Bile duct injury repair: when? what? who?

Open injury, robotic repair-moving ahead! Total robotic Roux-en-Y hepaticojejunostomy for post-open cholecystectomy Bismuth type 2 biliary stricture using indocyanine green dye

Hepaticojejunostomy is currently the best treatment for post-cholecystectomy biliary strictures. Laparoscopic repair has not gained popularity due to difficult reconstruction. We present case of 43-year-old-female with Bismuth type 2 stricture following laparoscopic converted open cholecystectomy with bile duct injury done elsewhere. Position was modified Llyod-Davis position and four 8-mm robotic ports (including camera) and 12-mm assistant port were placed. The procedure included noticeable steps such as adhesiolysis, identification of gallbladder fossa, identification of common hepatic duct, lowering of hilar plate etc. Operating and console time were 420 and 350 minutes and blood loss was 100 mL. Patient was discharged on postoperative day 4. Robotic repair (hepaticojejunostomy) of biliary tract stricture after cholecystectomy is safe and feasible with good outcomes.

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

Objective

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

Background

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

Methods

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

Results

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

Conclusions

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

[Bile duct repair after complete intersection]

OBJECTIVE

To determine the training period for imposing hepaticojejunostomy for bile duct repair.

MATERIAL AND METHODS

Reconstructive surgery on the bile ducts was performed in 53 patients. We analyzed the learning curves based on the incidence of anastomotic leakage after hepaticojejunostomy.

RESULTS

The learning curve has a downward nature. The number of anastomotic failures decreases by 2 times after 42 procedures. Surgeon had to perform 39-42 operations to reduce the incidence of this complication.

CONCLUSION

Treatment of patients with iatrogenic intersections of the bile ducts should be provided in appropriate hospitals.

A Review of the Management of Bile Leaks

Bile leaks can be a complication of abdominal surgeries, specifically trauma to the biliary system during laparoscopic cholecystectomy, and can occur from a variety of sources, commonly a bile duct injury (BDI). Their management involves a multidisciplinary approach and depends on a multitude of factors. This consequence has also led to increased health care costs and morbidity and mortality for patients. Currently, there are no professional society-initiated guidelines that provide surgeons with a clear algorithm for managing bile leaks, as there are for other operative approaches and management in various surgical diseases. Thus, a literature search was performed that surveyed current research on the effective prevention and management of the different types of bile leaks. This review aims to provide all clinicians with an overview of factors to consider in the management of bile leaks and supports referral to a tertiary center with a hepatobiliary specialist.

Laparoscopic hepaticojejunostomy for benign biliary stricture: A case series of 16 patients at a tertiary care centre in India

Background:

Gallstone disease is common in India, and since primary management involves surgery, it is one of the most commonly performed surgeries by a general surgeon either laparoscopically or open. There are various factors which are responsible for intra- and post-operative complications. These factors result in significant injuries which cause serious post-operative complications. Amongst them, benign biliary stricture is one such significant complication which is primarily managed by open surgery, but since advent of laparoscopy, there has been an increased interest in doing this repair laparoscopically.

Materials and Methods:

This is a retrospective study of 16 patients having obstructive jaundice due to benign biliary stricture on magnetic resonance cholangiopancreatography who were operated consecutively over the past 10 years laparoscopically and underwent laparoscopic Roux-en-Y hepaticojejunostomy.

Results:

All patients underwent laparoscopic hepaticojejunostomy. The mean surgical time was 280 min, and the mean blood loss was 176 ml. In the post-operative period, most of the patients were started orally after 48 h; four had atelectasis, eight had surgical site infection, none had seroma and two had bile leak. All post-operative complications responded to conservative management.

Conclusion:

The study demonstrates that laparoscopic surgery for benign biliary strictures is safe and feasible with acceptable results.

Iatrogenic bile duct injury during cholecystectomy presenting after 11 years as a biliary stricture: a case report

BACKGROUND

Benign biliary stricture is an infrequent condition and the majority occur following cholecystectomy. This case report highlights the occurrence of such a stricture 11 years after cholecystectomy without development of biliary cirrhosis.

CASE PRESENTATION

Our patient was a 55-year-old Nepalese woman who presented to our hospital with cholangitis of 1-month duration and a history of cholecystectomy 11 years ago. A diagnosis of benign biliary stricture without features of biliary cirrhosis was made, and the patient was successfully managed with a multidisciplinary approach.

CONCLUSION

Benign biliary stricture can present even decades after cholecystectomy. Roux-en-Y hepaticojejunostomy is the treatment of choice, and a long-term favorable outcome can be expected.

Treatment of postoperative accessory bile duct injury by fibrin glue and balloon tamponade: a case report

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Iatrogenic bile duct injuries are still a diagnostic and therapeutic problem and their incidence increased with the introduction of laparoscopic technique. This case report documents a patient with a biliary fistula from an accessory bile duct - Lushka's duct - after routine laparoscopic cholecystectomy, unresponsive to relaparoscopy, ERCP with papillosphincterotomy, biliary stent and nosobiliary tube placement and finally treated with injection of fibrin glue and balloon tamponade through the external drain. Iatrogenic bile duct injuries remain a challenging problem, in particular when they do not communicate with central biliary tree. The detection of this fistulas is more difficult and their management should be multidisciplinary. This case presentation is to emphasize importance of correct diagnostic evaluation and timely and adequate non-surgical methods of treatment of biliary fistulas. (www.actabiomedica.it).

[Management of bile duct injuries]

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

An Update on Iatrogenic Biliary Injuries: Identification, Classification, and Management

Common bile duct injury is a feared complication of cholecystectomy, with an incidence of 0.1% to 0.6%. A majority of injuries go unnoticed at index operation, and postoperative diagnosis can be difficult. Patient presentation can vary from vague abdominal pain to uncontrolled sepsis and peritonitis. Diagnostic evaluation typically begins with ultrasound or CT scan in the acute setting, and source control is paramount at time of presentation. In a stable patient, hepatobiliary iminodiacetic acid scan can be useful in identifying an ongoing bile leak, which requires intervention. A variety of diagnostic techniques define biliary anatomy. Treatment often requires a multidisciplinary approach.

Long-term effects and quality of life following definitive bile duct reconstruction

The study covered a cohort of 236 patients with transection of hepatic duct. It aimed to assess the long-term outcome of the reconstruction and a patient's quality of life.The literature contains many controversies over timing of biliary reconstruction and who ought to repair the injury but just few reports on the long-term outcomes and patient's quality of life.The bile duct system was reconstructed by hepaticojejunostomy in 236 patients. Of these, 139 patients were initially repaired at a public hospital and referred because of stricture (Group A, N = 59) or of an anastomosis dehiscence (Group B, N = 80); 97 were unrepaired and referred because of a surgical clip occluding the duct (Group C, N = 39) or bile leakage from an open duct (Group D, N = 58). All patients were surveyed in 2015 for quality of life using WHOQOL-BREF.The mean time of follow-up was 150 months. The time without symptoms amounted to >5 years in 78.6% of patients. The mean time before anastomosis renewal ranged from 8.9 to 4.7 years (P < .04). Multivariate analysis showed infection, failure of reconstruction in public hospital, and female sex as factors responsible for poor long-term outcome.Patients in Group C had better quality of life than the others (P < .001) with respect to physical health (median 67.85) and psychological condition (median 79.16). The overall mortality was 15.2%.The long-term result of reconstruction depends on the cause of referral which, in turn, arises from subsequent intervention taken in local hospitals.

Management for a complicated biliary stricture after iatrogenic bile duct injury

Bile duct injury (BDI) remains to be a serious complication of biliary surgery. Biliary stricture is likely to occur in cases without proper management of BDI, may be causing such severe complications as repeated strictures, cholangitis or impairment to liver function. Here, we reported a 69-year-old man with a one-more-year history of recurrent cholangitis caused by iatrogenic BDI. The patient underwent a reconstruction of choledochojejunostomy, with liver quadrate lobectomy, and hilar cholangioplasty. The procedure was difficult, but the recovery was smooth. Only through comprehensive pre-operative evaluation and meticulous intraoperative manipulate, the technical challenge of re-operation for complicated biliary stricture after BDI should be easily addressed.

Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

Bile duct injury repair —— earlier is not better

Bile duct injury is a common complication of cholecystectomy. The timing of bile duct injury repair remains controversial. A recent review conducted in France reported 39% complications and 64% failure after immediate repair in 194 patients compared with 14% complications and 8%failure after late repair in 133 patients. A national review of 139 consecutive early repairs conducted at five hepatopancreaticobiliary centers in Denmark reported 4% mortality, 36% morbidity, and 42 restrictures (30%) at a median follow-up of 102 months, and only 64 patients (46%) demonstrated uneventful short-term and long-term outcomes. Most patients with bile duct injury present with bile leak and sepsis; thus, early repair is not recommended. Percutaneous drainage of bile and endoscopic stenting are the mainstays of treatment of bile leak because they convert acute bile duct injury into a controlled external biliary fistula. The ensuing benign biliary stricture should be repaired by a biliary surgeon after a delay of 4–6 weeks once the external biliary fistula has closed.

Correlations of portal pressure in post-cholecystectomy benign biliary stricture

AIM

Presence of portal hypertension (PH) adversely affects perioperative and long-term outcome in patients with post-cholecystectomy benign biliary stricture (PCBBS). Identification of factors related to the development of PH will help to prevent this complication.

METHODS

From September 2010 to December 2012, 30 patients with PCBBS were studied prospectively for correlation of portal pressure (PP) with injury repair interval (IRI), biliary pressure (BP), severity of hepatic fibrosis (FS), severity of hepatic inflammation (IS) and obstructive biliary pathology score (OBPS). Appropriate statistical methods employed and P ≤ 0.05 (two-sided) was considered statistically significant.

RESULTS

Mean PP, mean BP and median IRI were 19.4 ± 4.74 mmHg, 20.1 ± 3.99 mmHg and 145 days, respectively. Spearman's rank correlation coefficients (P-value) of PP with IRI, FS, IS and OBPS were 0.564 (0.001), 0.502 (0.004), 0.752 (0.0001) and 0.242 (0.19), respectively. Pearson correlation of PP with BP was r = 0.383 (r(2)  = 0.146, P = 0.03). Spearman's rank correlation coefficients (P-value) of FS with IS and OBPS were 0.561 (0.003) and 0.371 (0.04), respectively. Spearman's rank correlation coefficient of serum bilirubin with OBPS was 0.550 (P = 0.001). Incidence of PH was 33.3% and mean fall of PP following biliary repair was 6.2 ± 1.98 mmHg (P < 0.0001).

CONCLUSION

PP in patients with PCBBS has a good correlation with IS, and a fair correlation with both FS and IRI whereas PP was not directly related to BP and OBPS; further prospective trials are mandatory to confirm this correlation, and to evaluate mechanism of fall in PP following biliary decompression.

Long-term outcome after early repair of iatrogenic bile duct injury. A national Danish multicentre study

BACKGROUND

The aim of this retrospective study was to evaluate the peri-operative and long-term outcome after early repair with a hepaticojejunostomy (HJ).

METHODS

Between 1995 and 2010, a nationwide, retrospective multi-centre study was conducted. All iatrogenic bile duct injury (BDI) sustained during a cholecystectomy and repaired with HJ in the five Hepato-Pancreatico-Biliary centres in Denmark were included.

RESULTS

In total, 139 patients had an HJ repair. The median time from the BDI to reconstruction was 5 days. A concomitant vascular injury was identified in 26 cases (19%). Post-operative morbidity was 36% and mortality was 4%. Forty-two patients (30%) had a stricture of the HJ. The median follow-up time without stricture was 102 months. Nineteen out of the 42 patients with post-reconstruction biliary strictures had a re-HJ. Twenty-three patients were managed with percutaneous transhepatic cholangiography and dilation. The overall success rate of re-establishing the biliodigestive flow approached 93%. No association was found between timing of repair, concomitant vascular injury, level of injury and stricture formation.

CONCLUSION

In this national, unselected and consecutive cohort of patients with BDI repaired by early HJ we found a considerable risk of long-term complications (e.g. 30% stricture rate) and mortality in both the short- and the long-term perspective.

Iatrogenic injury to the common bile duct

Introduction:

The formation of gallstones in the gall bladder is very common. It is now considered that approximately 10% to 15% of the adult population has gallstones. It is more frequent in women than men.

Etiologies are various and include:

age, sex, diet, sudden weight loss, etc. According to the report of the US National Institute of Health, it is estimated that 6.3 million men and 14.2 million women, aged 20-74 years in the United States has calculosis of the gallbladder, due to which every year is performed about 700,000 cholecystectomy.

Case report:

Male patient, aged about 40 years, admitted at the Clinic and laparoscopic surgery was performed in our department for chronic, as multiple, symptomatic gallbladder calculi. Intraoperative findings showed chronically inflamed, curled gall bladder, and wall thickening. After the first postoperative day there is no content in the drain bag and it is taken out, and the patient leaves the hospital without any problems. The seventh post-operative day occurred abdominal pain, weakness and fatigue, with striking yellow skin and visible mucous membranes. Clinical, laboratory and echo determined abdomen full of fluids, so it was suspected lesion of the bile duct. Urgent revision was performed. Intraoperative was found a lesion of the common bile duct in the form of a complete interruption. Created is anastomosis through transhepatic drain according to Pradera. Early and late postoperative flow was entirely normal with normal laboratory and echofindings. Control, contrast imaging through a drain showed the orderly flow of extrahepatic bile ducts, with minimal extravasation of contrast.

Conclusion:

At the Department of Surgery of General Hospital in Konjic laparoscopic cholecystectomy is performed since 1999. In the beginning it was done by three trocars (European style), and later, in order to prevent complications or injury of the bile duct is performed surgery with four trocars (American style). The number of complicated procedures in our hospital does not differ from similar indicators in foreign surgical facilities.

Postcholecystectomy bile duct injury and its sequelae: pathogenesis, classification, and management

A bile duct injury sustained during cholecystectomy can change the life of patients who submit themselves to a seemingly innocuous surgery. It has far-reaching medical, socioeconomic, and legal ramifications. Attention to detail, proper interpretation of variant anatomy, use of intraoperative cholangiography, and conversion to an open procedure in cases of difficulty can avoid/lessen the impact of some of these injuries. Once suspected, the aims of investigation are to establish the type and extent of injury and to plan the timing and mode of intervention. The principles of treatment are to control sepsis and to establish drainage of all liver segments with minimum chances of restricturing. Availability of expertise, morbidity, mortality, and quality of life issues dictate the modality of treatment chosen. Endoscopic intervention is the treatment of choice for minor leaks and provides outcomes comparable to surgery in selected patients with lateral injuries and partial strictures. A Roux-en-Y hepaticojejunostomy (HJ) by a specialist surgeon is the gold standard for high strictures, complete bile duct transection and has been shown to provide excellent long-term outcomes. Percutaneous intervention is invaluable in draining bile collections and is useful in treating post-HJ strictures. Combined biliovascular injuries, segmental atrophy, and secondary biliary cirrhosis with portal hypertension are special circumstances which are best managed by a multidisciplinary team at an experienced center for optimal outcomes.

Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie

BACKGROUND

Bile duct injuries (BDIs) sustained during a cholecystectomy still remain a major surgical problem, and it is still not clear whether the injury should be repaired immediately or a delayed repair is preferred.

METHODS

A retrospective national French survey was conducted to compare the results of immediate (at time of cholecystectomy), early (within 45 days after a cholecystectomy) and late (beyond 45 days after a cholecystectomy) surgical repair for BDI sustained during a cholecystectomy.

RESULTS

Forty-seven surgical centres provided 640 cases of bile duct injury sustained during a cholecystectomy of which 543 were analysed for the purpose of the present study. The timing of repair was immediate in 194 cases (35.7%), early in 216 cases (39.8%) and late in 133 cases (24.5%). The type of repair was a suture repair in 157 cases (81%), and a bilio-digestive reconstruction in 37 cases (19%) for immediate repair; a suture repair in 119 cases (55.1%) and a bilio-digestive anastomosis in 96 cases (44.9%) for the early repair; and a bilio-digestive reconstruction in 129 cases (97%) and a suture repair in 4 cases (3%) for late repair. A second procedure was required in 110 cases (56.7%) for immediate repair, 80 cases (40.7%) for early repair (P < 0.05) and in 9 cases (6.8%) for late repair (P < 0.001).

CONCLUSION

The timing of surgical repair for a bile duct injury sustained during a cholecystectomy influences significantly the rate of a second procedure and a late repair should be preferred option.

Progressive balloon dilatation following hepaticojejunostomy improves outcome of bile duct stricture after iatrogenic biliary injury

Background

Iatrogenic biliary stricture (IBS) is a disastrous complication of cholecystectomy. Although the endoscopic treatments are well accepted as initial attempts for IBS, surgical hepaticojejunostomy (HJ) is often necessary for a considerable proportion of patients. However, the anastomotic stricture after HJ also occurs.

Methods

In the present study, a new procedure, progressive balloon dilation following HJ (HJPBD), was designed and utilized in the IBS treatment. We retrospectively compared HJPBD with the traditional HJ in term of the outcomes when used for IBS treatment.

Results

Between January 1997 and December 2009, 112 patients with IBS attributed to cholecystectomy enrolled in our hospital were treated with surgical reconstruction with either HJ (n=58) or HJPBD (n=54). Of the 58 patients in HJ group, 48 patients (82.8%) had a successful outcome, while 52 out of 54 patients (96.3%) in HJPBD group achieved success. The successful surgical reconstruction rates were significantly different between these two groups, with a further improved outcome in patient undergone progressive balloon dilation following HJ. Additionally, 8 of the 10 failure cases in HJ group were successfully rescued by HJPBD procedure.

Conclusions

Our findings suggest that the new procedure of HJPBD could be successfully applied to IBS patients, and significantly improve the outcome of IBS reconstruction.

Management of Bile Duct Injury at Various Stages of Presentation: Experience from a Tertiary Care Centre

The clinical presentation, management and outcome of all patients with bile duct injury who presented to our tertiary care centre at various stages after cholecystectomy were analyzed. The patients were categorized into three groups: group A-patients in whom the injury was detected during cholecystectomy, group B-patients who presented within 2 weeks of cholecystectomy and group C-patients who presented after 2 weeks of cholecystectomy. Our team acted as rescue surgeons and performed 'on-table' repair for injuries occurring in another unit or in another hospital. Strasberg classification of bile duct injury was followed. In group A, partial and complete transections were managed by repair over T-tube and high hepaticojejunostomy, respectively. Patients in group B underwent endoscopic retrograde cholangiogram and/or magnetic resonance cholangiogram to evaluate the biliary tree. Those with intact common bile duct underwent endoscopic papillotomy and stenting in addition to drainage of intra-abdominal collection when present. For those with complete transection, early repair was considered if there was no sepsis. In presence of intra-abdominal sepsis an attempt was made to create controlled external biliary fistula. This was followed by hepatico jejunostomy at least after 3 months. Group C patients underwent hepaticojejunostomy at least 6 weeks after the injury. The outcome was graded into three categories: grade A-no clinical symptoms, normal LFT; grade B-no clinical symptoms, mild derangement of LFT or occasional episodes of pain or fever; grade C-pain, cholangitis and abnormal LFT; grade D-surgical revision or dilatation required. Fifty nine patients were included in the study and the distribution was group A-six patients, group B-33 patients and group C-20 patients. In group A, one patient with complete transection of the right hepatic duct (type C) and partial injury to left hepatic duct (LHD) underwent right hepaticojejunostomy and repair of the LHD over stent. Two patients with type D and three patients with type E 2 injury underwent repair over T-tube and hepaticojejunostomy, respectively. In group B, all except one of the 18 patients with type A injury underwent endoscopic papillotomy and stenting. The bile leak subsided at a mean interval of 8 days in all, except one patient who died of fulminant sepsis. Of the 15 patients with type E injury, five underwent hepaticojejunostomy after a minimum gap of 3 months. Early repair was considered in 10 patients. Twenty patients in group C underwent hepaticojejunostomy. In a mean follow-up of 40 months, the outcome was grade A in 54 patients, grade B in three patients (one from each of the three groups) and grade D in one patient (group C). The latter patient with a type E3 injury developed recurrent stricture and cholangitis necessitating percutaneous transhepatic dilatation. The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

Treatment of Major Laparoscopic Bile Duct Injury: A Long-Term Follow-up Result

The goal of this study is to present the multiple institutions experience comparing the outcome of management between initial laparoscopic cholecystectomy (LC) surgeon and specialist as well as the outcome of different operative procedures to major bile duct injury (BDI) after LC. We have retrospectively collected data of 77 cases of perioperatively detected major BDI in LC at 15 general surgical institutions from 1997 to 2007. We classified 42 cases treated by an experienced biliary surgeon as Group A and 35 cases treated by the initial LC surgeon as Group B. Forty-eight cases were treated with duct-to-duct anastomosis as Group C and 29 cases were treated with Roux-en-Y choledochojejunostomy as Group D. The median duration of follow-up was 62 months. The outcome of groups was compared. In Group A, 7 of 42 (16.7%) patients developed a failure. Two of seven (28.6%) patients were treated by a secondary operation. In Group B, 24 of 35 (68.6%) patients developed a failure. Seventeen of 24 (70.8%) patients were treated by a secondary operation. One of 35 (2.85%) patients died. The significant differences were observed in failure and secondary operations (16.7 vs 68.6%, P < 0.01 and 28.6 vs 70.8%, P < 0.01). There is no significant difference Group C and Group D in failure rate (28.5 vs 11.7%, P > 0.05). A multiple institutional cooperative methodology between the local surgical institution and tertiary care centers provided a good way to limit further operations, failure. The reconstructive strategy is important and should be selected according to the type of injury and the diagnosed status of major BDI.

Transition from a low: to a high-volume centre for bile duct repair: changes in technique and improved outcome

BACKGROUND

Improvements in bile duct injury repairs have been shown in centres with specialized surgeons. The aim of the present study was to demonstrate the temporal change in the pattern of referral, technical variation associated with repair and long-term outcome of bile duct injuries at a tertiary referral centre in Mexico City.

METHODS

A retrospective case note review was performed. Patients were divided into two groups: group I (GI) 1990 to 2004 and group II (GII) 2005-2008, and appropriate statistical analysis undertaken.

RESULTS

Over a 20-year period, 312 patients with iatrogenic bile duct injuries required surgical treatment (GI = 169, GII = 140 patients). All injuries were reconstructed using a Roux-en-Y hepaticojejunostomy. The proportion of patients who had undergone a laparoscopic cholecystectomy increased from 24% to 36% (P = 0.017) over the two time periods. In the second time period there was an increase in segment IV and V partial resections (P = 0.020), a reduction in the use of transanastomotic stents (42% to 2%, P = 0.001) and an increase in the proportion of patients requiring a neoconfluence (2% to 11%, P = 0.003). In the second time period, the number of patients requiring a hepatectomy during repair (2% to 1%, P = 0.001), a portoenterostomy (16% to 9%, P = 0.060) or a double-barrel hepatico-jejunostomy (5% to 1%, P = 0.045) significantly decreased. During follow-up, patients in the second time period had a reduction in the incidence of post-operative cholangitis (11% to 6%, P = 0.310) and the frequency of post-operative anastomotic stenoses (13% to 5%, P = 0.010). Mortality remained low throughout the series but was absent in the second group.

CONCLUSIONS

Changes in technique and growing experience of the multidisciplinary team improved operative and long-term results of bile duct injury repair.

The dangers of using stapling devices for cystic duct closure in laparoscopic cholecystectomy

Laparoscopic stapling devices are used widely in laparoscopic surgery, for division of vessels and creation of anastomoses. Their use in the division of a widened cystic duct at laparoscopic cholecystectomy has been reported earlier. We present 3 different complications occurring after division of the cystic duct using the EndoGIA stapling device. A review of the literature has been performed and safe alternative techniques for laparoscopic ligation of the cystic duct are proposed.