Suspected biliary complications after laparoscopic and open cholecystectomy leading to endoscopic cholangiography: a retrospective comparison

Therapeutic strategies of iatrogenic portal vein injury after cholecystectomy

BACKGROUND

The incidence of vascular injury after a cholecystectomy is often underestimated. Although injuries to the portal vein are rare, they are devastating. The aim of the present study was to analyze suitable therapeutic strategies regarding portal vein injury in the absence of biliary injury.

MATERIALS AND METHODS

Eleven patients with portal vein injuries after laparoscopic or open cholecystectomy were referred to our hospital between 2004 and 2010. The clinical presentation, diagnosis, and management of patients with severe portal vein injuries were reviewed. All the patients were discharged without outstanding clinical conditions. During retrospective analysis, these patients were divided into early, middle, and late stages.

RESULTS

All the 11 patients had a portal vein and/or right hepatic artery injury, but no biliary injuries were observed. Among these patients, different management strategies were managed according to the stage of the injury. Eight patients received a direct suture at the time of injury by an experienced hepatobiliary surgeon. Two patients received thrombolytic and anticoagulation therapy after cholecystectomy, without additional surgery. One patient received a liver transplant 3 mo after the injury. After long-term follow-up, these patients had no clinical conditions.

CONCLUSIONS

Direct repair or suture is important during the early stage of portal vein injury. Conservative thrombolytic and anticoagulation therapy may serve an important role in the treatment of acute massive thrombus in portal vein injury during the middle stage. Liver transplantation is a salvage therapy that should be used during the late stage.

Subtotal Cholecystectomy versus Total Cholecystectomy in Complicated Cholecystitis

Complicated cholecystitis can make dissections around the triangle of Calot difficult with a higher risk of duct and arterial injury. We reviewed a series of patients with cholecystitis receiving either partial or subtotal cholecystectomies and compared it with total cholecystectomies with respect to complications. A retrospective chart review was performed on all subtotal cholecystectomies performed for cholecystitis at University Medical Center of El Paso from June 2004 to December 2010. A similar number of patients who had total cholecystectomies for cholecystitis were selected as a comparison group from that same time period. A total of 116 patients who had subtotal and total cholecystectomies were reviewed (58 patients in each group). There were seven postoperative complications noted in the subtotal cholecystecomy (SC) group versus 14 for the total cholecystectomy (TC) group. Three patients in the SC group had cystic duct leaks, all successfully treated by endoscopic retrograde cholangiopancreatography with biliary stenting. There were two patients who had common bile duct injuries in the TC group and none in the SC group. Two patients had duodenal injuries in the TC group. Subtotal cholecystectomy is a viable alternative to total cholecystectomy in cases of complicated cholecystitis

ERCP in the management of biliary complications after cholecystectomy

Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative biliary injury. Laparoscopic cholecystectomy, which has become the first-line surgical treatment of calculous gallbladder disease, has been associated with a 2.5-fold to fourfold increase in the incidence of postoperative bile duct injury. The biliary endoscopist can expect to see a varied spectrum of complications after cholecystectomy by either technique, including postoperative biliary strictures, bile leaks, and retained calculi in the biliary tree. Proper diagnosis and treatment are paramount in ensuring a satisfactory outcome after bile duct injury. Endoscopic retrograde cholangiopancreatography (ERCP) has become the primary modality for treatment and effectively manages most bile duct injuries.

Low incidence of retained common bile duct stones using a selective policy of biliary imaging

AIM

Biliary imaging has decreased since the advent of laparoscopic cholecystectomy. This study aimed to examine the incidence of retained common bile duct (CBD) stones, using a selective policy of biliary imaging.

METHODS

A prospective computerised database was used to study patients who underwent laparoscopic cholecystectomy by one surgeon over 36 months. Two hundred and thirty-five patients (191 female, 44 male) were operated on. Ages ranged from 15 to 82 years (mean 47 years). Follow-up periods ranged from six to 39 months (mean 23.3 months). Selection for pre-operative endoscopic retrograde cholangiopacreatogram (ERCP), intraoperative cholangiography (IOC) or neither depended on liver function tests (LFTs) and CBD diameter on ultrasound prior to surgery. If LFTs were persistently raised and/or the CBD was dilated on ultrasound, patients underwent pre-operative ERCP. If LFTs were raised, and returned to normal promptly, IOC was performed.

RESULTS

Of 235 patients, 26 had pre-operative ERCP, 62 had IOC and 157 had neither. Ten patients had both ERCP and IOC. To date, one patient (0.43%) has radiologically-proven unsuspected retained CBD stones; these were successfully treated with ERCP.

CONCLUSION

Selective biliary imaging in patients undergoing laparoscopic cholecystectomy is safe. This process identifies the majority of patients with ductal calculi and minimises the need for unnecessary ERCP and peroperative cholangiography.