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Is a peroperative end to end anastomosis for a bile duct injury justified?
Philip R. de Reuver1, Otto M. van Delden2, Erik A. Rauws3, Olivier R. Busch1, Thomas M. van Gulik1, Dirk J. Gouma1; 1Surgery, Amsterdam Medical Center, Amsterdam, Netherlands; 2Radiology, Amsterdam Medical Center, Amsterdam, Netherlands; 3Gastroenterology, Amsterdam Medical Center, Amsterdam, Netherlands

Introduction The management of a bile duct injury (BDI) detected during laparoscopic cholecystectomy is still under discussion. An end to end anastomosis (EEA) (with or without T-tube drainage) in patients without extensive tissue loss has been used frequently in the past, but is reported to be associated with a high incidence of recurrent jaundice due to stricture formation of the anastomosis area. A more complicated procedure as a primary hepaticojejunostomy is therefore recommended. Patients referred to a tertiary center after previous EEA will represent the worst selection of the population treated with EEA. The aim of this study was to evaluate the long term outcome in this selected group of patients after a complicated primary EEA. Results Of a total of 485 BDI patients referred between 1991 and 2005, 56 patients (11.5%) were referred after a primary EEA. In 42 patients (75%) a complete transsection was diagnosed during the initial operation. In 49 patients (87%) the anastomosis was performed over a T-tube, and a peroperative cholangiography was performed in 24 patients (43%). Median duration of T-tube drainage was 42 days, range 2-145. Patients were referred after a median of 16 weeks (range 0 - 141) after the initial operation. The indication for referral was leakage in 10 patients (18%) and biliary obstruction in 46 patients (82%). After referral 43 (77%) patients were initially treated endoscopically or by percutaneous transhepatic stent placement (n=3, 5%). After a mean follow up of 7 ± 3.3 years, 37 patients (66%) were successfully treated with dilatation and endoscopically placed stents, median duration 364 days range 36-1355, median stent replacements 6, range 2-15. A total of 18 patients (32%) underwent a hepaticojejunostomy, in 5 patients (9%) because initial treatment failed and in 13 patients (23%) primary reconstructive surgery was performed. Post operative complications occurred in 3 patients (5%). Leakage of the anastomosis (n=1) was treated by percutaneous transhepatic stent and in two patients a stenosis of the secondary anastomosis was successfully treated with a percutaneous transhepatic dilatation. Conclusion An end to end anastomosis might be considered as a primary treatment for BDI because even complications (stricture or leakage) can be adequately managed by endoscopic or percutaneous drainage in 66% and reconstructive surgery after EEA is a procedure with acceptable morbidity and no mortality.


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