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A Refined Approach to the Repair of Postcholecystectomy Bile Duct Strictures
Francis Sutherland, MD, FRCSC;
Bernard Launois, MD, FACS;
Mihail Stanescu, MD;
Jean Pierre Campion, MD;
Yorgos Spiliopoulos, MD;
Christian Stasik, MD
Arch Surg. 1999;134:299-302.
Objective To assess the results of a refined approach to repair of postcholecystectomy bile duct strictures.
Design An 11-year retrospective review of patients who had surgical repair of bile duct strictures developing late after cholecystectomy.
Setting A major university teaching hospital in France.
Patients and Interventions During an 11-year period from 1987 to 1997, 22 patients (mean [±SD] age, 55 ± 15 years) were operated on for bile duct strictures after cholecystectomy (11 after laparoscopic surgery and 11 after open surgery). Thirteen (59%) of the 22 patients had previous repair. Most patients had episodic cholangitis (14 patients [64%]) and biochemical evidence of cholestasis (20 patients [91%]). There were 5 Bismuth type 1 strictures; 4, type 2; 7, type 3; 5, type 4; and 1, type 5. The average (±SD) time from initial surgery to repair was 6.3 ± 9.6 years. Intraoperative cholangiography was used to plan the repair in 18 patients (82%). Fifteen patients (68%) were repaired with high Hepp-Couinaud hepaticojejunostomies. The last 4 patients had the hilum exteriorized by the posterior approach to improve access.
Results There was 1 intraoperative complication (bleeding) and 4 postoperative complications (biloma, fistula, and 2 cholangitis). There were no deaths; mean (±SD) length of stay was 12.8 ± 5.8 days; and mean (±SD) follow-up was 4.8±3.3 years (range, 1-10.7 years). Three patients were reoperated on, 1 with an obstructed Roux-en-Y limb and the 2 others for incisional hernias. Eighteen patients remain well, 3 had sporadic recurrent cholangitis after surgery that resolved spontaneously, and 1 patient remains unwell requiring antibiotics to control cholangitis.
Conclusions Hepp-Couinaud hepaticojejunostomy without stenting remains a reliable repair of postcholecystectomy strictures. Intraoperative cholangiography and exteriorizing the hilum by the posterior approach are useful adjuncts to this technique.
From the Clinique Chirurgicale et Unité de Transplantation,Hôpital Pontchaillou, Rennes, France. Dr Sutherland is now with the Department of Surgery, University of Calgary, Peter Lougheed Centre, Calgary, Alberta.
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