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3 Management of the Extrahepatic Bile Ducts Hamoud Hamed * Abstract Objective: Determining the ideal way and the best timing for management of injuries of the extrahepatic bile ducts in respect to appropriateness, results, and complications. Methods: The study included 25 patients who have an injury in the main extrahepatic bile ducts. All patients were managed in Al Assad University Hospital in Damascus between 2002 and Data was collected retrospectively to determine the mechanism, diagnostic tools, and management. All patients were followed until the date of publication. The results of surgical repair were assessed through evaluation of the clinical situation of the patients and according to the results of laboratory and imaging investigation. Results: A total of 25 patients were studied. The median age of patients was 33. The causes of injury were laparoscopic cholecystectomy (20 cases), open cholecystectomy (4 cases), and penetrating abdominal trauma (1 case). The injury was diagnosed either intraoperatively (6 cases) or postoperatively (19 cases). Of the latter group the patient presented with postoperative biliary leakage (12 cases), abdominal pain (3 cases), and obstructive jaundice (3 cases). Surgical management included Roux-en-Y hepaticojeujenal or choledochojeujenal anastomoses with bile duct stenting in 20 cases, direct closure at laparoscopy in one case, direct closure with T-tube placement at laparotomy in two cases, and only stenting through ERCP in one case. Management was successful without major complications in 21 cases. Four patients had significant complications: common hepatic duct stone, hepatic artery aneurysm with hemobilia, dehiscence of choledochoduedenal anastomoses, and stricture in the common bile duct. All complicated cases were managed successfully. Conclusion: Laparoscopic cholecystectomy is currently the leading cause of extrahepatic bile duct injury. The complications of these injuries are best avoided by prevention. when they happen they are best managed and repaired if diagnosed intraoperatively. When diagnosis is delayed surgical intervention must be delayed for months. The best surgical repair for these injuries is Roux-en-Y hepaticojeujenal or choledochojeujenal anastomoses, which is associated with the best results. * Prof. Ass. Department of Surgery Faculty of Medicine Damascus University. 133
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16 ( )* +, ' -! References 1. Briane F. Ceilchrist, Donald D. Trunkey. Surgery of the Alimentary Tract: Biliary Tract Trauma. Shackel Ford's Fourth edition, Volume III, Chapter 23: ; Fu-Quan Yang, Liang Wang: Iatrogenic extrahepatic bile duct injuries in 182 patients: causes and management. Hep Pan Inter 2002; 1,2: Jaques Testart. Chirurgie de la Voie Biliaire Accessoire. EMQ Tome 3, ( ); Johnson SR, Koehler A, Pennington LK, Hanto DW: Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery 2000;128: Lillimoe KD, Martin SA, Cameron JL, Yeo CJ,Talamini MA, Kaushal S, Coleman J, VenbruxAC, Savader SJ, Osterman FA, Pitt HA: Majorbile duct injuries during laparoscopic cholecystectomy.ann Surg 1997;25: Margret O, John Q. Hunter. Gallbladder and the Extrahepatic Biliary System Injury to the Biliary Tract. Schwartz Principles of Surgery, 8th edition, Chapter 31: ; Murr MM, Gigot JF, Nagorney DM, HarmsenWS, Ilstrup DM, Farnell MB: Long-term results of biliary reconstruction after laparoscopic bile duct injuries. Arch Surg 1999;134: Ress A.M, Sarr M.G, et al. Spectrum and Management of Major Complications of Laparoscopic Cholecystectomy. AM J Surg 165:655; S. C. Schmidt, J. M. Langrehr, R. E. Hintze, P. Neuhaus: Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Bri J Surg 2005; 92: Stewart L, Way LW: Bile duct injuries duringlaparoscopic cholecystectomy. Arch Surg 1995;130: Adamsen S, Hansen OH, Funch-Jensen P, et al. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg 1997; 184: Fletcher DR, Hobbs MST, Tan P, et al. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography. A population-based study. Ann Surg 1999; 229:
17 13. Savader SJ, Lillemoe KD, Prescott CA, et al. Laparoscopic cholecystectomy bile duct injuries: a health and financial disaster. Ann Surg 1997; 225: Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of major biliary complications after laparoscopic cholecystectomy. Ann Surg 1992; 215: Branum G, Schmitt C, Baillie J, et al. Management of major biliary complications after laparoscopic cholecystectomy. Ann Surg 1993; 217: Woods MS, Taverso LW, Kozarek RA, et al. Characteristics of biliary tract complications during laparoscopic cholecystectomy; a multiinstitutional study. Am J Surg 1994; 167: Bergman JJGHM, van den Brink GR, Rauws EAJ, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 1996; 38: Lillemoe KD, Martin SA, Cameron JL, et al. Major bile duct injuries during laparoscopic cholecystectomy. Ann Surg 1997; 225: Lillemoe KD, Melton GB, Cameron JL, et al. Postoperative bile duct strictures: management and outcome in the 1990s. Ann Surg 2000; 232: Carroll BJ, Birth M, Phillips EH. Common Bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc 1998; 12: /6/11 : 78 6 ^./3/13: K " ^ 147
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