Long-term results of biliary reconstruction after laparoscopic bile duct injuries

Hypothesis: The Kepp-Couinaud approach to biliary enteric reconstruction fo r laparoscopic bile duct injuries provides a durable, long-term result in m ost patients. Design: Retrospective study of patients who underwent operative repair of l aparoscopic bile duct injuries from January 1990 through December 1997. Setting: Academic tertiary referral. center. Main Outcome Measures: Outcome was assessed using a grading system based on clinical symptoms, liver function tests, and need for reintervention for a nastomotic stricture. The Kaplan-Meier method was employed to estimate stri cture-free survival. Results: Fifty-nine consecutive patients underwent operative repair of the following laparoscopic bile duct injuries (Strasberg classification): B: n = 2 (3%), C: n = 1 (1%), D: n = 2 (3%), E-1: n = 5 (8%), E-2: n = 16 (27%), E-3: n = 25 (42%). E-4: n = 5 (8%), and E-5: n = 3 (5%). Forty-seven patie nts (80%) had 1 or more interventions prior to the index repair. The extrah epatic left bile duct (Hepp-Couinaud approach) was used in 46 of 53 patient s who underwent a Roux-en-Y hepaticojejunostomy. Follow-up (mean +/- SEM, 3 .7 +/- 0.3 years) was complete in 54 of the 57 Patients still alive. Five p atients developed subsequent anastomotic strictures and were treated with p ercutaneous transhepatic dilation (n = 3), endoscopic dilation (n = 1), and operative revision (n= 1). Excellent to good longterm results were achieve d in the remaining 49 patients (91%). Life-table analysis yielded 95% and 8 8% chances of stricture-free survival at 2 and 5 years, respectively. Conclusions: Complex iatrogenic proximal bile duct injuries and strictures are amenable to operative repair using the extrahepatic left bile duct. The Hepp-Couinaud approach offers a durable result in more than 90% of patient s, even after previous interventions have failed.