Handling of biliary complications following laparoscopic cholecystectomy in the setting of Tripoli Central Hospital

Abstract

Background

Laparoscopic cholecystectomy (LC) has an increased incidence of bile duct injury and bile leak when compared with open cholecystectomy. This study reviews management of these complications in a general hospital setting. Data collected from patients diagnosed and treated in one surgical unit for biliary complications after LC between 1992 and 1996 were analysed.

Method

A total of 14 patients were examined. Diagnosis was defined mainly by Endoscopic retrograde cholangiopancreatography (ERCP) and undetected choledocholitiasis was discovered in association with two of these complications. 43% of patients presented after LC with early postoperative bile leak or jaundice due to partial or complete bile duct excision or slippage of clips from the cystic duct. 57% presented with late biliary strictures. Thirteen patients were treated surgically, with biliary reconstruction (11 patients), direct repair (one) and cystic duct ligation in combination with clearance of bile duct from large multiple stones (one). One patient,who had clip displacement from cystic duct in combination with misplaced clip on right hepatic duct, was treated elsewhere. Postoperatively, one patient developed anastomotic leak and another died from sequellaie of bile duct transection requiring staged operations.

Conclusions

It is concluded that, in an environment similar to that where the authors had to work, LC should be performed in hospitals with facility to perform ERCP or when access for this technique is available in a nearby institution. Early recognition and immediate management of biliary injuries is dependent on individual resources and circumstances but, if required, consultation with colleagues or referral of patients with suspected or established biliary complications should not be delayed.

Introduction

Iatrogenic bile duct injuries are major problems associated with LC and are life threatening complications. Strategies by which these complications can be avoided or minimised have been recommended by experienced laparoscopic teams ¹,² and new principles of treatment for their management have been developed in specialised centres ³,⁴,⁵. Cholelithiasis is a common surgical diagnosis in many developing countries hospitals and the number of symptomatic patients undergoing LC is increasing annually. The rate of post-cholecystectomy biliary complications in such an environment is difficult to assess and the advantages of the recently developed diagnostic and treatment methods may not be readily available for their optimal management. The purpose of this study is to present the authors experience in the management of 14 post-LC biliary complications, at the Central Hospital, Tripoli, over a period of 5 years.

Patients and methods

Between 1984 and 1996 our surgical unit has been the only available centre for ERCP in the region of Tripoli and treatment for choledocholithiasis and post-cholecystectomy biliary complications was readily available for referrals from hospitals in the region. Over a period of five years, from 1992 to 1996, fourteen cases with post-LC biliary complications were diagnosed. In this series is one biliary stricture that occurred as a result of diathermy damage to the CBD in one patient from our own series of 480 LCS, as well as other biliary complications that were referred from other hospitals. We included in the study cases in which the main extra hepatic biliary ducts were damaged or a bile leak from the cystic duct was recorded. The observed biliary strictures were considered late presentation of an injury sustained during LC, probably caused by thermal burn or prolonged clip application to the main extra-hepatic bile duct. In the environment where we work, surgeons perform LC in the absence of biliary obstruction or choledocholithiasis and most, if not all, LCs are carried out without intra-operative cholangiography (IOC). ERCP is carried out preoperatively in patients referred to us with suspected choledocholithiasis in order to exclude the presence of stones or to remove them before LC. For the diagnosis of post-LC biliary complications we resort to the facilities available to us, mainly to abdominal ultrasound (US) and to ERCP. Procedures like HIDAscan, nasobiliary drainage, dilatation and stenting of biliary strictures were not available, during the study period, in hospitals in the region of Tripoli and were not attempted in the group under study.

Data were collected prospectively with special regard to time and mode of presentation of biliary complications, to ERCP results and to the subsequent treatment and its final outcome. Bile duct injuries and strictures were classified according to Bismuth ⁶ and Strasberg ⁷ classification, on the basis of ERCP and operative findings. The treated patients were followed for 3 to 48 months (median 30 months) by repeated clinical and US examinations and liver profile analysis.

Results

Over a five year period, from 1992 to 1996, fourteen patients (2 men and 12 women, age range 35 to 60 years) were managed in our surgical unit for biliary complications associated with LC. All patients had LC performed for symptomatic gallbladder stones diagnosed by abdominal US. In none of the 14 patients, ERCP or IOC was attempted prior to or during LC. Biliary injuries were not detected at the time of initial surgery and none of LCs was converted to open surgery. Six patients (43%) manifested with early bile leaks and jaundice and eight (57%) presented with jaundice at variable intervals because of late biliary strictures. The diagnosis in all patients was defined, soon after referral, by ERCP which was combined with PTC in five patients in whom the proximal portion of the biliary system was not filled with contrast due to either complete CBD transection or severe high stricture (Figure 1). CT scans were carried out in three patients with evidence of intra-abdominal bile leaks. Thirteen patients were treated surgically and one patient, who was referred for an ERCP, returned to the referring hospital. The finding of ERCP in all patients are shown in (Table 1).

Figure 1. .

PTC showing a severe high biliary stricture involving the entire common hepatic duct with dilatation of bile ducts proximal to the stricture site.

Table 1. ERCP findings in 14 patients with biliary complications associated with LC.

Type of complication	No.
Complete transection of CBD	3
Partial excision of CBD	1
CBD/CHB strictures	7
Partial CBD clipping	1
Slippage of clips from cystic duct:
with CBD stones	1
with misplaced clip on RHD	1
Total	14

CBD: common bile duct, CHD: common hepatic duct, RHD: right hepatic duct.

Biliary complications with early presentation (n. 6):

Patients in this group were referred within two weeks of LC. Referral time was on the 4th postoperative day for one patient with bile peritontis secondary to complete CBD transection and between eleventh and fourteenth postoperative day in the remaining five. Of these, two had jaundice due to complete CBD transection, one had bile fistula as a result of partial CBD injury (Strasberg D injury) and two had bile leak and sub-hepatic bile collection secondary to clip slippage from the cystic duct. In one complete bile duct transection, the common hepatic duct was removed in its entirety and its junction with the hilar confluence was left widely open (Strasberg E3 injury). In the other two patients with bile duct transection, most of the common hepatic duct was excised at the time of LC (Strasberg E2 injury) and the proximal transected ends were secured by metal clips. Cystic duct stump leak occurred subsequent to slippage of metal clips applied to either a wide cystic duct associated with a dilated CBD with undetected stones (Figure 2A) or to a tortuous and elongated cystic duct in combination with occlusion of the right hepatic duct by a clip (Figure 2B). Unfortunately we are unable to report on further management of this later patient, who returned, after definition of diagnosis and percutaneous aspiration of bile collection, to complete further management at the primary referring hospital.

Figure 2a. .

ERCP demonstrating metal clips displacement from the cystic duct in the presence of undetected large and multiple CBD stones.

Figure 2b. .

ERCP showing displacement of metal clips from a long and tortuous cystic duct. The right hepatic duct appears to be completely closed by a metal clip.

Initial management of this group with early presentation included percutaneous aspiration of bile collection and treatment of associated sepsis in three patients. Successful surgical treatment was carried out to repair a partial CBD injury over a T tube in one patient, to secure a cystic duct stump bile leak with simultaneous clearance of CBD from large stones considered by us not amenable to endoscopic extraction in a second patient and to construct a roux-en Y hepatico-jejunostomy in two further patients with complete CBD transection. A laparotomy and external diversion of bile through a tube positioned into the bile duct remnant was required, as a first stage life saving procedure, in the third CBD transection with biliary peritonitis. This patient had an uneventful recovery and was informed about our planning for further surgery to establish an internal biliary drainage. The patient and her family, despite reassurance, were worried about the final outcome of a third surgical intervential and they had eventually decided to seek further management at a hospital outside our region. She was therefore discharged with normal liver profile analysis and tube drainage two weeks after surgery but unfortunately she was reported to have died a month later from an embolic event, one week after hepatico-jejunostomy.

Late presentation with biliary strictures (n. 8):

Eight patients presented with late biliary strictures and jaundice one to ten months (median two months) after surgery. All strictures were associated with a variable degree of biliary system dilatation. Undetected CBD stones were discovered in the CBD segment distal to one stricture (Figure 3). Five strictures involved the CBD as well as the CHD, Bismuth Type 2 (Strasberg E2 injury) in four patients and Bismuth Type 3 (Strasberg type E3 injury) in one patient. Three strictures were confined to the CBD, one of which in a patient who developed biliary obstruction ten months after surgery, was associated with a clip partially applied to the CBD (Figure 4). The use of monopolar diathermy to stop moderate bleeding while dissecting the cystic artery during LC was the cause of one of an extensive strictures in one patient (from the authors own LC series) who presented five weeks after operation with obstructive jaundice. Strictures, in the remaining six patients, are believed to be caused by thermal injury to the bile duct (Figure 5).

Figure 3. .

Undetected CBD stones distal to a CBD stricture.

Figure 4. .

ERCP showing a clip partially applied to the common bile duct with delayed bile leak and circumscribed stricture of the bile duct.

Figure 5. .

ERCP: A late stricture of the common bile duct secondary to diathermy injury.

All strictures were managed surgically, by Roux en Y hepatico-jejunostomy performed, in one layer with fine absorbable sutures, to a healthy CHD remnant, (n = 5 patients) or by choledocho-duodenostomy (n = 3 patients). The post-operative course was complicated by anastomotic leak following hepatico-jejunostomy in one of the most recently operated patients. This patient was managed conservatively and was discharged three weeks after his operation. He was considered to be at high risk for anastomotic stricture but at one year follow-up he continued to have no signs or symptoms of biliary obstruction. The remaining patients had an uneventful postoperative course and were discharged within fourteen days after surgery. On a follow-up of three to 48 months (median 30 months) none of the treated patients has developed biliary complications.

Discussion

Our series, although small in number, comprised a wide spectrum of LC related biliary complications. Incision or transection of the common bile duct and common hepatic duct or displacement of clips from the cystic duct were the cause of major postoperative bile leak or jaundice in 43% of patients, 50% of whom had, by the time they were referred, intra-abdominal bile collection and septic complications. Late biliary strictures, most frequently involving both the CBD and CHD ducts were encountered in 57% of patients. Patients were referred at variable intervals after LC with suspected biliary complications without having had attempted biliary repair. Neither ERCP nor IOC was used for evaluation of bile ducts prior or during LCs and in all patients the laparoscopic approach was not converted to open cholecystectomy. Nature and extent of damage to bile ducts were defined by ERCP after referral and unsuspected choledocholithiasis was discovered in association with either slippage of clips from the cystic duct or with a CBD stricture on two occasions. It is felt that both complications were avoidable with a more careful pre-operative or intra-operative assessment of bile ducts. The discovery of CBD stones prior or during LC, in the two patients, could have led to their exclusion from the laparoscopic approach or to the early conversion of operation to open cholecystectomy. Displacement of clips from the cystic duct stump in association with untreated choledocholithiasis and increased biliary pressure has been reported after LC ⁸ but our reporting of clip slippage from a long and tortuous cystic duct remnant in combination with complete occlusion of the right hepatic duct, probably by a clip, is unusual. Improper placement of clips and application of monopolar diathermy were associated with a large proportion of the encountered complications in the present series which may suggest that the surgeons lack of experience was an important etiological factor for the occurrence of these injuries. A bile duct stricture which was induced by the use of diathermy for the control of moderate bleeding while dissecting the cystic artery in one of our patients was taken as a clear lesson against the liberal use of diathermy in Calot's triangle. The optimal management of biliary complications associated with LC most frequently require referral to centres with skill and expertise in dealing with these complications. Some post-operative bile leaks and strictures can be treated successfully with endoscopic and/or radiological techniques ³,⁴,⁵ and percutaneous drainage in combination with endoscopic sphinchterotomy and/or biliary stenting currently appears to be the best initial treatment for bile leaks secondary to bile duct injury or to in adequate closure of the cystic duct or accessory bile duct ⁵,⁹,¹⁰,¹¹. This therapeutic regimen is however not applicable to all bile leaks and surgical management may be necessary in more complicated cases. Surgical repair at the time of injury by surgeons who are experienced in biliary reconstruction has the highest chance of success ⁶,⁷,⁸,⁹,¹⁰,¹¹,¹² but recognition of injuries during the initial operation has been reported to occur only in approximately one third of cases ⁷. Biliary strictures can be safely repaired in 85% of patients and the best results are obtained by adequate initial repair in patients with dilated bile ducts ¹³. Repair of lesions involving the hilar confluence or hepatic ducts proximal to it is however difficult and is more likely to be associated with post-reconstruction recurrent stenosis ¹⁴.

Thirteen patients in our study were treated surgically. Biliary reconstruction mainly by hepatico-jejunostomy was carried out in eleven of thirteen patients, mostly with severely transected or strictured bile ducts, meanwhile direct surgical repair was only possible in one patient with partial bile duct excision. Interestingly and in contrast to our experience with previous referral of patients with attempted biliary repair following open cholecystectomy, none of the patients in the present series had biliary repair before referral. This particular condition in addition to the presence of bile duct dilatation has facilitated, despite complexity of lesions, the construction of suitable bilio-enteric anastomosis and contributed to satisfactory early results. Only one patient developed a postoperative anastomotic leak which settled on conservative management and another patient died from sequellae of extensive bile duct disruption requiring staged operations. our follow-up is however relatively brief and a longer period is needed for proper evaluation of the obtained results.

Safer performance of LC and prompt management of its biliary complications require specific training and new technology. Sophisticated equipment, expertise and referral centres remain largely unavailable in many areas of the world or may not be as readily available as in other regions, and the newly developed diagnostic and treatment modalities may not be offered to some of the patients who sustain these complications. In the environment where we work we have developed facilities and acquired sufficient experience to perform techniques such as ERCP which has proved to be essential for precise diagnosis of patients with post-LC biliary complications. Additional endoscopic skills or other non operative techniques were, however, not available to us and our approach was mainly surgical. We feel that surgeons should carry out LC in hospitals with the possibility to perform ERCP investigation or where easy access for this technique is available in a nearby institution. Early recognition and immediate repair of bile duct injury is dependent on local resources and individual circumstances but if required, consultation with colleagues or referral of patients with suspected or established LC-related biliary complications should not be delayed.