Summary
This report concerns 44 patients with iatrogenic injuries to the bile ducts treated at the Mannheim University Clinic from 1973 to 1987. Group A: 12 own patients with lesions of the common bile duct among 6020 operations for chole lithiasis, i.e. a risk of 0,19%. All 12 lesions were recognized during operation and immediately repaired with eventual success. Group B: 32 patients referred to us from another hospital after cholecystectomy alone or previous repair. 11 of these patients had progressive jaundice in the immediate postoperative period (1. to 9. week) due to unrecognized bile duct injury. The other 21 patients developed strictures after an uneventful postoperative course within time intervals varying from 3 months to 23 years. 72% of patients (Group B) had reconstructive surgery within two years after last operation in another hospital. We performed 47 reconstructive operations in 42 patients without hospital mortality including 5 second or third operations for recurrent stricture. Biliary-intestinal anastomosis (70%) as sutured mucosa-to-mucosa anastomosis was the most favoured method of reconstruction (30 Roux-Y hepaticojejunostomies and 3 choledochoduodenostomies). An end-to-end anastomosis was only performed in 3 cases of plain transection of the common duct. In management of high biliary strictures (typ III and IV according to Bismuth's classification) preference would be given to Hepp-Couinaud's modification of hepaticojejunostomy using the left hepatic duct for a long side-to-side anastomosis. Overall morbidity amounted to 28% while the rate of relaparotomy for surgical complications was 13% (n=6 without postoperative death). 10 patients died since reconstructive surgery, death being independent from bile duct injury in 5 cases. The injury related one-year-mortality was 4.5%. Overall stricture recurrence rate was 15% (18% for hepaticojejunostomy) with a mean follow-up of 72 months. Local infection was the most obvious cause of recurrence, thus a two stage procedure with postponement of reconstructive surgery must be recommended in case of subhepatic abscess or biliary fistula. Including second and third repairs, a good longterm result was achieved in over 80% of patients.
Zusammenfassung
Von 1973–1987 behandelten wir 44 Patienten mit iatrogener Schädigung der Gallenwege. Gruppe A: 12 eigene Patienten mit frischer Verletzung des D. hepatocholedochus (Verletzungsrisiko 0,19% bei 6020 Gallensteinoperationen). In allen Fällen wurden die Verletzungen intraoperativ erkannt und erfolgreich rekonstruiert. Gruppe B: 32 überwiesene Patienten mit übersehener frischer Verletzung (n=11) oder Striktur (n=21). Insgesamt führten wir bei 42 Patienten 47 Operationen (42 Erst- und 5 Zweit- bzw. Drittrekonstruktionen) ohne Hospitalletalität durch. Biliodigestive Anastomosen (30 Hepatico-Jejunostomien und 3 Choledochoduodenostomien) waren mit etwa 70% am häufigsten. Dagegen erfolgte die Rekonstruktion durch End-zu-End Anastomose nur bei 3 eigenen Fällen mit frischer Gangdurchtrennung. Hohe Strikturen vom Typ 111 und IV nach Bismuth rekonstruierten wir meist durch eine Hepatico-Jejunostomie nach Hepp-Couinaud. Die Gesamtmorbidität betrug 28%, während die Rate der ohne Hospitalletalität durchgeführten Relaparotomien bei 13% lag. Insgesamt starben 10 Patienten, wobei die Todesursache in 5 Fällen im Zusammenhang mit der Gallengangsverletzung stand. Die abhängige 1-Jahres-Letalität betrug 4,5%. Bei einer durchschnittlichen Nachbeobachtungsdauer von 6 Jahren ergab sich insgesamt eine Restenoserate von 15% (18% bei Hepatico-Jejunostomien). Einschließlich der Zweit- und Drittrekonstruktion bei Restenosen wurde bei über 80% der Patienten ein gutes Langzeitergebnis erzielt.
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Herrn Professor Dr. M. Trede zum 60. Geburtstag gewidmet
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Raute, M., Schaupp, W. Iatrogene Schäden an den Gallenwegen infolge Cholecystektomie. Langenbecks Arch Chiv 373, 345–354 (1988). https://doi.org/10.1007/BF01272553
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DOI: https://doi.org/10.1007/BF01272553