Forty-nine bile duct injuries, representing 0.8 per cent of 6076 laparoscopic cholecystectomies performed in the Netherlands in 1990-1992, were reviewed. The aim of the study was to classify the injuries according to severity, to identify possible risk factors contributing to the aetiology of such injuries and to correlate these with the severity of the injury. On the basis of operative findings, bile duct injuries were classified from minor (classes I-IIIa) to extensive with loss of bile duct tissue (IIIb) or localization in the liver hilum (IV). Of 49 injuries, there were 11 in class I, six in class II, ten in class IIIa, 18 in class IIIb and four in class IV. In 16 patients the injury was detected during laparoscopic cholecystectomy and the procedure converted to laparotomy. The duct injury was minor (class I-IIIa) in 14 of these 16 patients. In 20 of the 33 patients in whom identification of the injury was delayed to a second or third operation, more severe types of injury (classes IIIb and IV) were observed. Delayed detection was associated with greater severity (P = 0.002). Of eight patients with histologically proven acute cholecystitis at cholecystectomy, seven suffered severe injury (class IIIb or IV). Surgical experience with laparoscopic cholecystectomy was an important factor in the incidence of bile duct injury.
Atherectomy does not result in an improved clinical and hemodynamic outcome. Furthermore atherectomy of segmental atherosclerotic femoropopliteal disease does not result in a better patency rate than BA, and, in lesions with greater length than 2 cm, the atherectomy results are significantly worse.
Treatment of bile duct injuries after laparoscopic cholecystectomy is still under discussion. The aim of this study was to evaluate the results of end-to-end or biliodigestive anastomosis for various types of bile duct injury. Patient charts of 49 (0.81%) classified bile duct injuries from a national survey of 6076 laparoscopic cholecystectomies in The Netherlands were analyzed. The median follow-up after repair was 183 days (range 14-570 days). Statistical analysis showed that an end-to-end anastomosis was preferred by the surgeons for less severe bile duct injuries and a biliodigestive repair for more severe injuries. Three patients died owing to a delayed detected bile duct injury. Twelve bile duct strictures occurred after repair, leading to a stricture rate of 25%. The time elapsed between repair and occurrence of a stricture was 134 days (range 13-270 days). The type of repair or the severity of the bile duct injury did not determine the outcome of the repair. Histologically proved cholecystitis predisposed a stricture at the repair site. It was concluded that treatment of bile duct injuries is associated with a high stricture rate at the repair site of the anastomosis. End-to-end anastomosis is mostly successful for the less severe injury detected during laparoscopic cholecystectomy. For all other cases this repair can at least be considered a temporary internal drainage procedure. The biliodigestive anastomosis can best be considered a delayed repair after a drainage procedure has resolved the local inflammatory status.
Laparoscopic cholecystectomy was introduced into the Netherlands in the Spring of 1990. The aim of this study was to evaluate the results of the procedure in Dutch hospitals over the first 2 years to obtain some insight into its safety and efficacy in general surgical practice. A written questionnaire was sent to all 138 Dutch surgical institutions enquiring about conversion rate, complications (with emphasis on mortality rate and common bile duct injuries), operating time and hospital stay. The surgeons' opinions were also sought on possible contraindications such as previous operation, bile duct stones and cholecystitis, as were their estimations of the percentage of patients in their practice eligible for laparoscopic cholecystectomy. Data were obtained for 6076 laparoscopic cholecystectomies; the response rate was 100 per cent. Conversion to open cholecystectomy was necessary in 413 patients (6.8 per cent), mostly because of adhesions, cholecystitis, haemorrhage and unclear anatomy. Postoperative complications were reported in 260 patients (4.3 per cent). There were seven deaths (0.12 per cent) and 52 (0.86 per cent) bile duct injuries, of which 20 were recognized during laparoscopy. The mean operating time for the ten most recent patients in each institute was 70 (range 30-180) min and the mean hospital stay 4.5 (range 2-8) days. Previous lower abdominal operations were not considered to be a contraindication by 96 per cent of surgeons, whereas previous upper abdominal procedures were regarded as a contraindication by 66 per cent. After successful clearance of the bile duct at endoscopic retrograde cholangiopancreatography, only 12 per cent would perform an open procedure. Moderate cholecystitis was not considered a contraindication to laparoscopic cholecystectomy by 71 per cent of surgeons, but severe cholecystitis was a reason for open cholecystectomy for 83 per cent. In most surgical practices 70-80 per cent of patients were considered to be eligible for the laparoscopic procedure. In conclusion, laparoscopic cholecystectomy has gained rapid acceptance in the Netherlands. Although the number of bile duct injuries is high, the findings of this general survey are similar to those from highly specialized centres and match the overall results of conventional cholecystectomy.
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