Diagnosis and management of bile leaks following laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is now the standard of care for the elective management of gallstone disease. Recent studies have shown the morbidity of laparoscopic cholecystectomy to be similar to that of open cholecystectomy. Postoperative bile leaks have been recognized to be a troublesome problem following laparoscopic cholecystectomy. We present a retrospective review of 854 patients undergoing laparoscopic cholecystectomy at a single institution. Records were reviewed of all patients identified as having postoperative bile leaks. Between January 1990 and April 1991, we have cared for, or been referred, 15 patients with postlaparoscopic cholecystectomy bile leaks (9/854, 1.1% index patients and 6 referred). The location of bile leakage was determined to be the common bile duct (CBD) in two, cystic duct in five, and small accessory ducts located close to the gallbladder bed in the remaining eight. Most patients presented in the first week following laparoscopic cholecystectomy (mean 4.3 +/- 0.7 days, range 2-10) with worsening abdominal pain (13/13, 100%), nausea, and low-grade fever (mean 99.6 +/- 0.3 degrees F, range 96.8-102.2). Eleven of fifteen (66.7%) patients underwent technectium-99m imidodiacetic acid scanning (Tc-99m IDA) to determine the presence of a possible bile leak. All eleven scans were positive, indicating the presence of a bile leak. Thirteen patients underwent endoscopic cholangiography confirming the presence of biliary leakage (the remaining two patients underwent prompt laparotomy). Five patients were taken to the operating room for management of their leaks (two with common bile duct injuries, two cystic duct leaks, one accessory duct leak).(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of laparoscopic cholecystectomy.

As laparoscopic cholecystectomy has become more widely practiced, the full spectrum of complications associated with this technique is being realized. We have performed 283 consecutive laparoscopic cholecystectomies with no deaths and a morbidity rate of 5.3% (15 of 283 patients; six major complications, nine minor complications). Major complications included one bile duct injury requiring laparotomy and t-tube insertion and two patients with retained stones. Symptomatic bile leakage occurred in three patients (1%). Two of these bile leaks were from accessory ducts entering the gallbladder bed; the third leak was secondary to a cystic duct leak. Eight patients (2.8%) required conversion to open cholecystectomy. Minor complications included three patients with subumbilical wound infections, two patients with urinary tract infections, one patient with costochondritis after operation, and three patients with prolonged hospital stays (more than 48 hrs) caused by ileus or fever. Several patients with life-threatening complications, including two patients who ultimately died, were transferred to our care from other centers. These included two patients with common duct injuries combined with duodenal perforations (one of whom died), one patient with a complete common duct transection, one patient with major common hepatic duct injury, and two patients with further instances of bile leakage. Laparoscopic cholecystectomy can be performed safely, and it can be associated with life-threatening complications. Prevention of complications is dependent on proper patient selection, meticulous technique, and an accepting attitude toward conversion to "open" cholecystectomy.

The use of endoscopy to treat bronchobiliary fistula caused by choledocholithiasis.

Bronchobiliary fistula is a rare disorder consisting of the formation of a passageway between the biliary ducts and the bronchial tree. We describe an 87-yr-old woman who had a bronchobiliary fistula secondary to obstruction caused by multiple common bile duct stones. The diagnosis was confirmed by the presence of bile in the sputum and transhepatic cholangiography. Successful stone extraction with balloon and basket techniques and endoscopic sphincterotomy decompressed the biliary tract and was followed by healing of the bronchobiliary fistula without surgical intervention, which has heretofore been considered the only successful means of treatment.

Clinical pastoral education: seasons of a group's life.

Proposes a model of small group processes which may be used as a guide by supervisors conducting programs in Clinical Pastoral Education. Outlines and discusses structures in a group's life--early life, mid-life, late life, and transitional phases--and notes the characteristic behavior of group members in each phase. Proposes ways of leadership functions throughout the life of the small group, illustrating with vignettes.