Original Paper Received: June 20, 2013 Accepted: September 23, 2013 Published online: November 29, 2013
Dig Surg 2013;30:434–438 DOI: 10.1159/000356455
Partial Liver Resection because of Bile Duct Injury K.A.C. Booij M.L.W. Rutgers P.R. de Reuver T.M. van Gulik O.R.C. Busch D.J. Gouma Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
Abstract Aim: To analyze the outcome of partial liver resection (PHx) after bile duct injury (BDI) in patients after multimodality treatment. Methods: Between 1990 and 2012, 800 BDI patients were referred to our tertiary center. Patient characteristics and long-term outcomes were described. Results: PHx was performed in 11 patients (1.4%), mean age 48.3 years (range 29.3–83.5 years), mainly because of complex injury [Amsterdam classification type D (n = 10, 91%), Strasberg type E (n = 7, 64%) and Bismuth type IV (n = 8, 73%)]. In 7 patients (64%), concomitant vasculobiliary injury had occurred in the right hepatic artery (n = 3), proper hepatic artery (n = 1), portal vein (PV; n = 2) and the right hepatic artery and PV simultaneously (n = 1). Early PHx was performed in 2 patients and delayed resection in 9 patients after a median of 57.8 months (range 3.9–183.4 months). The in-hospital mortality was 18% (n = 2) and long-term mortality 9% (n = 1). There were no significant differences in postoperative complications between early and late resection. Conclusions: Indications for PHx after BDI in patients referred to a tertiary center are relatively low (1.4%) and generally apply to vasculobiliary injury. The implications for treatment are important, so it is worthwhile to classify vascular injuries in the management of BDI.
Introduction
Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholelithiasis. In the Netherlands, over 19,000 patients undergo a cholecystectomy annually, approximately 16,500 of which are performed laparoscopically [1]. The overall complication rate after LC is 2–12% and the mortality rate is about 0.2% [2, 3]. The most devastating complication after a cholecystectomy is bile duct injury (BDI). In combination with vascular injury, in particular, this complication can cause substantial morbidity and mortality as well as a decrease in life-expectancy and long-term quality of life [2, 4, 5]. The incidence reported in the literature is dependent on the definition of BDI, study design and study population, with a range of 0.16 to 1.5% after LC versus 0.0–0.9% after open cholecystectomy [2, 6]. When BDI occurs in combination with vascular injury, the most common type of vasculobiliary injury is the ‘classical injury’, in which injury to the right hepatic artery (RHA) occurs in combination with injury (or transection) of the common bile duct; such injuries comprise around 25% of the total incidence of BDI [7]. Injuries to the portal vein (PV) or common hepatic artery are uncommon but are much more complex. These patients should immediately be referred to a tertiary center and considered for reconstruction or partial hepatectomy [7].
© 2013 S. Karger AG, Basel © 2013 S. Karger AG, Basel 0253–4886/13/0306–0434$38.00/0 E-Mail [email protected] www.karger.com/dsu
Prof. D.J. Gouma Department of Surgery Amsterdam Medical Centre Meibergdreef 9, NL–1105 AZ Amsterdam (The Netherlands) E-Mail d.j.gouma @ amc.uva.nl
Downloaded by: University of Tokyo 157.82.153.40 - 5/26/2015 12:54:42 AM
Key Words Cholecystectomy · Bile duct injury · Hemihepatectomy · Segmental liver resection
Patients and Methods Between January 1990 and May 2012, 803 consecutive patients were referred to the Academic Medical Centre in Amsterdam for management of BDI after (laparoscopic) cholecystectomy. They were included in a prospective database and retrospectively analyzed. Medical chart records were collected from the referring hospital with the patients’ permission or when they were deceased. In the other cases, the information that was available in our hospital (including that from the referring hospital) was used. For this study, patients with PHx were evaluated (n = 11). We analyzed patient characteristics including patient demography, an indication for cholecystectomy, initial operation, type of treatment in the referring hospital, time interval between referral and diagnosis of injury, type of treatment in our hospital, time between cholecystectomy and segmental liver resection, morbidity and mortality. The type of injury was classified according to the Amsterdam [12], Strasberg [13] and Bismuth classifications [14], respectively. Vascular injury was described according to information either from the operative report of the initial operation, radiology images or the operative report of the PHx. Overall mortality and morbidity, overall outcome and outcome after early versus delayed resection (i.e. within 3 months after cholecystectomy or after 3 months), were assessed [7]. Statistical Analysis Data from patient characteristics, management and outcome are represented in numbers and percentages. Means with standard deviation or median values with minimum and maximum values are presented, whichever is appropriate. Comparison between groups was performed with the Fisher exact test due to small numbers. Data analyses were performed using SPSS® software (SPSS, Chicago, Illinois, USA). p < 0.05 was considered statistically significant.
Results
Patient Characteristics Of the 800 patients referred to the Academic Medical Centre with BDI, surgical reconstruction was performed PHx for Bile Duct Injury
in 265; PHx was performed in 11 of these patients (1.4%). All patients were female with a mean age of 48.3 years (range 29.3–83.5 years). American Society of Anesthesiologists (ASA) classification was ASA I or II in 73% of patients (table 1). In 7 patients (63.6%), LC was converted to open cholecystectomy. The indication for conversion as stated in the operative report was an insufficient critical view of safety in 5 patients and intraoperatively detected BDI in 2 patients. Table 2 shows procedures that had been performed elsewhere before referral. In 1 patient, a direct right-sided hemihepatectomy was performed because of combined PV and RHA injury with intraoperative leftsided ischemia of the liver. Six patients were referred due to a diagnosis of BDI, 1 for stricture of a previous HJ, 1 for a late stenosis after treatment of BDI and 3 for persistent complaints and a request for a second opinion. The mean time from LC to referral was 274.91 days (median 24 and range 2–1,612 days). Injury Classification Ten of the 11 patients (91%) had a type D injury according to the Amsterdam classification. Further classification of these patients is described in table 3. The Strasberg classification was type E in 64% of the patients and Bismuth classification was type III or IV, i.e. showing proximal injury, in 82% of the patients. The mean delay between LC and diagnosis of BDI was 8.6 days (median 6 and range 0–35 days). Seven of the 11 patients (64%) had vascular damage. Partial Liver Resection The mean time from LC to PHx was 51.8 months (median 32.3 and range 0–183.4 months). The indication for resection was a persisting stricture of the hepaticojejunal anastomosis in 4 patients, or liver abscesses and/or partial ischemia of the liver in the remaining patients. Nine right hemihepatectomies (82%), 1 left hemihepatectomy and 1 segment 2/3 resection were performed. Two patients (18%) had an early liver resection. One of these was performed on the same day as the cholecystectomy in the referring hospital, but a biliary-enteric reconstruction was not performed because of the presence of gallbladder empyema. This patient had been referred to our hospital for construction of a HJ which was performed using the left hepatic duct. In the other patient, PHx was performed 1.5 months after cholecystectomy, while segmental liver resection was indicated due to injury to the right PV and RHA. Dig Surg 2013;30:434–438 DOI: 10.1159/000356455
435
Downloaded by: University of Tokyo 157.82.153.40 - 5/26/2015 12:54:42 AM
In most patients, repair of major BDI consists of immediate or delayed Roux-en-Y hepaticojejunostomy (HJ) [8]. In rare situations, a segmental, partial liver resection (PHx) or even a liver transplantation is required, particularly in patients with proximal BDI and concomitant injury to the RHA and PV [9–11]. The aim of this study was to assess the incidence of PHx for BDI in patients referred for multimodality treatment. We describe the type of BDI, vascular injuries, interventions prior to PHx, postoperative complications and mortality. Furthermore, we analyze differences in outcomes between patients undergoing early versus late PHx.
Table 3. Injury classification (n = 11)
Table 1. Patient characteristics (n = 11)
Age, years Mean Range Gender Female Initial procedure Open cholecystectomy LC Conversion Indication for LC Symptomatic cholecystolithiasis Cholecystectomy à froid Mirizzi’s syndrome ASA classification ASA 1 ASA 2 ASA 3
48.3 29.3 – 83.5 11 (100) 0 4 (36.4) 7 (63.6) 9 (81.8) 1 (9.1) 1 (9.1) 4 (36.4) 4 (36.4) 3 (27.3)
Figures represented as n (%), unless otherwise indicated.
Type of injury Amsterdam classification C D Strasberg classification C D E Level of injury Bismuth II Bismuth III Bismuth IV Vascular injury RHA Proper hepatic artery PV PV and RHA
1 (9) 10 (91) 2 (18) 2 (18) 7 (64) 2 (18) 1 (9) 8 (73) 3 (42.8) 1 (14.3) 2 (28.6) 1 (14.3)
Figures represented as n (%).
Table 2. Procedures performed in other hospitals before referral
Table 4. Short-term and long-term results of segmental liver resec-
(n = 11)
tion after BDI (n= 11)
Intraoperative reconstructions Right hemihepatectomy Biliodigestive anastomosis End-to-end reconstruction over T-drain Primary closure common bile duct Relaparotomy Exploration and surgical drainage Primary closure Biliodigestive anastomosis Postoperative interventions ERCP with papillotomy ERCP with stent placement PTCD Percutaneous drain
1 (9) 1 (9) 1 (9) 1 (9) 1 (9) 1 (9) 2 (18) 1 (9) 2 (18) 6 (55) 3 (27)
Short-term,
Dig Surg 2013;30:434–438 DOI: 10.1159/000356455
Partial Liver Resection because of Bile Duct Injury K.A.C. Booij M.L.W. Rutgers P.R. de Reuver T.M. van Gulik O.R.C. Busch D.J. Gouma Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
Abstract Aim: To analyze the outcome of partial liver resection (PHx) after bile duct injury (BDI) in patients after multimodality treatment. Methods: Between 1990 and 2012, 800 BDI patients were referred to our tertiary center. Patient characteristics and long-term outcomes were described. Results: PHx was performed in 11 patients (1.4%), mean age 48.3 years (range 29.3–83.5 years), mainly because of complex injury [Amsterdam classification type D (n = 10, 91%), Strasberg type E (n = 7, 64%) and Bismuth type IV (n = 8, 73%)]. In 7 patients (64%), concomitant vasculobiliary injury had occurred in the right hepatic artery (n = 3), proper hepatic artery (n = 1), portal vein (PV; n = 2) and the right hepatic artery and PV simultaneously (n = 1). Early PHx was performed in 2 patients and delayed resection in 9 patients after a median of 57.8 months (range 3.9–183.4 months). The in-hospital mortality was 18% (n = 2) and long-term mortality 9% (n = 1). There were no significant differences in postoperative complications between early and late resection. Conclusions: Indications for PHx after BDI in patients referred to a tertiary center are relatively low (1.4%) and generally apply to vasculobiliary injury. The implications for treatment are important, so it is worthwhile to classify vascular injuries in the management of BDI.
Introduction
Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholelithiasis. In the Netherlands, over 19,000 patients undergo a cholecystectomy annually, approximately 16,500 of which are performed laparoscopically [1]. The overall complication rate after LC is 2–12% and the mortality rate is about 0.2% [2, 3]. The most devastating complication after a cholecystectomy is bile duct injury (BDI). In combination with vascular injury, in particular, this complication can cause substantial morbidity and mortality as well as a decrease in life-expectancy and long-term quality of life [2, 4, 5]. The incidence reported in the literature is dependent on the definition of BDI, study design and study population, with a range of 0.16 to 1.5% after LC versus 0.0–0.9% after open cholecystectomy [2, 6]. When BDI occurs in combination with vascular injury, the most common type of vasculobiliary injury is the ‘classical injury’, in which injury to the right hepatic artery (RHA) occurs in combination with injury (or transection) of the common bile duct; such injuries comprise around 25% of the total incidence of BDI [7]. Injuries to the portal vein (PV) or common hepatic artery are uncommon but are much more complex. These patients should immediately be referred to a tertiary center and considered for reconstruction or partial hepatectomy [7].
© 2013 S. Karger AG, Basel © 2013 S. Karger AG, Basel 0253–4886/13/0306–0434$38.00/0 E-Mail [email protected] www.karger.com/dsu
Prof. D.J. Gouma Department of Surgery Amsterdam Medical Centre Meibergdreef 9, NL–1105 AZ Amsterdam (The Netherlands) E-Mail d.j.gouma @ amc.uva.nl
Downloaded by: University of Tokyo 157.82.153.40 - 5/26/2015 12:54:42 AM
Key Words Cholecystectomy · Bile duct injury · Hemihepatectomy · Segmental liver resection
Patients and Methods Between January 1990 and May 2012, 803 consecutive patients were referred to the Academic Medical Centre in Amsterdam for management of BDI after (laparoscopic) cholecystectomy. They were included in a prospective database and retrospectively analyzed. Medical chart records were collected from the referring hospital with the patients’ permission or when they were deceased. In the other cases, the information that was available in our hospital (including that from the referring hospital) was used. For this study, patients with PHx were evaluated (n = 11). We analyzed patient characteristics including patient demography, an indication for cholecystectomy, initial operation, type of treatment in the referring hospital, time interval between referral and diagnosis of injury, type of treatment in our hospital, time between cholecystectomy and segmental liver resection, morbidity and mortality. The type of injury was classified according to the Amsterdam [12], Strasberg [13] and Bismuth classifications [14], respectively. Vascular injury was described according to information either from the operative report of the initial operation, radiology images or the operative report of the PHx. Overall mortality and morbidity, overall outcome and outcome after early versus delayed resection (i.e. within 3 months after cholecystectomy or after 3 months), were assessed [7]. Statistical Analysis Data from patient characteristics, management and outcome are represented in numbers and percentages. Means with standard deviation or median values with minimum and maximum values are presented, whichever is appropriate. Comparison between groups was performed with the Fisher exact test due to small numbers. Data analyses were performed using SPSS® software (SPSS, Chicago, Illinois, USA). p < 0.05 was considered statistically significant.
Results
Patient Characteristics Of the 800 patients referred to the Academic Medical Centre with BDI, surgical reconstruction was performed PHx for Bile Duct Injury
in 265; PHx was performed in 11 of these patients (1.4%). All patients were female with a mean age of 48.3 years (range 29.3–83.5 years). American Society of Anesthesiologists (ASA) classification was ASA I or II in 73% of patients (table 1). In 7 patients (63.6%), LC was converted to open cholecystectomy. The indication for conversion as stated in the operative report was an insufficient critical view of safety in 5 patients and intraoperatively detected BDI in 2 patients. Table 2 shows procedures that had been performed elsewhere before referral. In 1 patient, a direct right-sided hemihepatectomy was performed because of combined PV and RHA injury with intraoperative leftsided ischemia of the liver. Six patients were referred due to a diagnosis of BDI, 1 for stricture of a previous HJ, 1 for a late stenosis after treatment of BDI and 3 for persistent complaints and a request for a second opinion. The mean time from LC to referral was 274.91 days (median 24 and range 2–1,612 days). Injury Classification Ten of the 11 patients (91%) had a type D injury according to the Amsterdam classification. Further classification of these patients is described in table 3. The Strasberg classification was type E in 64% of the patients and Bismuth classification was type III or IV, i.e. showing proximal injury, in 82% of the patients. The mean delay between LC and diagnosis of BDI was 8.6 days (median 6 and range 0–35 days). Seven of the 11 patients (64%) had vascular damage. Partial Liver Resection The mean time from LC to PHx was 51.8 months (median 32.3 and range 0–183.4 months). The indication for resection was a persisting stricture of the hepaticojejunal anastomosis in 4 patients, or liver abscesses and/or partial ischemia of the liver in the remaining patients. Nine right hemihepatectomies (82%), 1 left hemihepatectomy and 1 segment 2/3 resection were performed. Two patients (18%) had an early liver resection. One of these was performed on the same day as the cholecystectomy in the referring hospital, but a biliary-enteric reconstruction was not performed because of the presence of gallbladder empyema. This patient had been referred to our hospital for construction of a HJ which was performed using the left hepatic duct. In the other patient, PHx was performed 1.5 months after cholecystectomy, while segmental liver resection was indicated due to injury to the right PV and RHA. Dig Surg 2013;30:434–438 DOI: 10.1159/000356455
435
Downloaded by: University of Tokyo 157.82.153.40 - 5/26/2015 12:54:42 AM
In most patients, repair of major BDI consists of immediate or delayed Roux-en-Y hepaticojejunostomy (HJ) [8]. In rare situations, a segmental, partial liver resection (PHx) or even a liver transplantation is required, particularly in patients with proximal BDI and concomitant injury to the RHA and PV [9–11]. The aim of this study was to assess the incidence of PHx for BDI in patients referred for multimodality treatment. We describe the type of BDI, vascular injuries, interventions prior to PHx, postoperative complications and mortality. Furthermore, we analyze differences in outcomes between patients undergoing early versus late PHx.
Table 3. Injury classification (n = 11)
Table 1. Patient characteristics (n = 11)
Age, years Mean Range Gender Female Initial procedure Open cholecystectomy LC Conversion Indication for LC Symptomatic cholecystolithiasis Cholecystectomy à froid Mirizzi’s syndrome ASA classification ASA 1 ASA 2 ASA 3
48.3 29.3 – 83.5 11 (100) 0 4 (36.4) 7 (63.6) 9 (81.8) 1 (9.1) 1 (9.1) 4 (36.4) 4 (36.4) 3 (27.3)
Figures represented as n (%), unless otherwise indicated.
Type of injury Amsterdam classification C D Strasberg classification C D E Level of injury Bismuth II Bismuth III Bismuth IV Vascular injury RHA Proper hepatic artery PV PV and RHA
1 (9) 10 (91) 2 (18) 2 (18) 7 (64) 2 (18) 1 (9) 8 (73) 3 (42.8) 1 (14.3) 2 (28.6) 1 (14.3)
Figures represented as n (%).
Table 2. Procedures performed in other hospitals before referral
Table 4. Short-term and long-term results of segmental liver resec-
(n = 11)
tion after BDI (n= 11)
Intraoperative reconstructions Right hemihepatectomy Biliodigestive anastomosis End-to-end reconstruction over T-drain Primary closure common bile duct Relaparotomy Exploration and surgical drainage Primary closure Biliodigestive anastomosis Postoperative interventions ERCP with papillotomy ERCP with stent placement PTCD Percutaneous drain
1 (9) 1 (9) 1 (9) 1 (9) 1 (9) 1 (9) 2 (18) 1 (9) 2 (18) 6 (55) 3 (27)
Short-term,
