Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes.

摘要

BACKGROUND: Many factors contribute to the success of biliary reconstructions following laparoscopic bile duct injury. We previously reported that control of intra-abdominal infection, complete preoperative cholangiography, surgical technique and surgical experience affected the results. There is no consensus, however, on whether the timing of the operation is important. METHODS: We examined factors influencing the success of the first repair of 307 major bile duct injuries following laparoscopic cholecystectomy. Factors were assessed for cases initially repaired either by the primary surgeon or a biliary specialist. Bivariate and multivariate analyses were used to determine the significance of comparisons. RESULTS: A total of 137 injuries were initially repaired by a biliary surgeon and 163 injuries were initially repaired by the primary surgeon; seven were managed non-surgically. Repairs by primary surgeons were performed earlier than those by biliary surgeons (11 vs. 59 days; P < 0.0001). Bivariate analysis of the entire cohort suggested that later repairs might have been more successful than earlier ones (17 vs. 50 days; P = 0.003). Multivariate analysis, however, showed that the timing of the repair was unimportant (P = 0.572). Instead, success correlated with: eradication of intra-abdominal infection (P = 0.0001); complete preoperative cholangiography (P = 0.002); use of correct surgical technique (P = 0.0001), and repair by a biliary surgeon (P = 0.0001). Separate multivariate analyses of outcomes for primary and biliary surgeons revealed that timing was unrelated to success in either case. CONCLUSIONS: The success of biliary reconstruction for iatrogenic bile duct injuries depended on complete eradication of abdominal infection, complete cholangiography, use of correct surgical technique, and repair by an experienced biliary surgeon. If these objectives were achieved, the repair could be performed at any point with the expectation of an excellent outcome. We see no reason to delay the repair for some arbitrary period.