title: Transition from a low: to a high-volume centre for bile duct repair: changes in technique and improved outcome.
abstract: BACKGROUND
  Improvements in bile duct injury repairs have been shown in centres with specialized surgeons. The aim of the present study was to demonstrate the temporal change in the pattern of referral, technical variation associated with repair and long-term outcome of bile duct injuries at a tertiary referral centre in Mexico City.
  
  
  METHODS
  A retrospective case note review was performed. Patients were divided into two groups: group I (GI) 1990 to 2004 and group II (GII) 2005-2008, and appropriate statistical analysis undertaken.
  
  
  RESULTS
  Over a 20-year period, 312 patients with iatrogenic bile duct injuries required surgical treatment (GI = 169, GII = 140 patients). All injuries were reconstructed using a Roux-en-Y hepaticojejunostomy. The proportion of patients who had undergone a laparoscopic cholecystectomy increased from 24% to 36% (P = 0.017) over the two time periods. In the second time period there was an increase in segment IV and V partial resections (P = 0.020), a reduction in the use of transanastomotic stents (42% to 2%, P = 0.001) and an increase in the proportion of patients requiring a neoconfluence (2% to 11%, P = 0.003). In the second time period, the number of patients requiring a hepatectomy during repair (2% to 1%, P = 0.001), a portoenterostomy (16% to 9%, P = 0.060) or a double-barrel hepatico-jejunostomy (5% to 1%, P = 0.045) significantly decreased. During follow-up, patients in the second time period had a reduction in the incidence of post-operative cholangitis (11% to 6%, P = 0.310) and the frequency of post-operative anastomotic stenoses (13% to 5%, P = 0.010). Mortality remained low throughout the series but was absent in the second group.
  
  
  CONCLUSIONS
  Changes in technique and growing experience of the multidisciplinary team improved operative and long-term results of bile duct injury repair.
authors: Instituto Nacional de Ciencias Médicas y Nutrición 'Salvador Zubirán', Mexico City, Mexico. mercadiazma@yahoo.com
authors: Miguel Ángel
authors: MÁ
authors: Mercado
authors: Bernardo
authors: B
authors: Franssen
authors: Ismael
authors: I
authors: Dominguez
authors: Juan Carlos
authors: JC
authors: Arriola-Cabrera
authors: Fernando
authors: F
authors: Ramírez-Del Val
authors: Alejandro
authors: A
authors: Elnecavé-Olaiz
authors: Rigoberto
authors: R
authors: Arámburo-García
authors: Artemio
authors: A
authors: García
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000713:Anastomosis, Roux-en-Y; D001652:Bile Ducts / Q000293:injuries / Q000601:surgery*; D001662:Biliary Tract Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002983:Clinical Competence; D005260:Female; D006498:Hepatectomy; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007049:Iatrogenic Disease; D007582:Jejunostomy; D059032:Learning Curve; D008297:Male; D008800:Mexico; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000401:mortality / Q000601:surgery*; D055815:Young Adult