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 24 February 2018

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Management of bile duct injuries after laparoscopic cholecystectomy

Although perioperative complications are frequent, nearly all can be managed nonoperatively, with early referral to a tertiary care center necessary for optimal results, finds a study in the latest Annals of Surgery.

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The widespread application of laparoscopic cholecystectomy has led to a rise in the incidence of major bile duct injuries.

Despite the frequency of these injuries and their complex management, the published literature contains few substantial reports regarding the perioperative management of bile duct injuries.

Dr Sicklick and colleagues conducted a single institution retrospective analysis of 200 patients with major bile duct injuries.

A prospective database of all patients with a bile duct injury following laparoscopic cholecystectomy was maintained from 1990 to 2003.

The team retrospectively reviewed patients' charts to analyze perioperative surgical management.

The research team reported that 3 patients died without surgery due to uncontrolled sepsis.

The team also stated that 175 patients underwent surgical repair, with a 2 % postoperative mortality and a complication rate of 43 %.

The investigators noted that over 13 years, 200 patients were treated for a major bile duct injuries following laparoscopic cholecystectomy.

The researchers also observed that patient demographics were notable for 150 women with a mean age of 46 years.

In addition, the investigative team found that 188 patients sustained their bile duct injuries at an outside hospital.

Early postoperative cholangiography revealed an anastomotic leak in 5 % of patients
Annals of Surgery

The mean interval from the time of bile duct injury to referral was 29 weeks.

The team reported that 109 patients, more than half, were referred within 1 month of their injury for acute complications including bile leak, biloma, or jaundice.

25 patients did not undergo a surgical repair at this institution and 3 patients died after delayed referral before an attempt at repair due to uncontrolled sepsis.

The researchers found that 22 patients, having intact biliary-enteric continuity, underwent successful balloon dilatation of an anastomotic stricture.

Also, a total of 175 patients underwent definitive biliary reconstruction, including 172 hepaticojejunostomies and 3 end-to-end repairs.

The investigators reported 3 deaths in the postoperative period and 75 patients that sustained at least 1 postoperative complication.

The most common complications noted by the researchers were wound infection at 8 %, cholangitis at 6 %, intraabdominal abscess/biloma at 3 % and minor biliary stent complications occurred in 6 % of patients.

The research team noted that early postoperative cholangiography revealed an anastomotic leak in 5 % of patients and extravasation at the liver dome-stent exit site in 10 % of patients.

Postoperative interventions included percutaneous abscess drainage in 9 patients and new percutaneous transhepatic cholangiography and stent placement in 4 patients.

The investigators observed that no patient required reoperation in the postoperative period and that the mean postoperative length of stay was 10 days.

The timing of operation (early, intermediate, delayed), presenting symptoms, and history of prior repair did not affect the incidence of the most common perioperative complications or length of postoperative hospital stay.

Dr Sicklick concluded, “This series represents the largest single institution experience reporting the perioperative management of bile duct injuries following laparoscopic cholecystectomy.”

”Although perioperative complications are frequent, nearly all can be managed nonoperatively.”

”Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.”

Ann Surg 2005: 241(5): 786
26 April 2005

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