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BILIARY TRACT INJURIES: DIAGNOSTIC AND TREATMENT




JF Gigot , MD , PhD , Hôpital St Luc, Louvain Medical School, Brussels, Belgium
B Malassagne , MD , PhD , Hôpital Henri Mondor, Université Paris XII, Créteil, France




1. Introduction

2. Conventional cholecystectomy

3. Laparoscopic cholecystectomy

4. References


1. Introduction

Biliary tract injuries (BTIs) represent the most serious and potentially life-threatening complication of cholecystectomies ( Rossi, 1992 ; Kern, 1992 ; Strasberg, 1995 ; Woods, 1996 ).
Since the introduction of laparoscopic cholecystectomy in 1987 by Philippe Mouret ( Mouret, 1991 ) in France, an increase in these iatrogenic bile duct injuries has been observed worldwide.
Figure
Figure 1




1. Introduction

2. Conventional cholecystectomy

3. Laparoscopic cholecystectomy

4. References


2. Conventional cholecystectomy

2.1. Prevalence of BTI

During open cholecystectomies (OC), the prevalence of bile duct injuries has been estimated at only 0.1-0.2% in several national surveys ( Rosenquist, 1960 ; Bismuth, 1981a, 1981b ; Andren-Sandberg, 1985 ) and in multicenter series ( Clavien, 1992 ; Roslyn, 1993 ; Gouma, 1994 ).

Table 2.1: Incidence of biliary tract injury (BTI) during open cholecystectomy (OC)
Authors
Year of publication
Country
Number of OCs
Patients with BTI (%)
National surveys
Rosenquist
 1960
 Sweden
 21530
 43 (0.20%)
Bismuth
 1981
 France
 53637
 84 (0.16%)
Andren-Sandberg
 1985
 Sweden
 92856
 65 (0.07%)
168023
 192 (0.11%)
Multicenter series
Clavien
 1992
 USA/Switzerland
 1088
 0 (0%)
Roslyn
 1993
 USA
 42474
 91 (0.2%)
Gouma
 1994
 Netherlands
 8780
 45 (0.5%)
52342
 136 (0.25%)

2.2. Risk factors

Risk factors during OC include:
Biliary anatomical variations are encountered in 18-39% of cases ( Majeed, 1994; Martin, 1995; Ortega, 1995 ), with potentially hazardous anomalies predisposing to BTI in only 3-6%. Anomalous (aberrant) right hepatic ducts are considered to be the most dangerous type of anomaly ( Puente, 1983 ).

2.3. Type and severity of injuries

Bile duct injuries occurring during OC include:
Bismuth ( Bismuth, 1981a, 1981b ) also reported injuries involving:
  • the common bile duct in 51% of patients;
  • the common hepatic duct in 39%;
  • the right hepatic duct in 9.9%;
  • the biliary convergence in 0.7%.

Postoperative biliary strictures can be classified into 5 types according to the level where healthy biliary mucosa can be found (figure 1) ( Bismuth, 1982 ).
Type I: low common hepatic duct stricture (the hepatic stump is longer than 2 cm)
Type II: middle common hepatic duct stricture (the hepatic stump is less than 2 cm)
Type III: high stricture or hilar stricture preserving the biliary confluence
Type IV: hilar stricture with interruption of the biliary confluence
Type V: injury of an anomalous right posterior sectorial hepatic duct insertion
In two series reported by Bismuth et al . ( Bismuth, 1981a, 1981b ) and Blumgart et al . ( Blumgart, 1984; Chapman, 1995 ) respectively:
  • type I was observed in 13% and 16% of cases;
  • type II in 26% and 23% of cases;
  • type III in 38% and 37% of cases;
  • type IV in 18% and 23% of cases;
  • type V in 5% and 1% of cases.
flash
Figure 2.3

The severity of the bile duct injury found at the time of surgical repair is associated with:
  • a high percentage of previous attempted biliary repairs;
  • the presence of high biliary strictures;
  • the coexistence of intrahepatic stones, arterial lesions, liver atrophy or hypertrophy and secondary biliary cirrhosis (with portal hypertension).

Table 2.3: Complex clinical presentation in patients with bile duct strictures.

Chapman, 1995
Intrahepatic stones
44%
-
External biliary leak
12%
-
Hepatic-enteric fistulae
10%
-
Hepatic arterial injury
39%
14%
Liver atropho-hypertrophy
5%
16%
Secondary liver cirrhosis
8%
-
Portal hypertension
-
18%

There is a wide range in the reported rate of intraoperative recognition of BTI; 18% by Chapman ( Chapman, 1995 ), 25% by Pitt ( Pitt, 1982 ), 45% by Gigot ( Gigot, 1997 ), 52% by Mathisen ( Mathisen, 1987 ), 55% in the Bismuth's survey ( Bismuth, 1981a, 1981b ), 85% in the Andren-Sandberg's survey ( Andren-Sandberg, 1985 ).

2.4. Surgical management

The most frequent procedure used for biliary repair is Roux-en-Y hepaticojejunostomy ( Bismuth, 1981a, 1981b; Blumgart, 1984; Browder, 1987; Chapman, 1995 ), using the Hepp-Couinaud approach ( Hepp, 1956; Hepp, 1985 ). Attention has been given to a mucosa-to-mucosa hepato-enteric anastomosis to prevent recurrent bile duct stricture ( Bismuth, 1981a, 1981b; Hepp, 1985 ). End-to-end choledocho-choledochostomy, usually over a T-tube, is another surgical alternative provided that a microsurgical anastomosis on healthy biliary tissue is possible, there is absence of wide bile duct excision, and there is absence of any tension on the anastomosis ( Bismuth, 1981a, 1981b ).

The optimal conditions for bile duct reconstruction of BTI are reported as follows:
(a) absence of local inflammation;
(b) presence of proximal bile duct dilatation;
(c) delaying the repair for at least 2-3 months after initial bile duct injury;
(d) performance of a micro-surgical anastomosis with muco-mucosal biliary anastomosis;
(e) anastomosis on a healthy biliary mucosal.

2.5. Results of treatment

Most studies concerning bile duct injuries following open cholecystectomy focus on late clinical occurrences of biliary strictures. The operative mortality rate has decreased to less than 5% ( Pitt, 1982; Blumgart, 1984; Chapman, 1995 ). Satisfactory long-term results with biliary repair for bile duct strictures have been reported in 75% to 96% of patients in the surgical literature ( Way, 1972; Myburgh, 1993 ). However, the outcome seems to deteriorate with time, and long-term follow-up (10-15 years) is mandatory ( Bismuth, 1981a, 1981b; Blumgart, 1984; Mathisen, 1987 ).

Predictive factors affecting successful outcome after stricture repair include:
Recently, Tocchi ( Tocchi, 1996 ) showed (by multivariate statistical analysis) that the degree of biliary dilatation and the occurrence of postoperative biliary complications after the initial biliary repair were independent prognostic factors of recurrent strictures.




1. Introduction

2. Conventional cholecystectomy

3. Laparoscopic cholecystectomy

4. References


3. Laparoscopic cholecystectomy

3.1. Prevalence of BTI during laparoscopic cholecystectomy

The introduction of laparoscopic cholecystectomy (LC) was associated with a significantly increased risk of BTI.
In an American statewide survey of Connecticut ( Russel, 1996 ) which included 30,211 patients, the incidence of bile duct injury increased from 0.04% in 1989 (for open cholecystectomy) to 0.24% in 1991 (corresponding to the introduction of LC), but then decreased to 0.11% in 1993.
In a Belgian survey, the incidence of BTI was 0.5% varying from 0.35% to 1.3%, depending on the surgeon’s experience ( Gigot 1997 ).
In an Australian study, the prevalence of bile duct injuries before LC was 0.15%, increasing with introduction of LC to 0.23% in 1991-92 and to 0.29% in 1994 ( Fletcher, 1999 ).
Figure
Figure 3.1

From reported series, it would seem that the bile duct injury rate is 2.5 to 4 times higher than that with open cholecystectomy ( Shea, 1996; Adamsen, 1997; Gigot, 1997; Fletcher, 1999 ). Since more than 500,000 cholecystectomies are performed each year in United States, BTI affects about 1,500 patients per year in the U.S. alone.

Biliary tract injuries dramatically increase the total cost of surgery for symptomatic cholelithiasis. Indeed, a study from Johns Hopkins Medical Institution showed a mean sum of $51,411 (US) for all care related to BTI and stated an increased cost ranging from 4.5 to 26.0 times the cost of the procedure without complications ( Savader, 1997 ).

3.2. Risk factors

The most common cause of bile duct injury is the failure to recognize the anatomy of the triangle of Calot. This is attributed to factors inherent to the laparoscopic approach, to inadequate training of the surgeon and to local anatomical risk factors.

Inherent risk factors of the laparoscopic approach:
  • limitation of two-dimensional vision;
  • absence of manual palpation of the porta-hepatis;
  • use of a tangential and inferior approach to the common bile duct;
  • poor visualization of the operative field with increased difficulty to control significant bleeding;
  • mediocre quality of the operative equipment;
  • blind manipulation of the instruments;
  • use (or abuse) of electrocautery;
  • surgeon's level of experience with this technique ( Asbun, 1993 ).

The laparoscopic "learning curve" of the surgeon is a key contributing factor to the relatively high rates of bile duct injury ( The Southern Surgeons’ Club, 1995 ).
The Southern Surgeons’ Club series reported that 90% of BTI in a series of 8,839 LC occurred before the surgeons had performed 30 operations ( The Southern Surgeons’ Club, 1995 ). Using a statistical regression model, they calculated that the risk of BTI was 1.7% at the time of the first LC, compared to 0.57% at the time of the fiftieth LC.
Figure
Figure 3.2.a

In the Connecticut state audit reported by Orlando et al . ( Orlando 1993 ), half of the 15 reported BTIs occurred during the surgeon's first ten cases, a third between cases 11-50 and only two cases (13%) after case 50.
Deziel ( Deziel, 1993 ) found a 0.6% incidence of bile duct injury in an extensive national survey of 77,604 of LC cases, and demonstrated a significantly lower incidence at institutions where surgeons had performed more than 100 cases (0.65% versus 0.42%, p < 0.001). However, a recent report encompassing more than 10,000 cases of LC showed that, despite the decline in the BTI rate (corresponding to the “learning curve”), the rate still does return to the rate observed in open cholecystectomies ( Wherry, 1996 ).

Local anatomical risk factors are associated with BTI during LC:
Kum ( Kum, 1996 ) described a 0.2% incidence of BTI in patients operated for uncomplicated cholelithiasis compared to 5.5% in patients operated for acute cholecystitis (p = 0.005).
Russel ( Russel, 1996 ) described acute cholecystitis and gallstone pancreatitis as increasing significantly the incidence of BTI.

These local risk factors seem to be present in 15% to 35% of bile duct injuries ( Strasberg, 1995 ). Abnormal biliary anatomy, such as a short cystic duct or a cystic duct entering into the right hepatic duct are common and also may increase the incidence of BTIs ( Cates, 1993; Lee, 1993 ).
Figure
Figure 3.2.b

By multivariate analysis on 19,186 cholecystectomies ( Fletcher, 1999 ), the following independent predictive factors of BTI were determined:
  • male gender;
  • age;
  • teaching hospital;
  • laparoscopic approach;
  • cholecystectomy in the setting of complicated CL (pancreatitis, obstructive jaundice, cholangitis, acute cholecystitis);
  • surgeon’s learning curve;
  • absence of intraoperative cholangiography.
Some authors have also stressed the importance of a right hepatic arterial anomaly running parallel to the cystic duct such as an anomalous or accessory right hepatic artery ( Hugh, 1992; Scott-Conner, 1992; Ogenyk, 1994 ).
Figure
Figure 3.2.c

3.3. Type and severity

In a compiled series of 217 patients reported by specialized centers ( Asbun, 1993; Ress, 1993; Woods, 1994; Woods, 1995 ), the following types of injuries (Bismuth’s classification) were encountered:
- type I in 67 patients (31%);
- type II in 63 patients (29%);
- type III in 51 patients (23%);
- type IV in 19 patients (9%);
- and type V in 17 patients (8%).
However, in most American series, major BTIs were generally situated high in the biliary system, involving multiple proximal ducts ( Davidoff, 1992; Kern, 1992; Branum, 1993 ).
In a Connecticut statewide survey, Russel ( Russel, 1996 ) compared the type of bile duct injury in LC and OC: LC was associated with an increased number of major bile duct transection or excision (2 in 14.990 OC vs 20 in 15.221 LC (p < 0.001).
In an extensive literature review, Strasberg ( Strasberg, 1995 ) identified 270 patients from 24 published series with BTI following LC, and found that a circumferential BTI was present in 65% of the cases.
On the other hand, Gouma ( Gouma, 1994 ) found no significant difference regarding the type of injury between OC and LC.

Strasberg ( Strasberg, 1995 ) defined a new classification for bile duct injury following laparoscopic cholecystectomy.
Strasberg classification of bile duct injuries and strictures
Class A: Injury to small ducts in continuity with the biliary system, with a leak in the duct of Luschka or the cystic duct
Class B: Injury to a sectoral duct, with resultant obstruction of part of the biliary system
Class C: Injury to a sectoral duct with bile leak; bile leakage occurs from a duct not continuous with the biliary system
Class D: Lateral injury to the extrahepatic biliary ducts
flash
Figure 3.3.a

Class E1: Stricture more than 2cm from the bifurcation of the right and left bile ducts
Class E2: Stricture less than 2cm from the bifurcation of the right and left bile ducts
Class E3: Stricture at the bifurcation of the right and left bile ducts
Class E4: Stricture involving the right and left bile ducts; the left and right ducts are not continuous
Class E5: Complete occlusion of all bile ducts, including sectoral ducts ( Mayo Clinic, Rochester, Minn, 1998 ).
flash
Figure 3.3.b

In their comparative study, Gouma ( Gouma, 1994 ) found intraoperative detection of BTI in 34% of 2,932 LC and 55% of 8,780 OC, but the difference was not statistically significant.
On the other hand, a significantly higher number of cases of delayed recognition of BTI during LC was observed in Russel ( Russel, 1996 ): 0 out of 14,990 OC vs 11 out of 15,221 LC (p < 0.001).
In the Belgian survey, BTI was detected intraoperatively in 45% of LC cases ( Gigot, 1997 ).

3.4. Mechanisms of BTI

Several reports from American specialized referral centers have detailed the various mechanisms of BTI during LC ( Davidoff, 1992; Rossi, 1992; Branum, 1993; Roy, 1993; Soper, 1993 ).

The most common mechanism, often called the "classic injury", is the misidentification of the cystic duct and the common bile duct during the surgical dissection of Calot's triangle. Typically, a portion of the common bile duct is accidentally resected and injury to the right hepatic artery often occurs at this time. This “classic injury” was encountered in 67% of BTI during LC ( Soper, 1993 ).

Three variants of the classic injury have been described:
The first is a "common bile duct/cystic duct" variant ( Davidoff, 1992 ). In this injury, the common hepatic duct is misidentified, clipped and ligated. At the same time, the proximal clips are placed correctly on the cystic duct and the gallbladder is removed. This injury creates a biliary leak through the cystic duct stump.

The second variant is caused by the tenting of the common bile duct due to excessive traction on the gallbladder infundibulum ( Davidoff, 1992; Branum, 1993 ). Due to excessive traction, the common bile duct is removed between clips. Cystic duct avulsion may also be caused by the same mechanism ( Cates, 1993 ).

A third variant is an isolated right hepatic duct injury, related to its misidentification as the cystic duct, usually by anterosuperior retraction of the gallbladder and by posterior dissection ( Davidoff, 1992 ).

Simple ductal laceration with scissors or clip injury to the CBD have been observed during acute hemorrhage ( Rossi, 1992 ) or after urgent clip application ( Soper, 1993 ).
Thermal injury related to an extensive use of monopolar cautery ( Davidoff, 1992; Rossi, 1992; Voyles, 1992; Hunter, 1993 ) or laser ( Hunter, 1991; Moosa, 1992; Hunter, 1993 ) near the portal hilum, during dissection of the Calot's triangle or during attempts to stop haemorrhage, is a frequent mechanism involved in LC-induced BTI ( Hunter 1991, Davidoff 1992, Rossi 1992, Voyles 1992, Hunter 1993 ). Thermal injury could also be responsible for bile duct necrosis or late biliary stricture ( Park, 1992 ).

Schematic representation of the common mechanisms of BTI during laparoscopic cholecystectomy.
A: Classic injury: misidentification of the cystic duct and the common hepatic duct
B: Lateral clipping of the CBD
C: Traumatic avulsion the cystic duct junction
D: Tenting of the CBD
E: Instrument injury to the CBD during dissection of the triangle of Calot
F: Instrument injury to the CBD during cholecystectomy
G: Thermal injury of the CBD
H: Injury to an anomalous right hepatic duct
I: Injury to an anomalous right hepatic duct
flash
Figure 3.4

3.5. The role of intraoperative cholangiography


3.5.1. Detection
The role of intraoperative cholangiography in the prevention of BTI remains controversial ( Davidoff, 1992; Barkun, 1993; Branum, 1993; Woods, 1994; Lorimer, 1995; Olsen, 1997; Adamsen, 1997; Wright, 1998 ).
The greatest value of intraoperative cholangiography (IOC) is in the display of the biliary anatomy. For instance, accessory bile ducts can be identified on cholangiography, warning the surgeon of their presence during the dissection of the gallbladder ( Airan, 1992; Woods, 1994 ). When there is a doubt concerning the biliary anatomy, cholangiography must be performed in order to provide an anatomic "road mapping" ( Berci, 1991; Soper, 1993 ).
Figure
Figure 3.5.1

IOC will also alert the surgeons to the problem of tenting of the common bile duct during clip placement ( Clavien, 1992 ). IOC must be performed early in the procedure, after the cystic duct has been identified and prior to dividing it ( Hunter 1991; Davidoff, 1992; Hunter, 1993).
Nevertheless, BTI has been shown to occur despite the use and proper interpretation of IOC ( Branum, 1993 ).

However, there is a consensus about the ability of IOC to increase the frequency of BTI detection ( Berci, 1991; Deziel, 1993; Woods, 1994; Fletcher, 1995; Woods, 1995; Russel, 1996 ).

Woods ( Woods, 1994 ) found a BTI detection rate in 37% of the patients in whom IOC was not performed compared to 52% when IOC was performed. The difference was not statistically significant, but IOC was misinterpreted by surgeons in 16% of cases. Moreover, in the Belgian survey, a significant difference (68% vs 32%) was observed ( Gigot, 1997 ). The presence of contrast material extravasation, the lack of opacification of the proximal bile duct system and the incomplete opacification of the right posterior intrahepatic bile ducts should increase suspicion of BTI ( Soper, 1993; Woods, 1995 ).

3.5.2. Decreasing severity
Intraoperative cholangiography has been shown to play a role in decreasing the severity of BTI, with less extensive or complicated injuries being found when IOC was performed ( Rantis, 1993; Traverso, 1994; Woods, 1994; Woods, 1995 ).
Indeed, completed and correctly interpreted IOC will diagnose a lateral ductal injury caused by a supposed cystic duct incision during IOC, avoiding the occurrence of a complete transection or excision ( Woods, 1995; Rantis, 1993 ). This situation was encountered in at least 16% of all patients with correctly interpreted IOCs in the Woods et al . series ( Woods, 1995 ). In fact, Woods ( Woods, 1994; Woods 1995 ) has shown a decreased overall morbidity and mortality when IOC was utilized.

However, BTI can occur despite a normal (correctly interpreted) IOC ( Branum 1993, Woods 1994, Woods 1995) in the following cases:
(a) late injury during cholecystectomy, occurring after the performance of cholangiography
(b) the IOC is misinterpreted
(c) thermal injury due to electrocautery (leading to postoperative localized biliary necrosis or late stricture)
(d) biliary leak originating from the cystic duct after the performance of IOC and after gallbladder removal ( Woods, 1994; Woods, 1995 ).

3.5.3. Conclusion
The debate continues, but the aforementioned studies support the routine use of IOC for early detection and correction of LC-induced BTI. It may be especially important to use during the surgeon's learning curve when the risk is known to be the greatest ( Woods, 1994; Woods, 1995; Fletcher, 1999 ).

3.6. Technical considerations for preventing BTI

A meticulous operative technique in observance of strict guidelines is of utmost importance in preventing BTI:
The most important first principle is adequate exposure of the operative field.
This requires that the porta hepatis be put under tension by both upward, manual liver retraction and downward, passive retraction by the reverse Trendelenburg position ( Perissat 1989, Dubois 1990, Branum 1993, Hunter 1993 ).
Optimal visualization of the portal structures is also essential. A frontal view of the porta hepatis (similar to the one obtained with a right subcostal incision in open procedures) should be achieved with the liberal use of a 30° angle laparoscope ( Hunter, 1991; Horvarth, 1993 ).

Exposure of the triangle of Calot is critical for proper identification of the vital structures within. Experts ( Perissat, 1989; Dubois, 1990 ) have stressed the importance of a lateral traction on the gallbladder infundibulum in order to open Calot’s triangle. This places the cystic duct at a right angle to the common bile duct, thereby reducing the likelihood of misidentification.
There are several well-described techniques for achieving this goal, with certain differences between them.
In the French technique, the liver is retracted cephalad and the gallbladder infundibulum is retracted laterally to provide the necessary exposure.
In the American technique, the gallbladder fundus is retracted cephalad and laterally (to the patient’s right), placing cephalad retraction on the liver at the same time. This, in combination with posterolateral traction of the infundibulum, also provides the necessary exposure ( Hunter, 1993; Cox, 1994; Hunter, 1995 ).

It is also important to view both the dorsal and ventral aspect of Calot's triangle prior to cystic duct transection. Dissection begins at the gallbladder neck and working downwards, the cystic duct is exposed as it arises from the infundibulum ( Soper, 1993 ) facilitating identification of the cystic duct-gallbladder junction. Excessive traction of the gallbladder infundibulum should be avoided, to prevent tenting of the common bile duct and subsequent clip injury ( Davidoff, 1992; Moosa, 1992; Branum, 1993; Horvarth, 1993; Ress, 1993 ). Once again, no clip should be placed on, and no incision should be made in any structure of Calot's triangle, until the transition between the cystic duct and the gallbladder infundibulum is clearly visualized ( Hunter 1993 ). Taniguchi ( Taniguchi, 1993 ) and Ido ( Ido, 1996 ) described a "safety zone" near the gallbladder neck in Calot's triangle compared to a relative "danger zone" near the cystic duct - common bile duct junction.

Clear visualization of both the cystic duct and the CBD should be obtained during clip placement and transection of the cystic duct ( Davidoff, 1992; Asbun, 1993; Branum, 1993; Ress, 1993 ). Overuse of electrocautery must be avoided during the dissection of Calot's triangle. Intraoperative fluoroscopic cholangiography should be performed after complete dissection of all ductal structures in the triangle of Calot and before any division (thought to lead to an optimal detection of BTI) and finally, the dissection should be carried out close to the gallbladder during its removal from the liver bed ( Davidoff, 1992; Asbun, 1993; Hunter, 1993; Ress, 1993; Hunter, 1995 ).

Another important principle is a low threshold for conversion to OC, especially when the anatomy remains unclear during the surgical dissection. Conversion to laparotomy, in difficult cases involving inflammatory changes, aberrant anatomy, or excessive bleeding, is not to be considered as a failure but rather as good surgical judgement in order to ensure the patient's safety.

Findings that should increase the suspicion of a BTI and lower the threshold for immediate conversion to laparotomy include:
(a) continuous leakage of bile during the operation;
(b) "accessory" ductal or vascular structures;
(c) "large" or "multiple" cystic ducts;
(d) poorly defined biliary anatomy;
(e) extensive use of electrocautery;
(f) questionable bile duct injury on cholangiography;
(g) bleeding from the divided cystic duct stump not easily controllable;
(h) inability to identify a clear tissue plane during the gallbladder bed dissection.

3.7. Treatment


3.7.1. Intraoperative diagnosis
In case of intraoperative suspicion of BTI, a cholangiography must be performed immediately to identify the lesion. The recommended surgical strategy depends greatly on the expertise of the surgeon involved ( Stewart, 1995 ).
Strasberg’s class A to C BTIs may be treated by clipping of the transected accessory duct, provided the operative cholangiography demonstrates that the main duct system drains both lobes of the liver ( Wright, 1998 ).

In the case of a lateral tear of the common bile duct (Strasberg’s class D), a primary repair with interrupted suture may be performed as well as suturing over a T-tube.
In Strasberg’s class E, the best repair technique is hepatico-jejunostomy or Hepp-Couinaud procedure ( Hepp, 1956; Hepp, 1985 ) according to the length of the remaining CBD below the biliary convergence ( Murr, 1999 ). In some cases, a direct repair with end-to-end anastomosis is possible if biliary mucosa is preserved, well-vascularized and there is no tension on the anastomosis.

In Woods‘s reports ( Woods, 1994; Woods, 1995 ), early recognition and repair of BTI reduced the need for remedial re-operative procedures, thereby decreasing patient's morbidity. However, if the surgeon is not experienced with these surgical procedures, the best is to place a drain, close and refer the patient to a specialized center.

3.7.2. Delayed diagnosis
While all surgeons agree that injuries recognized during the operation are best treated immediately, there is no consensus on the management of injuries recognized only after operation. Many still attempt endoscopic stenting or early surgical repair in the post-laparoscopic inflammatory stage, despite the well established fact that delayed primary repair gives the best results (Bismuth, World J Surg, in press).
Figure
Figure 3.7.2

In the case of a delayed diagnosis, preoperative imaging is obtained by percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography. A precise diagnosis is crucial and all intrahepatic ducts must be visualized. The optimal timing to do biliary repair has not been clearly established.

Murr ( Murr, 1999 ) has recently reported the Mayo Clinic policy for treatment after BTI diagnosis. In the case of complete occlusion and no bile leakage, an operation can be done when bile ducts become dilated, within 2 to 3 weeks after injury. In patients with a bile leak, repair is delayed to allow duct dilatation and inflammatory recession, 3 to 6 months later. Repair is mostly performed in accordance with the Hepp procedure ( Hepp, 1956; Hepp, 1985 ) which is based on the extrahepatic portion of the left hepatic duct.

However, in certain patients with a more distal BTI (Class E1 and selected E2) and a well-vascularized and non-inflamed bile duct, repair without dissection of the hilar plate ( Murr, 1999 ) may be feasible. In patients presenting with an established stenosis following a previous surgical repair several months earlier, percutaneous dilatation may be indicated ( Lillemoe, 1997 ).

3.8. Results of treatment

Most results come from tertiary referral centers, and as such, do not give a realistic view of surgical practice in the general community ( Rantis, 1993; Solhein, 1995; Stewart, 1995; Russel, 1996; Lillemoe, 1997; Murr, 1999 ).
Most surgical series of biliary reconstruction by experts show good short-term results, ie 80% to 95% success rate ( Davidoff, 1992; Moosa, 1992; Rossi, 1992; Asbun, 1993; Branum, 1993; Rantis, 1993; Ress, 1993; Roy, 1993; Soper, 1993; Woods, 1994; Tocchi, 1996; Lillemoe, 1997; Murr, 1999 ). However, it is well known that successful outcome cannot be evaluated before a 10 to 20 year follow-up period ( Mouret, 1991; Satava, 1992; Glerup, 1995; Federle, 1981 ).

In a series by Branum ( Branum, 1993 ), a reoperation was required in 5 out of 38 patients in the short-term follow-up period. Four factors influencing success have been suggested by Stewart ( Stewart, 1995 ):
(a) intraoperative cholangiography;
(b) surgical repair rather than endoscopic dilatation;
(c) operative technique (Hepp-Couinaud procedure rather than end-to-end suture);
(d) experience of the surgeon.

Indeed, patients treated by their primary surgeons had a significantly higher number of complications than those reoperated on by specialized surgeons, particularly if the initial intraoperative cholangiography was not completely opacified. The combination of insufficient experience and incomplete opacification on cholangiography resulted in a 100% failure rate ( Stewart, 1995 ).

Finally, percutaneous dilatation of long-term strictures (ductal-to-ductal or hepato-enteric) may also be effective. This was confirmed in 64% of the cases in the series reported by Lillemoe ( Lillemoe 1997 ).




1. Introduction

2. Conventional cholecystectomy

3. Laparoscopic cholecystectomy

4. References


4. References

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