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January 17, 2011

Timing of Repair of Bile Duct Injuries Associated With Laparoscopic Cholecystectomy

Author Affiliations

Author Affiliations: Hepatobiliary Surgery Unit, Catholic University of the Sacred Heart School of Medicine, Rome, Italy.

Arch Surg. 2011;146(1):117. doi:10.1001/archsurg.2010.290

We read with great interest the article by Sahajpal et al1 on laparoscopic cholecystectomy–associated bile duct injuries (LC-BDIs). It conveys a wise message that early repair (≤72 hours after LC-BDI) and late repair (>6 weeks after LC-BDI) offer the best outcomes. A minor comment is that an interval between 0 and 72 hours after LC-BDI has an unclear meaning: 0 hours suggests intraoperative repair, which was never performed. Most important, within the intermediate timing of repair (from 72 hours to 6 weeks after LC-BDI), a critical distinction should be made between the presence of a clean surgical field (ie, complete common bile duct stenosis with obstructive jaundice, without bile spillage) and a field that is inflamed or infected by bile. We believe that in the former case, surgical repair would occur in an ideal condition within 2 weeks following LC-BDI, even facilitated by the biliary dilation caused by obstruction. Of note, this ideal condition may dismally be turned into biliary peritonitis by unsuccessful nonsurgical attempts at bile duct recanalization. Conversely, in an inflamed or infected field, repair is less smooth because of edema, friability of tissues, and bleeding.2 Our policy is to resolve biliary peritonitis percutaneously or by laparoscopy or laparotomy without approaching the subhepatic area except to position drainages, postponing repair after complete recovery from sepsis. Finally, Sahajpal and colleagues correctly highlight the importance of early LC-BDI repair in specialized multidisciplinary centers.3 In reality, however, referral is still often delayed, LC-BDI is compounded by unsuccessful treatments, and there are still suboptimal opportunities for early repairs.

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