Management of Bile Duct Injuries: Treatment and Long-Term Results

Only a few years after the introduction of laparoscopic cholecystectomy in the late 1980s, surgeons declared the laparoscopic procedure as the gold standard for symptomatic gallstone disease. Several studies have shown the efficacy and safety of the procedure as well as the advantages such as reduced hospital stay, earlier recovery, less intraabdominal adhesions and a better cosmetic outcome [1– 3]. More recently it has been shown that the procedure can also be performed safely as a day-care procedure [4]. There has been extensive controversy about the increased incidence of bile duct injury (BDI) after laparoscopic cholecystectomy. Injury rates as high as 2% were reported in the early ‘learning’ phase and more recently a decrease in BDI has been reported from different countries [5–7]. Remarkably, other papers suggested that the majority of BDI was due to surgeons who were far beyond the learning curve, as was reported many years ago for open surgery. It has therefore also been suggested that the learning curve is not only relevant for the occurrence of BDI, but that accidental injuries are partly due to failure of the technique [8]. Different mechanisms of injury have been described in the past but more recently, Cuschieri [9] preferred a more practical approach and he identified two major groups of errors, namely (1) misidentification of the anatomy of the biliary tract as being the dominant factor in around 70% of the injuries and (2) technical errors leading to bleeding and subsequent clipping of the bile duct/artery or leading to bile leakage by inadequate clipping or traction and subsequent lateral wall injuries. Prevention of injuries is most important and different measurements have been advocated as for example the use of routine operative cholangiography [3]. Inadequate management of BDI may lead to severe complications, such as biliary peritonitis leading to sepsis and multiple organ failure in the early phase, and biliary cirrhosis during long-term follow-up, eventually leading to the need for liver transplantation [10]. Not all forms of diagnostic work-up and treatment are available in all hospitals and there should be a low barrier for referral. The management of these patients should ideally be performed/discussed in a multidisciplinary team consisting of gastroenterologists, radiologists and surgeons. Unfortunately, lesions will occur, but suboptimal treatment of BDI is not acceptable nowadays. The Academic Medical Center (AMC) is a referral center for HPB surgery and in this review several aspects of BDI, treatment and long-term outcome will be discussed.