Is there a role for endoscopic therapy as a definitive treatment for post-laparoscopic bile duct injuries?
BACKGROUND
Excellent results of surgical reconstruction of major bile duct injuries (BDIs) have been well-documented. Reports of successful definitive management of central bile duct leakage and stenoses have been reported infrequently. The aim of this study was to assess treatment and outcomes for operative and endoscopic treatment of BDI after laparoscopic cholecystectomy (LC) and define the role of endoscopy in management.


METHODS
All patients undergoing treatment for post-laparoscopic BDI from 1998 to 2007 at Mayo Clinic, Rochester, Minnesota were reviewed. Outcomes of surgical and endoscopic intervention were analyzed.


RESULTS
BDI was identified in 159 patients (mean age 51 years). Injury was recognized intraoperatively in 39 (25%) patients. Primary intervention was surgical in 59 (37%) and endoscopic in 100 (63%) patients. Class A BDIs (n = 77) were successfully treated endoscopically in 76 (99%) patients. Seven had class D BDIs; 4 were managed surgically, and 3 endoscopically. Of 66 patients with E1 to E4 BDI, 44 (67%) were initially managed surgically and 22 (33%) endoscopically. Thirteen of the latter 22 underwent sustained endoscopic therapy (median stent time 7 months), which was successful in 10 (77%). Four patients with E5 were managed surgically. Median follow-up was 45 months. Sixty-three patients underwent Roux-en-Y hepaticojejunostomy reconstruction at Mayo; 3 (5%) failed and required stenting. None required operative revision.


CONCLUSIONS
Endoscopic management of class A BDI has excellent outcomes. Although surgical management remains the preferred therapy, short-term endoscopic treatment for class E1 to E4 can optimize the patient and operative field for reconstruction. Prolonged stenting in select patients with E1 to E4 characterized by stenosis is successful in the majority.
Fatima
Javairiah
J
Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
Barton
Joshua G
JG
Grotz
Travis E
TE
Geng
Zhimin
Z
Harmsen
William S
WS
Huebner
Marianne
M
Baron
Todd H
TH
Kendrick
Michael L
ML
Donohue
John H
JH
Que
Florencia G
FG
Nagorney
David M
DM
Farnell
Michael B
MB
D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D001649:Bile Duct Diseases / Q000209:etiology / Q000601:surgery*; D001652:Bile Ducts / Q000293:injuries*; D001662:Biliary Tract Surgical Procedures; D002760:Cholangiopancreatography, Endoscopic Retrograde; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects*; D016145:Endoscopy, Digestive System; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D055815:Young Adult