Surgical Treatment of Iatrogenic Biliary Injuries - Early Complications

Abstract

The aim of the study was the analysis of early complications following different methods of surgical treatment for iatrogenic biliary injury (IBI). Material and methods. From January 1990 to March 2005, 138 patients with iatrogenic biliary injuries were operated on in the Department of Gastrointestinal Surgery of Silesian Medical University in Katowice. The most frequent iatrogenic biliary injuries were caused by open and laparoscopic cholecystectomy. Clinical symptoms in patients included the following: pain, jaundice, pruritus, nausea, vomitus and cholangitis signs. The following diagnostic examinations were performed before surgical procedures: laboratory investigations and radiological examinations -including ultrasonography of the abdominal cavity, cholangiography, endoscopic retrograde cholangiopancreatography, computed tomography and magnetic resonance-cholangiography. The level of biliary injury was classified according to Bismuth. The following reconstruction methods were performed: Roux-Y hepaticojejunostomy in 49 patients, endto-end ductal anastomosis in 45 patients, jejunal interposition hepaticoduodenostomy in 27 patients, bile duct plastic reconstruction in 6 patients, choledochoduodenostomy in 2 patients and other methods in 8 patients.Results. The mean duration of hospitalization was 31 days. The mean duration of operation was 4.5 hours. Early complications were observed in 22 (16%) patients. The following early complications were noted: bile collection in 11 patients, intra-abdominal abscess in 4, wound infection in 13, peritonitis in 2, cholangitis in 2, eventeration in 1, pneumonia in 7 and acute circulatory insufficiency in 3 patients. Seven (5%) early re-operations were performed: 2 due to biliary-enteric anastomosis dehiscence, 1 due to eventeration, and 4 due to bile collection or intra-abdominal abscess. Three (2%) hospital deaths were noted: 1 due to due acute circulatory insufficiency, 1 due to liver necrosis and acute respiratory and circulatory insufficiency, and 1 due to biliary-enteric anastomosis dehiscence, bile collection, peritonitis, and acute circulatory and respiratory insufficiency. Conclusions. Surgical reconstructions of iatrogenic biliary injuries are procedures that require maximal precision and knowledge of different methods of reconstruction of biliary tract continuity. The choice of the method depends on the situation in the operation area. In treatment centers experienced in iatrogenic biliary injuries, early complications occur in 16% of surgical patients. Mortality does not exceed 2% of surgical patients.

Iatrogenic bile duct injuries: Etiology, diagnosis and management

“…The most frequent early complication is wound infection, which is described in 8%-17.7% [32,48,60,65] . Other complications reported in the literature are the following: bile collection, intra-abdominal abscess, biliary-enteric anastomosis dehiscence, biliary fistula, cholangitis, peritonitis, eventration, pneumonia, circulatory insufficiency, intraabdominal bleeding, sepsis, infection of the urinary tract, pneumothorax, acute pancreatitis, thrombosis and embolic complications, diarrhea, ileus and multi-organ insufficiency [18,32,42,66] .…”

“…In this surgical technique, a proximal common hepatic duct is identified and prepared and the distal common bile duct is sutured. End-to-side or end-to-end HJ is performed in a single layer using interrupted absorbable polydioxanone (PDS 4-0 or 5-0) sutures [48,49] . Most authors prefer HJ because of the lower number of postoperative anastomosis strictures.…”

“…Physiological conditions within the proximal gastrointestinal tract are changed as a result of duodenal exclusion from bile passage. An altered bile pathway is a cause of disturbances in the release of gastrointestinal hormones [48][49][50] . There is a hypothesis that in patients with HJ, the bile bypass induces gastric hypersecretion leading to a pH change secondary to altered bile synthesis and release of gastrin.…”

Long-Term Results in the Surgical Treatment of Iatrogenic Bile Duct Injuries

“…Roux-Y hepaticojejunostomy is the most frequently performed surgical reconstruction of IBDI (1,37,38). In our patients, different methods of reconstruction were performed.…”

End-to-end ductal anastomosis in biliary reconstruction: indications and limitations

“…Different biliary reconstructions have been reported in the surgical treatment of IBDI: Roux-en-Y HJ, end-to-end ductal biliary anastomosis, choledochoduodenostomy, Lahey HJ, jejunal interposition hepaticoduodenostomy, Blumgart (Hepp) anastomosis, Heinecke-Mikulicz biliary plastic reconstruction and Smith mucosal graft. 2,19,20 Hepaticojejunostomy versus end-to-end ductal anastomosis in the surgical treatment of IBDI Currently, Roux-en-Y HJ is the most common surgical reconstruction of IBDI.…”