Devastating and Fatal Complications Associated With Combined Vascular and Bile Duct Injuries During Cholecystectomy

Abstract

Hypothesis: Multiple centers have reported on bile duct injuries after cholecystectomy, but few have reported on the impact of concomitant vascular injuries. Design: Twenty-seven life-threatening complex injuries (CIs) (Bismuth level III, IV, or V or combined arterialductal injuries) were retrospectively compared with 22 noncomplex injuries (NCs) (level I or II). Setting: Tertiary referral center. Main Outcome Measures: The incidence and level of biliary and arterial injuries and their resulting morbidity and mortality. Results: Bismuth classifications of all injuries were as follows: level I in 6 patients (12%), II in 19 (39%), III in 12 (24%), IV in 8 (16%), and V in 4 (8%). Diagnosis was based on peritonitis (n = 13 [27%]), endoscopic retrograde pancreatography (n = 19 [39%]), and percutane-ous transhepatic cholangiography (n = 7 [14%]). Delayed referral was more common in levels I through IV (100 days) than in level V (15 days) (PϽ.001). Repairs were attempted in level IV (75%), III (67%), V (25%), and II (11%). Thirteen arterial injuries (26%) occurred irrespective of ductal injury level: I (n=1), II (n=3), III (n=1), IV (n=5), and V (n=3). There was, however, a higher incidence of repairs before referral in the CI group (59% vs 5%; PϽ.01), with resulting higher rates of complication (70% vs 23%; PϽ.01). Five deaths occurred in the CI group vs 1 in the NC group (P =.14). In univariate analysis, the presence of arterial injury vs no arterial injury was a predictor of mortality (5 [38%] of 13 patients vs 1 [3%] of 36 patients; PϽ.001). Conclusion: Bile duct injuries after cholecystectomy can be morbid and lethal with the incidence of arterial injury grossly underestimated.

Bile Duct Injury during Cholecystectomy Requiring Delayed Liver Transplantation: A Case Report and Literature Review

“…The long-term fate of the patients without excellent results according to the criteria proposed by Schweizer et al (1991) (normal alkaline phosphatase, freedom from cholangitis, no obstruction and/or calculi on radiological investigations) has not received adequate attention. This issue is particularly important because the mean age of the patients with biliary injury is in the 40-50 ranges, i.e., a patient group with long life expectancy (Lillemoe et al 1997;Johnson et al 2000;Loinaz et al 2001;Buell et al 2002). This case report and review of the literature suggests that liver transplantation will be a treatment modality for a selected group of patients with end-stage liver disease secondary to bile duct injury.…”

“…The hepatic vasculature and the biliary tree may be injured during cholecystectomy (Lillemoe et al 1997;Nishio et al 1999;Erkan et al 2001;Koffron et al 2001;Buell et al 2002;Bilge et al 2003). Although bile duct injury is more common, detailed studies show that "silent" concomitant arterial injury may be detected in patients with bile duct injury (Erkan et al 2001;Koffron et al 2001;Nordin et al 2001).…”

“…Biliary and hepatic vascular injuries during cholecystectomy are complex lesions, associated with high rates of morbidity and mortality (Lillemoe et al 1997;Buell et al 2002). The incidence of major bile duct injury has remained constant at the rate of 0.1-0.3% during open surgery, and 0.3-1% during laparoscopic surgery.…”

Surgical Treatment of Iatrogenic Biliary Injuries - Early Complications

“…The blood supply disturbances may be caused by injuries of the 3 o'clock and 9 o'clock axial arteries, which are the source of extrahepatic biliary tract vascularization. Injuries of the proper hepatic artery within the hepatoduodenal ligament also may be the cause of the biliary stricture (8,9). The symptoms of interruption of common bile or hepatic duct continuity usually appear within several days following the trauma procedure.…”

Management of Post-Cholecystectomy Benign Bile Duct Strictures: Review

“…In acute injuries, arterial reconstruction should be performed when the distal right hepatic artery can be exposed and can be reconstructed to prevent re-stenosis and ischemic complications. Biliary repair in this scenario is associated with a high morbidity and mortality [54][55][56][57]. In patients with delayed presentation, high anastomosis to the left duct and confluence ensures excellent long-term patency, as there is good revascularization by a robust collateral circulation via the hilar plate [48,49].…”