Changing clinical profile, management strategies and outcome of patients with biliary tract injuries at a tertiary care center in Sri Lanka

摘要

BACKGROUND: Biliary  tract  injuries  are  mostly  iatrogenic. Related  data  are  limited  in  developing  countries.  There are  lessons  to  be  learned  by  revisiting  the  clinical  profiles, management  issues  and  outcome  of  patients  referred  to  a tertiary care center in Sri Lanka, compared with the previous data from the same center published in 2006. Such a review is particularly relevant at a time of changing global perceptions of iatrogenic biliary injuries. This study aimed to analyze and compare  the  changes  in  the  injury  pattern,  management  and outcome  following  biliary  tract  injury  in  a  Sri  Lankan  study population treated at a tertiary care center. METHODS: A retrospective analysis was made of 67 patients treated  between  May  2002  and  February  2011.  The  profiles of the last 38 patients treated from October 2006 to February 2011 were compared with those of the first 29 patients treated from May 2002 to September 2006. Definitive management options included endoscopic biliary stenting, reconstructive hepaticojejunostomy  with  creation  of  gastric  access  loops, and  biliary  stricture  dilation.  Post-treatment  jaundice, cholangitis  and  abdominal  pain  needing  intervention  were considered as treatment failures. RESULTS: In  the  67  patients,  55  were  women  and  12  men. Their mean age was 40.6 (range 19-80) years. Five patients had traumatic injuries. Thirty-seven injuries (23 during the second study period) were due to laparoscopic cholecystectomy and 25 (10 during the second study period) to open cholecystectomy. The identification rate of intra-operative injury was 19% in the laparoscopic group and 8% in the open group. Bismuth type I, II, III and IV injuries were seen in 18, 18, 15 and 12 patients, respectively. Endoscopic stenting was the definitive treatment in  20  patients.  In  35  patients  who  had  hepaticojejunostomy, 33  underwent  creation  of  the  gastric  access  loop.  Twenty-two  reconstructions  were  performed  during  the  second study period. A gastric access loop was used for endotherapy in  three  patients  with  anastomotic  occlusion  at  the  site  of hepaticojejunostomy. The overall outcome was satisfactory in the majority of patients. There were four injury-related deaths. CONCLUSIONS: Biliary  tract  injuries  associated  with laparoscopic  cholecystectomy  have  become  the  most frequent  cause  of  biliary  injury  management  at  our  center. Although endotherapy was useful in selected patients, in the majority, surgical reconstruction with hepaticojejunostomy was  required  as  the  definitive  treatment.  Creation  of  the gastric  access loop was  found to be  a useful adjunct  in the management of hepaticojejunostomy strictures.