Biliary complications following laparoscopic cholecystectomy F. Taylor Wootton, Brenda J. Hoffman, William H. Marsh, John T. Cunningham,

MD MD MD MD

Laparoscopic cholecystectomy is a rapidly evolving surgical technique that removes the gallbladder in a fashion similar to open cholecystectomy yet without formal laparotomy. In the United States, more than 500,000 cholecystectomies are performed annually for the management of symptomatic gallstones. The rapidity with which laparoscopic cholecystectomy is gaining widespread acceptance is largely consumer driven. The potential advantages of this modality include reduced hospital stay, recovery interval, postoperative pain, cost, and cosmetic.l. 2 Nevertheless, enthusiasm must be tempered with the realization that complications are more common with this technique. 3 The incidence of biliary tract injury with laparoscopic cholecystectomy varies from 0 to 7% in the initial series from various institutions l-6 compared with an accepted 0.1 % incidence of biliary injury with standard elective cholecystectomy.7 The following complications have recently been encountered at our institution. PATIENTS AND METHODS

Between August 1990 and March 1991, eight patients were referred by general surgeons to the Gastroenterology Division of the Medical University of South Carolina after complications developed following laparoscopic cholecystectomy. All patients had undergone laparoscopic cholecystectomy for symptomatic biliary tract disease. ERCP was performed by a gastroenterology fellow with an experienced therapeutic endoscopist using the Olympus TJFV10 or JFV10 duodenoscope (Olympus Corporation of America, Lake Success, N. Y.). Conscious sedation was achieved with intravenous meperidine and/or midazolam. Following cannulation of the common bile duct (CBD) with an Olympus diagnostic catheter, a cholangiogram was obtained. RESULTS

Three patients had complete occlusion of the CBD with surgical clips (Fig. 1), three demonstrated cystic duct leaks (Fig. 2), and two had a CBD stricture at the level of the cystic duct (Fig. 3). All patients with transected CBDs presented with nausea, vomiting, fever, chills, anorexia, and progressive right upper quadrant abdominal pain. Two of the From the Department of Internal Medicine, Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina. Reprint requests: F. Taylor Wootton, MD, Gastroenterology Division, Medical University of South Carolina, 171 Ashley Avenue, Charleston, South Carolina 29425. VOLUME 38, NO.2, 1992

Figure 1. An abrupt cut-off of the common bile duct at the level of the surgical clips is demonstrated on endoscopic retrograde cholangiogram.

three were icteric; the patient that was anicteric also had leakage of bile from a small hole proximal to the occluding clip. All developed clinical symptoms 3 to 8 days after cholecystectomy. Surgical correction was undertaken in each patient with major duct transection. A side to side choledochoduodenostomy with T-tube drainage, choledochojejunostomy with Roux-en-Y and T-tube drainage, or T-tube alone was performed. Both of the latter patients had an uneventful recovery. The first patient experienced nausea, vomiting, and intermittent right upper quadrant pain and jaundice over the next 3 months. A percutaneous transhepatic cholangiogram revealed dilated intrahepatic ducts and stricturing at the anastomosis of the choledochoduodenostomy. Using a combined procedure with interventional radiology, the stricture was dilated and an 11.5 F biliary stent was successfully placed. The patient has been asymptomatic to date. All of our patients with cystic duct leaks had abnormal CT and HIDA scans prior to referral. All complained of nausea, vomiting, and abdominal pain. Bil183

Figure 2. Extravasation of dye is seen in the region of the cystic duct on this cholangiogram.

iary stents (7 F) were placed in two patients with resolution of symptoms. In our other patient, despite multiple attempts by various endoscopists, deep cannulation to place a biliary stent was unsuccessful. Similarly, the attempted stent placement by a percutaneous transhepatic approach failed. The patient had resolution of all of his symptoms with no therapy and the HIDA scan 8 days later demonstrated no leak. Last, two patients presented several weeks after surgery complaining of recurrent biliary colic. They denied fevers or chills, but one was icteric. The second patient had a ductal injury recognized at the time of surgery and a 6 F urological stent was placed in the CBD. Abdominal CT scans were essentially normal. In contrast to "normal" intraoperative cholangiograms, both ERCPs demonstrated 5-mm-Iong strictures of the CBD in the region of the cystic duct clips. After sphincterotomy, a 10 or 11.5 F biliary stent was placed. During this same time interval, only one patient with a bile duct injury from standard cholecystectomy was referred to our institution. 184

Figure 3. Endoscopic retrograde cholangiogram demonstrates a common bile duct stricture at the level of the cystic duct clips.

DISCUSSION

The emergence of laparoscopic cholecystectomy is the direct result of improved technology and methodology by which the gallbladder can now be removed in a minimally invasive fashion. Recognizing that laparoscopic cholecystectomy has the potential to reduce hospital stay, cost, post-operative pain, recovery interval, and is cosmetically more appealing, it should not be surprising that the conventional surgical management of symptomatic cholelithiasis is rapidly being replaced by this new technique. 8 - IO Surgeons performing this new procedure have varied training not only with diagnostic laparoscopy but with this new treatment modality. The recent recommendations expressed by Cuschieri et al. 11 that "laparoscopic cholecystectomy in humans should be confined to specialized centers that participate in current or planned prospective studies designed to optimize the technique and carefully refine its indications" and the proposal by Salky et al. 5 that "strict credentialing guidelines" be established have largely been ignored. Laparoscopic cholecystectomy ~SrnillNnSTI~LENDOOC@Y

has gained such widespread acceptance that this procedure is being performed daily in community hospitals. Complications specifically associated with this technique include hemorrhage, infection, perihepatic fluid collections, bile leak, and bile duct injury along with the usual potential complications encountered with diagnostic laparoscopy. Aside from limited access, the surgeon is limited to a two-dimensional perspective when performing laparoscopic cholecystectomy, whereas standard cholecystectomy affords the benefit of three-dimensional depth perception. Additionally, laparoscopic cholecystectomy requires increased traction on the cystic duct which may result in mispositioning or dislodging clips with a higher frequency using this approachY None of the seven bile duct injuries incurred in the Southern Surgeons Club prospective study was associated with aberrant anatomy.13 The eight patients we have seen in this short interval may reflect the steep learning phase associated with laparoscopic cholecystectomy which has been characteristic in other centers. 4, 6 Of the 1518 patients analyzed by the Southern Surgeons Club, the incidence of bile duct injury was 2.2% in the first 13 patients operated on by each surgical group compared with 0.1 % for subsequent patients. 13 Unfortunately, we do not know the total number of laparoscopic cholecystectomies performed in this interval in our region nor how many additional bile duct injuries occurred using this technique that were surgically corrected. Kozarek et al. 14 reported in a prospective series that 17 of 597 (2.9%) patients undergoing laparoscopic cholecystectomy at four hospitals in the Puget Sound area sustained a bile duct injury or bile leak. Three biliary transections were recognized acutely and repaired by conversion to open laparotomy. The 14 others with delayed recognition presented within 3 to 7 days; 6 had common bile duct leaks, 3 cystic duct leaks, 2 CBD transections, and three bilomas. Major bile duct transection will require urgent surgical correction, while cystic duct leak and biliary strictures are amenable to endoscopic managementY-17 What the long-term results of endoscopic management of biliary strictures will be is speculative. At best, the long-term success with endoprostheses is 50% in our experience; failures might ultimately require surgical correction.

VOLUME 38, NO.2, 1992

Although Reddick 18 has experienced only one bile leak in his personal series of more than 500 laparoscopic cholecystectomies, similar results in a prospective study with large numbers have not been duplicated in the literature to date. Only careful and cautious clinical experience with laparoscopic cholecystectomy will help identify the incidence of biliary complications associated with this new surgical technique.

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2. Perissat J, Collet D, Belliard R. Gallstones: laparoscopic treatment-cholecystectomy, cholecystostomy, and lithotripsy. Surg Endosc 1990;4:1-5. 3. Ponsky JL. Complications oflaparoscopic cholecystectomy. Am J Surg 1991;161:393-5. 4. Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy. Ann Surg 1991;1:3-12. 5. Salky BA, Bauer JJ, Kreel I, Gelernt 1M, Gorfine SR. Laparoscopic cholecystectomy: an initial report. Gastrointest Endosc 1991;37:1-4.

6. Zucker KA, Bailey RW, Gadacz TR, Imbembo AL. Laparoscopic cholecystectomy: a plea for cautious enthusiasm. Presented at the SSAT Plenary Session. San Antonio, Texas, May 1990.

7. Mullen JT, Carr RE, Rupnik EJ, Knapp RW. 1000 cholecystectomies, extraductal palpation, and operative cholangiography. Am J Surg 1976;131:672-5. 8. Gadacz TR, Talamini MA. Traditional versus laparoscopic cholecystectomy. Am J Surg 1991;161:336-8. 9. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;161:385-7. 10. Berci G, Sackier JM. The Los Angeles experience with laparoscopic cholecystectomy. Am J Surg 1991;161:382-4. 11. Cuschieri A, Berci G, McSherry CK. Laparoscopic cholecystectomy [Editorial]. Am J Surg 1990;159:273. 12. Cameron JL, Gadacz TR. Laparoscopic cholecystectomy [Editorial]. Ann Surg 1991;1:1-2. 13. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324: 1073-8. 14. Kozarek R, Gannan R, Baerg R, Wagonfeld J, Ball T. Bile leak

following laparoscopic cholecystectomy diagnostic and therapeutic application of ERCP [Abstract]. Gastrointest Endosc 1991;37:248. 15. Kozarek RA, Traverso LW. Endoscopic stent placement for

cystic duct leak after laparoscopic cholecystectomy. Gastrointest Endosc 1991;37:71-3. 16. Pitt HA, Kaufman SL, Coleman J, White RI, Cameron JL. Benign postoperative biliary strictures: operate or dilate? Ann Surg 1989;210:417-27. 17. Berkelhammer C, Kortran P, Haber GB. Endoscopic biliary prostheses as treatment for benign postoperative bile duct strictures. Gastrointest Endosc 1989;135:95-101. 18. Reddick EJ. Laparoscopic cholecystectomy: passing fancy or legitimate treatment option? Gastroenterology 1990;99: 1527-9.

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Biliary complications following laparoscopic cholecystectomy.

Biliary complications following laparoscopic cholecystectomy F. Taylor Wootton, Brenda J. Hoffman, William H. Marsh, John T. Cunningham, MD MD MD MD...
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