Long-term Results of Biliary Reconstruction After Laparoscopic Bile Duct Injuries

Abstract

HYPOTHESIS: The Hepp-Couinaud approach to biliary enteric reconstruction for laparoscopic bile duct injuries provides a durable, long-term result in most patients. DESIGN: Retrospective study of patients who underwent operative repair of laparoscopic bile duct injuries from January 1990 through December 1997. SETTING: Academic tertiary referral center. MAIN OUTCOME MEASURES: Outcome was assessed using a grading system based on clinical symptoms, liver function tests, and need for reintervention for anastomotic stricture. The Kaplan-Meier method was employed to estimate stricture-free survival. RESULTS: Fifty-nine consecutive patients underwent operative repair of the following laparoscopic bile duct injuries (Strasberg classification): B: n = 2 (3%), C: n = 1 (1%), D: n= 2 (3%), E1: n= 5 (8%), E2: n= 16 (27%), E3: n= 25 (42%), E4: n = 5 (8%), and E5: n = 3 (5%). Forty-seven patients (80%) had 1 or more interventions prior to the index repair. The extrahepatic left bile duct (Hepp-Couinaud approach) was used in 46 of 53 patients who underwent a Roux-en-Y hepaticojejunostomy. Follow-up (mean+/-SEM, 3.7+/-0.3 years) was complete in 54 of the 57 patients still alive. Five patients developed subsequent anastomotic strictures and were treated with percutaneous transhepatic dilation (n = 3), endoscopic dilation (n = 1), and operative revision (n= 1). Excellent to good long-term results were achieved in the remaining 49 patients (91%). Life-table analysis yielded 95% and 88% chances of stricture-free survival at 2 and 5 years, respectively. CONCLUSIONS: Complex iatrogenic proximal bile duct injuries and strictures are amenable to operative repair using the extrahepatic left bile duct. The Hepp-Couinaud approach offers a durable result in more than 90% of patients, even after previous interventions have failed.