Diagnostic and Surgical Treatment of Combined Bile Duct and Vesels Injury During Cholecystectomy

M.Ye. Nichitaylo, Profesor, A.V. Skums, MD, A.I. Lytvyn, PhD, V.P. Shkarban, PhD, B.L. Shevchuk, A.A. Skums. National Institute of Surgery and Transplantology named by A.A.Shalimov

Aims: Combined injury of extrahepatic bile ducts and the hepatic vessels, being more grievous complication by comparison than the plain bile duct damage, is now deemed the main culprit of high frequency of unsatisfactory treatment and mortality rate. The aim of the study is to estimate the value of the concomitant vascular injuries and the effect it has on the clinical development of coexistent iatrogenic biliary injuries and treatment outcome. Methods: Between January 1984 and May 2010, there were 56 patients with iatrogenic biliary tract injury. Twenty-six patients had concomitant vascu-lar injury, the biliovascular injury group (BVI), and the remaining 30 patients had iso-lated biliary tract injury (IBTI). The age of the patients varies from 31 to 75. Long-term outcomes were evaluated in accordance with the Terblanche schale data et al. (1990). Results: The BVI group included 19 patients (73,1%) comprising iatrogenic injuries fol-lowing open cholecystectomy and 7 (26,9%) with that after laparoscopic one, and the IBTI group was made up by 21 (70%) and 9 (30%) patients with iatrogenic injuries accordingly. Statistically, as regards our study, there was no striking discrepancy in the rate of high level bile duct injury instances (Bismuth III and IV ) ever established be-tween the two groups of patients (69,3% and 63,3% respectively, p=0,85). The main operation of choice in the IBTI group was offered high hepaticojejunostomy. Single liver abscesses managed by means of transcutaneous puncture or drainage under ultra-sound surveillance. The scope of surgical operative intervention in the BVI group was much broader. In two patients, the measures were taken to restore the arterial flow alongside with the consecutive reconstruction of the bile duct anatomy. Owing to hepatic artery collaterals development 16 patients resumed hepatic artery flow and underwent hepaticojejunostomy as a result only. Eight patients, in turn, were operated variously liver resection in connection with necrotic and abscessed alterations of the liver. The postoperative mortality rate constituted 3,9% (1 patient) in BVI group. Three patients (11,5%) have presented with unsatisfactory results postoperatively: one patient following hepaticojejunostomy accompanied with transcutaneous drainage has developed cyrrosis eight years since operation, another two patients have been diag-nosed with right hepatic lobe atrophy. The IBTI group has had no deaths. The positive and satisfactory results were obtained in 28 patients (93%), unsatisfactory ones presented as a recurrent cholangitice with cyrrossis were found in 2 patients (6,7%). Conclusions: Bile duct and hepatic vessels injury in 15 cases (57,7%) have led to ischemic necrotic alterations with abscess formation which appear to have occurred more frequently in this group as opposed to patients with isolated billiary duct injury (2-6,7%) (p<0.05). Eighteen patients (69,2%) as a result of adequate collateral hepatic blood supply development have undergone exclusively billiary reconstructive surgery, while in 8 patients (30,8%) there has been a need in broader scope of surgical interventions in connection with abscess formation. After the differentiation in surgical treatment the results in patients with IBTI and BVI did not have significant difference: positive results were achieved in 93,3% and 84,6% cases respectively (p>0,05).