Early Management of Operative Injuries of the Extrahepatic Biliary Tract

Abstract

Since 1980, the authors have managed 19 patients with operative injuries to their biliary tracts. Eleven patients (58%) incurred their injuries during cholecystectomies for acute cholecystitis (average age--56 years); seven patients (37%) received their injuries during elective cholecystectomies (average age--24 years); and in one patient (5%) the injury occurred during gastrectomy. In group I were eight patients in whom injuries were recognized and repaired intraoperatively during their initial operations. Seven of these patients (88%) had primary duct reanastomoses, and one patient had a choledochoduodenostomy. All healed without further surgery, and none later had cholangitis develop. In group II were 11 patients diagnosed and reoperated later after surgery (mean time until diagnosis, 12 days). Seven of these patients (64%) were managed with Roux-en-Y hepaticojejunostomies or choledochojejunostomies. Four patients had cholangitis develop after surgery: two had demonstrable anastomic stenosis and two had no stenosis. Three of these four patients (75%) who had cholangitis develop did not have stents used in their repairs. The overall mortality rate in this series of 19 patients was 11%. The major risk factors for biliary tract injury were the presence of acute cholecystitis and of anatomically small biliary ducts. For this latter reason, younger patients who had elective cholecystectomies were particularly at risk. In delayed repair, the use of internal stents appeared to be useful in preventing the later development of stenosis and/or cholangitis; however, recurrent cholangitis developed in two patients who did not have demonstrable anastomotic stenoses.

Reoperative Surgery for Postcholecystectomy Bile Duct Injuries

“…Moreover, the bile duct damage may be coupled with a vascular injury and the ischemia induced by this injury progresses over time [15], so the final stricture may be much ‘higher’ than the one originally created. It is well known that primary repairs performed for biliary injuries recognized during cholecystectomy, give the best results with minimal morbidity [8, 16]but our experience shows that if not properly executed, they are also the most prone to restricture. In a review of 18 patients who had immediate repair of the biliary injury sustained during laparoscopic cholecystectomy, the failed operative procedures resulted in progression of the biliary injury and development of biliary fibrosis and hepatic lobar atrophy [17].…”

Iatrogenic Biliary Strictures: Surgical Experience with 39 Patients

“…Transanastomotic tubes have been used by the vast majority of authors [5,8,10,13,22,23,[28][29][30][31], although some use them selectively [9,11,12]. How long tubes should be kept in place is controversial.…”

“…In general, it is recommended to maintain tubes for 3 to 6 months. In most complex cases, up to 12 months of stenting can be necessary [22,32,33]. The authors who use stents selectively consider that they are unnecessary if a tension-free anastomosis with wide stoma and good blood supply is accomplished.…”

Fascioperitoneal graft with T-tube drainage for patching bile duct defects

“…This type of injury may be complete or incomplete and the prognosis of incomplete cases is known to be more serious [9]. The junction of the cystic and common hepatic duct is reported by many authors as the most frequently injured region [9,10]. Bile duct injuries are seen in 25%-30% of the cases during operation [11,12].…”