Management and mid- to long-term results of early referred bile duct injuries during laparoscopic cholecystectomy.
OBJECTIVE
Bile duct injuries (BDI) usually need operative repair and remain as a challenge even for surgeons who specialize in hepatobiliary surgery. The objective of this study was to define the presentation, in-hospital management, and mid- to long-term outcome of BDIs during laparoscopic cholecystectomy (LC) referred to a tertiary center in their early period.


METHODS
From January 1996 to January 2006, 31 patients with BDI sustained during or after LC were treated at our institution. Patients were referred to our center from 18 community hospitals in their first 15 postoperative days. Patients' charts were retrospectively reviewed; presentation, management, and follow-up details recorded at the primary hospitals and at our institution were documented.


RESULTS
There were 5 patients with type-A and one with type-C injury, according to Strasberg classification. The remainders had a major BDI. The mean time to referral was 3.45 (median 2) days. Treatment methods chosen after referral were as follows: drainage-observation in 2 patients (6.5%), nasobiliary drainage in 4 (12.9%), endoscopic sphincterotomy plus biliary stenting in 1 (3.2%), and surgical intervention (duct-to-duct anastomosis or biliary-enteric reconstruction) in 24 patients (77.4%). Although a success rate of 83.3% was achieved in the early period, 10 patients (32.3%) had late postoperative complications (stricture and cholangitis), and of these, 3 required endoscopic stent placement, and 7 patients underwent a biliary diversion with Roux-en-Y Hepaticojejunostomy. One out of 24 patients with long-term follow-up developed biliary cirrhosis, and one patient with malignancy expired.


CONCLUSIONS
Minor BDIs can be satisfactorily treated with endoscopic interventions. Extended lateral injuries, complete CBD transsections, and long segment stenosis usually require surgical therapy. Duct-to-duct anastomosis may be an option as the first-line therapy in selected patients after early referral, though many patients eventually require a Roux-en-Y hepaticojejunostomy.
Ozturk
Erkan
E
Gulhane School of Medicine, Department of General Surgery, 06018 Etlik, Ankara, Turkey.
Can
Mehmet Fatib
MF
Yagci
Gokhan
G
Ersoz
Nail
N
Ozerhan
Ismail Hakki
IH
Harlak
Ali
A
Sahin
Mutlu
M
Cetiner
Sadettin
S
Tufan
Turgut
T
D000328:Adult; D000368:Aged; D001652:Bile Ducts / Q000293:injuries* / Q000601:surgery*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects*; D004724:Endoscopy; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012017:Referral and Consultation; D012189:Retrospective Studies; D016896:Treatment Outcome