role of surgery in the management of latrogenic bile duct injuries in the era of minimally invasive techniques

ABSTRACT

The management of postoperative bile duct strictures and major bile duct injuries remains a challenge. A multidisciplinary approach is advocated for diagnosis and appropriate management. Thirty-six patients constituted the subject of this retrospective study, conducted at Ain Shams University hospitals, Menoufyia University hospitals [Egypt] and Croix Rousse University hospital [Lyon, France] in between March 1998 and March 2003. All the patients suffered bile duct injury diagnosed in the postoperative period after a hepatobiliary operation. Overall, management pursued three paths; endoscopic, radiological or surgical or a combination of the three. Intraperitoneal bile leakage whether contained as biloma or diffuse as peritonitis can be relieved by Ultrasound-guided aspiration [USGA]. Re-laparoscopy with peritoneal toilet and drainage is another alternative. Endoscopic management in the form of ERCP sphincterotomy and stent insertion is to be carried out if the leak does not resolve. Bergman type A lesions more likely resulted in biloma formation that was successfully treated by USGA in most cases. For patients with Bergman type B lesions resulting in external biliary fistula, surgical intervention is indicated to repair the underlying bile duct injury with bilio-enteric bypass. For minimally invasive techniques, the failure rate was 23.5% for the radiological approach [4/17] and 33.3% [5/15] for the endoscopic approach. Failure of the biliary-enteric bypass occurred in 7 out of 22 bypasses [31.9%] done in 16 patients. Five patients underwent multiple anastomoses. Bypass surgery was the most appropriate management adopted in the presence of complete CBD division. We may be able to draw the conclusion that the higher the lesion the less likely the Endoscopic Approach meets success. Major bile duct injuries can be managed successfully by combined surgical and radiological techniques. A minimally invasive approach could be pursued for the management of postoperative bile duct injuries as long as the general condition of the patient permits and in the absence of complete CBD division. High bile duct lesions more likely require surgical correction. Of all the bypass procedures, hepatico-jejunostomy performed under optimal conditions by an experienced surgeon yields the best results: