Long-term results of major bile duct injury associated with laparoscopic cholecystectomy.

BACKGROUND: Major bile duct injury (MBDI) is the most serious complication associated with laparoscopic cholecystectomy (LC). This study reports on long-term outcomes and clinical factors which predicted the outcome of 25 patients with LC-associated MBDI. METHODS: Twenty-five consecutive patients receiving either primary (n = 11) or redo (n = 14) biliary reconstructive surgery at Cathay General Hospital for LC-associated MBDI were prospectively followed for 2 to 10 (mean, 4.5) years to assess their long-term outcomes. Twelve clinical factors relevant to their outcomes were analyzed. RESULTS: There was no mortality. Although the 1-year postoperative results were successful in 23 patients (92%), the mid- to long-term outcomes were successful in only 17 patients (68%). Eight patients (32%) developed biliary strictures at an average of 3.3 years postoperatively and required subsequent reoperation or biliary stenting. Statistical comparison of 12 risk factors between the successful and unsuccessful groups revealed that two were significant, namely, repair performed by a nonreferral surgeon (p = 0.02) and repair at a stage with recent active inflammation (p = 0.04). A serum alkaline phosphatase level greater than 400 IU in the sixth postoperative month was highly correlated with long-term nonsuccess (p = 0.01). CONCLUSIONS: Only 68% of patients with LC-associated MBDI who underwent reconstructive surgery at our institution had long-term success. A serum alkaline phosphatase level above 400 IU in the sixth postoperative month was predictive of nonsuccess. For better long-term results, repair should be performed by the referral surgeon at a stage without coexisting active inflammation.

Complications of laparoscopic cholecystectomy: an analysis of 200 cases.

Complications of the initial 200 cases of laparoscopic cholecystectomy (LC) at the Cathay General Hospital within a period of 11 months were reviewed from video documents of the operations and clinical records. The major complication rate was 3.5%, including one common bile duct (CBD) injury (0.5%), three retained CBD stones (1.5%), one subphrenic fluid accumulation (0.5%), one liver abscess (0.5%) and one cystic duct stump bile leakage (0.5%). All major complications were cholecystectomy-related, and only one of the seven occurred in cases of acute cholecystitis. Age and sex were not related to its occurrence. The rate of minor complications ranged from 0.5% to 10%; they were: shoulder and back pain (10%), gall bladder perforation (10%), retained stones in the abdominal cavity (5%), transient nausea and diarrhea (5%), extension of umbilical port to a mini-laparotomy (3.5%), prolonged operation time > three hours (2%), subcutaneous emphysema (1.5%), wound infection (1.5%) and prolonged ileus (0.5%). The minor complications occurred largely in patients with acute cholecystitis. The complications occurred mostly during the early period of our study, indicating a learning period phenomenon. These could have been avoided if we had had a thorough knowledge of the potential complications and had strictly followed the principles of laparoscopic surgery. We conclude that LC is safe and the complication rate is not higher than that for open cholecystectomy. Most of the complications are preventable if LC is performed by qualified biliary surgeons following strict precautions.

[Laparoscopic cholecystectomy: the first 50 patients].

Laparoscopic cholecystectomy (LC) has rapidly gained wide acceptance in the United States. The applicability, safety and efficacy of this new procedure for the treatment of cholelithiasis in Taiwan, however, needs evaluation. We performed LC in 50 out of 98 cases of cholelithiasis at Cathay General Hospital from 28 December 1990 to 28 April 1991. We found that the applicability rate was 51%. The reasons for not selecting LC in the 48 open cases were: acute and gangrenous cholecystitis (13), common bile duct stones (11), concomitant intra-abdominal malignancy (5), intrahepatic stones (5), multiple upper abdominal incisions (4), pancreatitis or pancreatic abscesses (3) and other causes (7). In the LC group, there were 44 patients with symptomatic chronic calculus cholecystitis, 3 patients with acute calculus cholecystitis and 3 patients with gall bladder polyps. The age of the patients ranged from 27 to 79. There were 14 males and 36 females. All of the patients had a detailed preoperative workup including complete liver function test and sonographic examination of the hepatobiliary system. Additional pre-operative endoscopic retrograde cholangiopancreatographies were done in 3 and operative cholangiograms were done in another 3 to confirm the absence of common bile duct stones or to delineate anatomy. Although we encountered a few problems during the operations, such as severe adhesion, bleeding, difficult dissection, CO2 leakage, difficult insufflation, or large stones, all of the 50 patients completed the LC successfully without conversion to open cholecystectomy. The average operation time was 60 minutes, ranging from 30 to 135 minutes. Drain tubes were used in 7 cases.(ABSTRACT TRUNCATED AT 250 WORDS)