Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review

Traumatic and iatrogenic extrahepatic biliary tract injuries are rare but may lead to exceedingly morbid complications. Traumatic extrahepatic biliary tract injuries represent less than 1 per cent of all traumatic injuries. Iatrogenic injuries result in 0.2 to 1 per cent of laparoscopic or open cholecystectomies. The objective of this study was to review the incidence of biliary tract injuries--iatrogenic as well as traumatic--and their subsequent management. A multi-institutional chart review was done including Louisiana State University Health Sciences Center (LSUHSC)-Shreveport, LSUHSC-Monroe, and Richland Parish medical centers. Charts were reviewed for patients with iatrogenic biliary tract injuries and those with biliary tract injuries related to noniatrogenic trauma. The etiology of the biliary tract injury, symptoms of injury, pertinent laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, days hospitalized, intensive care unit stay, and complications were reviewed. There are 1500 trauma patients admitted to LSUMC-Shreveport each year. The incidence of biliary tract injury in trauma patients admitted to LSUMC is 0.1 per cent. Traumatic injuries were classified according to the injury scale by Mattox et al. (Trauma 1996; Vol 515). There were five Type II, four Type IV, and two Type V injuries. Five patients underwent cholecystectomy, three had endoscopic retrograde cholangiopancreatography with stent placement, and two had choledochojejunostomy; one patient died from associated injuries. There were no complications of repair. Approximately 220 cholecystectomies are done at LSUMC-Shreveport each year. Eighty-eight per cent are laparoscopic, and 12 per cent are open. The incidence of iatrogenic biliary tract injuries at LSUMC-Shreveport during the past 8 years was 0.2 per cent. Immediate diagnosis of iatrogenic injuries was made in five of 17 cases and eight of 11 trauma cases. Laparoscopic injuries were classified by the Way injury classification (Stewart L, Way LW. Arch Surg 1995;130:1123). There were one Type I, one Type II, and nine Type III injuries. Treatment included suturing of the laceration (n = 1), hepaticojejunostomy (n = 8), and primary repair (n = 2). Open injuries were classified using the Bismuth classification. There were one Type I and three Type III injuries. All were treated with hepaticojejunostomy. There were two iatrogenic injuries unrelated to cholecystectomy. One patient suffered a perforation of the gallbladder during laparoscopic nephrectomy. This patient subsequently underwent cholecystectomy and has done well. The second patient suffered ligation of the intraduodenal portion of the common bile duct during hemigastrectomy and oversewing of a duodenal ulcer. This patient underwent hepaticojejunostomy and has done well. Complications of iatrogenic injury repair included leaking of a repaired laceration (n = 1), failed hepaticojejunostomy (n = 1), and an anastomotic stricture after hepaticojejunostomy (n = 1). Laparoscopic injuries by LSUMC hospitals is 0.2 per cent. Extrahepatic biliary tract injuries resulting from open cholecystectomy were diagnosed later than those occurring during laparoscopic cholecystectomy and were most likely to result in stricture formation. Repair of Way Type II and III injuries is associated with a higher complication rate. Hepaticojejunostomy has a complication rate of 15 per cent. Minor common duct lacerations are amenable to conservative therapy with oversewing and/or endoscopic retrograde cholangiopancreatography with stent placement. Repair of extrahepatic biliary tract injuries with hepaticojejunostomy at a level of good blood supply remains our gold standard for treatment of more severe injuries and strictures.