Postoperative Bile Duct Strictures: Management and Outcome in the 1990s (original) (raw)
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Surgical Endoscopy, 2010
Background Endoscopic stent therapy is routinely used to treat postoperative bile duct strictures. However, no studies have detailed long-term follow-up evaluation for more than 10 years. Methods This study enrolled 22 consecutive patients with a diagnosis of postoperative bile duct strictures from 1987 to 2006. Cases involving digestive tract reconstruction were excluded. Dilation was performed after passage of a guidewire through the stricture followed by temporary stent placement. The final objective was to achieve stentfree status after sufficient dilation. The stent was removed when the cholangiogram showed apparent resolution of the stricture. If stent removal was not possible within 12 months, the authors proposed a surgical treatment option. Results Initial therapy was performed for 21 patients (21/ 22, 95%). The remaining patient had complete occlusion, which required surgical repair. For 3 of the 21 cases, guidewire passage through the narrow stricture under fluorographic guidance alone was impossible. However, visualization by peroral cholangioscope enabled passage of the guidewire in all three cases. In two cases, the stricture persisted longer than 12 months, rendering stent removal impossible. Therefore, stent removal within 12 months was achieved in 90% of the cases (19/21). Two patients requested prolonged stenting in lieu of the authors' proposal to repeat the surgery. This resulted in sufficient dilation after an additional 6 months. Consequently, a total of 21 patients were enrolled for long-term follow-up evaluation. The posttreatment follow-up period was 121 ± 64 months (range, 31-254 months; median, 120 months). Three patients died of causes unrelated to hepatobiliary disease. The remaining patients were successfully followed up until this writing. The overall long-term success rate was 95% (20/21). No hepatobiliary malignancies developed within the follow-up period. Conclusions Endoscopic stent therapy is available for postoperative bile duct strictures. Long-term prognosis for more than 10 years is excellent. Repeat surgical interventions may be unavoidable in some cases, but endoscopic treatment should be proposed as the first-line treatment. Keywords Bile duct strictures Á Endoscopic treatment Á Long-term follow-up Á Peroral cholangioscope Á Postoperative Á Stent
Revisional surgery for recurrent benign bile duct strictures
European Surgery-acta Chirurgica Austriaca, 2020
Background Bile duct injuries during cholecystectomy are not rare and may have significant long-term morbidity. Treatment of these injuries is complex and needs a multidisciplinary approach. This study aims to evaluate the results of revisional surgery performed for recurrent biliary strictures that developed after a prior repair. Methods Patients who had been surgically treated for a major biliary injury during open or laparoscopic cholecystectomy and operated on for recurrent stricture in our institute were reviewed retrospectively. A total of 11 patients who were referred to the surgery clinic were included. Results The median length of stay after revisional surgery was 9 days (range 5-30 days). Five patients (45%) had experienced at least one postoperative complication. The median follow-up period was 36 months (range 5-69 months). Terblanche clinical scores of all patients were 1 or 2 at their last clinical visit. None of the 11 patients required reoperation and no mortality was seen during the postoperative period. Conclusion Although revisional biliary surgery for recurrent biliary strictures is a challenging procedure, these revisions can be performed with favorable results. Meticulous preoperative evaluation and imple-T. Erol () • Ass.
Management of bile duct injuries and strictures following cholecystectomy
World Journal of Surgery, 1993
During 7057 conventional cholecystectomies (1972)(1973)(1974)(1975)(1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989)(1990)(1991), 16 bile duct injuries occurred, amounting to a risk of 0.22%. A total of 1022 laparoscopic cholecystectomies were performed without such a complication since April 1990. In a retrospective study, 64 patients (16 of our patients and 48 referrals) with an injury or stricture due to conventional cholecystectomy were investigated. In 14 of our 16 patients the injury was recognized and immediately repaired with a good long-term result of 93 %, including one successful repair of a subsequent stricture. Two cases of unrecognized injury were managed by nonoperative means. The group of 48 referred patients comprised 10 early postoperative complications (21%) and 38 strictures after an "uneventful" cholecystectomy. Of the 64 total patients, 10 (16%) underwent nonoperative treatment, and 54 required surgery. The mean foUow-up period after surgery was 7.4 -+ 4.9 years. Most cases (93%) were repaired by bilioenteric anastomosis (i.e., foremost hepaticojejunostomy) with an 18% restricture rate. Including second and third repairs for restricture, a total of 60 operations (14 primary and 46 secondary reconstructions) were performed without hospital mortality. A good long-term result after stricture repair was achieved in 75% of the patients, whereas 17% had a poor outcome owing to restricture or death (10% had related mortality within 10 years). The other 8% had a moderate result due to recurrent cholangitis. Thus immediate repair of a bile duct injury offers the better chance of a favorable prognosis compared to secondary stricture repair.
Surgery and Interventional Radiology for Benign Bile Duct Strictures
Hpb Surgery, 1993
- Combined surgical and interventional radiological approach for complex benign biliary tract obstruction. British Journal of Surgery; In patients with complicated high benign biliary strictures surgical technique alone cannot exclude the possibility of recurrent problems, and hepatic atrophy/ hypertrophy, portal hypertension and intrahepatic stones may all complicate surgical management. A multidisciplinary approach to these complex cases, which minimizes the need for repeated surgical interventions, has been pursued.
Long-term Outcome and Risk Factors of Failure after Bile Duct Injury Repair
Journal of Gastrointestinal Surgery, 2008
Background The real long-term outcome of a hepaticojejunostomy (HJ) to repair bile duct injury (BDI) is unclear, and the risk factors for repair failure are partially defined. Study Design A retrospective, nonrandomized study of the long-term outcome of biliary reconstructions after major BDIs. All injuries occurred in association with cholecystectomy. Results Twenty-nine patients were referred with complete transection of the common (n = 16), right (n = 5), or right sectoral (n = 4) hepatic ducts or of >1 major duct (n = 4) between October 2002 and January 2007. Mean follow-up was 24 months, range 12-60 months. Original repairs were "immediate" in 14, "delayed" (within 24-72h) in 5, and "elective" (after >8 weeks) in 10, and strictures developed in 9, 5, and 1 of those HJs, respectively. The surgical outcomes were significantly better when the intervention took place electively (p = 0.003). Original HJ repairs were done by a hepatobiliary surgeon (n = 23) or by a general surgeon (n = 6): the outcome was significantly better for the former (p < 0.001). Conclusions The 51.7% incidence of strictures after BDI repair in this study was higher than reported in the literature, probably because of selection bias secondary to the referral pattern. The timing of repair and the surgeon's expertise are significant risk factors of failure.
HPB, 2011
Background: Improvements in bile duct injury repairs have been shown in centres with specialized surgeons. The aim of the present study was to demonstrate the temporal change in the pattern of referral, technical variation associated with repair and long-term outcome of bile duct injuries at a tertiary referral centre in Mexico City. Methods: A retrospective case note review was performed. Patients were divided into two groups: group I (GI) 1990 to 2004 and group II (GII) 2005-2008, and appropriate statistical analysis undertaken. Results: Over a 20-year period, 312 patients with iatrogenic bile duct injuries required surgical treatment (GI = 169, GII = 140 patients). All injuries were reconstructed using a Roux-en-Y hepaticojejunostomy. The proportion of patients who had undergone a laparoscopic cholecystectomy increased from 24% to 36% (P = 0.017) over the two time periods. In the second time period there was an increase in segment IV and V partial resections (P = 0.020), a reduction in the use of transanastomotic stents (42% to 2%, P = 0.001) and an increase in the proportion of patients requiring a neoconfluence (2% to 11%, P = 0.003). In the second time period, the number of patients requiring a hepatectomy during repair (2% to 1%, P = 0.001), a portoenterostomy (16% to 9%, P = 0.060) or a double-barrel hepatico-jejunostomy (5% to 1%, P = 0.045) significantly decreased. During follow-up, patients in the second time period had a reduction in the incidence of post-operative cholangitis (11% to 6%, P = 0.310) and the frequency of post-operative anastomotic stenoses (13% to 5%, P = 0.010). Mortality remained low throughout the series but was absent in the second group. Conclusions: Changes in technique and growing experience of the multidisciplinary team improved operative and long-term results of bile duct injury repair.
Gastrointestinal Endoscopy, 2001
Background: Endoscopic dilation with stents has been proposed as an alternative to hepaticojejunostomy for management of postoperative biliary strictures. Good long-term results with double 10F plastic stent insertion for 1 year have been reported in 74% to 90% of cases. This is a review of our experience with a more aggressive approach. Methods: The technique, short-term results, and long-term results of placement of increasing numbers of stents until complete disappearance of the biliary stricture are reported. At each exchange, the maximum possible number of stents in relation to the tightness of the stricture and diameter of the bile duct were inserted. All stents were removed at the end of treatment. Results: The records of 45 of 55 patients with postoperative biliary strictures treated in this manner and observed consecutively were reviewed retrospectively. By intention-to-treat analysis the success rate was 89% (40/45). Early complications developed in 4 (9%) patients (3 cholangitis, 1 pancreatitis) and stent occlusion that required early exchange occurred in 8 (18%) patients. There was 1 death caused by a stroke 2 months after a stent exchange. Forty-two patients completed the protocol (mean number of stents 3.2 ± 1.3; range 1-6). Mean duration of treatment was 12.1 ± 5.3 months (range 2-24 months). Two patients died of unrelated causes during follow-up. Among the remaining 40 patients there was no recurrence of symptoms caused by relapsing biliary stricture at a mean follow-up of 48.8 months (range 2-11.3 years). One patient sustained 2 episodes of cholangitis but without stricture recurrence. Conclusions: This more aggressive approach to endoscopic treatment with stents may improve longterm results for patients with postoperative biliary strictures. (Gastrointest Endosc 2001;54:162-8.)
Surgery, 2018
Hepaticojejunostomy is commonly indicated for major bile duct injury after cholecystectomy. The debate about the timing of hepaticojejunostomy for bile duct injury persists since data on postoperative outcomes, including postoperative strictures, are lacking. The aim of this study was to analyze short- and long-term outcomes of hepaticojejunostomy for bile duct injury, including risk factors for strictures. Analysis of outcome of hepaticojejunostomy in bile duct injury patients referred to a multidisciplinary team. Between the years1991 and 2016, 281 patients underwent hepaticojejunostomy for bile duct injury. Clavien-Dindo grade III complications occurred in 31 patients (11%) and 90-day mortality occurred in 2 patients (0.7%). After a median follow-up of 10.5 years (interquartile range 6.7-14.8 years), clinically relevant strictures were found in 37 patients (13.2%). Strictures were treated with percutaneous dilatation in 33 patients (89.2%), and 4 patients (1.4%) were reoperated. ...
Endoscopic Management of Postcholecystectomy Bile Duct Strictures
Journal of the American College of Surgeons, 2008
BACKGROUND: Review of 1.6 million cholecystectomies, from 1992 to 1999, demonstrated a 0.5% incidence of bile duct injury, despite increasing experience with laparoscopy. The incidence has not decreased after the "learning curve." The management of major bile duct injuries has traditionally been by hepaticojejunostomy. Endoscopy has been increasingly used to treat these injuries. This study reviews the senior author's endoscopic treatment of bile duct injuries. STUDY DESIGN: This is a retrospective study, from 1991 to 2006, examining data on 292 patients who were referred for postcholecystectomy problems; 199 had cholecystectomy-related injuries and 93 had other pathologies. Sixty-seven patients had bile duct injuries (Amsterdam Academic Medical Center Classification, types B, C, and D). Nineteen patients underwent bilioenteric bypass for complete bile duct occlusion or transection. In the remaining 48, endoscopic retrograde cholangiopancreatography (ERCP) evaluation and treatment were possible. Our protocol called for biliary stenting for 11 to 14 months, with stent changes at 3-month intervals. Short-and longterm results were evaluated by clinical, radiologic, and laboratory studies.