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Management of complex bile duct injuries
588
Journal of Gastrointestinal Surgery
Abstracts
8 mm balloon angioplasty catheters with an excellent cholangiographic result. A brush biopsy was obtained at the end of the procedure and it showed no evidence of malignancy. There were no complications. The patient was discharged home the next day. The technique described combines laparoscopic cholecystectomy with laparoscopic balloon dilatation and brush biopsy using a transcystic approach. This allowed us to manage simultaneously the cholelithiasis and the benign CBD stricture without the morbidity of additional procedures. We are not aware of any description of this technique in surgical literature.
217 SURGICAL INDICATION FOR GALLBLADDER CANCER Hiroyuki Baba, MD, PhD, Gaku Matsumoto, MD, PhD, Koji Tsuruta, MD, PhD, Atsutake Okamoto, MD, PhD, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan There are still controversies for adequate lymph node dissection for advanced gallbladder cancer. The aim of this study is to evaluate the long-term results in patients who had undergone various surgical procedures against gallbladder cancer from the standpoint of lymph node metastases. 144 patients who were diagnosed as gallbladder cancer from July 1975 to May 2001 at Tokyo Metropolitan Komagome Hospital were briefly reviewed. Lymph node dissection was carried out in every surgical procedure. Extended cholecystectomy was defined as cholecystectomy with liver resection of any volume. Modified extended cholecytectomy was defined as cholecystectomy without liver resection. 81 patients underwent surgery and the total number of extended cholecystectomy was 65. Dissected lymph nodes were examined according to the TNM classification (sixth edition, 2002) and number of positive nodes was counted. There were 22 males and 59 females, with the average age of 68. Extended cholecystectomy group included 8 cases of hepatopancreatoduodenectomies. Modified extended cholecystectomy group consist of 12 cholecystectomies and 4 pancreaticoduodenectomies. Average number of dissected lymph nodes were 15.1 ⫾ 11.4. There were 36 node positive cases and the average positive nodes were 2.9 ⫾ 2.5. Significant prognostic factors according to the Coxhazard model were number of involved nodes (node negative group vs. 4 or more node positive group; HR 0.059, P ⬍ 0.0001, 95% CI: 0.024-0.143, 1 to 3 node positive group vs. 4 or more node positive group; HR 0.189, P ⫽ 0.0001, 95% CI: 0.080-0.445) and operative procedure (extended cholecystectomy group vs. modified extended cholecystectomy group; HR 0.507, P ⫽ 0.0366, 95% CI: 0.268-0.959). When the involved lymph nodes were within the regional nodes (pN1), survival curve was significantly better than cases with extensive node involvement (M1: LYM) (P ⫽ 0.0001). However, even in pN1 group, when the number of involved nodes was 4 or more, the survival did not differ from M1: LYM group. Liver resection included 25 partial resections, 26 segmentectomies, and 14 lobectomies. Liver resection method did not influence the survival (P ⫽ 0.1216); 79% of pathologically liver invasion positive cases showed node involvement (P ⫽ 0.0005). Survival ratio did not differ among none, one or two involved organs, which may encourage radical resection. Regional lymph node dissection and liver resection can be concluded as a standard procedure for gallbladder cancer. Regional lymph node dissection is indispensable but sufficient, although the number of involved nodes is a prognostic factor.
218 BILE DUCT INJURIES: RESULTS OF 44 CASES IN A SINGLE UNIT Andre De Moricz, MD, Fabricio Pereira Andrade, MD, Tercio De Campos, MD, Alexandre Schinit Sassatani, MD, Fernando Leal Pereira, MD, Fernando Torres Vasquez, MD, Adhemar Monteiro
Pacheco, Jr., MD, PhD, Santa Casa School of Medicine, Sao Paulo, Brazil The aim of this study was to evaluate how the moment of diagnosis, the severity of injury (classification), and the different kinds of repair affect outcome of the patients treated with iatrogenic bile duct injuries. There were 4077 elective cholecystectomies (2497 open and 1580 laparoscopic) performed in our service between March 1984 and August 2004. Forty-four patients sustained biliary tract injury, and 21 among them were referred from other hospitals. There were 39 women (88.6%) and 5 men (11.4%) with a mean age of 46.7 years. They were evaluated for the moment of the injury: during-operation, precocious (until 30th day after surgery), and later. The injuries were separated under Strasberg and Bismuth classification, and their surgical repair results were evaluated as well. The data of cholangiography results during operation time were collected. The injury rates in open and laparoscopic cholecystectomies were 0.6% and 0.5%, respectively (P ⫽ 0.861). The injury diagnosis was established during operation in 28 patients, precocious in 7 and later in 9. There were 19 (43.2%) cholangiographic studies performed with 10.5% of missed injuries during operation (P ⫽ 0.290). The rates of success of bile duct injury treatment were 67.9%, 14.3%, and 88.9% for the three different moments evaluated. The patients treated in the precocious period of time had worse outcome compared with those treated during and later after surgery (P ⫽ 0.027 and 0.01). When the modalities of surgical repair were analyzed, the results about success rates showed single suture, 69.2%; suture with T-tube, 83.3%; duct-to-duct anastomosis, 33.3%; and biliary bypass, 63.2% (P ⫽ 0.686). There were no statistical differences between outcomes of patients submitted to one- or two-layer biliary bypass and the severity of injury did not influence outcome. The mean follow-up period of time was 26.9 months (1-192 months). For patients with bile duct injuries treated in our institution: the moment of treatment had influenced the outcome; the modality of repair and the severity of injury did not change the outcome, and the cholangiography had no significance in the final results.
219 MANAGEMENT OF COMPLEX BILE DUCT INJURIES Eduardo de Santiban˜es, Juan Pekolj, Rodrigo Sa´nchez Claria´, Martı´n Palavecino, Christian Bertona, Emilio Quin˜onez, Hospital Italiano, Buenos Aires, Argentina Laparoscopic cholecystectomy (LC) is the treatment of choice for gallbladder stones. This approach was associated with a higher incidence of biliary injuries (BDI). These injuries seem to be more complex. We considered complex injuries those 1) that involve the confluence; 2) with a previous failed repair; 3) associated with a vascular injury; or 4) with portal hypertension or secondary biliary cirrhosis. Between 1989 and 2003, 166 patients with BCI were treated in our Unit. 91 patients were female. The mean age of the patients was 46.2 years (range: 6-74). 21 BDIs were inflicted in our institution and 133 were referred from other institutions. Injuries were diagnosed during the surgical procedure in 39 cases (25.3%). In our own series of 5084 LCs, the incidence of BDI was 0.15% (8 patients) whereas in the open procedure it was 0.18%. 115 were produced during the open procedure and 51 occurred during LC. 107 patients (64.4%) were complex BDIs, 10 of which met more than one criterium. 54 involved the hepatic confluence, 38 were high stenoses with unsuccessful repair attempts, 7 had associated vascular injuries, and 18 had associated portal hypertension or secondary biliary cirrhosis. Percutaneous transhepatic biliary drainage (PTBD) was employed in 30 patients. Balloon dilatation was used in 12 patients and auto-expandable metallic prosthesis in 1 patient. Hepaticojejunostomy (HJ) as initial treatment was performed in 87 cases. HJ was also carried out for biliary stenosis
Vol. 9, No. 4 2005
with previous repair failures in 38 patients. Hepatic resection was performed in seven patients, 5 right hepatectomies and 2 left hepatectomies. 18 patients were included in the liver transplantation (LT) waiting list, 12 were transplanted while 4 died waiting for an organ. The mean follow-up was 77.8 months (range: 4-168). The mortality rate for the whole series was 4.8% (8/166). 4 out of these 8 patients died in the waiting LT list. The surgical treatment success rate was 85%. The effectiveness for the treatment of primary stenosis was 93%. Hepatic resection had 100% success rate. The actuarial survival for LT at one year was 91.7%. Percutaneous dilatation of biliary stenosis had 58% success rate. Complex BDI should be treated in tertiary centers with HPB specialists. LT has to be considered for treatment of these complex lesions when no other therapeutic option is available.
220 THE OUTCOME OF SURGERY FOR 97 CASES OF BILIARY ATRESIA: A SINGLE INSTITUTIONAL EXPERIENCE Ibrahim K. Marwan, MD, A. Shawky, T. Ibrahim, M. Osman, El-Said Soliman, H. Konsowa, B. Hegab, Amany Ibrahim Saleh, MD, National Liver Institue, Cairo, Egypt; Faculty of Medicine Ain Shams University, Cairo, Egypt Retrospective evaluation of the outcome for 97 patients with biliary atresia who underwent surgical treatment. Between June 1995 and June 2004, 97 cases of biliary atresia were treated in 47 females and 50 males. The mean age at surgery was 101 days for 37 cases done from June 1995 to June 2000 and 78 days for 60 cases done from July 2000 to June 2004, respectively. Hepatecojejunostomy was done for type I (5 cases). Hepatic portocholecystostomy was performed for type II (13 cases). For type III, Kasai operation was done in 53 cases, interposition jejunal loop with an intussusceptive anti-reflux valve for 16 cases, and hepatic portojejunostomy with valve for 10 cases. The mean age for type I was 111 days (range: 80-155 days); all are still alive, two for 7.5 years, two for 5 years, and one for 3.7 years. Type II was observed in 13 cases with a mean age of 78.58 days (range: 45-102 days); two of them were identical twins. The procedure was failed in four and converted to portoenterostomy, seven of them are alive, two for 4 years, two for 3 years, one for 2 years, and 2 for 1 year. The remaining 79 cases were type III with mean age of 76 days (range: 43-149 days). Thirteen patients underwent the operation below the age of 60 days, between age 61-90 days for 57 cases and above the age of 91 days for 27 cases. The overall survivors are 47 cases (48.45%), 21 of them are clinically jaundice free, hospital mortality was 31 cases, and 19 were lost in the follow-up. Five cases from the survivors received LRLT, one jaundice-free case because of hematemesis 5.5 years after Kasai operation and four due to recurrent attacks of cholangitis and liver failure. Close long-term care, follow-up, and elevation of the medical awareness of the family are essential to achieve good results especially in centers where liver transplantation has not started yet.
221 IMPACT OF CONCOMITANT VASCULAR INJURIES, SPECIALITY OF SURGEON PERFORMING THE REPAIR, AND SUBSEQUENT PATIENT PSYCHOLOGICAL CONCERNS IN THE MANAGEMENT OF IATROGENIC BILE DUCT INJURIES Asma Sultana, MBBS, C. H. Byrne, J. Evans, P. Ghaneh, G. J. Poston, Royal Liverpool University Hospital, Liverpool, United Kingdom Of laparoscopic cholecystectomies, 0.3% of open and 0.8% continue to result in serious biliary injury (BI). While data suggest that the outcome
Abstracts
589
of repair is better in expert hands, little is known of the incidence and impact of associated vascular injuries (VI), nor the effect of BI on quality of life after seemingly successful repair. We conducted a retrospective study to address these issues. Case note review of 27 BI patients managed at a single center with an additional 17 medicolegal cases (all Strasburg grade E). VIs were detected following visceral angiography or documentation in the operative notes. 24 patients also completed The Hospital Anxiety and Depression Scale (HADS) and The Concerns Checklist. Median age: 47 (20-77) years; Median time to recognition of injury: 7 (0-730) days. Median duration of followup: 69 (8-168) months. BI occurred following laparoscopic cholecystectomy in 37, open cholecystectomy in 8 and right hemicolectomy in one patient.17/44 had associated VI. Vessels involved: right hepatic artery (RHA) 10; common hepatic artery (CHA) 3; RHA with right branch of portal vein (PV) 2; PV injury 1; CHA plus PV 1. Six underwent immediate hepaticojejenostomy (HJ), while 38 had delayed primary/secondary HJ. Stricture development following immediate HJ: 1/4 (25%) without VI; 2/2(100%) in the group with VI (P ⬍ 0.05). Twenty-seven underwent repair by HPB surgeons and 17 by non HPB surgeons. Six (22%) strictures occurred following repair by HPB surgeons while 13 (77%) strictured when repaired by non HPB surgeons (P ⬍ 0.001). The patients completing HADS and Concerns checklist reported an average 5 (0-11) concerns. Association between concerns number and psychological distress was not dependent on injury severity or repair type. Concerns about disabling effects of cholangitis and unresolved issues (referral delay, anger) were linked with depressive mood in 6. Strategies to reduce concerns included speedy referral to an HPB team; open access to HPB team; self-start protocol for treatment when cholangitis occurred. Imaging to exclude VI is necessary in the management of bile duct injury, since if detected, definitive surgery should be delayed to allow time for re-vascularisation of the biliary system. The complications of BI, even after seemingly successful repair, can have a significant psychological impact. Suitable strategies referred to above should be implemented early on to limit this negative effect. These outcomes, even in expert hands mandate early referral (as soon as BI is evident) to an HPB center.
222 INTRAOPERATIVE BILE DUCT INJURY AND ITS MANAGEMENT Jun-ichi Tanaka, MD, Yoshio Deguchi, MD, Akiko Umezawa, MD, Hirohisa Kato, MD, Hisashi Kasugai, MD, Shin-ei Kudo, MD, Showa University Northern Yokohama Hospital, Yokohama, Japan We introduced preoperative DIC-CT to evaluate an anatomy of bile duct, and intraoperative cholangiography (IOC) to avoid intraoperative bile duct injury. Intraoperative bile duct injury (IBDI) and its management were investigated. During resent two and half years, we performed laparoscopic cholecystectomy (LC) for 280 patients in our hospital. DIC-CT revealed anatomical anomaly on 15 patients of 280. IOC was performed completely on 96% patients. One patient out of 280 patients who underwent LC, encountered IBDI due to marked inflammation around the cystic duct, and she was treated with T-tube drainage under laparoscopic guidance and postoperative course was uneventful. IOC is still controversial; however, it is reported to be useful for intraoperative Examination of CBD stones, and also to be useful to avoid injury of bile duct. Routine IOC during LC including skeletonization of cystic duct and catheterization into cystic duct could improve skill of laparoscopic surgical procedures such as CBD exploration, colorectal surgery, and gastric surgery.
Journal of Gastrointestinal Surgery
Abstracts
8 mm balloon angioplasty catheters with an excellent cholangiographic result. A brush biopsy was obtained at the end of the procedure and it showed no evidence of malignancy. There were no complications. The patient was discharged home the next day. The technique described combines laparoscopic cholecystectomy with laparoscopic balloon dilatation and brush biopsy using a transcystic approach. This allowed us to manage simultaneously the cholelithiasis and the benign CBD stricture without the morbidity of additional procedures. We are not aware of any description of this technique in surgical literature.
217 SURGICAL INDICATION FOR GALLBLADDER CANCER Hiroyuki Baba, MD, PhD, Gaku Matsumoto, MD, PhD, Koji Tsuruta, MD, PhD, Atsutake Okamoto, MD, PhD, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan There are still controversies for adequate lymph node dissection for advanced gallbladder cancer. The aim of this study is to evaluate the long-term results in patients who had undergone various surgical procedures against gallbladder cancer from the standpoint of lymph node metastases. 144 patients who were diagnosed as gallbladder cancer from July 1975 to May 2001 at Tokyo Metropolitan Komagome Hospital were briefly reviewed. Lymph node dissection was carried out in every surgical procedure. Extended cholecystectomy was defined as cholecystectomy with liver resection of any volume. Modified extended cholecytectomy was defined as cholecystectomy without liver resection. 81 patients underwent surgery and the total number of extended cholecystectomy was 65. Dissected lymph nodes were examined according to the TNM classification (sixth edition, 2002) and number of positive nodes was counted. There were 22 males and 59 females, with the average age of 68. Extended cholecystectomy group included 8 cases of hepatopancreatoduodenectomies. Modified extended cholecystectomy group consist of 12 cholecystectomies and 4 pancreaticoduodenectomies. Average number of dissected lymph nodes were 15.1 ⫾ 11.4. There were 36 node positive cases and the average positive nodes were 2.9 ⫾ 2.5. Significant prognostic factors according to the Coxhazard model were number of involved nodes (node negative group vs. 4 or more node positive group; HR 0.059, P ⬍ 0.0001, 95% CI: 0.024-0.143, 1 to 3 node positive group vs. 4 or more node positive group; HR 0.189, P ⫽ 0.0001, 95% CI: 0.080-0.445) and operative procedure (extended cholecystectomy group vs. modified extended cholecystectomy group; HR 0.507, P ⫽ 0.0366, 95% CI: 0.268-0.959). When the involved lymph nodes were within the regional nodes (pN1), survival curve was significantly better than cases with extensive node involvement (M1: LYM) (P ⫽ 0.0001). However, even in pN1 group, when the number of involved nodes was 4 or more, the survival did not differ from M1: LYM group. Liver resection included 25 partial resections, 26 segmentectomies, and 14 lobectomies. Liver resection method did not influence the survival (P ⫽ 0.1216); 79% of pathologically liver invasion positive cases showed node involvement (P ⫽ 0.0005). Survival ratio did not differ among none, one or two involved organs, which may encourage radical resection. Regional lymph node dissection and liver resection can be concluded as a standard procedure for gallbladder cancer. Regional lymph node dissection is indispensable but sufficient, although the number of involved nodes is a prognostic factor.
218 BILE DUCT INJURIES: RESULTS OF 44 CASES IN A SINGLE UNIT Andre De Moricz, MD, Fabricio Pereira Andrade, MD, Tercio De Campos, MD, Alexandre Schinit Sassatani, MD, Fernando Leal Pereira, MD, Fernando Torres Vasquez, MD, Adhemar Monteiro
Pacheco, Jr., MD, PhD, Santa Casa School of Medicine, Sao Paulo, Brazil The aim of this study was to evaluate how the moment of diagnosis, the severity of injury (classification), and the different kinds of repair affect outcome of the patients treated with iatrogenic bile duct injuries. There were 4077 elective cholecystectomies (2497 open and 1580 laparoscopic) performed in our service between March 1984 and August 2004. Forty-four patients sustained biliary tract injury, and 21 among them were referred from other hospitals. There were 39 women (88.6%) and 5 men (11.4%) with a mean age of 46.7 years. They were evaluated for the moment of the injury: during-operation, precocious (until 30th day after surgery), and later. The injuries were separated under Strasberg and Bismuth classification, and their surgical repair results were evaluated as well. The data of cholangiography results during operation time were collected. The injury rates in open and laparoscopic cholecystectomies were 0.6% and 0.5%, respectively (P ⫽ 0.861). The injury diagnosis was established during operation in 28 patients, precocious in 7 and later in 9. There were 19 (43.2%) cholangiographic studies performed with 10.5% of missed injuries during operation (P ⫽ 0.290). The rates of success of bile duct injury treatment were 67.9%, 14.3%, and 88.9% for the three different moments evaluated. The patients treated in the precocious period of time had worse outcome compared with those treated during and later after surgery (P ⫽ 0.027 and 0.01). When the modalities of surgical repair were analyzed, the results about success rates showed single suture, 69.2%; suture with T-tube, 83.3%; duct-to-duct anastomosis, 33.3%; and biliary bypass, 63.2% (P ⫽ 0.686). There were no statistical differences between outcomes of patients submitted to one- or two-layer biliary bypass and the severity of injury did not influence outcome. The mean follow-up period of time was 26.9 months (1-192 months). For patients with bile duct injuries treated in our institution: the moment of treatment had influenced the outcome; the modality of repair and the severity of injury did not change the outcome, and the cholangiography had no significance in the final results.
219 MANAGEMENT OF COMPLEX BILE DUCT INJURIES Eduardo de Santiban˜es, Juan Pekolj, Rodrigo Sa´nchez Claria´, Martı´n Palavecino, Christian Bertona, Emilio Quin˜onez, Hospital Italiano, Buenos Aires, Argentina Laparoscopic cholecystectomy (LC) is the treatment of choice for gallbladder stones. This approach was associated with a higher incidence of biliary injuries (BDI). These injuries seem to be more complex. We considered complex injuries those 1) that involve the confluence; 2) with a previous failed repair; 3) associated with a vascular injury; or 4) with portal hypertension or secondary biliary cirrhosis. Between 1989 and 2003, 166 patients with BCI were treated in our Unit. 91 patients were female. The mean age of the patients was 46.2 years (range: 6-74). 21 BDIs were inflicted in our institution and 133 were referred from other institutions. Injuries were diagnosed during the surgical procedure in 39 cases (25.3%). In our own series of 5084 LCs, the incidence of BDI was 0.15% (8 patients) whereas in the open procedure it was 0.18%. 115 were produced during the open procedure and 51 occurred during LC. 107 patients (64.4%) were complex BDIs, 10 of which met more than one criterium. 54 involved the hepatic confluence, 38 were high stenoses with unsuccessful repair attempts, 7 had associated vascular injuries, and 18 had associated portal hypertension or secondary biliary cirrhosis. Percutaneous transhepatic biliary drainage (PTBD) was employed in 30 patients. Balloon dilatation was used in 12 patients and auto-expandable metallic prosthesis in 1 patient. Hepaticojejunostomy (HJ) as initial treatment was performed in 87 cases. HJ was also carried out for biliary stenosis
Vol. 9, No. 4 2005
with previous repair failures in 38 patients. Hepatic resection was performed in seven patients, 5 right hepatectomies and 2 left hepatectomies. 18 patients were included in the liver transplantation (LT) waiting list, 12 were transplanted while 4 died waiting for an organ. The mean follow-up was 77.8 months (range: 4-168). The mortality rate for the whole series was 4.8% (8/166). 4 out of these 8 patients died in the waiting LT list. The surgical treatment success rate was 85%. The effectiveness for the treatment of primary stenosis was 93%. Hepatic resection had 100% success rate. The actuarial survival for LT at one year was 91.7%. Percutaneous dilatation of biliary stenosis had 58% success rate. Complex BDI should be treated in tertiary centers with HPB specialists. LT has to be considered for treatment of these complex lesions when no other therapeutic option is available.
220 THE OUTCOME OF SURGERY FOR 97 CASES OF BILIARY ATRESIA: A SINGLE INSTITUTIONAL EXPERIENCE Ibrahim K. Marwan, MD, A. Shawky, T. Ibrahim, M. Osman, El-Said Soliman, H. Konsowa, B. Hegab, Amany Ibrahim Saleh, MD, National Liver Institue, Cairo, Egypt; Faculty of Medicine Ain Shams University, Cairo, Egypt Retrospective evaluation of the outcome for 97 patients with biliary atresia who underwent surgical treatment. Between June 1995 and June 2004, 97 cases of biliary atresia were treated in 47 females and 50 males. The mean age at surgery was 101 days for 37 cases done from June 1995 to June 2000 and 78 days for 60 cases done from July 2000 to June 2004, respectively. Hepatecojejunostomy was done for type I (5 cases). Hepatic portocholecystostomy was performed for type II (13 cases). For type III, Kasai operation was done in 53 cases, interposition jejunal loop with an intussusceptive anti-reflux valve for 16 cases, and hepatic portojejunostomy with valve for 10 cases. The mean age for type I was 111 days (range: 80-155 days); all are still alive, two for 7.5 years, two for 5 years, and one for 3.7 years. Type II was observed in 13 cases with a mean age of 78.58 days (range: 45-102 days); two of them were identical twins. The procedure was failed in four and converted to portoenterostomy, seven of them are alive, two for 4 years, two for 3 years, one for 2 years, and 2 for 1 year. The remaining 79 cases were type III with mean age of 76 days (range: 43-149 days). Thirteen patients underwent the operation below the age of 60 days, between age 61-90 days for 57 cases and above the age of 91 days for 27 cases. The overall survivors are 47 cases (48.45%), 21 of them are clinically jaundice free, hospital mortality was 31 cases, and 19 were lost in the follow-up. Five cases from the survivors received LRLT, one jaundice-free case because of hematemesis 5.5 years after Kasai operation and four due to recurrent attacks of cholangitis and liver failure. Close long-term care, follow-up, and elevation of the medical awareness of the family are essential to achieve good results especially in centers where liver transplantation has not started yet.
221 IMPACT OF CONCOMITANT VASCULAR INJURIES, SPECIALITY OF SURGEON PERFORMING THE REPAIR, AND SUBSEQUENT PATIENT PSYCHOLOGICAL CONCERNS IN THE MANAGEMENT OF IATROGENIC BILE DUCT INJURIES Asma Sultana, MBBS, C. H. Byrne, J. Evans, P. Ghaneh, G. J. Poston, Royal Liverpool University Hospital, Liverpool, United Kingdom Of laparoscopic cholecystectomies, 0.3% of open and 0.8% continue to result in serious biliary injury (BI). While data suggest that the outcome
Abstracts
589
of repair is better in expert hands, little is known of the incidence and impact of associated vascular injuries (VI), nor the effect of BI on quality of life after seemingly successful repair. We conducted a retrospective study to address these issues. Case note review of 27 BI patients managed at a single center with an additional 17 medicolegal cases (all Strasburg grade E). VIs were detected following visceral angiography or documentation in the operative notes. 24 patients also completed The Hospital Anxiety and Depression Scale (HADS) and The Concerns Checklist. Median age: 47 (20-77) years; Median time to recognition of injury: 7 (0-730) days. Median duration of followup: 69 (8-168) months. BI occurred following laparoscopic cholecystectomy in 37, open cholecystectomy in 8 and right hemicolectomy in one patient.17/44 had associated VI. Vessels involved: right hepatic artery (RHA) 10; common hepatic artery (CHA) 3; RHA with right branch of portal vein (PV) 2; PV injury 1; CHA plus PV 1. Six underwent immediate hepaticojejenostomy (HJ), while 38 had delayed primary/secondary HJ. Stricture development following immediate HJ: 1/4 (25%) without VI; 2/2(100%) in the group with VI (P ⬍ 0.05). Twenty-seven underwent repair by HPB surgeons and 17 by non HPB surgeons. Six (22%) strictures occurred following repair by HPB surgeons while 13 (77%) strictured when repaired by non HPB surgeons (P ⬍ 0.001). The patients completing HADS and Concerns checklist reported an average 5 (0-11) concerns. Association between concerns number and psychological distress was not dependent on injury severity or repair type. Concerns about disabling effects of cholangitis and unresolved issues (referral delay, anger) were linked with depressive mood in 6. Strategies to reduce concerns included speedy referral to an HPB team; open access to HPB team; self-start protocol for treatment when cholangitis occurred. Imaging to exclude VI is necessary in the management of bile duct injury, since if detected, definitive surgery should be delayed to allow time for re-vascularisation of the biliary system. The complications of BI, even after seemingly successful repair, can have a significant psychological impact. Suitable strategies referred to above should be implemented early on to limit this negative effect. These outcomes, even in expert hands mandate early referral (as soon as BI is evident) to an HPB center.
222 INTRAOPERATIVE BILE DUCT INJURY AND ITS MANAGEMENT Jun-ichi Tanaka, MD, Yoshio Deguchi, MD, Akiko Umezawa, MD, Hirohisa Kato, MD, Hisashi Kasugai, MD, Shin-ei Kudo, MD, Showa University Northern Yokohama Hospital, Yokohama, Japan We introduced preoperative DIC-CT to evaluate an anatomy of bile duct, and intraoperative cholangiography (IOC) to avoid intraoperative bile duct injury. Intraoperative bile duct injury (IBDI) and its management were investigated. During resent two and half years, we performed laparoscopic cholecystectomy (LC) for 280 patients in our hospital. DIC-CT revealed anatomical anomaly on 15 patients of 280. IOC was performed completely on 96% patients. One patient out of 280 patients who underwent LC, encountered IBDI due to marked inflammation around the cystic duct, and she was treated with T-tube drainage under laparoscopic guidance and postoperative course was uneventful. IOC is still controversial; however, it is reported to be useful for intraoperative Examination of CBD stones, and also to be useful to avoid injury of bile duct. Routine IOC during LC including skeletonization of cystic duct and catheterization into cystic duct could improve skill of laparoscopic surgical procedures such as CBD exploration, colorectal surgery, and gastric surgery.