Timely management of bile duct complications after laparoscopic cholecystectomy

Introduction: Bile duct complications after laparoscopic cholecystectomy occur twice to three times more frequently than after an open procedure. Four different types of lesions may be differentiated by the Siewert classification: postoperative bile fistulas (type I), late strictures (type II), tangential injuries of the bile duct (type III) and defect lesions (type IV). The diagnostic and therapeutic management is demonstrated in relation to our own experience and the literature. Methods: Eleven patients (median age 43.8 ± 17.2) with bile duct complications after laparoscopic cholecystectomy were operatively treated between November 1993 and December 1998. Nine patients (four type-II lesions, five type-IV lesions) were referred from another hospital; 2 defect lesions out of 410 laparoscopic cholecystectomies (0.5%) were documented in our own patient group. Results: Four patients with late strictures were operatively treated with a hepaticocholedochostomy (n = 2) or hepaticojejunostomy (n = 2) after 14.3 ± 8.4 months and were discharged from hospital after 10.6 ± 3.8 days. In both cases with type-IV lesion and a short defect, an end-to-end anastomosis was successful (hospital stay 11.6 ± 1.0 days). However, a retrocolic Roux-Yend-to-side hepaticojejunostomy was perfomed in all cases with a larger defect (n = 5; hospital stay 14.8 ± 2.0 days). The two defect lesions in our own group were detected by intraoperative cholangiography and immediately treated after conversion either with hepaticocholedocho-stomy or hepaticojejunostomy (hospital stay 11.2 ± 0.6 days). Conclusions: The incidence of bile duct complications after laparoscopic cholecystectomy might be kept down by anatomic preparation, selective intraoperative cholangiography and early consideration of conversion to open procedure. The clinical course after biliary tract injury can be positively influenced only by a standard diagnostic and operative procedure and by an early transfer to a specialized center.