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May 1992

Bile Leak After Laparoscopic Cholecystectomy: Diagnostic and Therapeutic Application of Endoscopic Retrograde Cholangiopancreatography

Author Affiliations

From the Section of Gastroenterology, Virginia Mason Medical Center, Seattle, Wash (Drs Kozarek and Ball); Sections of Gastroenterology, Swedish Hospital, Seattle, and Overlake Hospital, Bellevue, Wash (Dr Gannan); and Section of Gastroenterology, Tacoma General Hospital, Humana Hospital, and St Joseph's Hospital and Health Care Center, Tacoma, Wash (Drs Baerg and Wagonfeld).

Arch Intern Med. 1992;152(5):1040-1043. doi:10.1001/archinte.1992.00400170118022

Background.—  Laparoscopic cholecystectomy, introduced less than 2 years ago, is widely accepted by patients and physicians despite the lack of controlled trials comparing this technology with conventional cholecystectomy. Recent series have described a variable incidence of biliary tract injury with laparoscopic gallbladder removal. The primary interaction of endoscopic retrograde cholangiopancreatography with this technology is usually in the preoperative or postoperative diagnosis and treatment of common bile duct stones.

Methods. —  During a 12-month period, 597 patients under-went laparoscopic cholecystectomy by 20 general surgeons at six Puget Sound (Wash) hospitals. All patients with symptomatic postoperative biloma diagnosed by abdominal ultrasound or computed tomography with or without endoscopic retrograde cholangiopancreatography, as well as those who had acute bile duct injury diagnosed and repaired at the time of cholecystectomy, were retrospectively reviewed.

Results.—  Three bile duct transections were acutely recognized and treated with hepaticojejunostomy. Fourteen additional patients presented within 7 days with biloma, three of whom were treated with percutaneous drainage alone. Of the remaining 11 patients who underwent endoscopic retrograde cholangiopancreatography, six were noted to have common bile duct injuries; two, bile duct transections; and 3, cystic duct leaks that required a variety of endoscopic or surgical therapies. In all, 17 (2.9%) of 597 patients sustained a bile duct injury and, to date, seven (1.2%) of 597 patients required surgery for such injury.

Conclusions.—  In a regional setting, laparoscopic cholescystectomy appears to be associated with a higher incidence of bile duct injury than previous reports of open cholecystectomy. Possible explanations include variant anatomy plus failure to obtain an operative cholangiogram, inadequate dissection, injudicious use of cautery or clip placement, inherent limitations of the procedure, or the learning curve associated with a new technology.(Arch Intern Med. 1992;152:1040-1043)

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