Complex Post-cholecystectomy Biliary Injuries: Management with 10 Years' Experience in a Major Referral Center

Abstract

A prospective and retrospective work to evaluate management of post-cholecystectomy biliary injuries. From March 2000 to February 2010, 419 patients (224 females and 195 males) complaining of post-cholecystectomy biliary injuries were managed using surgery in 135 patients and endoscopy in 317 patients, in addition to percutaneous techniques in 32 patients. Endoscopy was very successful initial treatment of 317 patients (76%), as being less invasive, with low morbidity and mortality, and being competitive with surgery in treatment of mild/moderate biliary leakage (82%) and biliary stricture (74%). Its success increased by 2.8% and 8.3% for leakage and stricture, respectively, by addition of percutaneous techniques. However, surgery was needed for major leakage and massive stricture in 19% and 14% of cases, respectively. Surgery remains the choice in common bile duct transection, ligation, and combined injuries of stones, stricture, and leakage in 60% of cases. Bilio-enteric anastomosis was the procedure of choice, done in 76 cases, with trans-anastomotic stent in 30 cases with unhealthy or small ducts. Stricture was encountered in 5 cases (6.5%), treated by the percutaneous route in 3 cases and repeat surgery in 2 cases. The learning curve seems influential in both endoscopy and surgery. The cumulative experience increased the success of endoscopy from 60% to 95%. Also, surgery improved with decreased morbidity and mortality. Endoscopy was competitive with surgery in initial treatment of simple problems, but in major leak, ligation, transection, and complex problems, surgery plays the main treatment with its invasiveness and high morbidity and morbidity. Cumulative experience influences endoscopic and surgical treatment of such challenging problems.