Page 11 - Journal of WALS

Haile M Mezghebe

rates were significantly reduced after implementation of the • Type 4—hilar stricture, with involvement of confluence and
80-hour work rule for residents. One could extrapolate and loss of communication between right and left hepatic duct
recommend LC surgery cases be scheduled at the beginning of • Type 5—combined common hepatic and aberrant right
the day when the surgeon and his team are fresh. hepatic duct injury, separating from the distal common bile
8
Fletcher advocated routine use of operative cholangio- duct.
graphy to minimize and identify duct injuries though the true
value of this approach has been inconsistent. 15 to 30% of the Strasberg classification:
injuries are detected during the initial surgical procedure. Most • Type A—bile leak from cystic duct or liver bed without further
injuries diagnosed on the OR table are treated immediately, injury
often by conversion to open. Selected patients or those with • Type B—partial occlusion of the biliary tree, most frequently
failed repairs are referred to specialized centers. For patients of an aberrant right hepatic duct
not diagnosed on the table, the presenting symptoms may vary • Type C—bile leak from duct (aberrant right hepatic duct)
widely and are frequently not in accordance with the severity that is not communicating with the common bile duct
of the injury or extent of the intra-abdominal fluid/bile collection. • Type D—lateral injury of biliary system, without loss of
Krige places an emphasis on the presence or absence of continuity
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sepsis in determining early or late repair. Sahajpal examined • Type E—circumferential injury of biliary tree with loss of
factors influencing outcomes of repair in a large retrospective continuity.
study of LC associated BDIs and concluded that repairs in the Results from various centers and individual authors have
intermediate period after injury (72 hours) were associated with reported excellent short-term results after surgical repair and
increased incidence of strictures compared to the immediate long-term follow-up with good functional outcome in more than
and delayed (more than 6 weeks) repairs. 10 90%. 14,15 However, the definition of long-term follow-up is not
Kappor reported poor outcome (stricture) in patients who standardized. Many of these patients demonstrated good
underwent early repair. 11 outcome on initial follow-up only to show up years later with
Gouma stresses that when the local anatomy is unclear, delayed complications, which at a different center is not well
further exploration should be avoided to minimize proximal studied.
extension of the lesion and damage to blood supply that could CONCLUSION
have an adverse effect on future reconstruction. If the diagnosis
is made late, these patients should be stented and/or drained Though the often quoted 0.5 to 0.7% incidence of bile duct
and return for repair 6 to 8 weeks later. 12 injury, incidence of laparoscopic cholecystectomy may seem
Walsh retrospectively reviewed 144 repairs of BDIs using unalarming, when considered in light of the voluminous LC
the Bismuth-Strasberg stratification and found that the level of that is performed worldwide, the number of patients with short
injury was predictive of postoperative stricture. At a mean and long-term adverse consequences of this injury are immense.
follow-up of 67 months, more strictures developed in the cases Unfortunately, there are no prospective, controlled, randomized
repaired after 7 days of injury (19%) vs 8% in the delayed repair trials to guide the surgeon on the issue of whether early repair
five patients developed. 13 is better than a late one. Based on experiences reported by
Whether repair is performed early or late, operative technique various authors, deciding when to repair should be
focuses on the site of proximal BDI and conducts the repair individualized depending on the physiologic status of the
according to the type or classification of BDI. Jin-Shu 7 patient, presence or absence of co-morbid conditions, experience
advocates the proximal duct should have at least an 8 mm of the surgeon and the type of injury. When in doubt, it seems
diameter before duct repair can be contemplated. He does not prudent to minimize further damage by draining and waiting for
consider chills, fever or jaundice as contraindication to repair the inflammatory process to resolve before attempts at repair.
but abscess in the vicinity of the injury is a contraindication. Immediate repair in the right hands is better than intermediate
There are various classifications of BDI, including the repair (in 3 to 14 days), and delayed repair in 6 to 8 weeks is
Corlette-Bismuth, Wu, McMahon and Strasberg classification. probably the most appropriate course to follow.
Each has its own merit and can guide a surgeon to select the
best appropriate repair for each injury. REFERENCES
1. Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG,
Corlette-Bismuth classification: Wara P. Bile duct injury during laparoscopic cholecystectomy:
• Type 1—low common hepatic duct stricture, with a length A prospective nationwide series. J Am Coll Surg 1997;184:
of the common hepatic duct stump of > 2 cm 571-78.
• Type 2—middle stricture, length of common hepatic duct 2. Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile duct
< 2 cm injury during cholecystectomy and survival in medicare
beneficiaries. Jama 2003;290:2168-73.
• Type 3—hilar stricture, no remaining common hepatic duct, 3. Lai EC, Lau WY. Mirizzi syndrome: History, present and future
but the confluence is preserved development. ANZ J Surg 2006;76:251-57.

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