CHARACTERISTICS OF BILIARY-TRACT COMPLICATIONS DURING LAPAROSCOPIC CHOLECYSTECTOMY - A MULTIINSTITUTIONAL STUDY

We collected the records of 81 patients with biliary tract injuries oc curring during laparoscopic cholecystectomy (LC) who were referred to 3 referral centers during a 33-month (May 1990 to March 1993) period. Ah records were reviewed to provide data concerning the anatomy of the lesion induced, method of injury, timing of injury detection, role of intraoperative cholangiography (IOC), methods of treatment, and outco me of these injuries. Injuries were classified by our own method as fo llows: (1) cystic duct leaks (n = 15), (2) bile leaks and/or ductal st rictures (n = 27), and (3) ductal transections or excisions (n = 39). Peak occurrence by quarter of the year was 4th quarter, 1990 (Lahey), and 3rd quarter, 1991 (Mason), and Ist quarter, 1992 (Mayo). The major ity (62%) of the injuries were recognized after LC. At the time of LC, 31 of 81 (38%) injuries were recognized and converted to open procedu res. Data regarding IOC were available in 63 of 81 (78%) cases. In pat ients in whom IOC was not performed, 14 of 38 (31%) operations were co nverted; if an IOC was obtained and interpreted correctly, 13 of 21 (6 2%) operations were converted. Primary repair was attempted in 11 leak s and/or strictures, but 36% required additional treatment. Primary re pair was used in six transections or excisions, and 17% have required further intervention. In patients who had biliary-enteric bypass (BEB) performed outside (17) versus at the referral institution (29), 94% ( 16 patients) versus 0%, respectively, required additional operative (e .g., revision of a hepaticojejunostomy) or nonoperative (e.g., radiolo gic or endoscopic stenting or balloon dilation) procedures. When used as initial therapy or after a primary ductal repair, stents (with or w ithout balloon dilation) resolved 100% of simple cystic duct leaks and 91% of leaks and/or strictures. In conclusion, the peak incidence of LC-related biliary injuries appears to have passed. A completed and co rrectly interpreted IOC increases the chance of detection of biliary i njuries intraoperatively and should assist surgeons who use routine IO C. Nonsurgical techniques allow treatment of most simple cystic duct l eaks, major ductal leaks and/or strictures, and postoperative BEB stri ctures, although followup is limited. The poor results of pre-referral BEB is not surprising since all of these patients were selected for r eferral because their treatments had not been successful.