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Surgical management and outcome of bile duct injuries following cholecystectomy: a single-center experience

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Abstract

Purpose

Biliary injury is a severe complication of cholecystectomy. The Hepp–Couinaud reconstruction with the hepatic duct confluence and the left duct may offer best long-term outcome as long as the confluence remains intact (Bismuth I–III). Complex liver surgery is usually indicated in most proximal (Bismuth IV) injuries in non-cirrhotic patients. The aim of this study was to evaluate the surgical treatment and outcome of bile duct injuries managed in a referral hepatobiliary unit.

Methods

We retrospectively analyzed surgical management and outcome of biliary injuries following cholecystectomy in 35 patients (27 laparoscopic) referred to our center between June 2001 and December 2009. There was no liver cirrhosis diagnosed in any patient. High injuries (Bismuth III–IV) were found in 14 patients. Management after referral included the Hepp–Couinaud hepaticojejunostomy in 32 patients with Bismuth I–III injuries, which in four cases with biliary peritonitis was preceded by abdominal lavage and prolonged external biliary drainage. Liver transplantation was performed in two patients with Bismuth IV injuries.

Results

After median follow-up of 59 months (range, 6–102), 34 (97%) patients are alive and 32 (92%) remain in good general condition with normal liver function. One patient who had combined biliary and colonic injury died of sepsis before repair. Recurrent strictures following the Hepp–Couinaud repair developed in two (6%) patients with high injuries combined with right hepatic arterial injury.

Conclusion

The Hepp–Couinaud hepaticojejunostomy offers durable results, even after previous interventions have failed. In case of diffuse biliary peritonitis, delayed biliary reconstruction following external biliary drainage may be the best option.

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Abbreviations

CHL:

Cholecystectomy

HJ:

Hepaticojejunostomy

References

  1. Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA (1993) Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 218:129–137

    Article  PubMed  CAS  Google Scholar 

  2. Gouma DJ, Go PM (1994) Bile duct injury during laparoscopic and conventional cholecystectomy. J Am Coll Surg 178:229–233

    PubMed  CAS  Google Scholar 

  3. Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125

    PubMed  CAS  Google Scholar 

  4. Richardson MC, Bell G, Fullarton GM, and The West of Scotland Laparoscopic Cholecystectomy Audit Group (1996) Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5,913 cases. Br J Surg 83:1356–1360

    Article  PubMed  CAS  Google Scholar 

  5. Jarnagin WR, Blumgart LH (1999) Operative repair of bile duct injuries involving the hepatic duct confluence. Arch Surg 134:769–775

    Article  PubMed  CAS  Google Scholar 

  6. Alves A, Farges O, Nicolet J, Watrin T, Sauvanet A, Belghiti J (2003) Incidence and consequence of an hepatic artery injury in patients with postcholecystectomy bile duct strictures. Ann Surg 228:93–96

    Google Scholar 

  7. Northover JMA, Terblanche J (1979) A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg 66:379–384

    Article  PubMed  CAS  Google Scholar 

  8. Stapleton GN, Hickman R, Terblanche J (1998) Blood supply of the right and left hepatic ducts. Br J Surg 85:202–207

    Article  PubMed  CAS  Google Scholar 

  9. Vellar ID (1999) The blood supply of the biliary ductal system and its relevance to vasculobiliary injuries following cholecystectomy. Aust N Z J Surg 69:816–820

    Article  PubMed  CAS  Google Scholar 

  10. Hepp J, Couinaud C (1956) Approach to and use of the left hepatic duct in reparation of the common bile duct. Presse Méd 64:947–948

    PubMed  CAS  Google Scholar 

  11. Bismuth H, Majno PE (2001) Biliary stricture classification based on the principles of surgical treatment. World J Surg 25:1241–1244

    Article  PubMed  CAS  Google Scholar 

  12. Starzl TE, Hakala TR, Shaw BW Jr, Hardesty RL, Rosenthal TJ, Griffith BP, Iwatsuki S, Bahnson HT (1984) A flexible procedure for multiple cadaveric organ procurement. Surg Gynecol Obstet 158:223–230

    PubMed  CAS  Google Scholar 

  13. Cherqui D, Lauzet JY, Rotman N, Duvoux C, Dhumeaux D, Julien M, Fagniez PL (1994) Orthotopic liver transplantation with preservation of the caval and portal flows. Technique and results in 62 cases. Transplantation 58:793–796

    PubMed  CAS  Google Scholar 

  14. Terblanche J, Worthley CS, Spence RAJ, Kringe JE (1990) High or low hepaticojejunostomy for bile duct strictures? Surgery 108:828–834

    PubMed  CAS  Google Scholar 

  15. Martin RF, Rossi RL (1994) Bile duct injuries: spectrum, mechanisms of injury, and their prevention. Surg Clin North Am 74:781–803

    PubMed  CAS  Google Scholar 

  16. Connor S, Garden OJ (2006) Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 93:158–168

    Article  PubMed  CAS  Google Scholar 

  17. Mirza DF, Narsimhan KL, Ferraz Neto BH, Mayer AD, McMaster P, Buckels JAC (1997) Bile duct injury following laparoscopic cholecystectomy: referral pattern and management. Br J Surg 84:786–790

    Article  PubMed  CAS  Google Scholar 

  18. Lillemoe KD, Martin SA, Cameron JL, Yeo CJ, Talamini MA, Kaushal S, Coleman J, Venbrux AC, Savader SJ, Osterman FA, Pitt HA (1997) Major bile duct injuries during laparoscopic cholecystectomy: follow-up after combined surgical and radiologic management. Ann Surg 225:459–471

    Article  PubMed  CAS  Google Scholar 

  19. Stewart L, Way LW (1995) Bile duct injuries during laparoscopic cholecystectomy: factors that influence the results of treatment. Ann Surg 130:1123–1129

    CAS  Google Scholar 

  20. Csendes A, Diaz JC, Burdiles P, Maluenda F (1989) Late results of immediate primary end to end repair of accidental section of the common bile duct. Surg Gynecol Obstet 168:125–130

    PubMed  CAS  Google Scholar 

  21. Sutherland F, Launois B, Stanescu M, Campion JP, Spiliopoulos Y, Stastik C (1999) A refined approach to the repair of postcholecystectomy bile duct strictures. Arch Surg 134:299–302

    Article  PubMed  CAS  Google Scholar 

  22. Lillemoe KD, Melton GB, Cameron JL, Pitt HA, Campell KA, Talamini MA, Sauter PA, Coleman J, Yeo CJ (2000) Postoperative bile duct strictures: management and outcome in the 1990s. Ann Surg 232:430–441

    Article  PubMed  CAS  Google Scholar 

  23. Robinson TN, Stiegmann GV, Durham JD, Johnson SI, Wachs ME, Serra AD, Kumpe DA (2001) Management of major bile duct injury associated with laparoscopic cholecystectomy. Surg Endosc 15:1381–1385

    PubMed  CAS  Google Scholar 

  24. Murr MM, Gigot JF, Nagorney DM, Harmsen WS, Ilstrup DM, Farnell MB (1999) Long-term results of biliary reconstruction after laparoscopic bile duct injuries. Arch Surg 134:604–610

    Article  PubMed  CAS  Google Scholar 

  25. Doctor N, Dooley JS, Dick R, Watkinson A, Rolles K, Davidson BR (1998) Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy. Br J Surg 85:627–632

    Article  PubMed  CAS  Google Scholar 

  26. Johnson SR, Koehler A, Pennington LK, Hanto DW (2000) Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery 128:668–677

    Article  PubMed  CAS  Google Scholar 

  27. Gouma DJ, Obertop H (2002) Management of bile duct injuries: treatment and long-term results. Dig Surg 19:117–122

    Article  PubMed  CAS  Google Scholar 

  28. Rothlin MA, Lopfe M, Schlumpf R, Largiader F (1998) Long-term results of hepaticojejunostomy for benign lesions of the bile ducts. Am J Surg 175:22–26

    Article  PubMed  CAS  Google Scholar 

  29. Nordin A, Halme L, Makisalo H, Isoniemi H, Hockerstedt K (2002) Management and outcome of major bile duct injuries after laparoscopic cholecystectomy: from therapeutic endoscopy to liver transplantation. Liver Transplant 8:1036–1043

    Article  Google Scholar 

  30. Thomson BN, Parks RW, Madhavan KK, Garden OJ (2007) Liver resection and transplantation in the management of iatrogenic biliary injury. World J Surg 31:2363–2369

    Article  PubMed  CAS  Google Scholar 

  31. Thomson BNJ, Parks RW, Madhavan KK, Wigmore SJ, Garden OJ (2006) Early specialist repair of biliary injury. Br J Surg 93:216–220

    Article  PubMed  CAS  Google Scholar 

  32. Savader SJ, Lillemoe KD, Prescott CA, Winick AB, Venbrux AC, Lund GB, Mitchell SE, Cameron JL, Osterman FA Jr (1997) Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster. Ann Surg 225:268–273

    Article  PubMed  CAS  Google Scholar 

  33. Carroll BJ, Birth M, Phillips EH (1998) Common bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc 12:310–313

    Article  PubMed  CAS  Google Scholar 

  34. Silva MA, Coldham C, Mayer AD, Bramhall SR, Buckels JA, Mirza DF (2008) Specialist outreach service for on-table repair of iatrogenic bile duct injuries—a new kind of ‘travelling surgeon’. Ann R Coll Surg Engl 90:243–246

    Article  PubMed  CAS  Google Scholar 

  35. Bachellier P, Nakano H, Weber JC, Lemarque P, Oussoultzoglou E, Candau C, Wolf P, Jaeck D (2001) Surgical repair after bile duct and vascular injuries during laparoscopic cholecystectomy: when and how? World J Surg 25:1335–1345

    Article  PubMed  CAS  Google Scholar 

  36. Bektas H, Schrem H, Winny M, Klempnauer J (2007) Surgical treatment and outcome of iatrogenic bile duct lesions after cholecystectomy and the impact of different clinical classification systems. Br J Surg 94:1119–1127

    Article  PubMed  CAS  Google Scholar 

  37. Bismuth H (1981) How to treat a postoperative stenosis? In: Bismuth H, Lazorthes F (eds) Operative injury of the common bile duct. Paris, Masson, pp 47–107

    Google Scholar 

  38. Gupta N, Soloman H, Fairchild R, Kaminski DL (1998) Management and outcome of patients with combined bile duct and hepatic artery injuries. Arch Surg 133:176–181

    Article  PubMed  CAS  Google Scholar 

  39. Koffron A, Ferrario M, Parsons W, Nemcek A, Saker M, Abecassis M (2001) Failed primary management of iatrogenic biliary injury: incidence and significance of concomitant hepatic arterial disruption. Surgery 130:722–728

    Article  PubMed  CAS  Google Scholar 

  40. Schmidt SC, Langrehr JM, Raakow R, Klupp J, Steinmuller T, Neuhaus P (2002) Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases. Langenbeck’s Arch Surg 387:183–187

    Article  CAS  Google Scholar 

  41. Stewart L, Robinson TN, Lee CM, Liu K, Whang K, Way LW (2004) Right hepatic artery injury associated with laparoscopic bile duct injury: incidence, mechanism, and consequences. J Gastrointest Surg 8:523–531

    Article  PubMed  Google Scholar 

  42. Mays ET, Wheeler CS (1974) Demonstration of collateral arterial flow after interruption of hepatic arteries in man. N Engl J Med 290:993–996

    Article  PubMed  CAS  Google Scholar 

  43. Couinaud C (1989) Exposure of the left hepatic duct through the hilum or in the umbilical of the liver: anatomic limitations. Surgery 105:21–27

    PubMed  CAS  Google Scholar 

  44. Hochwald SN, Burke EC, Jarnagin WR, Fong Y, Blumgart LH (1999) Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma. Arch Surg 134:261–266

    Article  PubMed  CAS  Google Scholar 

  45. Strasberg SM, Picus DD, Drebin JA (2001) Results of a new strategy for reconstruction of biliary injuries having an isolated right-sided component. J Gastrointest Surg 5:266–274

    Article  PubMed  CAS  Google Scholar 

  46. Walsh RM, Henderson JM, Vogt DP, Brown N (2007) Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies. Surgery 142:450–456

    Article  PubMed  Google Scholar 

  47. Schmidt SC, Langrehr JM, Hintze RE, Neuhaus P (2004) Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Br J Surg 92:76–82

    Article  Google Scholar 

  48. Mercado MA, Chan C, Orozco H, Hinojosa CA, Podgaetz E, Ramos-Gallardo G, Galvez-Trevino R, Valdes-Villarreal M (2005) Prognostic implications of preserved bile duct confluence after iatrogenic injury. Hepatogastroenterology 52:40–44

    PubMed  Google Scholar 

  49. Laurent A, Sauvanet A, Farges O, Watrin T, Rivkine E, Belghiti J (2008) Major hepatectomy for the treatment of complex bile duct injury. Ann Surg 248:77–83

    Article  PubMed  Google Scholar 

  50. Schmidt SC, Fikatas P, Denecke T, Schumacher G, Aurich F, Neumann U, Seehofer D (2010) Hepatic resection for patients with cholecystectomy related complex bile duct injury. Eur Surg 42(2):77–82

    Article  Google Scholar 

  51. Uenishi T, Hirohashi K, Tanaka H, Fujio N, Kubo S, Kinoshita H (1999) Right hepatic lobectomy for recurrent cholangitis after bile duct and hepatic artery injury during laparoscopic cholecystectomy: report of a case. Hepatogastroenterology 46:2296–2298

    PubMed  CAS  Google Scholar 

  52. Nishio H, Kamiya J, Nagino M, Uesaka K, Kanai M, Sano T, Hiramatsu K, Nimura Y (1999) Right hepatic lobectomy for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 6:427–430

    Article  PubMed  CAS  Google Scholar 

  53. Mercado MA, Orozco H, de la Garza L, Lopez-Martinez LM, Contreras A, Guillen-Navarro E (1999) Biliary duct injury. Partial segment IV resection for intrahepatic reconstruction of biliary lesions. Arch Surg 134:1008–1010

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Hepatobiliary Surgery and Liver Transplantation, Marie Curie Hospital, ul. Arkonska 4, 71-455, Szczecin, Poland

    Jerzy Lubikowski, Mariola Post & Maciej Wójcicki

  2. Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland

    Andrzej Białek

  3. Department of Radiology, Pomeranian Medical University, Szczecin, Poland

    Janusz Kordowski

  4. Liver Unit, Pomeranian Medical University, Szczecin, Poland

    Piotr Milkiewicz & Maciej Wójcicki

Authors
  1. Jerzy Lubikowski
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  2. Mariola Post
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  6. Maciej Wójcicki
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Correspondence to Maciej Wójcicki.

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Lubikowski, J., Post, M., Białek, A. et al. Surgical management and outcome of bile duct injuries following cholecystectomy: a single-center experience. Langenbecks Arch Surg 396, 699–707 (2011). https://doi.org/10.1007/s00423-011-0745-3

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