Bile duct injury following laparoscopic cholecystectomy: a cause for continued concern.

Previous reports suggest that bile duct injuries sustained during laparoscopic cholecystectomy (lap chole) are frequently severe and related to cautery and high clip ligation. We performed a review of patients who sustained bile duct injury from lap chole since 1990 and assessed time to injury recognition, time to referral, Bismuth classification, initial and subsequent repairs, rate of recurrence, and length of follow-up. Seventy-four patients [median age 44 years, 58 of 74 female (78%)] were referred with a bile duct injury after lap chole. The level of injury was evenly divided between the bile duct bifurcation and the common hepatic duct: Bismuth III, IV, and V (40 of 74, 54%) versus Bismuth I and II (34 of 74, 46%). Concomitant hepatic arterial injury was identified in nine (12%) patients. Patients referred early after bile duct injury and requiring operative intervention underwent hepaticojejunostomy at a median of 2 days after referral. After surgical reconstruction at our center there has been an overall success rate of 89 per cent with no need for reintervention. Six (10%) of these patients have required one additional balloon dilatation at a mean follow-up of >24 months. One (2%) patient underwent biliary-enteric revision in follow-up. In patients with bile duct injury, stricture repair without delay was successful in the majority of patients treated in this series. Only one of 64 patients reconstructed at our center has required reoperation; six others have required a single balloon dilatation with subsequent good or excellent results. The majority of patients treated with operative repair at an experienced center can expect good long-term results with rare need for reintervention.

Superior vena cava syndrome.

Lung cancer is the most common cause of superior vena cava syndrome (SVCS) and requires timely recognition and management. The syndrome is rarely an oncologic emergency in the absence of tracheal compression and airway compromise. Treatment depends on the etiology of the obstructive process. Treatment should also be individualized and should not be undertaken until a diagnosis is obtained. Most patients with SVCS secondary to lung cancer can be treated with appropriately directed chemotherapy or radiotherapy. With the refinement of endovascular stents, percutaneous stenting of the SVC is being increasingly used as primary treatment modality. Thrombotic occlusion can be treated with appropriate lytic agents. In rare circumstances, surgical decompression can be performed; bypass or replacement of the SVC results in immediate improvement in the majority of cases and can be accomplished with low morbidity.