European Review for Medical and Pharmacological Sciences
2000; 4: 123-126
Conservative approach in the treatment of
the biliary tract’s iatrogenic lesions
G. SPORTELLI, M. CROVARO, M. MERCURI*, A. CARRARA, S. GIRI, F. FIOCCA
Department of Surgery Paride Stefanini, La Sapienza University - Rome (Italy)
*
Istituto di Clinica Chirurgica Generale, Catholic University of Sacro Cuore - Rome (Italy)
Abstract. – Iatrogenic lesions of the biliary tract have always represented a problem of
real actuality in the abdominal surgery. The incidence of post-cholecystectomy complications is from 0.1% to 0.25% and it’s increased
to 0.3-0.6% for laparoscopic surgery. Potential
predisposing factors to iatrogenic biliary lesions are anatomic anomalies, acute and
chronic phlogosis and technical mistakes.
Anatomic anomalies are present in 6-25% of all
cases according to different statistics; an incomplete knowledge of the biliary tract can predispose to a mistake legating or dissecting a
wrong branch.
This paper present a caseload of 27 patients
admitted to our Service of Digestive Endoscopy
owing to post laparoscopic cholecystectomy
complications. Patients have been recruited in a
period from two days to six months to the intervention. Detected complicances have been divided in “major”, which comprehended biliary
lesions (7 cases) and biliary stenosis (8 cases),
and in “minor” which included biliary leakages
(12 cases). CPRE, PTC, Ultrasound, CT and
cholangio-MR were used to diagnose the biliary
damage.
Conservative approach has been resolutive in
all patients with minor biliary lesions and in
three cases of major lesions; in seven cases of
biliary stenosis endoscopic-radiologic combined treatment has been successfully performed, in the other patients surgical operation
was obliged choice.
Comparing our results with literature we can
affirm that conservative treatment represents
the first choice in case of minor lesions (100% of
successes), whereas in case of major biliary lesions it constitutes a valid alternative to the
reparative surgery; when surgical option results
impossible to defer, it can help the surgeon
identifying the damage and draining the biliary
tract.
Key Words:
Iatrogenic lesions, Biliary tract, Laparoscopic
surgery.
Introduction
Iatrogenic lesions of the biliary tract have
always represented a problem of real actuality in the abdominal surgery.
The incidene of post-cholecystectomy complicances is comprised between 0.1% and
0.25% and it’s increased to 0.3-0.6% for laparoscopic surgery.
The fast development of the laparoscopic
technique has certainly changed the risk factors for biliary lesions wich are actually represented by surgeon experience and training,
acute and chronic phlogosis, thermic injuries
by electric scalpel or laser and anatomical
varaints.
Causes responsible of the iatrogenic damage are currently divided in two groups:
wrong identification of the cystic duct and
technical causes as bed use of metal clips or
eccessive traction on the Calot’s triangle.
Casistic
In this study we have included 27 patients
admitted to the Special Service of Digestive
Endoscopy of II° Surgical Clinic owing to
post laparoscopic choleystectomy complicances.
The sample group was composed by 17
male and 10 female patients from 29 to 85
years old. Patients have been recruited in a
period comprised between two days and six
months to the intervention. Detected complicances have been devided in “major”,
which comprehended biliary lesions (7 cases) and biliary stenosis (8 cases), and in “minor” which included biliary leakages (12 cas123
G. Sportelli, M. Crovaro, M. Mercuri, A. Carrara, S. Giri, F. Fiocca
es). Patients with biliary fistula referred
manifestations attributable to choleperitoneum; patients with biliary stenosis presented symptoms of cholestatic jaundice
more or less intense. CPRE, PTC, US, TC
and cholangio RMN were used to diagnose
the biliary damage.
Results
Conservative approach has been resolutive
in all patients with minor biliary lesions: all
leakages from cystic duct were resolved by
endoscopic sphincterectomy and by positioning an endoscopic drainage; follow up of
these patients in one year has demonstrate
the complete solution of the case.
Endoscopic-radiologic combined treatment
has been used in seven cases of biliary stenosis; in one case of biliary costriction we have
recurred to surgical intervention to remove a
wrong positioned endoloop. Four of these
cases have been definitely resolved, the other
ones are still continuing the treatment by periodical substitutions of the stents. In major
lesions endoscopic treatment of the damage
has been performed only in three cases; in
the other ones surgical operation was obliged
choice. Anastomotic stenosis occurred in one
patient submitted to surgery who required
pneumatic dilatations by percutaneous transhepatic access. Follow up of these cases from
tree months to three years have demonstrate
the full welfare of six patients. Our results
show that 22 of 27 patients have been treated
with a non-invasive method; in patients with
tight stenosis and biliary lesions of III° and
IV° type according to Bismuth (four cases in
total) the prolonged treatment raises perplexities about the opportunity either of a continuation of the conservative therapy or of an
adequate surgical correction.
Discussion
Surgical complicances secundary to laparoscopic cholecystectomy represent a topic
of real interest because of the rapid develop124
ment of this method which about in ten years
has almost replaced the traditional surgery.
Incidence of specific complications is about
0.5-5% according to different statistics, two
or three times more than the “open surgery”,
and represents concretely a problem not easy
to solve.
Potential predisposing factors to iatrogenic biliary lesions are anatomic anomalies,
acute and chronic phlogosis, technical mistakes due to improper use of laparoscopic
instruments, thermic or mechanic injuries,
insufficient exposition of the Calots’ triangles structures. Anatomic anomalies are
present in 6-25% of all cases according to
different statistics; an incomplete knowledge
of the biliary tract can predispose to a mistake ligating or dissecting a wrong branch.
Therefore when the laparoscopic thecnique
results difficult to perform because of phlogosis or adherences or when a lesion is suspected, an intraoperative cholangiograpy
should be executed to value the biliary
anatomy, to define the type and the location
of possible lesions and to start an immediate
therapy. Treatment results of tardive discovered lesions are worse than those of cases
submitted to an immediate treatment. In
spite of controversial advices it’s clear that
an intraoperative cholangiography well performed can show the presence of residual
biliary stones or anatomic anomalies and
can reveal damages which could be repared
immediately. All patients included in our
study were submitted to CPRE associated to
PTC in case of serried stenosis with incomplete images of the biliary tract. Bile walled
off in abdomen (10 patients) were drained
by percutaneous puncture. In ten patients
with leakage from cystic duct and in one patient with patency of the Lushkas’ duct endoscopic spincterotomy and positioning of a
trans papillar drainage have resolved the
damage. In the patient with biliary overflow
from an anomalous right duct we recurred
to a combined treatment endoscopic-radiologic to have an exact definition of the hepatic parenchyma drained by the duct and
of the lesions’ location. All patient with biliary stenosis were submitted to CPRE, in
two cases of stenosis of the hepatics’ confluence (Bismuth III and IV) a PTC was necessary to define the stenosis grade and the
number of included ductal stenosis; more-
Conservative approach in the treatment of the biliary tract’s iatrogenic lesions
over combined treatment permitted the positioning two internal external drainages after pneumatic dilatations of the stenosis.
One patient with stenosis due to endoloop
was submitted to a CPRE and successively
to surgical operation to remove the loop.
Two patients of those with biliary lesions
and overflow (4 patients) were treated successfully using CPRE; the other two ones
were operated after unlucky combined attemps to resolve the fistula. Therefore we
assume that mini-invasive treatment should
be the first approach to biliary complicances
because also in case of total transection of
the common bile duct it can bring the patient to surgical intervent in optimal conditions draining and decompressing the biliary
tract; in this case the surgical treatment can
be managed in a steryl aphlogistic field with
minor conseguent complicances. The same
mini-invasive approach appear less standardizable when a lesion or a stenosis of the
common bile duct is present.
In conclusions, laparoscopic cholecystectomy is certaienly the best treatment in
terms of comfort and social coasts; higher elevate incidence of complicances represent
the only blind point of a real valid intervention. Its routinary use associated to an instrumentarium improvment and a standardization of this technique will probably obtain
a decrease of complicances in few years. The
exact exposition of the Calots’ triangles’
structures (common bile duct, cystic duct,
cystic artery), an anatomic dissection of the
gallbladder bed and finally an adequate use
of the electrocoagulation and of the metal
clips seem to be primary assumptions for a
correct laparoscopic cholecystectomy. All
this must be supported by a perfect knowledge of the biliary anatomy; therefore the
intraoperative cholangiography become a
point of extreme importance to recognize
prospective anatomic anomalies and expecially to spot the location of a prospective
biliary lesion. Comparing our results with
licterature we can assert that conservative
treatment represents the first choice in case
of minor lesions (100% of success), whereas
in case of major biliary lesions it constitutes
a valid alternative to the reparative surgery;
when surgical operation results impossible
to refer it can help the surgeon identifying
the damage and draining the biliary tract.
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