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Postcholecystectomy bile duct strictures. Management and outcome in 130 patients
W C Chapman1, A Halevy, L H Blumgart
1Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn., USA.
Objective:
To evaluate management strategies for the treatment of patients with postcholecystectomy bile duct strictures.
Design:
Retrospective study.
Setting:
The Hepatobiliary Unit of Hammersmith Hospital, London, England.
Patients:
One hundred thirty consecutive patients referred for treatment of postcholecystectomy bile duct strictures. The majority (80 patients [61.5%]) had undergone multiple operative procedures before referral, and 81 (62.3%) had undergone at least one previous stricture repair. At referral, more than half of the patients had a stricture involving the confluence of the bile ducts (n = 78 [60%]), and 23 (17.7%) had evidence of portal hypertension.
Main Outcome Measures:
Perioperative mortality, stricture recurrence, and long-term outcome.
Results:
One hundred twenty-two patients (94%) underwent operative treatment: 110, stricture repair alone; four, portosystemic shunt and stricture repair; and eight, miscellaneous operative procedures. Among the 110 patients treated by stricture repair alone, there was an operative mortality rate of 1.8% (n = 2), and 79 patients (76%) had a good result, with no biliary symptoms and no need for intervention during mean follow-up of 7.2 years (range, 1 to 13 years). Twenty-two patients (21%) required either radiological intervention or operative revision of the biliary-enteric anastomosis, but 11 (50%) of these patients subsequently did well and had no biliary symptoms. Thus, 90 patients (87%) had a good or excellent long-term result after initial or follow-up treatment. There were no deaths among the 108 patients who underwent stricture repair alone by direct suture techniques. Factors influencing mortality included hypoalbuminemia, an elevated serum bilirubin level, and the presence of liver disease and portal hypertension. Preoperative factors influencing failure of the stricture repair in long-term follow-up included discontinuity of the right and left ducts at the time of stricture repair (Bismuth grade 4) and three or more previous attempts at operative repair before referral to our center.
Conclusions:
Operative repair of bile duct strictures using direct sutured techniques remains the procedure with which alternative methods will need to be compared, with close attention to long-term outcome.