important issues.

METHODS

Articles identified via a MEDLINE (the National Library of Medicine's computerized database) search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes of cholecystectomy were abstracted and summarized across studies.

RESULTS

Outcomes of laparoscopic cholecystectomy are examined for 78,747 patients reported on in 98 studies and compared with outcomes of open cholecystectomy for 12,973 patients reported on in 28 studies. Laparoscopic cholecystectomy appears to have a higher common bile duct injury rate and a lower mortality rate. Estimated rates of other types of complications after laparoscopic cholecystectomy generally were low. Most conversions followed operative discoveries (e.g., dense adhesions) and were not the result of injury.

CONCLUSIONS

There is wide variability in the amount and type of data reported within any single study, and patient populations may not be comparable across studies. Except for a higher common bile duct injury rate, laparoscopic cholecystectomy appears to be at least as safe a procedure as that of open cholecystectomy.

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

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

Sump syndrome complicating Roux-en-Y hepaticojejunostomy: case report and review of the literature

Sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by gastrointestinal debris after choledochoduodenostomy, resulting in cholangitis or, less commonly pancreatitis. Obstruction of the biliary tree by gastrointestinal contents after Roux-en-Y choledochojejunostomy or hepaticojejunostomy has not been described in the English-language literature. This report details the diagnostic and operative management of the first patient with sump syndrome after hepaticojejunostomy. The presumed pathophysiology was reflux of vegetable matter up the efferent limb, resulting in hepatic duct obstruction and cholangitis. The patient ultimately required complex choledochoscopic drainage of the intrahepatic biliary tree and revision of the previous Roux-en-Y hepaticojejunostomy.

Benign biliary strictures: repair and outcome with a contemporary approach

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Bile duct injury and bile leakage in laparoscopic cholecystectomy

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