Incidence and Impact of Concomitant Vascular Injuries on Repair of Post-Cholecystectomy Bile Duct Strictures

Abstract

Purpose: To study the incidence of associated vascular injuries and their effect on clinical course, intraoperative difficulty and the outcome of repair in patients with post-cholecystectomy bile duct strictures. Methods: Forty consecutive patients referred with a diagnosis of post-cholecystectomy bile duct stricture were prospectively evaluated with Magnetic Resonance Angiography (MRA) along with Magnetic Resonance Cholangiography (MRC). Strictures were classified as per Bismuth's classification and strictures at or above the primary biliary confluence were considered as high strictures. Details of index cholecystectomy, any radiological interventions and surgical repair (Roux-en-Y hepaticojejunostomy) were recorded. Patients were followed up at 6 monthly intervals with clinical examination, liver function tests, abdominal ultrasound and hepatobiliary scintigraphy. Outcome assessment was done using Mcdonald's grading. Results: Four patients in whom MRA could not be completedwere excluded. Vascular injury was present in 22 (61%) and all of them had interruption of right hepatic artery (RHA). Additionally right portal vein injury was also present in one of these patients. RHA injury was noted in 17 (65%) patients with fresh injuries and in 5 (50%) patients who had prior failed repair. Prominent hilar collaterals were demonstrated in 20 (91%) of RHA injuries. Associated hepatic arterial anomalies were noted in 12 patients. Twenty three (64%) patients had high strictures (Type ≥3). There was no significant difference in the incidence of vascular injury between high and low strictures. Thirty four patients underwent stricture repair. There was no significant difference in blood loss, need for blood transfusion and duration of surgery in patients with or without vascular injury. There was no increase in overall complications and bile leak in patients with vascular injury. At median follow-up of 6 months (range 1-24), three failures of stricture repair were encountered. There was no effect of vascular injury on stricture repair in this short duration of follow up. Attempted prior repair and secondary biliary cirrhosis were found to have significant association with failure of stricture repair. Conclusion: On prospective evaluation with MRA post-cholecystectomy bile duct injuries were found to be associated with a very high incidence of asymptomatic vascular injuries mostly injury to the right hepatic artery. Vascular injuries are not associated with increased operative difficulty or post-operative complications. On a short follow-up they also did not have any negative impact on bile duct injury repair, performed by Hepp-Couinaud approach and after allowing adequate time for inflammation to settle.Table: Table. Factors affecting outcome of stricture repair