Surg Endosc (1995) 9:29-36

Surgical Endoscopy

© Springer-Verlag New York Inc. 1995

Complications after laparoscopic cholecystectomy

C o o r d i n a t e d r a d i o l o g i c , e n d o s c o p i c , a n d s u r g i c a l t r e a t m e n t

M. Bezzi, 1 G. Silecchia, 2 F. Orsi, 1 A. Materia, 2 F. M. Salvatori, 1 F. Fiocca, 3 A. Fantini, 2 N. Basso, 2 P. Rossi 1

Department of Radiology, III Cattedra, University of Rome "La Sapienza," 00161 Rome, Italy z Department of Surgery, VII Patologia Chirurgica, University of Rome "La Sapienza," 00161 Rome, Italy

Department of Surgery, II Clinica Chirurgica, University of Rome "La Sapienza," 00161 Rome, Italy

Received: 21 December 1993/Accepted: 10 June 1994

Abstract. The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic chole- cystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical ap- proach were assessed.

From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained com- mon bile duct (CBD) stones, and one had a minor cys- tic duct leak. Five patients had miscellaneous abdom- inal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iat- rogenic lesions was mainly made by endoscopic retro- grade cholangiography (ERCP) (n = 15), associated in six cases also with percutaneous cholangiography (PTC). "Minimally invasive" treatment included the full range of endoscopic and interventional radiologi- cal procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with re- sidual CBD stones, and four patients with abdominal collections were treated by "minimally invasive" techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was nec- essary in 7/23 patients (30%), because of ductal lesion (n = 4), ductal stricture by endoloop (n = I), iliac artery injury (n = 1), and phlegmon of gallbladder bed (n = l).

It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging. After a first diagnostic phase, complications should be man- aged by a multidisciplinary approach wherein the ra- diologist and the endoscopist strictly cooperate with

Correspondence to: M. Bezzi

the surgeon in order to obtain an immediate relief of the initial clinical problem, such as jaundice, bile leak, or infection, and then plan a definitive treatment which is tailored to each patient's problem. Using this ap- proach the whole event of LC and its complications can be managed within the field of minimally invasive therapy in most cases.

Key words: Complications - - Bile duct injuries - - Co- ordinated approach

The introduction of laparoscopic cholecystectomy (LC) has caused a real "revolution" in the surgical treatment of symptomatic gallbladder diseases. The new technique is "minimally invasive"; it allows a short hospital stay, a decreased postoperative pain with an early post-operative recovery, a better cos- metic result, and, finally, a reduction of costs. All these features prompted unconditioned world-wide ac- ceptance of the procedure by both surgeons and pa- tients, so in the last 6 years, since Dr. Mouret's first LC in 1987, open cholecystectomy has gradually be- come the second choice in the surgical management of gallbladder symptomatic diseases.

LC compares favorably with the conventional op- eration regarding morbidity and mortality, although a slightly higher incidence of biliary injury after LC has been reported [22]. The safety of LC has been there- fore established in referral centers with large series of laparoscopic procedures, but not in centers that are starting their experience and are still in the "learning curve. ' '

Complications after LC will probably become more and more infrequent but in certain instances they can

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still be devas t a t i ng . The i n t e r v e n t i o n a l r ad io log i s t and the e n d o s c o p i s t a re o f ten a s k e d to he lp the re fe r r ing su rgeon in the d i agnos i s and t r e a t m e n t o f such com- p l i ca t ions [2, 23]. T h e r e is, in fac t , a gene ra l t r end a m o n g su rgeons to e m p h a s i z e the " m i n i m a l l y inva- s i v e " t echn iques so tha t L C ' s c o m p l i c a t i o n s a re man- aged wi th in the f ie ld o f " m i n i m a l l y i n v a s i v e " t h e r a p y . The p u r p o s e o f this s t u d y was to r e v i e w our exper i - ence in the m a n a g e m e n t o f c o m p l i c a t i o n s af te r L C and d i scus s the ro le o f a m u l t i d i s c i p l i n a r y a p p r o a c h wh ich is t a i l o red a c c o r d i n g to the t y p e o f l e s ions encoun - te red .

Materials and methods

From April 1991 to October 1993, 23 patients (6 men, 17 women; age range 25-73 years, average age 49 years) were referred to us because of LC-related complications. Three LCs had been performed in our hospital; 20 patients had undergone surgery in other institutions and were subsequently referred to us for the treatment of complications. Because of this referral, the total number of LCs represented in this series is unknown; also, the real number of complications after LC in this patient population is unknown. In the same time period the number of LCs performed in our institution was 785.

The patients presented from 2 to 180 days after LC (mean, 30 days). All surgical procedures had been performed with the standard technique [14] using blunt dissection and electrocautery coagula- tion. Cystic-duct cholangiography was performed in five cases. Two cases were converted to open surgery: in one patient an iliac artery injury occurred on insertion of the umbilical trocar; in an other case the common bile duct (CBD) was transected and repaired with an end-to-end coledochal anastomosis and T-tube insertion. In five other cases the possibility of a complication had been suspected at the time of LC.

All data regarding the patients are summarized in Table 1. The type of complications encountered were subdivided into dif-

ferent groups:

1. Biliary strictures (n = 7). Five patients presented with CBD strictures: two probably caused by ischemic injury, one after end-to-end choledochal anastomosis, and two due to a cystic duct ligature (endoloop or clip) partially incorporating the com- mon duct; two patients had high hilar strictures (Bismuth types 4 and 5 [3]) due to extensive cauterization for bleeding and subse- quent formation offibrotic scar tissue around the hilar confluence [10].

2. Biliary injuries (n = 5). Two patients had complete transection of the CBD, one presented with transection of an aberrant right hepatic duct, and two patients had minor lesions of right hepatic duct and fifth segment accessory duct.

3. Retained CBD stones (n = 5). 4. Miscellaneous fluid collections (n = 5): one liver abscess, one

perihepatic phlegmon, one subhepatic hematoma, one infected biloma with dropped stones, and one retroperitoneal haematoma.

5. Minor leaks (n = 1): One patient presented with bile leak from the cystic duct, probably due to a misplaced clip, without evi- dence of biliary injury.

Coleperitoneum, defined as the presence of a large amount of con- centrated bile into the peritoneal cavity, and biloma, defined as a confined collection of bile [11], were present in 10 patients and were associated with ductal injury (n = 6), retained stones (n = 2), or ductal strictures (n = 2).

Imaging tests used for the diagnosis of complications included ultrasound (US) (n = 15), computed tomography (CT) (n = 8), percutaneous transhepatic cholangiography (PTC) (n = 6), endo- scopic retrograde cholangiography (ERCP) (n = 15), and HIDA scanning (n = 5).

The interventional radiological procedures performed included percutaneous biliary drainage (PTBD) alone or in association with balloon dilation of strictures or stone extraction and CT or US guided drainage of fluid collections. Endoscopic procedures in- cluded sphincterotomy, positioning of plastic endoprosthesis, or na-

sobiliary drainage. All radiological and endoscopic procedures were performed in a standard fashion according to techniques extensively described in the literature.

Results

Biliary strictures (n = 7)

Six pa t i en t s we re m a n a g e d b y m i n i m a l l y i nvas ive p ro- c edu re s and one b y surgery .

The two pa t i en t s wi th B i s m u t h t y p e 4 and 5 s t r ic- tu res , due to e x t e n s i v e c a u t e r i z a t i o n , u n d e r w e n t bo th r ight- and l e f t - s ided P T B D ; the s t r i c tu res w e r e subse - quen t ly d i l a t ed wi th 8 -10- ram h igh -p re s su re b a l l o o n ca the t e r s (Medi - t ech , W a t e r t o w n , M A ) and b i l a t e ra l ex t e rna l - i n t e rna l d ra inage c a t h e t e r s we re left in p l a c e in o r d e r to s ten t the d i l a t ed s egmen t s .

O n e p a t i e n t w i th a p r i m a r y C B D s t r i c t u r e was t r ea t ed wi th P T B D and ba l l oon s t r i c tu re d i l a t ion ; she had to be d i la ted th ree t imes wi th a 10-mm b a l l o o n c a t h e t e r dur ing a p e r i o d o f 10 m o n t h s , s ince the s t r ic- ture r e c u r r e d af te r the f irst two d i la t ions . A n o t h e r pa - t ien t wi th a s imi lar s t r i c tu re was m a n a g e d b y endo- scop ic s p h i n c t e r o t o m y , ba l l oon d i la t ion o f the s t eno- sis, and p l a c e m e n t o f a p l a s t i c s ten t (Fig. 1).

One pa t i en t had s e c o n d a r y C B D s t r i c tu re due to an end - to - end c h o l e d o c h a l a n a s t o m o s i s p e r f o r m e d to re- pa i r a C B D t r ansec t i on ; she a lso was t r e a t ed b y endo- scop ic s p h i n c t e r o t o m y , e n d o s c o p i c b a l l o o n d i la t ion o f the s t r i c tu re , and p l a c e m e n t o f a p l a s t i c s tent .

One pa t i en t wi th the C B D sl ight ly n a r r o w e d b y a cl ip u n d e r w e n t e n d o s c o p i c n a s o b i l i a r y d r a i n a g e wi th p l a c e m e n t o f an e n d o p r o s t h e s i s . F ina l l y , one pa t i en t wi th the C B D s t r i c tu red by an e n d o l o o p had o p e n sur- ge ry for r e m o v a l o f the suture .

F o l l o w - u p r anged f rom 3 to 24 m o n t h s , wi th a m e a n o f 11.4 mon ths ; t h r ee pa t i en t s had ea r ly succe s s a f te r t r e a tmen t , whi le two pa t i en t s wi th C B D s t r i c tu re and two pa t i en t s wi th hi lar s t r i c tu res a re c u r r e n t l y be ing m a n a g e d wi th ongo ing e n d o s c o p i c o r p e r c u t a n e o u s t r e a t m e n t (Table 1).

Biliary lesions (n = 5)

One pa t i en t wi th a l e s ion o f an a c c e s s o r y duc t o f the fif th s egmen t cou ld be t r e a t ed b y e n d o s c o p i c nasob i l - ia ry d ra inage , w h i c h a l l owed for succes s fu l b i l i a ry di- ve r s i on and l eakage seal . This was the on ly p a t i e n t wi th a b i l i a ry les ion tha t cou ld be t r e a t e d by m i n i m a l l y i nvas ive t echn iques .

The o t h e r fou r pa t i en t s w i th b i l i a ry l e s ions had open surgery . One case o f C B D t r a n s e c t i o n u n d e r w e n t open su rge ry for a c h o l e d o c h a l a n a s t o m o s i s i m m e d i - a te ly af te r d i agnos t i c E R C P . T h e o t h e r pa t i en t w i th high C B D t r a n s e c t i o n u n d e r w e n t l e f t - s ided P T B D in o r d e r to d ive r t the bi le f low and a l low for c o r r e c t iden- t i f ica t ion o f the left hepa t i c duc t a t su rge ry ; she was d e f i n i t i v e l y t r e a t e d w i t h a R o u x - e n - Y h e p a t i c o - j e j u n o s t o m y .

The ind iv idua l wi th a t r a n s e c t e d r ight a b e r r a n t duc t was in i t ia l ly t r e a t e d b y a r ight P T B D , wi th the c a t h e t e r p l a c e d in the i n t r ahepa t i c duc t s of the s ix th s e g m e n t

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Table 1. Data on patients with complications after laparoscopic cholecystectomy a

Patient Days Biloma Diagnostic no./ Sex/ after or imaging initials Age LC Complication Coleperit. tests

Interventional radiologic procedure

Endoscopic procedures Surgery Follow-up

1/CA M/61 7 Transection of yes PTC, ERCP, aberrant CT, HIDA right hepatic duct

2/ML F/58 30 Parietal lesion yes HIDA, US, of right ERCP hepatic duct

3/NM F/32 10 Lesion of 5th yes HIDA, TC, segment ERCP accessory duct

4/EL F/53 5 CBD yes US, ERCP occlusion by endoloop

5/FG M/43 21 Residual CBD yes PTC, US, stone CT

6/CE M/66 33 Peri-hepatic no CT, US phlegmon

7/LD M/73 20 Abscess of the no US, CT right hepatic lobe

8/FM F/69 6 CBD yes US, ERCP, transection CT, PTC

9/PN F/67 20 CBD stricture no US, PTC 10/RA F/28 15 Lesion of left no CT, ANGIO

iliac artery + retroperitoneal hematoma

ll/PO F/36 18 CBD stricture yes US, ERCP, by clip CT

12/PD F/41 40 CBD residual no US, ERCP stone

13/LD M/55 30 CBD residual yes US, ERCP stone

14/LT F/47 37 CBD residual no US, ERCP stone

15/ZU F/34 7 CBD residual no US, ERCP stone

16/OD F/39 6 Leak from no US, ERCP cystic duct stump

17/NM F/25 6 Subhepatic no US hematoma

18/SP F/41 64 Hilar stricture no ERCP, PTC

19/VA F/43 2 Infected yes US biloma

20/AC M/39 110 Hilar stricture no HIDA, PTC

21/PL F/35 180 Stricture of no ERCP "end-to-end" choledochal anastomosis

22/FM F/68 15 CBD stricture no ERCP

23/AG F/72 5 Choledocohal yes HIDA, ERCP transection

PTBD

PFCD

PFCD

BD, PSR

PFCD

PTBD, BD

PTBD PFCD

PFCD

PFCD

PFCD

PTBD, BD

PFCD

PTBD, BD

Failed EE

NBD, SPH

NBD, EE

SPH, ESR

SPH, ESR

SPH, ESR

SPH, ESR

SPH

SPH

SPH, EE

NBD, EE

Biliary Cured diversion on Roux-en-Y loop

Lesion repair, Cured surgical sphincterotomy + stent

Cured

Endoloop Cured removal

Cured

Debridement Cured of the gallbladder fossa

Cured

Roux-en-Y Anastomotic hepatico- stricture jejunostomy

Surgical patch on arterial lesion

Cured Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Under treatment

Cured

Under treatment

Under treatment

End-to-end choledochal anastomosis

Under treatment

Cured

a CBD = common bile duct; PTC = percutaneous transhepatic cholangiography; ERCP = endoscopic retrograde cholangiopancreatography; CT = computed tomography; US = ultrasound; PTBD = percutaneous transhepatic biliary drainage; PFCD = percutaneous fluid collection drainage; BD = percutaneous balloon dilation; PSR = percutaneous stone removal; NBD = naso-biliary drainage; EE = placement of endoscopic endoprostheses; SPH = endoscopic sphincterotomy; ESR = endoscopic stone removal

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Fig. 1. CBD stricture, bile leak, and coleperitoneum. Thirty-seven-year-old female presenting 18 days after LC with abdominal pain and malaise. An ultrasound study (not shown) indicates the presence of abdominal fluid. A ERCP demonstrates a tight stricture of the middle third of the CBD, at the level of the metallic clips (arrow). B A naso-biliary tube is placed above the stricture and a bile leak is proven (arrowhead). ACT scan C shows that the fluid collection, opacified by the leaking contrast medium, extends in the left subphrenic space and is amenable to percutaneous drainage. The combination of nasobiliary drainage and percutaneous drainage of the bile collection is successful in managing the bile leak. The stricture is treated by placement of an endoscopic endoprostheses D which is removed after 4 months. The patient is asymptomatic at a follow-up of 11 months.

draining into the aberrant duct, and subsequently by a biliary-enteric diversion with a Roux-en-Y loop anas- tomosed onto the t ransected duct. The catheter placed transhepatical ly through the t ransected duct played an important role since it was used by the surgeon to localize the leaking site and for temporar i ly stenting (3 weeks) the anastomosis (Fig. 2).

Finally in the case with a parietal lesion of the right hepatic duct the injured segment was too high and could not be reached endoscopical ly for placement of a plastic stent. Open surgery was therefore per formed in order to repair the injury, per form sphincterotomy, and place an endoscopic endoprosthesis to stent the

repaired segment. The endoprosthesis was r emoved after 4 months by the endoscopist .

During the follow-up, the patient with a Roux-en-Y hepat ico-jejunostomy developed an anas tomot ic stric- ture after 7 months and is currently being managed by left and right percutaneous balloon dilation. The other three patients have been asymptomat ic after t rea tment (follow-up range 5-30 months; mean 23.2 months) .

R e t a i n e d s tones (n = 5)

All retained stones were removed by minimally inva- sive procedures; four patients had endoscopic sphync-

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Fig. 2. Transection of right aberrant hepatic duct. Sixty-one-year-old male presenting with persistent bile drainage through a subhepatic tube placed at the time of LC. A ERCP shows a small leak from the cystic duct stump and incomplete opacification of the intrahepatic right biliary tree (arrowhead indicates subhepatic drain). A nasobiliary drain is placed with no resolution of bile discharge. A PTC B opacities the intrahepatic bile ducts of segments 5, 6, and 7, which do not communicate with the CBD but drain through a small leak (arrow) directly into the subhepatic biloma, The clip in close proximity to the leak indicates that the aberrant duct has been injured during dissection of the cystic duct. C A transhepatic drainage (arrowhead) is placed through the transected duct and used by the surgeon to localize the leaking site, while performing a biliary-enteric diversion with a Roux-en-Y loop. The same catheter is left in place in order to temporarily stent the anastomosis for 3 weeks after surgery.

terotomy and stone extraction (Fig. 3). In one patient who had undergone partial gastrectomy with Billroth- II reconstruction 10 years before, endoscopy was un- successful; PTBD was then performed, the papilla was dilated with a 10-mm angioplasty balloon catheter, and the stone was pushed into the bowel. All patients are alive and well at follow-up.

Fluid collect ions (n = 5)

Fluid collections were successfully drained percutane- ously in four patients. One patient with a liver abscess had a 14F catheter placed under CT guidance. One patient with a subhepatic haematoma (Fig. 4) and one with an infected biloma due to a leak from the cystic duct had percutaneous 12F catheters placed under US

guidance. The patient with right retroperitoneal he- matoma due to lesion of the right iliac artery had sur- gical repair of the arterial lesion with a synthetic patch; the hematoma was drained under CT guidance by placement of two 14F catheters. One patient presented with a perihepatic phlegmon due to retained fragments of an infected gallbladder wall and had open surgery for debridement of the gallbladder fossa.

None of the patients had recurrence of symptoms or evidence of recurrent fluid collections.

Minor leaks (n = 1)

This patient had persistent bile drainage through a sur- gical tube placed at time of LC. ERCP demonstrated a small leak at the level of the cystic duct stump, prob-

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Fig. 3. Retained CBD stone. Thirty-four-year-old female presenting 7 days after LC with right-upper-quadrant pain and increase in serum bilirubin (patient No. 15). A ERCP shows one residual stone in the distal portion of the CBD (arrow). B After endoscopic sphincterotomy the stone (arrowheads) is removed by means of a wire basket. Fig. 4. Subhepatic hematoma. Twenty-five-year-old female referred 6 days after LC for right-upper-quadrant pain and fever (patient No. 17). A Longitudinal ultrasound scan of the right lobe of the liver demonstrates a multiloculated fluid collection around the liver edge (H = hematoma; L = liver). B Under ultrasound guidance a pigtail catheter with multiple side holes is placed within the fluid collection. The patient was discharged after 2 days and came as an out-patient for definitive catheter removal after 12 days.

ably due to an incorrect ly placed clip, without evi- dence of either CBD or cystic duct lesion. The patient was successfully managed by endoscopic sphincterot- omy alone and has been free of symptoms since then.

Bi lomas or co leper i toneum (n = 10)

Bile collections were successfully drained percutane- ously in six patients. US guidance was used in five cases and f luoroscopic guidance in one case, using the clips on the cystic duct as a target. In the other four patients the bile collections were drained at the time of open surgery per formed to correct a biliary complica- tion.

Discussion

L a p a r o s c o p i c c h o l e c y s t e c t o m y has rapidly gained populari ty as an alternative to conventional cholecys- tec tomy in the t rea tment of symptomat ic gallbladder disease. The rapid acceptance of laparoscopic chole-

cys tec tomy and the increasing demand for this proce- dure have been surprising when one considers that it is still unclear at present if LC can match the safety of open cholecys tec tomy as a "gold s tandard" in the t reatment of cholelithiasis or if the main advantages will be cost savings due to short hospital stay and early return to work. It seems, however , that LC is here to stay, and therefore one has to accept its several ben- efits as well as its complete set of complications.

Complications of LC are well analyzed in several large surgical reports and include those of any laparo- scopic procedure (abdominal or retroperi toneal vessel injury, bowel or bladder perforation, abdominal wall bleeding or wound infection) and those c o m m o n also to cholecys tec tomy (bile duct injury, bile leakage, re- tained CBD stones, infection and bleeding f rom the gallbladder fossa) [4, 22].

Injuries to the extrahepatic bile ducts are a major cause of concern in LC. In open cholecys tec tomy, the incidence of CBD injury is an est imated 0.07-0. I% [I, 12]. For LC the data are highly variable. Initial studies quoted an incidence of CBD injuries ranging f rom 0 to 7% [9, 13-15, 17, 18, 20, 26] while more recent reports showed an incidence of 0.2-0.3% [6, 21, 22, 27]. Given

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this risk rate and a total number of approximately 500,000 cholecystectomies performed each year in the United States, an estimated 1,000-1,500 patients per year would suffer a CBD injury after LC, a number two to three times greater as compared to open chole- cystectomy.

Initially Zucker used the phrase "learning curve" and postulated that complication rates would decrease as surgeons acquired more experience with the new technique [27]. This is desirable, but there are reasons for concern that the incidence of complications may even increase. First, the initial data reported on CBD injuries after LC originated from series of healthy, low-risk patients, and the possibility of higher injury rate as patient population is less strictly selected re- mains. Second, the widespread diffusion of the tech- nique to primary-care centers means that in the near future there will be an even larger number of surgeons who have not yet performed their first 10-15 proce- dures and are in the "learning curve." Third, since biliary strictures can occur months to years after sur- gery, the real incidence of CBD will be known only after a 5-10-year follow-up period has elapsed.

When a biliary lesion is suspected at the time of operation, accurate diagnosis of the injury must be made by intraoperative cholangiography or intraoper- ative ERCP, and the lesion should be immediately re- paired [7]. The long-term results of delayed repairs are, in fact, inferior to those obtained with repairs per- formed at the time of injury [25].

Unfortunately, most biliary injuries are not recog- nized during LC; therefore, it is extremely important to be aware of any untoward symptom early in the postoperative period. As suggested by Morgestern et al. [11], any patient who presents with unusual abdom- inal discomfort, anorexia, nausea, lack of appetite, or listlessness the day after LC should be suspected of having a possible complication. If this symptom is ac- companied by abdominal distension, low-grade fever, and/or leukocytosis, further diagnostic imaging tests are necessary. In such situations HIDA scan is the imaging test indicated to rule out major bile leak [24]. US is also useful in the detection of postoperative fluid collections; however, clinically irrelevant collections in the gallbladder bed after LC are seen in 53% of patients [8], and both US and CT are unable to dem- onstrate the presence of bile within such collections. If the HIDA scan is positive for bile extravasation, the patient may be referred to the endoscopist or the ra- diologist. In our institution we prefer to perform an ERCP first, followed by a PTC, which is indicated case by case, according to the ERCP findings. It is at this point of the post-operative course that both the radiologist and the endoscopist start playing a major role in the treatment of the patient, in strict coopera- tion with the surgeon. This coordinated management to the patient's problem usually takes place through three consecutive phases.

First phase: The diagnosis of a complication should be made readily and the level of the problem should be determined carefully. Most CBD strictures and leaks from the cystic or common bile duct can be diagnosed by ERCP. In hilar strictures (Bismuth type 3-5), a PTC

is necessary in order to assess the degree of stenosis and the number of ductal systems involved. PTC is essential also in case of transection of the right aber- rant duct: As observed in one case of our series, only by PTC could the real extent of liver parenchyma drained by the aberrant duct be determined and could the site of transection identified [16].

Second phase: The initial clinical problem, such as jaundice, bile leak, or infection, should be relieved by "minimally invasive" techniques so that in a few days the clinical conditions of the patient improve and de- finitive treatment can be undertaken.

If the ERCP demonstrates a leak from the cystic duct, a CBD stricture, or a retained stone, the endos- copist should immediately place a plastic endoprosthe- ses or a nasobiliary drain or should perform a sphinc- terotomy with CBD clearance. All three procedures decrease ductal pressure and in our series have proven successful in managing cystic duct leaks or minor duc- tal lesions. In case of tight CBD strictures, the endo- scopic placement of a plastic endoprosthesis is often a temporizing maneuver performed to relieve jaundice until more definitive treatment is undertaken, either surgically or by percutaneous balloon dilation.

Retained stones are the obvious domain of the en- doscopist: sphincterotomy and stone extraction was successful in four of five patients with CBD stones of our series. PTBD is a "minimally invasive" alterna- tive for stone removal, if ERCP fails as observed by us in one case.

When ERCP demonstrates transection of a major duct, surgery is usually indicated for either primary repair or anastomotic reconstruction; in such cases im- mediate PTBD can be performed to establish external bile diversion and prevent ongoing bile leakage into the peritoneal cavity.

If among the initial clinical problems there is sepsis or pain due to an abdominal fluid collection, with or without a bile leak, percutaneous catheter drainage un- der US or CT guidance can provide an effective cure.

We observed that the immediate "minimally inva- sive" treatment provided by the interventional radiol- ogist and/or endoscopist in this second phase of man- agement was actually curative in 11/23 cases (48%), and no further procedures were necessary.

The third phase consists of planning the definitive treatment. As mentioned above, ductal transections require open surgery. In two cases of our series (cases 1 and 8), however, a definitive operation was per- formed after PTBD and percutaneous drainage of bile collections had eliminated the factors of obstruction and sepsis. Another major advantage of PTBD per- formed before surgery, and one that we appreciated in both these cases, is that the catheter placed at the level of transection represents a useful intraoperative land- mark for biliary reconstruction and can be used to tem- porarily stent the biliary-enteric anastomosis in the postoperative period, without need for additional cath- eters placed through the anastomosed segment.

Planning definitive treatment does not always in- volve surgery. Nonoperative management of biliary strictures has been reported by several authors and by us [5, 19], and is currently a valid alternative in the

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treatment of patients with strictures recurring after surgical repair, with a success rate of 69-88% [191. We treated seven patients--five patients with primary strictures and two with secondary strictures following surgical repair of a t ransec ted CBD--wi th this method. The strictures were crossed in all cases and balloon dilation with catheter stent placement was possible in all patients. These results contrast with those of Trerotola et al. [23], in whose study only one of five primary strictures following LC could be crossed after several attempts. Four of our seven pa- tients are under treatment and definitive results are still to be evaluated.

Altogether 70% of the patients in this series could be treated by minimally invasive techniques, while open surgery was necessary in 30% of them. These data confirm the hypothesis that in case of suspected biliary tract damage or other major complication after LC, the correct management consists of precise defi- nition of the problem and multidisciplinary planning of the therapeutic steps to be undertaken in order to achieve cure. If this is done under the philosophy of "minimally invasive treatment," approximately two- thirds of patients can avoid laparotomy. We believe that it would be advisable that major complications after LC be treated in referral centers, where multidis- ciplinary expertise can guarantee a tailored treatment for each patient.

Acknowledgment. The authors express their appreciation to Mr. Salvatore Genna (Department of Radiology) for the photographic reproduction.

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