Factors influencing outcome in patients with postoperative biliary strictures

doi:10.1016/0002-9610(82)90595-5

The American Journal of Surgery

Volume 144, Issue 1, July 1982, Pages 14-21

https://doi.org/10.1016/0002-9610(82)90595-5 Get rights and content

Abstract

We reviewed our experience from 1955 to 1979 with benign postoperative biliary strictures to determine which factors were associated with a favorable outcome. Patients operated on from 1970 to 1979 were significantly more likely (p <0.01) to achieve a good result (86 percent) than were patients undergoing surgery between 1955 and 1969 (68 percent). An inverse correlation (r = −0.96, p <0.05) was present between the number of previous repairs and the percentage of good results. Patients referred without a previous repair were most likely to achieve a good result (86 percent). Roux-Y jejunal reconstructions were associated with the best results (p < 0.01). In recent years Silastic transhepatic stents were used in 20 patients with hilar strictures; 18 (90 percent) achieved good results. Patients stented for the shortest period (less than 1 month) were less likely to achieve a good outcome than those stented for longer periods (p <0.025). Patients with difficult hilar strictures who were stented for more than 9 months were more likely to have a good result if a changeable Silastic transhepatic stent was employed (p <0.01). This analysis suggests that early referral, Roux-Y jejunal reconstruction, judicious use of Silastic transhepatic stents, and prolonged stenting of hilar strictures will improve the outlook in patients with postoperative biliary strictures.

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Risk factors for anastomotic stricture after hepaticojejunostomy for bile duct injury–A systematic review and meta-analysis
2021, Surgery (United States)
After major bile duct injury, hepaticojejunostomy can result in good long-term patency, but anastomotic stricture is a common cause of long-term morbidity. There is a need to assimilate high-level evidence to establish risk factors for development of anastomotic stricture after hepaticojejunostomy for bile duct injury.
A systematic review of studies reporting the rate of anastomotic stricture after hepaticojejunostomy for bile duct injury was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses of proposed risk factors were then performed.
Meta-analysis included 5 factors (n = 2,155 patients, 17 studies). Concomitant vascular injury (odds ratio 4.96; 95% confidence interval 1.92–12.86; P = .001), postrepair bile leak (odds ratio: 8.03; 95% confidence interval 2.04–31.71; P = .003), and repair by nonspecialist surgeon (odds ratio 11.29; 95% confidence interval 5.21–24.47; P < .0001) increased the rate of anastomotic stricture of hepaticojejunostomy after bile duct injury. Level of injury according to the Strasberg Grade did not significantly affect the rate of anastomotic stricture (odds ratio: 0.97; 95% confidence interval 0.45–2.10; P = .93). Owing to heterogeneity of reporting, it was not possible to perform a meta-analysis for the impact of timing of repair on anastomotic stricture rate.
The only modifiable risk factor, repair by a nonspecialist surgeon, demonstrates the importance of broad awareness of these data. Knowledge of these risk factors may permit risk stratification of follow-up, better informed consent, and understanding of prognosis.
Management of Benign Biliary Strictures
2020, Image-Guided Interventions: Expert Radiology Series, Third Edition
The percutaneous management of benign biliary strictures is challenging. This chapter outlines the nonsurgical (i.e., percutaneous) image-guided techniques used to treat a variety of biliary strictures. Etiologies of benign biliary strictures include inflammatory, iatrogenic, and ischemic causes. Also reviewed in the text will be a discussion of sequential balloon dilation of strictures. Patient preparation, outcomes, and complications of these biliary interventions will be outlined.
Prevention and Management of Bile Duct Injury
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
Biliary injuries are among the most difficult challenges that a surgeon will face. Although numerous technologic developments have facilitated diagnosis and management, bile duct injuries remain a significant clinical problem. If they go unrecognized or are managed improperly, life-threatening early complications such as sepsis and multisystem organ failure or late complications of biliary cirrhosis, portal hypertension, and cholangitis can develop. To avoid these complications, virtually every patient with a bile duct stricture should undergo evaluation and treatment with the goal of relieving the obstruction to bile flow and its associated hepatic injury. Finally, the occurrence of a major bile duct injury during an elective cholecystectomy remains one of the most common indications of medical malpractice claims within the United States. This chapter will discuss the epidemiology, prevention, cognitive factors, clinical presentation, diagnostic evaluation, management, morbidity, mortality, and long-term outcomes associated with biliary injuries.
Operative Management of Bile Duct Strictures
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
Bile duct strictures are common and result from both benign and malignant conditions. The most common causes include surgery of the gallbladder or biliary tree, other endoscopic or percutaneous interventions, or inflammatory or congenital conditions. The clinical presentation varies based upon the etiology of the bile duct stricture. Radiologic evaluation is essential to define the anatomy of the biliary tree and for planning of corrective intervention. Surgical management of bile duct strictures can involve either early repair or staged late repair. Control of sepsis is an important element that helps to determine the proper timing of repair. The most common operative approach to bile duct stricture repair involves Roux-en-Y hepaticojejunostomy. The use of transhepatic or transanastomotic biliary stenting at the time of stricture repair is controversial. The postoperative complication rates range between 20% and 40% in the literature, with mortality rates being in the 1% to 3% range. In all, bile duct injuries and strictures should be considered complex problems requiring a multidisciplinary approach involving surgeons, radiologists, and gastroenterologists. Excellent outcomes can be achieved in the majority of cases.
Benign Biliary Strictures
2018, ERCP, Third Edition
Benign biliary strictures (BBS) are most commonly caused by iatrogenic surgical injury, usually after cholecystectomy, or may occur at the site of biliary anastomosis after hepatic resection or liver transplantation. Other causes of BBS include primary sclerosing cholangitis, chronic pancreatitis, immunoglobulin G4–related cholangiopathy, and a variety of other causes. Endoscopic retrograde cholangiopancreatography has a pivotal role in the treatment of the vast majority of patients with BBS.
Iatrogenic injuries of the extrahepatic biliary system
2017, Journal of Surgical Research
Citation Excerpt :
Lillemoe et al. 12 described the outcome of 156 patients after surgical reconstruction for bile duct strictures with a mean follow-up of 57.5 mo which showed overall success rate of 90.8% and one case of mortality due to pulmonary embolism. Pitt et al. 16 reported that by 3 y after a repair, only two-thirds of the patients who eventually had a recurrent stricture returned for reoperation, and even 5 y after operation for benign postoperative stricture, only 80% of recurrences occurred. Another analysis underscores the need for prolonged follow-up in determining the results of surgery in these patients, so close surveillance for at least 5 y is mandatory after a stricture repair.19
Iatrogenic traumatic extrahepatic biliary tract injuries though rarely occur; they can lead to exceedingly morbid complications. The aim of this study was to evaluate the management strategies and outcomes of patients presented with iatrogenic bile duct injuries.
This is a retrospective study. Over 19 y, 124 patients were managed for iatrogenic biliary injuries at our institution. The data related to the etiology of biliary tract injury, symptoms of injury, laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, hospitalization time, and postoperative complications were reviewed.
The main clinical presentations were jaundice or recurrent cholangitis in 64 (51.61%) patients, followed by bile peritonitis in 34 (56.67%) and biliary fistula in 26 (43.33%) patients. Only in 23 (18.54%) cases, the injury was recognized intraoperatively. The most frequent surgical procedure was open cholecystectomy in 81 (65.32%) of 124 patients. The remaining patients were operated on laparoscopically. Good results were achieved in 99 of 101 patients with direct suture repair including hepaticojejunostomy, choledocoduodenostomy, and choledochocholedochostomy (98.02% success rate) at the first attempt. Three cases (2.97%) of biliary strictures after direct suture technique and four (3.96%) cases of postoperative mortalities were detected. The mortality rate was mostly affected by male gender, advanced age, and existence of bile peritonitis. Totally, 111 (89.52%) patients are still alive with a mean follow-up time of 78 ± 38 (2–230) mo.
Biliary injuries can be sometimes life-threatening complications. A successful repair may provide patients with a lifelong relief from symptoms, whereas a failed repair may result in recurrent biliary obstruction, reoperation, and even death.

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^☆: Presented at the 53rd Annual Meeting of the Pacific Coast Surgical Association, Napa, California, February 14–17, 1982.

¹: From the Department of Surgery, UCLA School of Medicine, Los Angeles, California.

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Scientific paperFactors influencing outcome in patients with postoperative biliary strictures☆

Abstract

Surg Clin North Am

Surg Clin North Am

Am J Surg

Am J Surg

Am J Surg

Early management of injury to the extrahepatic biliary tract

JAMA

The diverse causes of biliary obstruction and their remedies

Curr Probl Surg

Long-term results of Roux-en-Y hepaticojejunostomy

Surg Gynecol Obstet

The use of silastic transhepatic stents in benign and malignant biliary strictures

Ann Surg

Surgical treatment of bile duct strictures

Surgery

Scientific paper
Factors influencing outcome in patients with postoperative biliary strictures☆