When Gallstone Removal Goes Awry

here’s no doubt that laparoscopic cholecystectomy is the best way to get rid of gallstones,” declares gastrointestinal surgeon Keith Lillemoe, M.D. “It’s simple, doesn’t cause a lot of pain and gets patients back on their feet sooner than open surgery.

“But,” he warns, “there’s a dark side to the procedure.” What can happen, as the physician uses the laparoscope to remove the stone-laden gallbladder, is a tear in the vital bile duct. One study reported injuries in about 6,200 of 124,000 patients nationwide. A simple nick allows bile to leak into the body. After such an accident, patients have no choice but to have the bile duct repaired—if possible through a radiologic procedure or, more often, through surgery.

“These patients are very sick, and are very difficult to take care of,” Lillemoe says. Most medical centers that take on the complicated repairs point the way straight to the operating room. But today, after studying nearly 90 patients referred with injuries ranging from tears to complete lacerations of the fragile duct tissue, a team of Hopkins surgeons and interventional radiologists has found that by working together in a series of cautious techniques, patients are coming through the mending process with startling success.

Treatment begins with a procedure called percutaneous trans-hepatic cholangiography and biliary drainage, in which interventional radiologist Scott Savader, M.D., injects a radiologic contrast medium into the patient’s bile duct to pinpoint the exact location and the severity of the injury. One or more supportive stents at the injured spot keep the duct open and help drain bile from the liver. Other catheters can be used to funnel leaking bile away from the abdomen. These preliminary steps, the team reported in Annals of Surgery, allow the inflammation to subside and the team to observe whether the injury improves on its own.

For patients who still require the crucial operation, Lillemoe, known for his skill in repairing the delicate tissue of the common bile duct, reattaches the injured tissue to the bowel. To keep the channel of the duct open as the tissue scars and heals, he replaces the stents with larger ones. The tissue can take up to 10 months to heal, and patients return every two months to have stents replaced by way of a guidewire so they don’t clog with debris.

When the reattached duct has finally healed, Savader tests the success of the operation by infusing saline into the liver to measure intrahepatic pressure and make sure that the draining channels remain open. “It’s an excellent indication of the status of healing and helps ensure that the patient won’t develop new strictures,” he explains.

“Overall,” Savader says, “the treatment tends to take longer, but we believe that a longer period of stenting after the operation offers better long-term results.” Adds Lillemoe: “With the combined approach, 100 percent of our patients have had successful outcomes.”

—KL