THE DRAMATIC REALITY OF BILIARY-TRACT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY - AN ANONYMOUS MULTICENTER BELGIAN SURVEY OF 65 PATIENTS

Background: Most reports concerning the outcome of patients with bilia ry tract injury during laparoscopic cholecystectomy come from tertiary referral centers, and results could be very different in the everyday practice of community surgeons. Objective: The objective is to define the presentation, mechanisms, results of treatment, and long-term out come of biliary tract injuries during laparoscopic cholecystectomy in the setting of a community surgeon's practice. Methods: An anonymous r etrospective multicenter survey of 9,959 patients who underwent laparo scopic cholecystectomy was conducted by the Belgian Group for Endoscop ic Surgery, composed mainly of community general surgeons. Results: Si xty-five patients with bile duct injury were reported on; the incidenc e was 0.5%, varying from 0.35 to 1.3% according to the experience of t he surgeon. Thirty-four percent of ductal injuries occurred with exper ienced surgeons, often in association with local predisposing risk fac tors. injury occurred in 87% of cases during dissection of the Calot t riangle, with severe injury occurring in 46% of patients. Intraoperati ve cholangiography was performed in 34% of patients and was associated with a significantly improved operative detection rate of injury (68% vs 32%, p = 0.007). Operative detection of injury occurred in 45% of patients; diffuse bile ascitis was encountered postoperatively in 29%. The overall mortality was 9%, the postoperative biliary complication rate 31%, and the reintervention rate 14%. During a median follow-up o f 49 months (range, 3-78 months), 20 of the 61 surviving patients (33% ) had recurrent biliary strictures. Multivariate analysis demonstrated that the age of the patient (odds ratio: 0.893) and the presence of b iliary peritonitis (odds ratio: 0.061) were independent predictive fac tors for mortality and that the age of the patient (odds ratio: 1.049) and the occurrence of postoperative biliary complications (odds ratio : 0.161) after the initial biliary repair were independent predictive factors for late biliary stricture. Conclusions: Biliary tract injury is associated with significant mortality and complications in the prac tice of Belgian community surgeons. Intraoperative detection of ductal injury by the routine use and a correct interpretation of intraoperat ive cholangiography improved outcome. The impact of the primary biliar y repair on long-term outcome is an argument to refer these patients t o specialized multidisciplinary experts. The results highlight the imp ortance of surgical experience, proper selection of patients for lapar oscopic cholecystectomy, and conversion to laparotomy in difficult cas es.