Abstract

MANAGING CBD INJURY IS A CHALLENGING TASK - AN ANALYSIS

Dr. Purujit Choudhury and Dr. Abhijit Sarma*

ABSTRACT

L H Blumgart pointed out that “it is important to remember that cholecystectomy is a major operation and should never be undertaken lightly”. According to him incidence is 1 in 300-500 gallstones operations. The clinical presentation, management and outcome of all patients with bile duct injury who presented to our institute at various stages after cholecystectomy were studied. The patients were categorized into three groups; group A – patients in whom the injury was detected during cholecystectomy, group B – patients who presented within 2 weeks of cholecystectomy and group C – patients who presented after 2 weeks of cholecystectomy. Our team performed „on-table‟ repair for injuries occurring in another unit as and when informed. Or when referred from other hospital. Strasberg classification of bile duct injury was followed. In group A, partial and complete transactions were managed by repair over T-tube and high hepaticojejunostomy, respectively. Patients in group B underwent endoscopic retrograde cholangiogram and/or magnetic resonance cholangiogram to evaluate the biliary tree. Those with intact common bile duct underwent endoscopic papillotomy and stenting in addition to drainage of intra-abdominal collection when present.(endoscopy was done by gastroenterologist in our institute). For those with complete transaction, early repair was considered if there was no sepsis. In presence of intra-abdominal sepsis an attempt was made to create controlled external biliary fistula. This was followed by hepatico jejunostomy at least after 3 months. Group C patients underwent hepaticojejunostomy at least after 3 months. Group C patients underwent hepaticojejunostomy at least 6 weeks after the injury. The outcome was graded into four categories:grade A-no clinical symptoms, normal LFT; grade B-no clinical symptoms, mild derangement of LFT or occasional episodes of pain or fever; grade C-pain, cholangitis and abnormal LFT; grade D-conditions demanded surgical revision or dilatation. Seventy five patients were included in the present study and the distribution was in group A-six patients, group B-forty five patients and group C-twenty four patients. In group A, one patient with complete transaction of the right hepatic duct (type C of Strasberg) and partial injury to left hepatic duct (LHD) underwent right hepaticojejunostomy and repair of the LHD over stent. Two patients with type D and three patients with type E- 2 injury underwent repair over T-tube and hepaticojejunostomy, respectively. In group B, all except one patient out of twenty five patients with type A injury underwent endoscopic papillotomy and stenting. The bile leak subsided at a mean interval of eleven days in all, except one patient who died of fulminate sepsis. Of the remaining twenty patients with type E injury, five underwent hepaticojejunostomy (HJ) after a minimum gap of three months. Early repair was considered in fifteen patients. Twenty four patients in group C underwent hepaticojejunostomy. In a mean follow-up of 36-40 months, the outcome was as- grade A in sixty eight patients, grade B in six patients (two from each of the three groups) and grade D in one patient (group C). The latter patient with a type E3 injury developed recurrent stricture and cholangitis necessitating percutaneous transhepatic dilatation. Due to proper timing, appropriate technique and superior tertiary care the high success rate of bile duct repair in the present study can be achieved.

Keywords: Cholecystectomy. Benign biliary stricture. Bile duct injury(BDI), Liver function test ( LFT).