Outcome of surgical repair of iatrogenic injuries of major bile ducts

ABSTRACT

Bile duct injury is a severe and potentially life-threatening complication of open cholecystectomy [OC] or laparoscopic cholecystectomy [LC]. The management of bile duct injuries remains a challenge for most surgeons. The purpose of this study was to evaluate the presentation, characteristics, related investigation, and outcome of patents who underwent immediate or late repair of iatrogenic major bile duct injuries [MBDI]. Twenty three patients with post-cholecystectomy [OC or LC], and postoperative abdominal surgery presented with manifestation of biliary tract strictures or injuries between January 2000 and March 2005 in Sohag university hospital were included in this study. Those patients either underwent their primary surgery in the university hospital or were referred to the university hospital after their primary surgery was performed in other hospitals in our locality. Patients were subjected to clinical examination and to the following; laboratory investigations [blood picture, blood sugar, liver function test, serum urea and creatinine], abdominal ultrasound examination, CT scan, PTC, ERCP, and MRCP in selected cases. These patients then subjected to endoscopic and/or open surgical treatment. This study included 23 patients, 21[91.3%] after cholecystectomy [14 OC and 7 LC], and 2 patients after other abdominal surgeries. Bile duct injuries were recognized immediately in 5 patients [21.7%] [2 after OC and 3 after LC], and 18 patients [78.3%] presented later after the primary surgery. Their clinical presentations were obstructive jaundice in 13 patients [56.5%], external biliary fistula in 5 patients [21.7%], and biliary collection in 3 patients [13%]. The level of obstruction or injury was classified as Bismuth type 1 in 14 cases [61%], Bismuth type 11 in 6 cases [26%], and Bismuth type III in 3 cases [13%]. Bismuth IV and V types were not recorded among the studied cases. End-to-end anastomosis was done for 5 cases [21.7%]. The 5 patients [21.7%] to whom end-to-end anastomosis was done; failure was seen in 4 of these 5 cases [80%] and was corrected by re-exploration and reaired by hepaticojejunostomy. Choledochojejunostomy and hepaticojejunostomy were performed in majority of cases and showed no failures. Cholecystojejunostomy was done for the 2 cases [8.7%] that presented with bile duct obstruction after other abdominal operations. Postoperative complications includes, minor leakage in 5 [21.8%] patients was managed conservatively. Wound sepsis was seen in 8 [34.8%] with burst abdomen occurred in 3 [13%] of them. No operative mortality encountered in our patients. Late stricture encountered on long-term follow up [3 years] in 3 cases [13%]. The overall success after repair by Roux-en-Y hepaticojejunostomy was 78.3%. Major bile duct injuries after cholecystectomy and other abdominal surgeries are a considerable surgical challenge. Surgical reconstruction using Roux-en-Y hepaticojejunostomy mucosa to mucosa repair remains the golden standard procedure of choice for treating these injuries with successful outcome and better long-term result. Early recognition and adequate treatment at socialized institutions account for the key of prognostic parameters. Finally, as always, the true key to successful treatment of these injuries remains prevention