Abstract
Purpose: A prospective and retrospective work to study and evaluate management techniques either surgical and/or endoscopic used in treatment of complex post cholecystectomy biliary injuries.
Patients & Methods: In the period from Mars 2000 to Feb. 2010, 419 patients (224 females and 195 males) were collected from general surgery department, and gastro-intestinal endoscopy unit, Assuit University hospitals, complaining of post cholecystectomy biliary injuries, and managed accordingly using surgery in 135 patients, and endoscopy in 317 patients, in addition to percutaneous techniques in 32 patients.
Results: Post cholecystectomy complex biliary injuries still seen in Upper Egypt frequently and erroneously managed till presented in late stages to referral tertiary centers. Endoscopy was very successful as an initial treatment of 317 patients (76%), as being less invasive, low morbidity and mortality, competitive to surgery in treatment mild/moderate biliary leakage (82%), and biliary stricture (74%). Its success increased by 2.8% & 8.3% for leakage, and stricture by addition of percutaneous techniques. But endoscopy was complementary to surgery in major leakage, and massive stricture, and surgery was resold to in 19%, and 14% of cases respectively.
Surgery remains the treatment of choice in cases of CBD transection, ligation, and combined injuries of stones, stricture, and leakage in 60% of cases. Bilio-enteric anastomosis was the procedure of choice, done in 76 cases, with trans-anastomotic stent splintage in 30 cases with unhealthy fibrosed, or small sized ducts. And stricture complication was encountered in 5 cases (6.5%), treated by percutaneous rout in 3, and redo surgery in 2 case.
The learning curve seems influential in both endoscopy and surgery. The cumulative experience increase the success rate of endoscopy from initial 50% to 95%nowadays, also surgery improved with decreased morbidity and mortality as complications encountered was seen in initial experience and decreased with time.
Conclusion: Endoscopy was competitive to surgery in simple problems and advised to be the initial treatment choice, but complementary in major leak, ligation, transection, and complex problems, where surgery plays the main role in treatment with its invasiveness, high morbidity and morbidity. Cumulative experience influence endoscopic and surgical treatment of such problems and it is mandatory with other facility and equipment for management of such challenging cases.