Iatrogenic Biliary Injuries: Multidisciplinary Management in a Major Tertiary Referral Center

Abstract

Background. Iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. Better outcomes of such injuries have been shown in cases managed in a specialized center. Objective. To evaluate biliary injuries management in major referral hepatobiliary center. Patients & Methods. Four hundred seventy-two consecutive patients with postcholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist, and radiologist) at major Hepatobiliary Center in Egypt over 10-year period using endoscopy in 232 patients, percutaneous techniques in 42 patients, and surgery in 198 patients. Results. Endoscopy was very successful initial treatment of 232 patients (49%) with mild/moderate biliary leakage (68%) and biliary stricture (47%) with increased success by addition of percutaneous (Rendezvous technique) in 18 patients (3.8%). However, surgery was needed in 198 patients (42%) for major duct transection, ligation, major leakage, and massive stricture. Surgery was urgent in 62 patients and elective in 136 patients. Hepaticojejunostomy was done in most of cases with transanastomotic stents. There was one mortality after surgery due to biliary sepsis and postoperative stricture in 3 cases (1.5%) treated with percutaneous dilation and stenting. Conclusion. Management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging early referral to highly specialized hepatobiliary center.

Management of Bile Duct Injuries: A 6-year Experience in a High Volume Referral Center

“…Iatrogenic bile duct injuries are complications seen between 0.2% and 0.3% during OC 5 whereas this percentage is slightly higher between 0.3% and 1.4% with LC. Biliary duct injuries may lead to morbidities such as biliary leak, peritonitis, and biliary stenosis and mortality.…”

Minimally invasive management of biliary leakage after cholecystectomy

“…Повреждение желчных протоков считают серьезным осложнением холецистэктомии. Частота повреждений желчных протоков при выполнении холецистэктомии составляет 0,1-0,95% [1,5,7,8,12]. В США и Великобритании до 50% хирургов за свою профессиональную карьеру отмечают от 1 до 2 случаев повреждений внепеченочных желчных протоков при выполнении холецистэктомии [6].…”

“…Несмотря на большое количество публикаций, общепринятая тактика лечения отсутствует, а отдаленные результаты остаются не всегда удовлетворительными [1]. Активное развитие малоинвазивных вмешательств и высокий процент удачного их использования при лечении «свежих» повреждений внепеченочных желчных протоков позволяют в ряде случаев применять их как самостоятельный метод лечения [8,10,11,13].…”

Post-cholecystectomy bile duct injuries: when to repair?

“…7 The advantages of immediate repair of BDIs, when an experienced hepatobiliary surgeon is available, include single anesthesia, surgical procedure for the patient, decreases pain, better surgical outcome, shorter hospital stay, no need for referral of the patient to a tertiary center, also it decreases the need for prolonged external biliary drainage and associated increased risk of sepsis. 10,11 The disadvantages of such repair of BDIs are that these injuries are often complex, requiring high hepaticojejunostomy reconstruction for normal diameter (usually 3-8 mm) ducts with thin wall. 10 Advocates of late repair claim that an early repair has a higher risk of developing biliary stricture also late repair allows subsidence of inflammation in the operation field prior to definitive repair.…”

“…10,11 The disadvantages of such repair of BDIs are that these injuries are often complex, requiring high hepaticojejunostomy reconstruction for normal diameter (usually 3-8 mm) ducts with thin wall. 10 Advocates of late repair claim that an early repair has a higher risk of developing biliary stricture also late repair allows subsidence of inflammation in the operation field prior to definitive repair. [11][12][13] In the same time there may be an undiagnosed vascular injury with resultant bile duct ischemia and progressive biliary damage over time which may settled with a late repair, as the true extent of injury will become well established by the time of repair so investigations to exclude vascular injury to the liver should be done in all complex BDIs.…”