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Background and Study Aims: Bile duct injury (BDI) is associated with increased morbidity and poor survival. The aim of the present study was to compare quality of life (QoL) between patients with BDI and those without after laparoscopic cholecystectomy. A longitudinal assessment was performed and risk factors for poor QoL were determined., Patients and Methods: In March 2005 a survey was performed of 403 eligible patients with BDI who were referred to a tertiary center for multidisciplinary treatment by gastroenterologists, radiologists, and surgeons. A longitudinal quality-of-life study was performed to determine changes in outcome after a mean of 5.5 and 11 years' follow-up., Results: Of the eligible 403 patients with BDI, 278 (69 %) responded to the survey after a mean follow-up of 5.9 years. The quality-of-life outcome of injured patients was significantly lower in three of the eight domains compared to patients who underwent cholecystectomy without an injury ( P < 0.05). In seven of the eight QoL domains injured patients scored significantly worse than the healthy population norms ( P < 0.05). The longitudinal assessment after another 5.5 years of follow-up did not show improvement in QoL. Clinical characteristics such as the type of injury and the type of treatment did not affect outcome. Nineteen percent of the patients (n = 53) filed a malpractice claim after BDI. These patients reported better QoL (effect size = 0.6, P = 0.02) when the claim was resolved in their favor than when the claim was rejected., Conclusions: BDI has a detrimental effect on long-term QoL. QoL in patients with BDI is poor and does not improve during follow-up. The outcome of a malpractice litigation claim is associated with QoL.

Objective: To evaluate the frequency of claims for damages initiated by patients referred to a tertiary centre for the treatment of bile-duct injury after a (laparoscopic) cholecystectomy. To determine the relationship between patient characteristics and the initiation of a claim procedure., Design: Descriptive., Method: Between 1 January 1990 and 31 December 2005, 500 patients with a bile-duct injury were referred to the Academic Medical Centre, Amsterdam, 454 of whom in the period up to 31 December 2004. Of these, 403 received a mailed questionnaire about the initiation of legal claims for damages., Results: The questionnaire was completed and returned by 278 patients (69%), a representative cohort ofthe 500. Of these, 53 (19%) had submitted a claim for damages. The percentage of claims did not increase over the periods 1991-1995 (19%), 1996-2000 (18%) and 2001-2005 (20%). In the univariate analysis, factors associated with the initiation of a claim procedure were: younger age, the severity of the injury, surgical treatment, being employed at the time of the initial cholecystectomy, and having been placed on sick leave. A complete transection of the common bile duct was the only independent predictive factor for starting a claim procedure (odds ratio: 7.5; 95% CI: 1.9-30.6).

The management of a bile duct injury detected during laparoscopic cholecystectomy is still under discussion. An end-to-end anastomosis (with or without T-tube drainage) in peroperative detected bile duct injury has been reported to be associated with stricture formation of the anastomosis area and recurrent jaundice. Between 1991 and 2005, 56 of a total of 500 bile duct injury patients were referred for treating complications after a primary end-to-end anastomosis. After referral, 43 (77%) patients were initially treated endoscopically or by percutaneous transhepatic stent placement (n = 3; 5%). After a mean follow-up of 7 +/- 3.3 years, 37 patients (66%) were successfully treated with dilatation and endoscopically placed stents. One patient died due to a treatment-related complication. A total of 18 patients (32%) underwent a hepaticojejunostomy. Postoperative complications occurred in three patients (5%) without hospital mortality. These data confirm that end-to-end anastomosis might be considered as a primary treatment for peroperative detected transection of the bile duct without extensive tissue loss. Complications (stricture or leakage) can be adequately managed by endoscopic or percutaneous drainage the majority of patients (66%) and reconstructive surgery after complicated end-to-end anastomosis is a procedure with relative low morbidity and no mortality.

Laparoscopic cholecystectomy has become the first choice of management for symptomatic cholecystolithiasis. While it is associated with decreased postoperative morbidity and mortality, bile duct injuries are reported to be more severe and more common (0-2.7%), when compared to open cholecystectomy (0.2-0.5%) [New Engl. J. Med. 234 (1991) 1073; Am. J. Surg. 165 (1993) 9; Surg. Clin. N Am. 80 (2000) 1127]. These bile duct injuries include leaks, strictures, transection and removal of (part of) the duct, with or without vascular damage. Bile duct injury might be due to misidentification of the biliary tract anatomy due to acute cholecystitis, large impacted stones, short cystic duct, anatomical variations, but also due to technical errors leading to bleeding with subsequent clipping and coagulation trauma [Ann. Surg. 237 (2003) 460]. Early recognition and adequate multidisciplinary approach is the cornerstone for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature with as consequences biliary peritonitis, sepsis, abscesses, multiple organ failure, a more difficult (proximal) reconstruction and in the long run, secondary biliary cirrhosis, and liver failure. Despite increasing experience in performing laparoscopic cholecystectomy, the frequency of bile duct injuries has not decreased [Ann. Surg. 234 (2001) 549]. Therapy encompasses endoscopic stenting, percutaneous transhepatic dilatation (PTCD) and surgical reconstruction.

Previous studies showed that bile duct injury after cholecystectomy is associated with substantial morbidity and a negative effect on Quality of Life. In a recent study, patients with a bile duct injury after cholecystectomy exhibited a 3-fold increase in mortality during a follow-up period of nine years compared to patients without injury. This is the first study to demonstrate a negative impact of bile duct injury on survival. Repair by a less experienced surgeon leads to an 11% higher mortality during follow-up. Cholangiography should probably be performed routinely during cholecystectomy. A bile duct lesion should be suspected when the patient has not recovered within 48 hours. Endoscopic or percutaneous treatment of stenoses or leakage is usually successful, even after several weeks.

Objective: To assess the impact of bile duct injury (BDI) sustained during laparoscopic cholecystectomy on physical and mental quality of life (QOL)., Summary Background Data: The incidence of BDI during laparoscopic cholecystectomy has decreased but remains as high as 1.4%. Data on the long-term outcome of treatment in these patients are scarce, and QOL after BDI is unknown., Methods: One hundred six consecutive patients (75 women, median age 44 +/- 14 years) were referred between 1990 and 1996 for treatment of BDI sustained during laparoscopic cholecystectomy. Outcome was evaluated according to the type of treatment used (endoscopic or surgical) and the type of injury. Objective outcome (interventions, hospital admissions, laboratory data) was evaluated, a questionnaire was filled out, and a QOL survey was performed (using the SF-36). Risk factors for a worse outcome were calculated., Results: Median follow-up time was 70 months (range 37-110). The objective outcome of endoscopic treatment (n = 69) was excellent (94%). The result of surgical treatment (n = 31) depended on the timing of reconstruction (overall success 84%; in case of delayed hepaticojejunostomy 94%). Five patients underwent interventional radiology with a good outcome. Despite this excellent objective outcome, QOL appeared to be both physically and mentally reduced compared with controls (P <.05) and was not dependent on the type of treatment used or the severity of the injury. The duration of the treatment was independently prognostic for a worse mental QOL., Conclusions: Despite the excellent functional outcome after repair, the occurrence of a BDI has a great impact on the patient's physical and mental QOL, even at long-term follow-up.

Background: Biliary obstruction changes the spectrum of lipoproteins, which are now known to bind and neutralize endotoxin. Postoperative septic complications related to an increased susceptibility to endotoxin occur frequently in patients with obstructive jaundice. The effect of preoperative biliary drainage on changes in the lipoprotein spectrum and its relation to endotoxin sensitivity was studied., Methods: Abnormalities in the lipoprotein spectrum were assessed in 15 patients with malignant obstructive jaundice before and 3 weeks after endoscopic biliary drainage. Changes in endotoxin responsiveness were assessed by using endotoxin-neutralizing reagents (anti-CD14 monoclonal antibody, polymyxin B, and recombinant bactericidal permeability increasing protein) to block cytokine production in whole blood cell cultures that were stimulated by cholestatic plasma taken before and after drainage., Results: Drainage normalized very-low-density, low-density, and high-density lipoprotein cholesterol fractions from, respectively, 43% to 19%, 50% to 65%, and 6% to 16% (P <.01). Ex vivo stimulation of whole blood with predrainage cholestatic plasma was 20-fold higher (P <.001) than with postdrainage plasma. Blocking the endotoxin response during the stimulation with predrainage cholestatic plasma with anti-CD14 monoclonal antibody, polymyxin B or recombinant bactericidal permeability increasing protein resulted in attenuation of the inflammatory response, reducing tumor necrosis factor-alpha levels at least 5-fold., Conclusions: Preoperative biliary drainage normalizes the changed lipid profile and the endotoxin-stimulating capacity of cholestatic plasma, and this signifies a change in sensitivity to endotoxin.

Eight years after the introduction of laparoscopic cholecystectomy a decrease of the incidence of bile duct injuries is reported in the literature. The incidence of a bile duct injury after laparoscopic cholecystectomy is now slightly higher than after open cholecystectomy. A minority of these injuries are detected during surgery. Most patients have a delayed identification of the bile duct injury, even after discharge from the hospital. An early diagnostic work-up with ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) is mandatory in every patient with persisting symptoms (more than 48 hours) after laparoscopic cholecystectomy. Still, one-third of the patients are subjected to a 'diagnostic' exploratory laparotomy without preoperative visualization of the biliary tract by ERCP or percutaneous transhepatic cholangiography. Minor lesions are mostly treated successfully by endoscopy with a stent. After transection of the bile duct surgical reconstruction by a hepaticojejunostomy has to be performed. A delayed elective reconstruction was associated with fewer complications than acute repair under suboptimal circumstances such as local inflammatory changes and bile leakage.

At the Academic Medical Center, 133 patients with a bile duct injury after laparoscopic cholecystectomy were treated between 1991 and April 1998. The management of these patients is discussed in a hepato-pancreato-biliary team consisting of radiologist, gastroenterologists and surgeons. In this paper, a summary of the previously reported AMC experience is presented in combination with a reflection of the findings in the literature concerning incidence, aetiology, symptoms, classification, diagnosis and treatment of iatrogenic bile duct injury after laparoscopic cholecystectomy.

Background: Previous studies have suggested that improvements in diagnostic workup and treatment of bile duct injuries (BDI) sustained during laparoscopic cholecystectomy can be expected as experience increases with the laparoscopic procedure. Many published articles reported that early diagnosis, proper classification, and optimal timing of treatment of BDI increase the likelihood of successful treatment. This study determined whether diagnosis and management of BDI have improved over the years., Study Design: Between June 1990 and November 1996, 106 patients were diagnosed and treated in the Amsterdam Academic Medical Center for BDI sustained during laparoscopic cholecystectomy. Detailed information was obtained about peroperative findings, time interval from laparoscopic cholecystectomy to symptoms, and interval from symptoms to diagnosis. Bile duct injuries were classified into four types. Two patient groups were compared: BDI patients diagnosed from 1990 until 1994 ("learning phase") and patients diagnosed from 1995 until 1996., Results: Bile duct injuries combined with bile leakage were diagnosed significantly earlier in the second period after the learning phase. The percentages of injuries diagnosed peroperatively, "blind laparotomies," and suboptimal timed hepaticojejunostomies were not different between the groups., Conclusions: Except for earlier diagnosis of BDI in the later period than in previous years, there appeared to be no significant improvement in diagnostic workup and management during the past 2 years.

From January 1990 to June 1994, 53 patients who sustained bile duct injuries during laparoscopic cholecystectomy were treated at the Amsterdam Academic Medical Centre. There were 16 men and 37 women with a mean age of 47 years. Follow up was established in all patients for a median of 17 months. Four types of ductal injury were identified. Type A (18 patients) had leakage from cystic ducts or peripheral hepatic radicles, type B (11 patients) had major bile duct leakage, type C (nine patients) had an isolated ductal stricture, and type D (15 patients) had complete transection of the bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) established the diagnosis in all type A, B, and C lesions. In type D lesions percutaneous cholangiography was required to delineate the proximal extent of the injury. Initial treatment (until resolution of symptoms and discharge from hospital) comprised endoscopy in 36 patients and surgery in 26 patients. Endoscopic treatment was possible and successful in 16 of 18 of type A lesions, five of seven of type B lesions, and three of nine of type C lesions. Most failures resulted from inability to pass strictures or leaks at the initial endoscopy. During initial treatment additional surgery was required in seven patients. Fourteen patients underwent percutaneous or surgical drainage of bile collections, or both. After endoscopic treatment early complications occurred in three patients, with a fatal outcome in two (not related to the endoscopic therapy). During follow up six patients developed late complications. All 15 patients with complete transection and four patients with major bile duct leakage were initially treated surgically. During initial treatment additional endoscopy was required in two patients. Early complications occurred in eight patients. During follow up seven patients developed stenosis of the anastomosis or bile duct. Reconstructive surgery in the early postoperative phase was associated with more complications than elective reconstructive surgery. Most type A and B bile duct injuries after laparoscopic cholecystectomy (80%) can be treated endoscopically. In patients with more severe ductal injury (type C and D) reconstructive surgery is eventually required in 70%. Multidisciplinary approach to these lesions is advocated and algorithms for treatment are proposed.