This is a report on 126 prospectively registered and controlled complications in 29,695 consecutive endoscopic procedures of the lower gastrointestinal tract. The overall complication rate is 0.4%. All endoscopic procedures were performed in our institution; no referrals "from other hospitals" are included. The therapy and prognosis of occurring complications are described. Especially after therapeutic endoscopy--above all, after polypectomy--the complication rate of 0.83% is not negligible. A serious aspect is the average interval of 30 h from endoscopically caused complication to the onset of symptoms. Bleeding could be managed conservatively in 76% of cases. Nevertheless perforation and transmural burn injuries required surgical intervention in 78% of cases. The authors conclude that in the case of transmural burn an attempt at "active conservative treatment" is justified if the patient is under close surgical control, if the symptoms improve, and if there is a possibility of immediate surgery.

During 7057 conventional cholecystectomies (1972-1991), 16 bile duct injuries occurred, amounting to a risk of 0.22%. A total of 1022 laparoscopic cholecystectomies were performed without such a complication since April 1990. In a retrospective study, 64 patients (16 of our patients and 48 referrals) with an injury or stricture due to conventional cholecystectomy were investigated. In 14 of our 16 patients the injury was recognized and immediately repaired with a good long-term result of 93%, including one successful repair of a subsequent stricture. Two cases of unrecognized injury were managed by nonoperative means. The group of 48 referred patients comprised 10 early postoperative complications (21%) and 38 strictures after an "uneventful" cholecystectomy. Of the 64 total patients, 10 (16%) underwent nonoperative treatment, and 54 required surgery. The mean follow-up period after surgery was 7.4 +/- 4.9 years. Most cases (93%) were repaired by bilioenteric anastomosis (i.e., foremost hepaticojejunostomy) with an 18% restricture rate. Including second and third repairs for restricture, a total of 60 operations (14 primary and 46 secondary reconstructions) were performed without hospital mortality. A good long-term result after stricture repair was achieved in 75% of the patients, whereas 17% had a poor outcome owing to restricture or death (10% had related mortality within 10 years). The other 8% had a moderate result due to recurrent cholangitis. Thus immediate repair of a bile duct injury offers the better chance of a favorable prognosis compared to secondary stricture repair.

This report concerns 44 patients with iatrogenic injuries to the bile ducts treated at the Mannheim University Clinic from 1973 to 1987. Group A: 12 own patients with lesions of the common bile duct among 6020 operations for cholelithiasis, i.e. a risk of 0.19%. All 12 lesions were recognized during operation and immediately repaired with eventual success. Group B: 32 patients referred to us from another hospital after cholecystectomy alone or previous repair. 11 of these patients had progressive jaundice in the immediate postoperative period (1. to 9. week) due to unrecognized bile duct injury. The other 21 patients developed strictures after an uneventful postoperative course within time intervals varying from 3 months to 23 years. 72% of patients (Group B) had reconstructive surgery within two years after last operation in another hospital. We performed 47 reconstructive operations in 42 patients without hospital mortality including 5 second or third operations for recurrent stricture. Biliary-intestinal anastomosis (70%) as sutured mucosa-to-mucosa anastomosis was the most favoured method of reconstruction (30 Roux-Y hepaticojejunostomies and 3 choledochoduodenostomies). An end-to-end anastomosis was only performed in 3 cases of plain transection of the common duct. In management of high biliary strictures (type III and IV according to Bismuth's classification) preference would be given to Hepp-Couinaud's modification of hepaticojejunostomy using the left hepatic duct for a long side-to-side anastomosis. Overall morbidity amounted to 28% while the rate of relaparotomy for surgical complications was 13% (n = 6 without postoperative death). 10 patients died since reconstructive surgery, death being independent from bile duct injury in 5 cases. The injury related one-year-mortality was 4.5%. Overall stricture recurrence rate was 15% (18% for hepaticojejunostomy) with a mean follow-up of 72 months. Local infection was the most obvious cause of recurrence, thus a two stage procedure with postponement of reconstructive surgery must be recommended in case of subhepatic abscess or biliary fistula. Including second and third repairs, a good longterm result was achieved in over 80% of patients.