Hepaticojejunostomy with or without stent for biliary reconstruction

Twenty cases of bile duct injury or benign biliary stricture, following open or laparoscopic cholecystectomy, were included in this study. All cases were operated upon at Ahmed Maher Teaching Hospital, within the period 1999 to 2003. All the patients were subjected to a full clinical, laboratory and radiological investigations. All cases underwent operative reconstruction for their iatrogenic bile duct injuries or stricture. For the 20 cases, the procedure was hepaticojejunostomy. In 10 cases [50%] transanastomotic stents were left. The time for stenting was ranging between short-term [<4 months] in 6 cases, intermediate [4 to 9 months] in 2 cases and long-term [9 months or more] in 2 cases. No mortality was detected among our cases. Postoperative complications occurred in 35% of cases, including wound infection, pulmonary complications, and cholangitis but, all a good response to medical treatment. In the group without stents the outcome was excellent in 100% of cases, while in the group with stents it was excellent in 90% of cases and good in 10% [one case]. This case of the stent group had an attack of cholangitis during the period of follow-up, but treated by medical treatment and did not need any surgical or radiological intervention. The mean follow-up period was 16.8 [ +/- 10.2] months [ranging from 6 to 30 months]. Total bilirubin and alkaline phosphatase levels remained within the normal range during the follow-up period, except in 2 cases one from each group of patients there was mild elevation of alkaline phosphatase without any proof of restricture. Both HIDA scanning and cholangiogram for all cases remained normal till the end of follow-up period. We concluded that transanastomotic stenting is not necessary for an average patient and is not an alternative to a good technique for anastomosis with viable mucosa-to-mucosa approximation

Management of bile duct injuries

The incidence of bile duct injuries increased with the wide spread shift from open to laparoscopic cholecystectomy. The estimated incidence of major bile duct injuries, which was 0.1% to 0.3% [Strasberg et al, 1995 and Roslyn et al, 1993] during the open cholecystectomy era, has risen to an estimated 0.4% to 0.6% [Fletcher et al, 1999, Adamsen et al, 1997, and Wherry et al, 1996] for laparoscopic cholecystectomy. This increase has led to substantial patient morbidity and major financial implications [Misra et al, 2004 and Savader et al, 1997]. Proper management of iatrogenic bile duct injury is mandatory to avoid immediate or later life-threatening sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery [Tsalis et al, 2002]. A review of our experience with bile duct injuries was performed to determine the optimal management and outcomes of patients presented with biliary tract injuries. The present study included 11 patients with cystic and/or bile duct injuries. They were collected from inpatients of Ain Shams University and Specialized Hospitals in Egypt and Al Jedani Hospitals in Saudi Arabia, between August 1999 and January 2004. They were 7 females and 4 males whose age ranged from 25 to 68 years [mean 40.5]. All patients were subjected to the following: History, Clinical Examination, Laboratory investigations, Radiological investigations [Abdominal U/S. ERCP, MRCP], Preoperative Preparation, and Operative and / or nonoperative management according to the case and type of injury. A total of II patients were treated for a bile duct injury. Eight patients presented after laparoscopic cholecystectomy [72.7%] and 3 patients after open cholecystectomy [27.3%]. The majority of patients were operated on for chronic cholecystitis [72.7%]. An intra operative diagnosis of a biliary injury was determined in 4 patients [36.4%]. Two different groups of patients can be identified according to the clinical presentation and this is mainly dependent on the time interval between the procedure, the start of the first symptoms and the detection of injury. Injury detected during laparoscopic cholecystectomy [intraoperatively]: An intra operative diagnosis of a biliary injury was determined in 4 patients [36.4%]. One patient had avulsed cystic duct and three had injury of CBD. The four patients diagnosed intra operatively with bile duct injury were treated by: Roux-en-Y choledechojejunostomy in 2 cases with CBD injuries. Direct CBD repair in one patient with CBD injury, Stitching of avulsed cystic duct in one patient. Delayed identification of a bile duct injury in the postoperative period: Seven patients [63.6%] presented with jaundice, fever, biliary peritonitis, biliary fistula, vomiting, and abdominal pain. Four of them were diagnosed as ligated common bile duct and managed surgically by Roux-en-Y hepatico-jejunostomy [36.4%]. While 3 patients [27.3%] were managed by endoscopic stenting, 2 with cystic duct leakage and 1 with lacerated right hepatic duct. Morbidity occurred in 1 patient [9.1%] in the form of wound infection. And there was one mortality case [9.1%] from biliary peritonitis. Bile duct injury represents a serious life threatening problem that represents a challenge even to the experienced biliary surgeon. Early referral to specialist center gives the best chance of long term success. Patients with bile duct injury should be investigated very thoroughly by laboratory tests radiological investigations and must be managed very carefully preoperatively by correction of the anemia and hypoalbuminemia and the clotting abnormalities. The results of this study showed that surgical exploration and hepaticojejunostomy played the main role in management of patients with ligated common bile duct. Also choledechojejunostomy or direct repair of CBD injuries was the main surgical strategy for cases diagnosed intraoperatively. Meanwhile, ERCP sphincterotomy and/or stenting played a role in management of patients with cystic duct leakage