Complicanze biliari della colecistectomia: la gestione della fase acuta delle lesioni iatrogene della via biliare principale

Background Iatrogenic bile duct injury is a severe complication of cholecystectomy. Purpose To describe the experience of a hepatobiliary surgery unit in the management of iatrogenic bile duct injuries in the acute stage. Methods A total of 103 patients with iatrogenic bile duct injuries occurred during cholecystectomy were treated between 1994 and 2007. This study includes 62 patients who were referred to our Unit in the acute stage of the complication. The injury was intraoperatively identified in 21 patients (conversion to open surgery in 19, cholangiography in 2; attempted repair in 20 and simple abdominal drainage in 1), with 6 re-operations for choleperitoneum; it was postoperatively identified in 41 patients (obstructive jaundice in 7 and biliary fistula/choleperitoneum in 34), with attempted repair in 27. After referral to our Unit, 7 patients with jaundice underwent hepaticojejunostomy (Hepp-Couinaud). With regard to the 55 patients with bile leak (of whom 12 reoperated on immediately due to choleperitoneum), 13 with minor injury/cystic stump leak underwent endoscopic/conservative treatment. As regards the 42 patients with major injury, 3 died from sepsis prior to repair, 15 with partial common bile duct (CBD) transection underwent endoscopy with stenting, and 24 with complete CBD transection/complex injury underwent surgical reconstruction at a mean distance of 90 days from cholecystectomy, after fully recovering from acute problems. Results Three patients (4.8%) died from sepsis before any repair. The 7 surgical reconstructions for simple jaundice and the endoscopic/conservative treatments for minor injury/partial CBD transection yielded excellent/good results. The 24 surgical reconstructions for complete CBD transection/complex injury yielded excellent/good results; in 4 cases treatment was completed with percutaneous dilatation. Conclusions This analysis demonstrates that early referral and management of iatrogenic bile duct injuries in a specialised multidisciplinary centre are of fundamental importance for patient prognosis and yield good results.