Iatrogenic injury to the bile duct. Who, how, where?
A. R. Moossa, A. D. Mayer and B. Stabile
Department of Surgery, University of California San Diego Medical Center 92103.
We reviewed 81 patients with bile duct injuries that occurred at
cholecystectomy and/or common bile duct exploration. Thirty-two of the
strictures were recurrent. The median follow-up was 9 years. High injuries
were inflicted during the performance of cholecystectomy while low injuries
were related to common bile duct exploration. Mitigating circumstances
appear to be as follows: (1) inadequate access, exposure, and assistance;
(2) absence of operative cholangiogram; (3) patient's obesity; and (4)
early dissection of Calot's triangle. Noncontributory factors include the
following: (1) level of training of surgeon, and (2) type of institution
where the operation was performed. Following repair, 15 patients eventually
died and 8 suffered intermittent cholangitis and/or cirrhosis. Mortality
and morbidity were related to the following: (1) level of stricture; (2)
number of previous attempts at repair; and (3) adequacy of reconstruction.
Mucosa-to-mucosa anastomosis without tension is essential for optimal
results.
