Surgical repair of iatrogenic bile duct injuries

ABSTRACT

Bile duct injury perhaps is the most fearful 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 outcome of patients who underwent immediate or late repair of iatrogenic major bile duct injuries as ligation, transection, or resection. This study included 20 patients, 18 [90 percent] after cholecystectomy [14 OC and 4 LC], and 2[10 percent] after other abdominal surgeries. Bile duct injuries were recognized immediately in 3 patients [15 percent] [2 after OC and one after LC], and 17 patients [85 percent] presented later after the primary surgery. Five patients [25 percent] to whom OC was done presented with an ongoing bile leak [2 with external leak and 3 with internal leak]. Twelve patients [60 percent] presented with obstructive jaundice [9 after OC and 3 after LC]. Open surgical repair in the form of, end-to-end, cholecystojejunostomy, choledochojejunostomy, or hepaticojejunostomy was done. End-to-end anastomosis was done for 5 cases [25 percent]. Cholecystojejunostomy was done for the 2 cases [10 percent] that presented with bile duct obstruction after other abdominal operations. Among the 20 patients in this study, the level of obstruction or injury was classified as Bismuth type 1 in 12 cases [60 percent], Bismuth type 2 in 5 cases [25 percent], and Bismuth type 3 in 3 cases [15 percent]. Bismuth 4 and 5 types were not seen among the studied cases. The 5 patients [25 percent] to whom end-to-end anastomosis was done, failure was seen in 4 of these 5 cases [80 percent] and was corrected by reexploration and repair by hepaticojejunostomy. Choledochojejunostomy and hepaticojejunostomy showed no failures, but late stricture developed on long-term follow up [3 years] in 4 cases [20 percent]. The overall success was 80 percent after revision in 4 cases to which end-to-end anastomosis was done. Major bile duct injuries after cholecystectomy and other abdominal surgeries are a considerable surgical challenge. Surgical reconstruction of the extra hepatic bile ducts induced iatrogenic injuries and strictures after cholecystectomy using hepaticojejunostomy, mucosa to mucosa repair, is associated with successful outcome and better long-term result, but end-to-end repair is followed by high rate of failure, and it is better to be avoided