title: Devastating and fatal complications associated with combined vascular and bile duct injuries during cholecystectomy.
abstract: OBJECTIVE
  Multiple centers have reported on bile duct injuries after cholecystectomy, but few have reported on the impact of concomitant vascular injuries.
  
  
  METHODS
  Twenty-seven life-threatening complex injuries (CIs) (Bismuth level III, IV, or V or combined arterial-ductal injuries) were retrospectively compared with 22 noncomplex injuries (NCs) (level I or II).
  
  
  METHODS
  Tertiary referral center.
  
  
  METHODS
  The incidence and level of biliary and arterial injuries and their resulting morbidity and mortality.
  
  
  RESULTS
  Bismuth classifications of all injuries were as follows: level I in 6 patients (12%), II in 19 (39%), III in 12 (24%), IV in 8 (16%), and V in 4 (8%). Diagnosis was based on peritonitis (n = 13 [27%]), endoscopic retrograde pancreatography (n = 19 [39%]), and percutaneous transhepatic cholangiography (n = 7 [14%]). Delayed referral was more common in levels I through IV (100 days) than in level V (15 days) (P<.001). Repairs were attempted in level IV (75%), III (67%), V (25%), and II (11%). Thirteen arterial injuries (26%) occurred irrespective of ductal injury level: I (n = 1), II (n = 3), III (n = 1), IV (n = 5), and V (n = 3). There was, however, a higher incidence of repairs before referral in the CI group (59% vs 5%; P<.01), with resulting higher rates of complication (70% vs 23%; P<.01). Five deaths occurred in the CI group vs 1 in the NC group (P =.14). In univariate analysis, the presence of arterial injury vs no arterial injury was a predictor of mortality (5 [38%] of 13 patients vs 1 [3%] of 36 patients; P<.001).
  
  
  CONCLUSIONS
  Bile duct injuries after cholecystectomy can be morbid and lethal with the incidence of arterial injury grossly underestimated.
authors.affiliation: Section of Transplantation, Department of Surgery, the University of Chicago, Pritzker School of Medicine, 5841 S Maryland Ave, Chicago, IL 60637, USA. Joseph.buell@uc.edu
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Buell
authors.forename: David C
authors.initials: DC
authors.lastname: Cronin
authors.forename: Brian
authors.initials: B
authors.lastname: Funaki
authors.forename: Alan
authors.initials: A
authors.lastname: Koffron
authors.forename: Atsushi
authors.initials: A
authors.lastname: Yoshida
authors.forename: Agnes
authors.initials: A
authors.lastname: Lo
authors.forename: Jeffery
authors.initials: J
authors.lastname: Leef
authors.forename: J Michael
authors.initials: JM
authors.lastname: Millis
mesh_terms: D000328:Adult; D001652:Bile Ducts / Q000293:injuries*; D002763:Cholecystectomy / Q000009:adverse effects*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects; D005260:Female; D006499:Hepatic Artery / Q000293:injuries*; D006801:Humans; D007049:Iatrogenic Disease; D007431:Intraoperative Complications; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies