Management of bile duct injuries following laparoscopic cholecystectomy: long-term outcome and risk factors infuencing biliary reconstruction.

BACKGROUND: Bile duct injury following cholecystectomy remains a severe complication with major implications for the patient outcome. AIM: To assess the outcome of surgical treatment and study the risk factor infuencing biliary reconstruction in patients with bile duct injuries following laparoscopic cholecystectomy. METHODS: Between January 2005 and December 2010, 43 patients with bile duct injuries following laparoscopic cholecystectomy were treated to our center. According to Strasberg classification, the types of injuries were as follows: type A in 7 patients (16.28%), type D in 4 (9.3%), type E1 in 9 (20.93%), type E2 in 11 (25.58%), type E3 in 10 (23.25%),and type E4 in 2 (4.65%) patients respectively. Management after referral included endoscopic sphincterotomy in patients with minor lesions (Strasberg type A) and Roux-en-Y hepaticojejunostomy in 36 patients with major duct injuries(Strasberg type D and E). 55.55% of patients with major bile duct injuries have endoscopic or surgical attempts of repair sprior to referral. In case of biliary peritonitis or acute cholangitis, the reconstruction was preceded by prolonged external biliary drainage. RESULTS: All minor lesions were successfully treated endoscopically,with outstanding long term results. For patients with major duct injuries, the postoperative mortality and morbidity rate were 5.55% and 25%, respectively. After a median follow-up period of 34.1 (range, 12-68) months, 30 patients(88.23%) remain in good general condition (using McDonald classification) and 4 patients (11.77%) developed a late anastomotic stricture. Multivariate analyses have identified postoperative biliary leak (p=0.012) as an independent predictor factor for the occurrence of late anastomotic stricture. CONCLUSIONS: Minor bile duct injuries can be successfully treated endoscopically if proper abdominal drainage is maintained. Roux-en-Y hepaticojejunostomy is feasible and safe with contained morbidity and durable results even when previous surgery has failed. Postoperative biliary leak is a significant predictor for poor long term outcome.

Modern therapeutic approach of acute severe forms of pancratitis. A review of the literature and experience of Surgical Department No III Cluj.

UNLABELLED: The title of "the great abdominal drama" attributed to acute pancreatitis is fully justified by the impressive clinical presentation, the deep consumptive character of physio-pathological processes taking place, the severity of the complications and the complexity of the treatment. MATERIALS AND METHODS: The aim of our study was to analyze the results on a number of 81 consecutive patients hospitalized in the Surgical Clinic III Cluj during 28 months, all diagnosed with severe forms of acute pancreatitis. There were two groups of patients, non-surgical (43 cases) and surgical cases (38 cases), respectively. The diagnosis and forms of the disease took into account the clinical picture, serum amylase, CPR and Balthazar procalcitonine,together with the classification of the lesions on CT scan. RESULTS: All patients were admitted to the intensive care unit and received supportive treatment such as antibiotics, pancreatic exocrine secretion inhibitors and proton pump inhibitors. The surgical act in the 38 cases was indicated by septic intra-abdominal pressure or high functionality threatening vital viscera. Intraoperatively the abscesses were drained, the necrotic areas were removed and cholecystectomy was performed in patients with biliary etiology. Statistically, we obtained significant differences in the incidence of complications between the group of patients operated and those not operated (p = 0.000048), but not in what concerns the length of hospitalization (p = 0.99999) and the number of deaths (p = 0.2102). The overall mortality was 14.41%, comparable to that found in the literature. In none of the patients CT guided drainage of collections was performed prior to surgery, which was a major drawback of the treatment. CONCLUSIONS: Our results support the importance of an early diagnosis and medical treatment, the delayed surgery being required in high intra-abdominal pressure or SEPS.