Role of hepatectomy in the management of bile duct injuries

Abstract

Abstract Background Laparoscopic cholecystectomy is associated with bile duct injuries of a more severe nature than open cholecystectomy. This study examined the emerging role of hepatectomy in the management of major iatrogenic bile duct injuries in the laparoscopic era. Methods This was a retrospective cohort study of patients referred to a tertiary hepatobiliary unit with bile duct injuries over a 16-year period until April 2000. Data are expressed as median (range). Results Eighty-eight patients (34 men, 54 women) were referred during this interval; their median age was 55 (19–83) years. Injuries resulted from 50 laparoscopic cholecystectomies and 35 open cholecystectomies, with three occurring during gastroduodenal procedures. Laparoscopic surgery was associated with injuries of greater severity than open cholecystectomy: Bismuth type I–II, 32 per cent versus 69 per cent for the open operation; type III–IV, 66 per cent versus 31 per cent for the open procedure (P = 0·02, χ2 test). After referral 73 patients underwent definitive surgical interventions: 57 hepaticojejunostomies, 11 revisions of hepaticojejunostomy, two orthotopic liver transplants and three right hepatectomies. Two patients had subsequent hepatectomy following initial hepaticojejunostomy. Four of the five hepatectomies were for the management of injuries perpetrated at laparoscopic cholecystectomy. Criteria necessitating hepatectomy were liver atrophy on computed tomography (80 versus 11 per cent; P = 0·0001, χ2 test) and a greater incidence of angiographically proven vascular injury (40 versus 6 per cent; P = 0·006, χ2 test); in addition, type III–IV injuries were more frequent (60 versus 42 per cent) in the hepatectomy group. There were no procedure-related deaths. The overall postoperative morbidity rate was 13 per cent. Median hospital stay was 10 days. Conclusion Major hepatectomy allows the successful and safe repair of cholecystectomy-related bile duct injuries complicated by concomitant vascular injury, unilateral lobar atrophy and destruction of the biliary confluence.