Management of failed biliary repairs for major bile duct injuries after laparoscopic cholecystectomy1

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Abstract
Many bile injuries are managed without referral to tertiary centers. Management of patients referred for a primary repair, or after a failed repair, was reviewed to compare outcomes. Retrospective review of data collected in prospective database. A total of 133 patients had been treated over 12 years ending in December 2002. Forty-six (35%) were treated for failed earlier repairs and 40 (30%) had their primary surgical repair at our institution. Patients with a failed repair were referred at a longer interval (165 versus 9 days, p < 0.001), were more often diagnosed intraoperatively (28 [61%] versus 13 [33%], p = 0.009), and presented with biliary obstruction (41 [89%] versus 13 [33%], p < 0.001). Of the failed repairs, 26 patients (56%) had an earlier biliary-enteric anastomosis and 20 had primary end-to-end repair. One-third of failed repairs was successfully treated with stenting and was significantly more successful after a biliary-enteric anastomosis. Surgical revision of failed repairs was required in 27 patients (59%) and was more likely in earlier primary repairs. At a mean followup of 64 months, recurrent biliary strictures occurred in 5 patients (6%). Management of a failed major bile duct repair requires multiple modalities, but eventually the majority of repairs require surgical revision. Good results can be expected for all surgical biliary repairs at tertiary centers.

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