Delayed reconstruction of the biliary tract after postcholecystectomy bile duct injury

ABSTRACT

Bile duct injury is one of the most serious complications of cholecystectomy. Proper diagnosis and appropriate treatment of bile duct injury are paramount in preventing life-threatening complications of cholangitis, biliary cirrhosis, portal hypertension, end stage liver disease and death. Sixty patients with postcholecystectomy bile duct injury were managed in Ain- Shams University Hospitals during the period from April 2003 till January 2007. The age of the patients ranged from 28 to 65 years [average 35 years]. The patients were assessed clinically, then by full laboratory investigations. Abdominal ultrasonography was performed as the first radiological investigation to diagnose biliary leakage and/or intrahepatic biliary radicle dilatation. Then MRCP was done to identify the nature and the type of the lesion. The initial goal of the treatment was to control sepsis by broad spectrum antibiotics, to aspirate bile by U/S or CT guided drainage, and to decompress the biliary tree by ERCP and stent insertion [in patients with distal bile duct or minor bile duct leaks 30 patients = 50%] or by PTC and stenting [in patients with proximal bile duct leaks or total occlusion of the major bile ducts 30 patients = 50%]. Patients with cystic duct or minor bile duct leaks [10 patients = 16.7%] were adequately treated by the above mentioned protocol without further complications. While patients with major bile ducts leaks or occlusion [50 patients = 83.3%] required delayed reconstruction by Roux-en-y hepaticojejunostomy after 6-8 weeks. These patients were followed up for 6-36 months [average 18 months]. 47 patients [94%] showed favorable postoperative results with no further complications. Three patients [6%] showed postoperative stricture of the anastomosis which responded to PTC pneumatic balloon dilatation. The control of sepsis and the ongoing bile leak is the primary goal of the initial management of bile duct injury. A delayed elective reconstruction of major biliary injuries following cholecystectomy, is associated with less complications compared to acute repair under suboptimal circumstances