Iatrogenic Bile Duct Injury Research Articles

Concomitant vascular injuries associated with post-cholecystectomy iatrogenic bile duct injuries: incidence and management in a high volume center

Aims: Concomitant vascular injury with post cholecystectomy bile duct injury is possible. It is considered as an increasing finding during repair. Thus, assessment of those injuries is crucial for defining the optimal surgical management. Methods: One hundred and thirty patients were managed surgically for post cholecystectomy bile duct injury between January 2010 and December 2014 in the department of HPB surgery, National Liver Institute, Menoufiya University in Egypt. Patient's records were revised including preoperative, intraoperative and postoperative data. Follow up visits were also revised. Vascular injury was identified intra-operatively at the beginning of the study while, later, all patients were carried out Computed Topographic hepatic angiography. Results: Twenty eight patients had concomitant vascular injury. Majority were females (75%) with mean age 35years (range, 30–50years). Most of the injuries were post open cholecystectomy (71%). All the patients had right hepatic artery injury while seven had added right portal vein injury. Fifteen patients had right hepatectomy and left hepatico-jejunostomy (53%). Three patients died (11%) due to sepsis and multi-organ failure. The remaining patients had conventional hepatico-jejunostomy. Conclusions: Assessment of vascular injury is an important part in the management of patients with bile duct injuries. Isolated arterial or combined portal injuries may lead to hepatectomy while mortality occurred due to cholangitic abscesses, severe cholangitis with subsequent sepsis.

Concomitant vascular injuries associated with post-cholecystectomy iatrogenic bile duct injuries: incidence and management in a high volume center

Concomitant vascular injuries associated with post-cholecystectomy iatrogenic bile duct injuries: incidence and management in a high volume center

Early laparoscopic primary repair of an iatrogenic bile duct injury during laparoscopic cholecystectomy

Early laparoscopic primary repair of an iatrogenic bile duct injury during laparoscopic cholecystectomy

Management of iatrogenic bile duct injuries: Multiple logistic regression analysis for predictive factors effective on morbidity and mortality

Management of iatrogenic bile duct injuries: Multiple logistic regression analysis for predictive factors effective on morbidity and mortality

Non-operative management of iatrogenic bile duct injury results in impaired quality of life – a systematic review

Non-operative management of iatrogenic bile duct injury results in impaired quality of life – a systematic review

Diagnosis and treatment of patients with bile duct injury after laparoscopic cholecystectomy

Objective To study the role of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating iatrogenic bile duct injury after laparoscopic cholecystectomy (LC). Methods A retrospective study was conducted on 45 patients with iatrogenic bile duct injury after LC who were investigated and treated by ERCP from December 2002 to August 2015. Results Using the Strasberg-Bismuth classification, there were 14 patients with type A and 4 with type C who were managed successfully using endoscopic nasobiliary drainage (ENBD) and interventional ultrasound abdominal localized puncture and drainage; 7 patients with type D were managed successfully using endoscopic sphincterotomy (EST) and endoscopic retrograde biliary drainage (ERBD). For the 5 patients with type EⅠand 3 patients with type EⅡ who were treated by EST and ERBD, one patient who had common bile duct transection required cholangioenteric Roux-en-Y anastomosis. For the 6 patients with type EⅢ and 6 patients with type EⅣ who were treated by EST and ERBD, a patient required a cholangioenteric Roux-en-Y anastomosis to achieve good results. Conclusions When iatrogenic bile duct injury is suspected after LC, correct assessment with ERCP should be taken immediately. ERCP when combined with ENBD and (or) ERBD could reduce bile duct pressure and dilate stenotic bile ducts to avoid further operation. Key words: Laparoscopic cholecystectomy; Bile duct injury; Endoscopic retrograde cholangio-pancreatography; Stasberg-Bismuth classification

Prognostication of Learning Curve on Surgical Management of Vasculobiliary Injuries after Cholecystectomy.

Background. Concomitant vascular injury might adversely impact outcomes after iatrogenic bile duct injury (IBDI). Whether a new HPB center should embark upon repair of complex biliary injuries with associated vascular injuries during learning curve is unknown. The objective of this study was to determine outcome of surgical management of IBDI with and without vascular injuries in a new HPB center during its learning curve. Methods. We retrospectively reviewed patients who underwent surgical management of IBDI at our center. A total of 39 patients were included. Patients without (Group 1) and with vascular injuries (Group 2) were compared. Outcome was defined as 90-day morbidity and mortality. Results. Median age was 39 (20–80) years. There were 10 (25.6%) vascular injuries. E2 injuries were associated significantly with high frequency of vascular injuries (66% versus 15.1%) (P = 0.01). Right hepatectomy was performed in three patients. Out of these, two had a right hepatic duct stricture and one patient had combined right arterial and portal venous injury. The number of patients who developed postoperative complications was not significantly different between the two groups (11.1% versus 23.4%) (P = 0.6). Conclusion. Learning curve is not a negative prognostic variable in the surgical management of iatrogenic vasculobiliary injuries after cholecystectomy.

Iatrogenic bile duct injury: A retrospective analysis of short- and long-term outcomes after surgical repair

Background: Iatrogenic bile duct injuries (IBDIs) remain an important problem in gastrointestinal surgery and represent a big challenge for surgeons. Aim: To review the management of IBDI and describe short- and long-term postoperative complications of surgical repair at our tertiary referral institute. Patients and Methods: This was a retrospective review of the medical record of all patients referred for the management of IBDIs between January 2005 and January 2015. One hundred patients formed the study cohort. Preoperative data including patient demographics, mechanism of injury, operative details, and postoperative outcomes were extracted. Research Ethics Board approval was obtained. Results: There were 36 men and 64 women, with a mean age 45.4 ΁ 11.5 years. Open cholecystectomy was the most common procedure in 61 patients, whereas laparoscopic surgery was the primary treatment in 39 patients. Twenty-nine patients treated by nonsurgical management in the form of endoscopic retrograde cholangiopancreatography (ERCP) and stenting and percutaneous abdominal drainage. Seventy patients underwent operative surgery in the form of Roux-en-Y H.J, and T-tube insertion in the common bile duct in two cases. Short-term complications encountered in 15 (20.8%) cases, with a significant correlation with a previous ERCP intervention (P = 0.047). Long-term complications encountered in 12 (16.6%) patients, with a significant relation with the intermediate timing (within 2 weeks) of repair (P = 0.037). Conclusions: Prompt diagnosis of the type and grade of injury is mandatory before deciding management. Intermediate time for surgical intervention was significantly related to stricture complications. ERCP should be done only in cases that can benefit from conservative management (Strasberg from A-D) as the incidence of postoperative complication is high after surgical repair.

Our Clinical Experience in Iatrogenic and Traumatic Bile Duct Injury: A Retrospective Analysis / Iyatrojenik ve Travmatik Safra Yolu Yaralanmalarindaki Klinik Deneyimlerimiz: Bir Retrospektif Analiz

Background: The purpose of this study is to present our experience of diagnosis, clinical course, treatment and outcome in iatrogenic and traumatic bile duct injury. Methods: Sixteen patients, who were treated due to iatrogenic and traumatic bile duct injury between June 2009 and October 2014 at Inonu Universty, were analysed retrospectively. Result: Of the sixteen patients with bile duct injury, 4 (%25) were males and 12 (%75) were females. 3 (%18.75) of the bile duct injuries occured due to trauma and 13(%81.25) occurred due to laparoscopic cholecystectomy. 2 (%12.5) patients were taken to emergency surgery due to trauma in our center. 14 (%87.5) patients were operated previously in other clinics and referred to our center due to complications. In the treatment of bile duct injury, 1 (%6.25) patient underwent duct to duct anastomosis while the others 15 (%93.75) were treated with Roux-en-Y hepaticojejunostomy. The average length of stay of patients in the hospital was18.9 days, and the average follow-up time was 25.6 months. Conclusion: Bile duct injury may occur with iatrogenic or traumatic causes and can cause severe morbidity and mortality. Laparoscopic cholecystectomy is still the most common

The Hepaticojejunostomy Technique with Intra-Anastomotic Stent in Biliary Diseases and Its Evolution throughout the Years: A Technical Analysis.

Roux-en-Y hepaticojejunostomy (RYHJ) is currently considered as the definitive treatment for iatrogenic bile duct injuries and the principal representative of biliary diversion procedures. This technique has met many milestones of extensive evolution, particularly the last years of concomitant technological evolution (laparoscopic/robotic approach). Anastomotic strictures and leaks, which may have deleterious effects on the survival and quality of life of a patient with biliary obstruction of any cause, made the need of the development of a safe and efficient RYHJ compulsory. The aim of this technical analysis and the juxtaposed discussions is to elucidate with the most important milestones and technical tips and tricks all aspects of a feasible and reliable RYHJ technique that is performed in our center for the last 25 years in around 400 patients.

Bile duct injuries after laparoscopic cholecystectomy: 11-year experience in a tertiary center

Incidence of bile duct injuries (BDI) is low but remains a dramatic complication after laparoscopic cholecystectomy (LC). This study aimed to assess BDI incidence and management strategies. All patients treated in our institution for BDI after LC between 2000 and 2011 were retrospectively analyzed. Patients referred from others centers were excluded. Strasberg classification was used to determine the type of lesion. Thirteen patients presented iatrogenic BDI among 2,840 consecutive cholecystectomies performed (0.46%). Four cases were classified Strasberg type A, 4 type D, and 5 type E. Injury was recognized intraoperatively in 6 cases (46%). Three of these 6 required conversions to open surgery and all but one were primary sutured on a drain; the remaining patient required immediate biliodigestive anastomosis. In 7 patients, the injury was discovered postoperatively (54%). Among them, one was treated by direct closure of a cystic leak through immediate re-laparoscopy. Six underwent initially main bile duct stenting, but 4 required delayed secondary surgery (mean time 115 days), 2 to improve bile duct drainage and 2 for biliodigestive derivation. BDI incidence remains low but management depends on the time of diagnosis. BDI are complex and require tailored treatment usually in a tertiary center for a multidisciplinary approach.

Diagnosis and Treatment of Biliary Fistulas in the Laparoscopic Era

Biliary fistulas are rare complications of gallstone. They can affect either the biliary or the gastrointestinal tract and are usually classified as primary or secondary. The primary fistulas are related to the biliary lithiasis, while the secondary ones are related to surgical complications. Laparoscopic surgery is a therapeutic option for the treatment of primary biliary fistulas. However, it could be the first responsible for the development of secondary biliary fistulas. An accurate preoperative diagnosis together with an experienced surgeon on the hepatobiliary surgery is necessary to deal with biliary fistulas. Cholecystectomy with a choledocoplasty is the most frequent treatment of primary fistulas, whereas the bile duct drainage or the endoscopic stenting is the best choice in case of minor iatrogenic bile duct injuries. Roux-en-Y hepaticojejunostomy is the extreme therapeutic option for both conditions. The sepsis, the level of the bile duct damage, and the involvement of the gastrointestinal tract increase the complexity of the operation and affect early and late results.

Severity of Acute Cholecystitis and Risk of Iatrogenic Bile Duct Injury During Cholecystectomy, a Population-Based Case-Control Study.

Acute cholecystitis is a common complication to gallstone disease. The relation between the severity of acute cholecystitis and risk of bile duct injury during cholecystectomy has not yet been addressed and is the main focus of this study. All cases with iatrogenic bile duct injury during cholecystectomy, within the Lake Mälaren region, Sweden, were identified through ICD procedure codes for biliary reconstruction within the Swedish Inpatient Register and matched to non-injured cholecystectomized controls. Information regarding perioperative variables was collected through medical record review. After review, 158 cases and 623 controls remained for analyses. Adjusted risk of bile duct injury was doubled among patients with acute cholecystitis (OR 1.97 95 % CI 1.05-3.72), whereas a mild acute cholecystitis (Tokyo grade I) did not affect the risk of bile duct injury (OR 0.96 95 % CI 0.41-2.25), a moderate (Tokyo grade II) more than doubled the risk (OR 2.41 95 % CI 1.21-4.80). Severe cholecystitis (Tokyo grade III) had a close to significant eightfold increase in risk (OR 8.43 95 % CI 0.97-72.9). The intention to use intraoperative cholangiography reduced injury risk by 52 % (OR 0.48, 95 % CI 0.29-0.81). Patients with on-going acute cholecystitis had twice the risk of sustaining a biliary lesion compared to patients without acute cholecystitis. There was a relation between the Tokyo guidelines severity grading of acute cholecystitis and injury risk and the intention to use intraoperative cholangiography halved the risk of reconstructed bile duct injury during cholecystectomy.

Iatrogenic injuries of the extrahepatic biliary system

BackgroundIatrogenic traumatic extrahepatic biliary tract injuries though rarely occur; they can lead to exceedingly morbid complications. The aim of this study was to evaluate the management strategies and outcomes of patients presented with iatrogenic bile duct injuries. MethodsThis is a retrospective study. Over 19 y, 124 patients were managed for iatrogenic biliary injuries at our institution. The data related to the etiology of biliary tract injury, symptoms of injury, laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, hospitalization time, and postoperative complications were reviewed. ResultsThe main clinical presentations were jaundice or recurrent cholangitis in 64 (51.61%) patients, followed by bile peritonitis in 34 (56.67%) and biliary fistula in 26 (43.33%) patients. Only in 23 (18.54%) cases, the injury was recognized intraoperatively. The most frequent surgical procedure was open cholecystectomy in 81 (65.32%) of 124 patients. The remaining patients were operated on laparoscopically. Good results were achieved in 99 of 101 patients with direct suture repair including hepaticojejunostomy, choledocoduodenostomy, and choledochocholedochostomy (98.02% success rate) at the first attempt. Three cases (2.97%) of biliary strictures after direct suture technique and four (3.96%) cases of postoperative mortalities were detected. The mortality rate was mostly affected by male gender, advanced age, and existence of bile peritonitis. Totally, 111 (89.52%) patients are still alive with a mean follow-up time of 78 ± 38 (2–230) mo. ConclusionsBiliary injuries can be sometimes life-threatening complications. A successful repair may provide patients with a lifelong relief from symptoms, whereas a failed repair may result in recurrent biliary obstruction, reoperation, and even death.

Longterm outcome after early repair of iatrogenic bile duct injury. A national Danish multicentre study

BackgroundThe aim of this retrospective study was to evaluate the perioperative and longterm outcome after early repair with a hepaticojejunostomy (HJ). MethodsBetween 1995 and 2010, a nationwide, retrospective multicentre study was conducted. All iatrogenic bile duct injury (BDI) sustained during a cholecystectomy and repaired with HJ in the five HepatoPancreaticoBiliary centres in Denmark were included. ResultsIn total, 139 patients had an HJ repair. The median time from the BDI to reconstruction was 5 days. A concomitant vascular injury was identified in 26 cases (19%). Postoperative morbidity was 36% and mortality was 4%. Fortytwo patients (30%) had a stricture of the HJ. The median followup time without stricture was 102 months. Nineteen out of the 42 patients with postreconstruction biliary strictures had a reHJ. Twentythree patients were managed with percutaneous transhepatic cholangiography and dilation. The overall success rate of reestablishing the biliodigestive flow approached 93%. No association was found between timing of repair, concomitant vascular injury, level of injury and stricture formation. ConclusionIn this national, unselected and consecutive cohort of patients with BDI repaired by early HJ we found a considerable risk of longterm complications (e.g. 30% stricture rate) and mortality in both the short and the longterm perspective.

Selective intraoperative cholangiography and risk of bile duct injury during cholecystectomy.

Whether intraoperative cholangiography can prevent iatrogenic bile duct injury during cholecystectomy remains controversial. Data from the national Swedish Registry for Gallstone Surgery, GallRiks (May 2005 to December 2010), were analysed for evidence of iatrogenic bile duct injury during cholecystectomy. Patient- and procedure-related risk factors for bile duct injury with a focus on the rate of intended intraoperative cholangiography were analysed using multivariable logistic regression. A total of 51 041 cholecystectomies and 747 bile duct injuries (1·5 per cent) were identified; 9008 patients (17·6 per cent) were diagnosed with acute cholecystitis. No preventive effect of intraoperative cholangiography was seen in uncomplicated gallstone disease (odds ratio (OR) 0·97, 95 per cent c.i. 0·74 to 1·25). Operating in the presence (OR 1·23, 1·03 to 1·47) or a history (OR 1·34, 1·10 to 1·64) of acute cholecystitis, and open surgery (OR 1·56, 1·26 to 1·94), were identified as significant risk factors for bile duct injury. The intention to perform intraoperative cholangiography was associated with a reduced risk of bile duct injury in patients with concurrent (OR 0·44, 0·30 to 0·63) or a history of (OR 0·59, 0·35 to 1·00) acute cholecystitis. Any proposed protective effect of intraoperative cholangiography was restricted to patients with (or a history of) acute cholecystitis.

Infundibulinės laparoskopinės cholecistektomijos metodika turi kokybiškai atsinaujinti: 18 metų 13 274 cholecistektomijų analizė, 45 jatrogeninių tulžies latakų sužalojimų aptarimas ir įvertinimas

ĮžangaAtliktas Respublikinės Vilniaus universitetinės ligoninės 1996–2013 metų tulžies pūslės chirurgijos retrospektyvusis auditas, apibendrinantis 18 metų operacijų patirtį. Svarbiausias tyrimo tikslas – apibūdinti su laparoskopine cholecistektomija (LC) siejamą tulžies latakų sužalojimo riziką.MetodaiLC metu, siekdami identifikuoti tulžies pūslės lataką ir jos arteriją, laikėmės infundibulinės metodikos principų. Jatrogeniniai tulžies latakų sužalojimai susisteminti į penkias klases pagal Bismutho ir Strasbergo klasifikaciją. Siekdami nustatyti Lietuvos gydytojų publikacijas, kuriose analizuojamos laparoskopinės cholecistektomijos komplikacijos, naudojomės http://scholar.google.co.uk paieškos sistema. Taikyti standartiniai vienfaktoriai ir daugiafaktoriai statistinės analizės būdai.RezultataiAtliktos 13 274 cholecistektomijos, iš jų LC – 11 189 kartus (84,29 %). 5241 (39,48 %) pacientas laparoskopiškai operuotas dėl ūminio, 8033 (60,52 %) – dėl lėtinio cholecistito. Tulžies latakai sužaloti 45 ligoniams, iš jų 42 sužalojimai siejami su LC. Laparoskopinės operacijos metu tulžies latakai buvo sužaloti 2,7 karto dažniau nei per atvirąją (0,38 % vs 0,14 %, ŠS = 2,6149, 95 % PI 0,8097–8,4442, z = 1,607, p = 0,1080). Operuojant pacientus dėl ūminio cholecistito, jatrogeninių tulžies latakų sužalojimų pasitaikė du kartus dažniau (0,5 % vs 0,24 %, ŠS = 2,1029, 95 % PI 1,1627–3,8034, z = 2,459, p = 0,0140). Su LC siejamų jatrogeninių tulžies latakų sužalojimų rizika yra 1:261. 2010–2013 metais jų padaugėjo. Tulžies pūslės latako nesandarumo rizika po LC yra 1:323 (tai didele dalimi atspindi specifinę technologijos problemą). Pagrindinių šoninių tulžies latakų sužalojimų rizika yra 1:247 (tai chirurginės technikos problema). E klasės sužalojimo rizika 1:1243. 2000–2013 metais su LC siejama 40 % (17/42) jatrogeninių tulžies latakų sužalojimų. Hospitalinis mirštamumas nuo tulžies latakų sužalojimo buvo 11 % (5/45).IšvadosJatrogeniniai tulžies latakų sužalojimai yra nedažni, bet pavojingi. Tyrimas išryškino koncepcinius, sisteminius ir techninius LC trūkumus. Kadangi laparoskopinės cholecistektomijos kultūra prasideda nuo operacijai tinkamų pacientų atrankos, išsamiai infomuoto paciento sutikimo, šiuolaikinių pripažintų technologinių ir techninių priklausinių bei racionalių, pacientų saugumą užtikrinančių sprendimų, ji turi keistis. Ir ne tik įstaigoje, kurioje buvo atliktas šis klinikinis tyrimas, bet ir visose kitose geografinio regiono gydymo įstaigose, jeigu jose praktikuojama tokia pati arba metodologiškai panaši tulžies pūslės chirurgija.

Incidence, diagnostics and management of iatrogenic bile duct injuries: 20 years experience in a high volume centre

Background-Aim The vast majority of bile duct injuries occur in cases of open or laparoscopic cholecystectomy. Numerous reports have demonstrated that the incidence of iatrogenic bile duct injuries (IBDI) has risen from 0.3% to 0.6% since the introduction of laparoscopic cholecystectomy. There are many classifications of iatrogenic bile duct injuries, none of which is universally accepted as each has its own limitation. The aim of the present study is to present the results of our investigation of this clinical topic and to propose a therapeutic algorithm for IBDI, considering the time of treatment, diagnosis and multimodal therapy of these lesions.

Age and Obesity are Independent Predictors of Bile Duct Injuries in Patients Undergoing Laparoscopic Cholecystectomy.

Iatrogenic bile duct injury is a serious complication of cholecystectomy. The aim of this study was to assess predictors of bile duct injury using a national database. The Nationwide Inpatient Sample (2010-2012) was queried for laparoscopic cholecystectomy. We used a) diagnoses for bile duct injury and b) bile duct injury repair procedure codes as a surrogate marker for bile duct injuries. A total of 1,015 patients had bile duct injury. The mean age was 58.2 ± 19.7 years, 53.5 % were males, and median Charlson co-morbidity score was 2 [2, 3]. Multivariate analysis revealed morbid obesity [2.8 (2.1-4.3); p = 0.03] and age >65 [1.5 (1.05-2.1); p = 0.01] as the independent predictors for bile duct injury in patients undergoing cholecystectomy. Our study finds a new association between obesity, aging, and bile duct injuries which has never been reported in literature before.

Is the Age of Patients with Iatrogenic Bile Duct Injuries Increasing?

Resection of the gall-bladder is still the most common surgical procedure performed at general surgery departments. The laparoscopic method used in the majority of cases offers considerable benefits but at the same time is associated with an increased rate of bile duct complications. So far, a slim female aged 25-50 years was a typical patient with a iatrogenic bile duct injury. The aim of the study was to identify the age of patients with iatrogenic bile duct injuries as well as the clinical course observed in recent years. Gender and age structure of patients admitted to the Department of General, Transplant and Liver Surgery between the beginning of 2011 and June 2014 and treated for iatrogenic bile duct injuries, complications of laparoscopic cholecystectomy, were analysed. The patients were referred to the department as a reference centre. In the group of 186 patients, females predominated (69.4%) and the mean age was 52 years. A considerable increase in the mean age of patients treated in 2014 as compared with previous years was seen. This was related to an increased rate of bile duct injuries in patients aged over 70 years, who accounted for about 25% of the group. In previous years, bile duct injuries in patients of such an advanced age happened considerably less frequently. A iatrogenic bile duct injury in an elderly person may prove a fatal complication. A repair surgery, i.e. the biliary-enteric anastomosis, is a major and burdensome procedure, particularly in the case of patients aged over 70 years. Special caution during laparoscopic cholecystectomy is advised in this population, and the slightest doubts should lead to conversion.