Postoperative bile duct strictures

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.

How to do it: rescue duct-to-duct biliary reconstruction techniques to avoid severe biliary complications of hepatic resection for hepatocellular carcinoma

There are few reports on duct-to-duct biliary reconstruction for complex liver resection with limited bile duct resection. We performed duct-to-duct biliary reconstruction in two patients undergoing limited bile duct resection where Roux-en-Y hepaticojejunostomy (HJ) was difficult. An external biliary drainage tube was placed routinely at the anastomotic site to prevent stenosis. In case 1, the tumor-infiltrated part of the left hepatic duct (LHD) was resected and the LHD was repaired using duct-to-duct reconstruction with interrupted sutures. In case 2, after the tumor-infiltrated part of the LHD and posterior hepatic duct (PHD) were resected, T-tube reconstruction was performed on the PHD, and the LHD was anastomosed using interrupted sutures for the posterior wall and a round ligament patch for the anterior wall. Our literature review suggests that an external biliary drainage tube with stenting over the anastomosis may reduce the risk of biliary complications.

Bile Duct Injuries during Laparoscopic Cholecystectomy: Management and Outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux- en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux- en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.

Treatment of post-cholecystectomy biliary strictures with fully-covered self-expanding metal stents - results after 5 years of follow-up

Background

Endoscopic treatment of post-cholecystectomy biliary strictures (PCBS) with multiple plastic biliary stents placed sequentially is a minimally invasive alternative to surgery but requires multiple interventions. Temporary placement of a single fully-covered self-expanding metal stent (FCSEMS) may offer safe and effective treatment with fewer re-interventions. Long-term effectiveness of treatment with FCSEMS to obtain PCBS resolution has not yet been studied.

Methods

In this prospective multi-national study in patients with symptomatic benign biliary strictures (N = 187) due to various etiologies received a FCSEMS with scheduled removal at 6–12 months and were followed for 5 years. We report here long-term outcomes of the subgroup of patients with PCBS (N = 18). Kaplan Meier analyses assessed long-term freedom from re-stenting. Adverse events were documented.

Results

Endoscopic removal of the FCSEMS was achieved in 83.3% (15/18) of patients after median indwell of 10.9 (range 0.9–13.8) months. In the remaining 3 patients (16.7%), the FCSEMS spontaneously migrated and passed without complications. At the end of FCSEMS indwell, 72% (13/18) of patients had stricture resolution. At 5 years after FCSEMS removal, 84.6% (95% CI 65.0–100.0%) of patients who had stricture resolution at FCSEMS removal remained stent-free. In addition, at 75 months after FCSEMS placement, the probability of remaining stent-free was 61.1% (95% CI 38.6–83.6%) for all patients. Stent or removal related serious adverse events occurred in 38.9% (7/18) all resolved without sequalae.

Conclusions

In patients with symptomatic PCBS, temporary placement of a single FCSEMS intended for 10–12 months indwell is associated with long-term stricture resolution up to 5 years. Temporary placement of a single FCSEMS may be considered for patients with PCBS not involving the main hepatic confluence.

Trial registration numbers

NCT01014390; CTRI/2012/12/003166; Registered 17 November 2009.

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.

Duct-to-duct biliary reconstruction during complex hepatectomy: a useful technique in selected cases

BACKGROUND

Roux-en-Y anastomosis is the standard of care for biliary reconstruction. Yet, a direct bilio-biliary anastomosis preserves the normal sphincter mechanism and endoscopic access to the biliary tree for diagnostic and therapeutic purposes. Duct-to-duct biliary reconstruction is widely used in liver transplantation. The objective of this study was to analyze the feasibility and results of duct-to-duct biliary reconstruction in the setting of complex hepatic resection with limited biliary confluence involvement.

METHODS

We identified patients from our prospectively maintained database that underwent major hepatic resection and bile duct resection with a concomitant direct duct-to-duct biliary anastomosis. Postoperative oncological and functional biliary outcomes were analyzed.

RESULTS

Ten patients were studied. In 9 cases, a biliary stent was left in place to decompress the anastomosis. Two patients developed a biliary fistula: one resolved spontaneously and the other required percutaneous drainage and an endoscopic biliary stent. This latter patient (the only nonstented patient) also developed a biliary stricture that was treated endoscopically. With a mean follow-up of 22 months, no other biliary-related complications were recorded. No patients had a recurrence at the biliary reconstruction site only. In the setting of multifocal hepatic recurrence presenting with jaundice, two patients were palliated by interventional endoscopy.

CONCLUSIONS

For hepatectomy requiring a short resection of the bile duct or for high bile duct injury during complex hepatectomy, a tension-free, well-vascularized duct-to-duct reconstruction over a stent is a suitable option that offers good oncological clearance of the bile duct and satisfactory functional results.

Bile duct injuries in the era of laparoscopic cholecystectomies

Bile duct injuries incurred during laparoscopic cholecystectomies remain a major complication in an otherwise safe surgery. These injuries are potentially avoidable with proper techniques and correct interpretation of the anatomy. The scope of the injury can range from a simple cystic duct leak to the injury of the left and right hepatic duct confluence. The key to successful outcomes from these injuries is to know when a referral to a specialized tertiary center is necessary. Evaluation and treatment of bile duct injuries is complex and often requires the expertise of an advanced endoscopist, interventional radiologist, and hepatobiliary surgeons. Before any planned intervention or operative repair, detailed evaluation of the biliary system and its associated vasculature is required. Better outcomes are achieved when patients are referred to centers specialized in biliary injury evaluation, treatment, and performing pretreatment planning early.

Long-term follow-up evaluation for more than 10 years after endoscopic treatment for postoperative bile duct strictures

BACKGROUND

Endoscopic stent therapy is routinely used to treat postoperative bile duct strictures. However, no studies have detailed long-term follow-up evaluation for more than 10 years.

METHODS

This study enrolled 22 consecutive patients with a diagnosis of postoperative bile duct strictures from 1987 to 2006. Cases involving digestive tract reconstruction were excluded. Dilation was performed after passage of a guidewire through the stricture followed by temporary stent placement. The final objective was to achieve stent free status after sufficient dilation. The stent was removed when the cholangiogram showed apparent resolution of the stricture. If stent removal was not possible within 12 months, the authors proposed a surgical treatment option.

RESULTS

Initial therapy was performed for 21 patients (21/ 22, 95%). The remaining patient had complete occlusion, which required surgical repair. For 3 of the 21 cases, guidewire passage through the narrow stricture under fluorographic guidance alone was impossible. However, visualization by peroral cholangioscope enabled passage of the guidewire in all three cases. In two cases, the stricture persisted longer than 12 months, rendering stent removal impossible. Therefore, stent removal within 12 months was achieved in 90% of the cases (19/21). Two patients requested prolonged stenting in lieu of the authors' proposal to repeat the surgery. This resulted in sufficient dilation after an additional 6 months. Consequently, a total of 21 patients were enrolled for long-term follow-up evaluation. The posttreatment follow-up period was 121 + or - 64 months (range, 31-254 months; median, 120 months). Three patients died of causes unrelated to hepatobiliary disease. The remaining patients were successfully followed up until this writing. The overall long-term success rate was 95% (20/21). No hepatobiliary malignancies developed within the follow-up period.

CONCLUSIONS

Endoscopic stent therapy is available for postoperative bile duct strictures. Long-term prognosis for more than 10 years is excellent. Repeat surgical interventions may be unavoidable in some cases, but endoscopic treatment should be proposed as the first-line treatment.

Reappraisal of duct-to-duct biliary reconstruction in hepatic resection for liver tumors

BACKGROUND

Duct-to-duct reconstruction is theoretically suitable for short segmental defects of the bile duct. This technique would also be useful, without jeopardizing the curability, in selected cases with hepatic malignancies requiring concomitant liver and bile duct resection.

METHODS

For biliary reconstruction after hepatectomy, duct-to-duct reconstruction was performed in 4 patients at our institution between 1994 and 2004. The surgical techniques used are presented, along with the results of evaluation of the outcome, including postoperative and long-term morbidity and survival.

RESULTS

Duct-to-duct reconstruction was safely performed in the 4 patients with the defects ranging in size from 10 to 19 mm. None of the cases developed local recurrence at the anastomotic site. None of the cases developed stenosis of the anastomotic site either, but cholangitis occurred in 1 patient.

CONCLUSIONS

Duct-to-duct reconstruction for short segmental defects after the removal of hepatic malignant tumors is feasible with less operative and long-term morbidity. It is essential to select patients carefully when thinking of performing duct-to-duct anastomosis without complication and cancer infiltration.

Chirurgische Behandlung benigner Läsionen und Strikturen der Gallenwege

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

Differentiating Malignant from Benign Common Bile Duct Stricture with Multiphasic Helical CT

PURPOSE

To evaluate retrospectively the use of multiphasic helical computed tomography (CT) to differentiate malignant and benign common bile duct (CBD) strictures in patients with only a focal CBD stricture and to determine predictors for this differentiation.

MATERIALS AND METHODS

Institutional review board approval and informed patient consent were not required. Fifty patients (35 men, 15 women; age range, 35-87 years; mean age, 61.6 years) with only a focal CBD stricture comprised the sample for this study (32 malignant and 18 benign strictures). The diagnosis of all malignant and five benign CBD strictures was confirmed by reviewing patients' surgical and pathology records; in 13 benign CBD strictures, the diagnosis was confirmed by means of clinical features. Multiphasic CT findings were analyzed with regard to the wall thickness, location, length, and enhancement pattern of the involved CBD, the upstream CBD diameter, and other findings. CT features to identify benign and malignant CBD strictures were compared by means of univariate analysis and multivariable stepwise logistic regression analysis.

RESULTS

Malignant strictures were longer (17.9 mm +/- 6.6 [+/- standard deviation]) than benign strictures (8.9 mm +/- 6.8) (P < .0001), and upstream CBD diameters were larger in malignant cases (22.0 mm +/- 5.4) than in benign cases (17.8 mm +/- 4.6) (P = .033). The involved wall thickness was more than 1.5 mm in 26 malignant cases and three benign cases (P < .0001). During both hepatic arterial and portal venous phases, greater enhancement than that in the normal CBD were more frequently observed in malignant cases (in 27 and 30 patients for hepatic arterial and portal venous phase scans, respectively) than in benign cases (in two and three patients, respectively) (P < .0001). Results of multivariable stepwise logistic regression analysis showed that hyperenhancement of the involved CBD during the portal venous phase was the only variable that could be used to independently differentiate malignant from benign strictures.

CONCLUSION

Hyperenhancement of the involved CBD during the portal venous phase is the main factor distinguishing malignant from benign CBD strictures.

Tratamento cirúrgico das estenoses da via biliar

OBJETIVO: As estenoses benignas da via biliar (EBVB) decorrem de lesões iatrogênicas em 95% casos. Embora pouco freqüentes seu prognóstico é sombrio, e a prevenção é o melhor tratamento. O objetivo deste trabalho é estudar a conduta cirúrgica nas EBVB e seus resultados. MÉTODO: Foram analisados retrospectivamente, 11 pacientes submetidos à correção de EBVB no Hospital Universitário Regional do Norte do Paraná (HURNP) no período de Julho/1992 a Dezembro/2001. RESULTADOS: Nove pacientes eram do sexo feminino e dois do masculino,com média de idade de 43,71 (± 17,05) anos. A cirurgia que originou a lesão foi colecistectomia aberta em 81,8% dos pacientes e por laparoscopia em 18,2%. Os sinais e sintomas mais freqüentes foram icterícia (64,3%), dor (64,3%), e febre (21,4%). O diagnóstico foi confirmado por colangiopancreatografia retrógrada endoscópica (CPRE) em 90,9% dos casos e por colangiografia transparieto- hepática (CTPH) em 9,1%. Segundo os critérios de Bismuth lesões do tipo I ocorreram em 18,2% dos casos, tipo II em 45,4%, tipo III em 18,2% e tipo IV em 18,2%. O tratamento cirúrgico para as EBVB foi anastomose colédoco-duodenal, anastomose hepático-jejunal em Y de Roux , anastomose hepático-jejunal à Hepp- Couinaud e anastomose hepático-jejunal com enxertia de mucosa (Smith), para as lesões tipo I,II,III e IV, respectivamente. Seis (54,55%) pacientes apresentaram complicações pós-operatórias , e dois (18,2%) evoluíram para óbito CONCLUSÕES: As correções cirúrgicas das EBVB apresentam altos índices de complicações e devem ser realizadas em centros especializados. Em geral estas estenoses decorrem de lesões iatrogênicas durante colecistectomias.

Percutaneous management of benign biliary strictures

The interventional radiologist plays an increasing role in the management of patients with benign biliary disease. This article summarizes the percutaneous management of patients with benign biliary strictures and includes a discussion of currently available techniques. The techniques of percutaneous transhepatic cholangiography and biliary drainage will be reviewed. This includes anatomic and technical considerations of the right midaxillary and left subxyphoid percutaneous approaches, a review of percutaneous dilation of biliary strictures and the management of patients with chronic indwelling biliary drainage catheters. (ie, periodic catheter exchanges, catheter flushing, etc). The article concludes with a discussion of biliary drainage catheters and the clinical and physiologic parameters used in making a decision to remove the tube.

MR cholangiopancreatography of bile and pancreatic duct abnormalities with emphasis on the single-shot fast spin-echo technique

Magnetic resonance cholangiopancreatography (MRCP) is used for noninvasive work-up of patients with pancreaticobiliary disease. MRCP is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis of extrahepatic bile duct abnormalities. In patients with choledocholithiasis, calculi appear as dark filling defects within the high-signal-intensity fluid at MRCP. Benign strictures due to sclerosing cholangitis are multifocal and alternate with slight dilatation or normal-caliber bile ducts, producing a beaded appearance. Dilatation of both the pancreatic and bile ducts at MRCP is highly suggestive of a pancreatic head malignancy. Side-branch ectasia is the most prominent and specific feature of chronic pancreatitis. MRCP is more sensitive than ERCP in detection of pancreatic pseudocysts because less than 50% of pseudocysts fill with contrast material. Because the mucin secreted by biliary cystadenomas and cystadenocarcinomas causes filling defects and partial obstruction of contrast material at ERCP, MRCP is potentially more accurate in demonstrating the extent of these tumors. In patients with biliary-enteric anastomoses, MRCP is the imaging modality of choice for the work-up of suspected pancreaticobiliary disease. A potential use of MRCP is the demonstration of aberrant bile duct anatomy before cholecystectomy. MRCP is also accurate in detection of pancreas divisum.

Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Magnetic resonance imaging of the pancreas and biliary tree

MRI of the pancreas and bile ducts is becoming more widely used due to recent advances in surface coils, breath-hold imaging techniques, and magnetic resonance cholangiopancreatography (MRCP). MRI provides a comprehensive and accurate examination for the detection, staging, and characterization of a variety of developmental, inflammatory, and neoplastic processes that involve the pancreas.

Benign post-operative bile duct strictures

The vast majority of post-operative bile duct strictures occur following cholecystectomy, these injuries having been seen at an increased frequency since the introduction of laparoscopic cholecystectomy. Bile duct injuries usually present early in the post-operative period, obstructive jaundice or evidence of a bile leak being the most common mode of presentation. In patients presenting with a post-operative bile duct stricture months to years after surgery, cholangitis is the most common symptom. The 'gold standard' for the diagnosis of bile duct strictures is cholangiography. Percutaneous transhepatic cholangiography is generally more valuable than endoscopic retrograde cholangiography in that it defines the anatomy of the proximal biliary tree that is to be used in surgical reconstruction. The most commonly employed surgical procedure with the best overall results for the treatment of bile duct stricture is a Roux-en-Y hepaticojejunostomy. The results of the surgical repair of bile duct strictures are excellent, long-term success rates being in excess of 80% in most series. Recent data have suggested that, at intermediate follow-up of approximately 3 years, an excellent outcome can be obtained following repair of bile duct injuries after laparoscopic cholecystectomy. Percutaneous and endoscopic techniques for the dilatation of bile duct strictures can be useful adjuncts to the management of bile duct strictures if the anatomical situation and clinical scenario favour this approach. In selected patients, the results of both endoscopic and percutaneous dilatation are comparable to those of surgical reconstruction.

Bilioenteric anastomosis reverses hyperkinetic circulation in bile duct-ligated cirrhotic rats

BACKGROUND/AIMS

The chronic bile duct-ligated rat is used to study hemodynamic changes in cirrhosis but suffers from total biliary obstruction and deep jaundice. The extent of reversibility of hemodynamics and histology following bile flow reconnection is controversial. We aimed to characterize the hemodynamics and histology of bile duct-ligated cirrhotic rats in which bile flow was reconnected by a Roux-en-y choledochojejunostomy.

METHODS

Operations created four groups: double sham (control), bile duct ligated, and two reconnected groups. Cardiac index and regional blood flows were measured by radioactive microspheres 4 weeks following the last operation in the first three groups and 8 weeks afterwards in the second reconnected group. Liver histology was assessed by a computer-aided scoring program.

RESULTS

Cardiac index, mean arterial pressure, and systemic vascular resistance in the reconnected groups were different from bile duct-ligated rats and returned to control values. Portal pressures in the reconnected groups (4-weeks, 10.0 +/- 0.5 and 8-week, 9.7 +/- 0.6 mmHg) were significantly lower than in bile-duct-ligated rats (13.7 +/- 0.6) but remained elevated compared to controls (7.0 +/- 0.3). Portal pressure in the reconnected rats was correlated with cardiac index and mesenteric blood flow, r = 0.66 and r = 0.45, respectively. Liver histology was improved in the reconnected rats, with decreased bile duct proliferation, fibrosis and apoptosis.

CONCLUSIONS

We conclude that many of the histological features of secondary biliary cirrhosis are reversible after bilioenteric anastomosis. Furthermore, the hyperdynamic circulation is also largely reversible and is related to the degree of portal hypertension.

Endoscopic management of benign and malignant biliary strictures

BACKGROUND

It is now possible to manage most extrahepatic bile duct strictures, benign or malignant, using endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic dilatation and stenting.

METHODS

Over a 5-year period we treated 218 patients with strictures of extrahepatic bile ducts. Eighty-six patients had benign biliary stricture. Endoscopic treatment was performed in 67 (78%) of these patients. Open surgical biliary drainage was preferred in 12 patients (14%), and 7 patients (8%) were managed conservatively without stenting or surgery. One hundred and thirty-two patients had malignant biliary stricture. One hundred and one patients (77%) underwent endoscopic stent placement. Thirty-one patients (23%) underwent surgery for potential curative resection after diagnostic ERCP. The average life span in the malignant stricture group was 5 months (range 0.1 to 25 months) after the initial endoscopic procedure.

RESULTS

Altogether 313 endoscopic procedures in 218 patients were performed for benign and malignant bile duct strictures. Complications included hemorrhage in 8 (3%), pancreatitis in 10 (3%), and suspected retroperitoneal perforation in 2 (0.6%). There were no ERCP related deaths; one patient died of uncontrolled bleeding from transhepatic stenting. In benign strictures, there has been no recurrence of strictures after the last stent removal with a mean followup of 21 months (range 0.1 to 31 months). All complications were successfully treated conservatively.

CONCLUSIONS

Endoscopic management of benign and malignant biliary stricture is possible with minimal morbidity and mortality and should be considered an acceptable option to surgical management.

Role of intraoperative cholangiography in laparoscopic cholecystectomy

The results of a policy of selective cholangiography were assessed in 400 patients undergoing laparoscopic cholecystectomy. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 81 patients (20 per cent) of whom 31 (38 per cent) showed definite or possible evidence of stones in the bile duct. Seventeen of the 400 patients underwent intraoperative cholangiography and the majority of these (12) were normal. After a minimum follow-up of 1 year, 17 patients (4 per cent) have had ERCP for suspected residual duct stones. Eight (2 per cent) of these revealed stones and all were successfully treated with sphincterotomy and duct clearance. Preoperative and postoperative ERCP was not associated with mortality or major morbidity. No major duct injury occurred and none was diagnosed within 2 years of operation. Routine intraoperative cholangiography is not a necessary part of laparoscopic cholecystectomy in the presence of an efficient and safe ERCP service.

Cholecystectomy without operative cholangiography. Implications for common bile duct injury and retained common bile duct stones

OBJECTIVE

This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography.

SUMMARY BACKGROUND DATA

There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC.

METHODS

Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized.

RESULTS

A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days.

CONCLUSIONS

LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.

Biliary drainage in obstructive jaundice: experimental and clinical aspects

Jaundiced patients undergoing invasive diagnostic and therapeutic procedures are at increased risk of complications and death. Despite the large number of clinical and experimental investigations carried out to identify relevant risk factors, no single parameter has been found to be consistently useful in predicting morbidity or mortality. Biliary decompression was initially employed by surgeons and subsequently by interventional radiologists. More recently, endoscopic retrograde cholangiopancreatography has provided an alternative route for decompression of the biliary tree and preliminary data using this method are encouraging. Although there are enthusiastic proponents of various therapeutic techniques, controlled trials have not been convincing in highlighting the benefits of biliary drainage or in determining the best approach. This article reviews the literature pertaining to this complex surgical problem; an attempt has been made to balance the advantages and disadvantages of biliary decompression as palliation and/or preliminary treatment for extrahepatic biliary obstruction.

Diagnosis and management of biliary complications of laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the operation of choice for symptomatic cholelithiasis. However, this operation may result in serious biliary complications. Our aims were to review our experience with biliary complications of laparoscopic cholecystectomy and to document the mechanisms of the injuries and the techniques of managing these complications. We treated 20 patients with biliary complications of laparoscopic cholecystectomy. Symptomatic collections of bile (bilomas) were present in five patients. One of these patients underwent operative ligation of an accessory bile duct in the gallbladder bed, whereas the others had percutaneous or endoscopic therapy. In the remaining 15 patients (of whom 13 were referred from other hospitals), injuries to the major bile ducts were managed by combined radiologic, endoscopic, and operative therapies. In 10 of these patients (67%), the mechanism of injury was the misidentification of the common bile duct as the cystic duct. In 3 of 15 patients, a noncircumferential injury to the lateral aspect of the common bile duct occurred. The Bismuth levels of the remaining bile duct injuries were type I in 3, type II in 4, type III in 3, and type IV in 2. Early outcome of therapy for these bile duct injuries has been favorable. One patient was lost to follow-up, and 2 died of nonbiliary causes, whereas 12 patients are alive and well with normal serum liver enzyme levels at 4 to 19 months postoperatively (mean: 14 months). The most common cause of major bile duct injury during laparoscopic cholecystectomy is mistaking the common bile duct for the cystic duct. Most bilomas can be managed successfully with noninvasive methods. Coordinated efforts by radiologists, endoscopists, and surgeons are necessary to optimize the management of patients with major bile duct injury, suggesting that patients with biliary complications of laparoscopic cholecystectomy should be referred to specialty centers for optimal care.