Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment
L. Stewart and L. W. Way
Department of Surgery, University of California, San Francisco, USA.
OBJECTIVE: To analyze the treatment of bile duct injuries during
laparoscopic cholecystectomy to discern the factors affecting outcome.
DESIGN: An analysis of the treatment of 88 patients with laparoscopic bile
duct injuries. SETTING: A university hospital. PATIENTS: Eighty-eight
patients with major bile duct injuries following laparoscopic
cholecystectomy. MAIN OUTCOME MEASURES: Success of treatment, morbidity
rate, mortality rate, and length of illness. RESULTS: Operations to repair
bile duct injuries were unsuccessful in 27 (96%) of 28 procedures when
cholangiograms were not obtained preoperatively, and they were unsuccessful
in 69% when cholangiographic data were incomplete. In some cases, lack of
complete cholangiographic information led to an inappropriate and harmful
operation. When cholangiographic data were complete, the first repair was
successful in 16 (84%) of 19 patients. A primary end-to-end repair over a T
tube (13 patients) was unsuccessful in every case in which the duct had
been divided. Direct closure of a partial defect in the duct was successful
in four of seven patients. Fifty-four (63%) of 84 Roux-en-Y
hepaticojejunostomies were successful. Factors responsible for the
unsuccessful outcomes were the following: incomplete excision of the
scarred duct, use of nonabsorbable suture material, use of two-layer
anastomosis, and failure to eradicate subhepatic infection before the
attempted repair. Dilatation and stenting was uniformly unsuccessful as
primary treatment (three patients) and was unsuccessful in only seven of 26
patients following a previous operative repair. Patients first treated by
the primary surgeon had an average length of illness of 222 days (P <
.01). Only 17% of primary repair attempts and no secondary repair attempts
performed by the laparoscopic surgeon were successful. Patients whose first
repair was performed by tertiary care biliary surgeons had a length of
illness of 78 days (P < .01), and 45 (94%) of 48 repairs by tertiary
care biliary surgeons were successful. CONCLUSIONS: Surgeons who specialize
in the repair of bile duct injuries achieve much better results than those
with less experience. The worse results of other surgeons could be
attributed in many instances to specific correctable errors. Nonsurgical
treatment was usually unsuccessful and substantially increased the duration
of disability.
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