title: Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy.
abstract: BACKGROUND
  Recent collective reviews have described the management and outcome of bile duct injuries during laparoscopic cholecystectomy. However, few have reported on the clinical significance of concomitant right hepatic arterial injuries. This study was conducted to examine the correlation of combined bile duct and vascular injuries and to evaluate the impact of these injuries on patient morbidity.
  
  
  METHODS
  From January 1990 to February 2002, a total of 54 patients with bile duct injuries during laparoscopic cholecystectomy were surgically treated in our institution. In 46 patients a Roux-en-Y hepaticojejunostomy was performed. Eleven patients had a concomitant vascular injury. Arterial reconstruction was performed in addition to Roux-en-Y hepaticojejunostomy in 2 patients. Eight patients underwent other surgical procedures and were not included in the statistical analysis. To evaluate the impact of vascular injuries, univariate and multivariate analysis was performed.
  
  
  RESULTS
  The rate of postoperative biliary complications was 21.7% for all patients. Univariate and multivariate analysis identified 2 risk factors for the development of biliary complications after reconstructive surgery: (1) combined bile duct and hepatic arterial injuries (6 of 11 patients [54.5%] vs 4 of 35 patients [11.4%]; P=.006) and (2) surgical repair in active peritonitis (8 of 13 patients [61.5%] vs 2 of 33 [6.1%]; P <.001). In the other, late referred patients with concomitant right hepatic arterial injury, the distal part of the artery was not exposable. After a median follow-up time of 44.6 months (range, 2 to 143.5 months) a successful outcome was achieved in 42 of 46 patients (91.3%), which included the patients who required additional endoscopic or surgical treatment after primary reconstruction.
  
  
  CONCLUSIONS
  The outcome of bile duct reconstruction is worse in patients with concomitant arterial injuries. We therefore recommend the assessment of patients with major bile duct injuries for additional vascular injuries. Further studies are needed to evaluate the importance of hepatic arterial revascularization in early recognized injuries to the long-term outcome of bile duct reconstructions.
authors.affiliation: Charité Campus Virchow Clinic, Department of General, Visceral, and Transplantation Surgery, Humboldt University of Berlin, Berlin, Germany.
authors.forename: Sven C
authors.initials: SC
authors.lastname: Schmidt
authors.forename: Ulz
authors.initials: U
authors.lastname: Settmacher
authors.forename: Jan M
authors.initials: JM
authors.lastname: Langrehr
authors.forename: P
authors.initials: P
authors.lastname: Neuhaus
mesh_terms: D000328:Adult; D000368:Aged; D000713:Anastomosis, Roux-en-Y; D001652:Bile Ducts / Q000293:injuries*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects*; D005260:Female; D006499:Hepatic Artery / Q000293:injuries*; D006801:Humans; D007582:Jejunostomy; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010538:Peritonitis / Q000601:surgery; D011171:Portoenterostomy, Hepatic; D012086:Reoperation; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000209:etiology / Q000601:surgery