title: Is there a role for endoscopic therapy as a definitive treatment for post-laparoscopic bile duct injuries?
abstract: 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.
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: Javairiah
authors.initials: J
authors.lastname: Fatima
authors.forename: Joshua G
authors.initials: JG
authors.lastname: Barton
authors.forename: Travis E
authors.initials: TE
authors.lastname: Grotz
authors.forename: Zhimin
authors.initials: Z
authors.lastname: Geng
authors.forename: William S
authors.initials: WS
authors.lastname: Harmsen
authors.forename: Marianne
authors.initials: M
authors.lastname: Huebner
authors.forename: Todd H
authors.initials: TH
authors.lastname: Baron
authors.forename: Michael L
authors.initials: ML
authors.lastname: Kendrick
authors.forename: John H
authors.initials: JH
authors.lastname: Donohue
authors.forename: Florencia G
authors.initials: FG
authors.lastname: Que
authors.forename: David M
authors.initials: DM
authors.lastname: Nagorney
authors.forename: Michael B
authors.initials: MB
authors.lastname: Farnell
mesh_terms: 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