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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Salvage treatment of laparoscopic cholecystectomy-associated bile duct stenosis combining laparoscopic and endoscopic procedures: A case report Yuji Iimuro, Toshihiro Okada, Koichiro Ohashi, Yugo Uda, Kazuhiro Suzumura & Jiro Fujimoto Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
Keywords Biliary stenosis; laparoscopic cholecystectomy; salvage surgery Correspondence Yuji Iimuro, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan. Tel: +81 798 45 6582 Fax: +81 798 45 6581 Email: [email protected] Received: 27 March 2013; revised 31 May 2013; accepted 20 June 2013 DOI:10.1111/ases.12053
Abstract The incidence of laparoscopic cholecystectomy (LC)-associated bile duct injury has reached a steady state despite learning curve effect. Herein we report the case of a 74-year-old Japanese man who suffered from bile duct stenosis and stones after LC. The stenosis was due to stricture caused by surgical clips used inappropriately during LC. We planned a salvage treatment combining laparoscopic and endoscopic approaches. At laparoscopic observation, the clips had already invaded the right side of the bile duct; minimal absorbable suture was performed after all the clips were removed. The bile duct stenosis was then endoscopically dilated and the biliary stones were successfully removed. For the recurrent biliary stenosis after discharge, endoscopic balloon dilation was performed and multiple plastic stent tubes were placed. The stent tubes were removed 4 months later, and the patient has had no symptoms for 1 year. A combined laparoscopic and endoscopic approach was useful for the salvage treatment of LC-associated bile duct stenosis.
Introduction The incidence of laparoscopic cholecystectomyassociated bile duct injury (LC-BDI), which remains a critical issue in laparoscopic cholecystectomy (LC), appears to have reached a steady state (approximately 0.4%–0.6%), at least double the rate observed with open cholecystectomy (0.2%), despite learning curve effect (1,2). Herein we report a case of iatrogenic bile duct stenosis after LC. The patient successfully underwent a salvage treatment for the stenosis that combined laparoscopic and endoscopic approaches.
Case Presentation A 74-year-old man was referred to our department in July 2011 with discomfort in the right-upper quadrant. He had undergone LC for cholecystitis in February 2011 in a private hospital (Figure 1a), but he began to suffer from general fatigue in June 2011. MRI showed that the upper part of the extrahepatic bile duct was severely narrowed and that multiple biliary stones existed
322
(Figure 1b). The patient underwent endoscopic retrograde chorangiography (ERC), and endoscopic removal of the biliary stones was attempted. ERC showed that the surgical clips used in the LC directly squeezed the bile duct, and only the stones below the stenosis could be endoscopically removed (Figure 1c). After ERC, the patient was referred to our institution. Contrastenhanced CT confirmed the ERC finding (Figure 1d). We determined that further aggressive endoscopic balloon dilation for the treatment of the stenosis would be risky but that recurrent stenosis of the bile duct would possibly occur if the surgical clips remained. Roux-en-Y hepaticojejunostomy seemed too aggressive an option. Therefore, we decided to laparoscopically remove the surgical clips first and then try the endoscopic approach thereafter. Laparoscopic surgery was performed 4 months after the first LC. After careful removal of the adhesion, the surgical clips buried beside the common bile duct became visible (Figure 2a,b). Two surgical clips used for the cystic duct closure were squeezing the common bile duct from the right side; other clips used for the cystic artery closure
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Salvage treatment of bile duct stenosis
Y Iimuro et al.
Figure 1 Radiological imaging of the LC-associated bile duct stricture in this case. (a) Preoperative MRCP showed no obvious stones in the bile duct or in the gallbladder (GB). (b) Four months after LC, severe stenosis (white arrow heads) in the upper part of the extrahepatic bile duct and bile duct stones (white arrow) were detected by MRCP. (c) ERC and (d) contrast-enhanced CT revealed that surgical clips (open arrows) used during LC directly squeezed the bile duct from both sides and that a relatively large stone (white arrow) existed above the stricture (white arrow head). ERC, endoscopic retrograde chorangiography; LC, laparoscopic cholecystectomy; MRCP, magnetic resonance cholangiopancreatography.
slightly compressed the bile duct from the left side. Removing the surgical clips was relatively easy after removing the adhesion. However, after the four surgical clips were removed (Figure 2c), bile leakage was detected from the right side wall of the bile duct, indicating that the surgical clips had already invaded the bile duct wall. The bile leakage was repaired with a Z-suture using an absorbable thread (4-0 Vicryl; Ethicon Endo-Surgery, Cincinnati, USA), and the cystic artery was ligated (Figure 2d). The total operation time was 66 min, and intraoperative blood loss was minimal. Endoscopic removal of the bile duct stone was performed 6 days after the laparoscopic surgery. ERC still showed the bile duct stenosis at the common bile duct with a biliary stone, although the surgical clips had already been removed (Figure 3a). Dilation of the
stenosis was achieved using an endoscopic balloon, and the biliary stone above the stenosis was successfully removed (Figure 3b,c). After these treatments, the patient was discharged, and he received follow-up at an endoscopic treatment center. In December 2011, stenosis of the bile duct and biliary stones recurred, as determined by magnetic resonance cholangiopancreatography. Endoscopic balloon dilation of the stenosis was performed, and the biliary stones were removed. Next, two plastic stent tubes were placed into the left (7 Fr) and the anterior (8.5 Fr) branches of the intrahepatic bile ducts (Figure 3d). In February 2012, the plastic stent tubes were replaced in the left (8.5 Fr), anterior (7 Fr), and posterior (7 Fr) branches (Figure 3e) to achieve a bougie effect. In April 2012, the endoscopic retrograde biliary drainage tubes were removed at the
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
323
Salvage treatment of bile duct stenosis
Y Iimuro et al.
Figure 2 Laparoscopic findings on the removal of surgical clips.(a, b) Surgical clips for the cystic duct (black arrow head) and the cystic artery (black arrow) appeared after careful removal of the adhesion. (c) Removed surgical metallic clips are shown. (d) After the surgical clips were removed, bile leakage from the bile duct was repaired with minimal absorbable suturing (white arrow head), and the cystic artery was ligated to avoid the use of clips (white arrow).
patient’s request, although slight stenosis was still detected (Figure 3f). Since the last treatment, the patient has been free of any symptoms for 1 year, and his laboratory data has been within normal ranges.
Discussion Despite several studies on the technical aspects of LC that can decrease the associated complication rate, the rate of LC-BDI has not declined (1). As such, laparoscopic surgeons must consider the optimal way to manage LC-BDI. Patients undergoing surgical reconstruction of the major LC-BDI reportedly have had excellent clinical outcomes and quality of life (3), and successful endoscopic management of bile duct leakage and stenosis have also been reported (4,5).
324
In the present case, the common bile duct was severely squeezed by surgical clips from LC and biliary stones appeared soon after the operation. Roux-en-Y hepaticojejunostomy seemed too invasive for the present case, but we determined that removal of the surgical clips was necessary and that an endoscopic approach might be required. The patient first underwent laparoscopic removal of the surgical clips, and soon after, endoscopic dilation of the stricture was performed. Because the surgical clips invaded the bile duct wall, simple balloon dilation while the surgical clips remained would possibly end in failure, even though transient dilation of the stenosis could be achieved. To dilate the bile duct stenosis effectively, it has been reported that placing multiple stent tubes is helpful, as performed in the present case (4). With combined laparoscopic and endoscopic approaches, the LC-associated bile duct stenosis was
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Salvage treatment of bile duct stenosis
Y Iimuro et al.
Figure 3 Endoscopic approaches to the bile duct stricture. (a) ERC shows biliary stenosis (white arrow heads) and stones (white arrow) after the surgical clips were laparoscopically removed. (b, c) After balloon dilation of the stricture (asterisk), the biliary stones were successfully removed. (c) Even after these procedures, slight stenosis of the bile duct (open arrow heads) remained. For the recurrent biliary stenosis, (d) double and (e) triple plastic stent tubes were placed 6 and 8 months after the laparoscopic operation, respectively, to achieve a bougie effect. (f) ERC after removal of the stent tubes reveals slight stenosis of the bile duct (open arrow heads). ERC, endoscopic retrograde chorangiography.
successfully treated in this case, and the patient did not encounter any recurrence for 9 months. The reason this type of iatrogenic biliary stenosis occurred on LC in this case is unknown, but there are some suspected causes. It is possible that the surgeon did not recognize a common cystic artery variant in which the cystic artery runs in front of the bile duct. This disorientation could have led to the surgical clips being inappropriately placed. To avoid this type of disorientation in anatomical variants, “dome-down cholecystectomy” has been reported to be feasible (6). It should be noted that metallic clips were used in LC. Late onset biliary stricture after LC due to metallic clips has been sporadically reported, and use of only absorbable materials has been recommended (7,8). The optimal management of LC-BDI depends on the timing of recognition, the extent of the injury, the patient’s condition, and the availability of experienced hepatobiliary surgeons and endoscopists. Notably, a review of bile duct injury after LC reported that only
17% of bile duct repairs were successful in those performed by the primary surgeon compared with 94% of those performed by a tertiary care biliary surgeon; also, hospital stay was three times longer in the former (9). Therefore, early referral to a tertiary care hospital that can provide a multidisciplinary approach to bile duct injury treatment seems most important (10). Biliary stricture without obvious jaundice can be overlooked for a long period and has a potential to lead to severe intrahepatic lithiasis and secondary liver fibrosis. Thus, careful examination of the biliary tract is required if the patient undergoing LC complains of undefined symptoms. A multidisciplinary approach combining surgical, endoscopic, and radiological techniques should be planned for LC-BDI on a case-by-case basis.
Acknowledgment The authors have no conflicts of interest to disclose.
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
325
Salvage treatment of bile duct stenosis
Y Iimuro et al.
References 1. Schmidt SC, Langrehr JM, Hintze RE et al. Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Br J Surg 2005; 92: 76–82. 2. Tantia O, Jain M, Khanna S et al. Iatrogenic biliary injury: 13 305 cholecystectomies experienced by a single surgical team over more than 13 years. Surg Endosc 2008; 22: 1077– 1086. 3. Lillemoe KD, Martin SA, Cameron JL et al. Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management. Ann Surg 1997; 225: 459–468; discussion 468–471. 4. Vitale GC, Tran TC, Davis BR et al. Endoscopic management of postcholecystectomy bile duct strictures. J Am Coll Surg 2008; 206: 918–923; discussion 924–915. 5. Weber A, Feussner H, Winkelmann F et al. Long-term outcome of endoscopic therapy in patients with bile duct
326
6.
7.
8.
9.
10.
injury after cholecystectomy. J Gastroenterol Hepatol 2009; 24: 762–769. Fullum TM, Kim S, Dan D et al. Laparoscopic “Dome-down” cholecystectomy with the LCS-5 Harmonic scalpel. JSLS 2005; 9: 51–57. McMahon GS, Attar S, Dennison AR. Bile duct “clipstones”–why a stitch in time could save nine. Hepatogastroenterology 2010; 57: 1037–1039. Bernhardt GA, Kornprat P, Schweiger W et al. Late onset bile duct stricture caused by iatrogenic injury during laparoscopic cholecystectomy, mimicking cholangiocellular carcinoma. Endoscopy 2010; 42 Suppl 2:E148–E149. Stewart L & Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 1995; 130: 1123–1128; discussion 1129. de Reuver PR, Grossmann I, Busch OR et al. Referral pattern and timing of repair are risk factors for complications after reconstructive surgery for bile duct injury. Ann Surg 2007; 245: 763–770.
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Salvage treatment of laparoscopic cholecystectomy-associated bile duct stenosis combining laparoscopic and endoscopic procedures: A case report Yuji Iimuro, Toshihiro Okada, Koichiro Ohashi, Yugo Uda, Kazuhiro Suzumura & Jiro Fujimoto Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
Keywords Biliary stenosis; laparoscopic cholecystectomy; salvage surgery Correspondence Yuji Iimuro, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan. Tel: +81 798 45 6582 Fax: +81 798 45 6581 Email: [email protected] Received: 27 March 2013; revised 31 May 2013; accepted 20 June 2013 DOI:10.1111/ases.12053
Abstract The incidence of laparoscopic cholecystectomy (LC)-associated bile duct injury has reached a steady state despite learning curve effect. Herein we report the case of a 74-year-old Japanese man who suffered from bile duct stenosis and stones after LC. The stenosis was due to stricture caused by surgical clips used inappropriately during LC. We planned a salvage treatment combining laparoscopic and endoscopic approaches. At laparoscopic observation, the clips had already invaded the right side of the bile duct; minimal absorbable suture was performed after all the clips were removed. The bile duct stenosis was then endoscopically dilated and the biliary stones were successfully removed. For the recurrent biliary stenosis after discharge, endoscopic balloon dilation was performed and multiple plastic stent tubes were placed. The stent tubes were removed 4 months later, and the patient has had no symptoms for 1 year. A combined laparoscopic and endoscopic approach was useful for the salvage treatment of LC-associated bile duct stenosis.
Introduction The incidence of laparoscopic cholecystectomyassociated bile duct injury (LC-BDI), which remains a critical issue in laparoscopic cholecystectomy (LC), appears to have reached a steady state (approximately 0.4%–0.6%), at least double the rate observed with open cholecystectomy (0.2%), despite learning curve effect (1,2). Herein we report a case of iatrogenic bile duct stenosis after LC. The patient successfully underwent a salvage treatment for the stenosis that combined laparoscopic and endoscopic approaches.
Case Presentation A 74-year-old man was referred to our department in July 2011 with discomfort in the right-upper quadrant. He had undergone LC for cholecystitis in February 2011 in a private hospital (Figure 1a), but he began to suffer from general fatigue in June 2011. MRI showed that the upper part of the extrahepatic bile duct was severely narrowed and that multiple biliary stones existed
322
(Figure 1b). The patient underwent endoscopic retrograde chorangiography (ERC), and endoscopic removal of the biliary stones was attempted. ERC showed that the surgical clips used in the LC directly squeezed the bile duct, and only the stones below the stenosis could be endoscopically removed (Figure 1c). After ERC, the patient was referred to our institution. Contrastenhanced CT confirmed the ERC finding (Figure 1d). We determined that further aggressive endoscopic balloon dilation for the treatment of the stenosis would be risky but that recurrent stenosis of the bile duct would possibly occur if the surgical clips remained. Roux-en-Y hepaticojejunostomy seemed too aggressive an option. Therefore, we decided to laparoscopically remove the surgical clips first and then try the endoscopic approach thereafter. Laparoscopic surgery was performed 4 months after the first LC. After careful removal of the adhesion, the surgical clips buried beside the common bile duct became visible (Figure 2a,b). Two surgical clips used for the cystic duct closure were squeezing the common bile duct from the right side; other clips used for the cystic artery closure
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Salvage treatment of bile duct stenosis
Y Iimuro et al.
Figure 1 Radiological imaging of the LC-associated bile duct stricture in this case. (a) Preoperative MRCP showed no obvious stones in the bile duct or in the gallbladder (GB). (b) Four months after LC, severe stenosis (white arrow heads) in the upper part of the extrahepatic bile duct and bile duct stones (white arrow) were detected by MRCP. (c) ERC and (d) contrast-enhanced CT revealed that surgical clips (open arrows) used during LC directly squeezed the bile duct from both sides and that a relatively large stone (white arrow) existed above the stricture (white arrow head). ERC, endoscopic retrograde chorangiography; LC, laparoscopic cholecystectomy; MRCP, magnetic resonance cholangiopancreatography.
slightly compressed the bile duct from the left side. Removing the surgical clips was relatively easy after removing the adhesion. However, after the four surgical clips were removed (Figure 2c), bile leakage was detected from the right side wall of the bile duct, indicating that the surgical clips had already invaded the bile duct wall. The bile leakage was repaired with a Z-suture using an absorbable thread (4-0 Vicryl; Ethicon Endo-Surgery, Cincinnati, USA), and the cystic artery was ligated (Figure 2d). The total operation time was 66 min, and intraoperative blood loss was minimal. Endoscopic removal of the bile duct stone was performed 6 days after the laparoscopic surgery. ERC still showed the bile duct stenosis at the common bile duct with a biliary stone, although the surgical clips had already been removed (Figure 3a). Dilation of the
stenosis was achieved using an endoscopic balloon, and the biliary stone above the stenosis was successfully removed (Figure 3b,c). After these treatments, the patient was discharged, and he received follow-up at an endoscopic treatment center. In December 2011, stenosis of the bile duct and biliary stones recurred, as determined by magnetic resonance cholangiopancreatography. Endoscopic balloon dilation of the stenosis was performed, and the biliary stones were removed. Next, two plastic stent tubes were placed into the left (7 Fr) and the anterior (8.5 Fr) branches of the intrahepatic bile ducts (Figure 3d). In February 2012, the plastic stent tubes were replaced in the left (8.5 Fr), anterior (7 Fr), and posterior (7 Fr) branches (Figure 3e) to achieve a bougie effect. In April 2012, the endoscopic retrograde biliary drainage tubes were removed at the
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
323
Salvage treatment of bile duct stenosis
Y Iimuro et al.
Figure 2 Laparoscopic findings on the removal of surgical clips.(a, b) Surgical clips for the cystic duct (black arrow head) and the cystic artery (black arrow) appeared after careful removal of the adhesion. (c) Removed surgical metallic clips are shown. (d) After the surgical clips were removed, bile leakage from the bile duct was repaired with minimal absorbable suturing (white arrow head), and the cystic artery was ligated to avoid the use of clips (white arrow).
patient’s request, although slight stenosis was still detected (Figure 3f). Since the last treatment, the patient has been free of any symptoms for 1 year, and his laboratory data has been within normal ranges.
Discussion Despite several studies on the technical aspects of LC that can decrease the associated complication rate, the rate of LC-BDI has not declined (1). As such, laparoscopic surgeons must consider the optimal way to manage LC-BDI. Patients undergoing surgical reconstruction of the major LC-BDI reportedly have had excellent clinical outcomes and quality of life (3), and successful endoscopic management of bile duct leakage and stenosis have also been reported (4,5).
324
In the present case, the common bile duct was severely squeezed by surgical clips from LC and biliary stones appeared soon after the operation. Roux-en-Y hepaticojejunostomy seemed too invasive for the present case, but we determined that removal of the surgical clips was necessary and that an endoscopic approach might be required. The patient first underwent laparoscopic removal of the surgical clips, and soon after, endoscopic dilation of the stricture was performed. Because the surgical clips invaded the bile duct wall, simple balloon dilation while the surgical clips remained would possibly end in failure, even though transient dilation of the stenosis could be achieved. To dilate the bile duct stenosis effectively, it has been reported that placing multiple stent tubes is helpful, as performed in the present case (4). With combined laparoscopic and endoscopic approaches, the LC-associated bile duct stenosis was
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Salvage treatment of bile duct stenosis
Y Iimuro et al.
Figure 3 Endoscopic approaches to the bile duct stricture. (a) ERC shows biliary stenosis (white arrow heads) and stones (white arrow) after the surgical clips were laparoscopically removed. (b, c) After balloon dilation of the stricture (asterisk), the biliary stones were successfully removed. (c) Even after these procedures, slight stenosis of the bile duct (open arrow heads) remained. For the recurrent biliary stenosis, (d) double and (e) triple plastic stent tubes were placed 6 and 8 months after the laparoscopic operation, respectively, to achieve a bougie effect. (f) ERC after removal of the stent tubes reveals slight stenosis of the bile duct (open arrow heads). ERC, endoscopic retrograde chorangiography.
successfully treated in this case, and the patient did not encounter any recurrence for 9 months. The reason this type of iatrogenic biliary stenosis occurred on LC in this case is unknown, but there are some suspected causes. It is possible that the surgeon did not recognize a common cystic artery variant in which the cystic artery runs in front of the bile duct. This disorientation could have led to the surgical clips being inappropriately placed. To avoid this type of disorientation in anatomical variants, “dome-down cholecystectomy” has been reported to be feasible (6). It should be noted that metallic clips were used in LC. Late onset biliary stricture after LC due to metallic clips has been sporadically reported, and use of only absorbable materials has been recommended (7,8). The optimal management of LC-BDI depends on the timing of recognition, the extent of the injury, the patient’s condition, and the availability of experienced hepatobiliary surgeons and endoscopists. Notably, a review of bile duct injury after LC reported that only
17% of bile duct repairs were successful in those performed by the primary surgeon compared with 94% of those performed by a tertiary care biliary surgeon; also, hospital stay was three times longer in the former (9). Therefore, early referral to a tertiary care hospital that can provide a multidisciplinary approach to bile duct injury treatment seems most important (10). Biliary stricture without obvious jaundice can be overlooked for a long period and has a potential to lead to severe intrahepatic lithiasis and secondary liver fibrosis. Thus, careful examination of the biliary tract is required if the patient undergoing LC complains of undefined symptoms. A multidisciplinary approach combining surgical, endoscopic, and radiological techniques should be planned for LC-BDI on a case-by-case basis.
Acknowledgment The authors have no conflicts of interest to disclose.
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
325
Salvage treatment of bile duct stenosis
Y Iimuro et al.
References 1. Schmidt SC, Langrehr JM, Hintze RE et al. Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Br J Surg 2005; 92: 76–82. 2. Tantia O, Jain M, Khanna S et al. Iatrogenic biliary injury: 13 305 cholecystectomies experienced by a single surgical team over more than 13 years. Surg Endosc 2008; 22: 1077– 1086. 3. Lillemoe KD, Martin SA, Cameron JL et al. Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management. Ann Surg 1997; 225: 459–468; discussion 468–471. 4. Vitale GC, Tran TC, Davis BR et al. Endoscopic management of postcholecystectomy bile duct strictures. J Am Coll Surg 2008; 206: 918–923; discussion 924–915. 5. Weber A, Feussner H, Winkelmann F et al. Long-term outcome of endoscopic therapy in patients with bile duct
326
6.
7.
8.
9.
10.
injury after cholecystectomy. J Gastroenterol Hepatol 2009; 24: 762–769. Fullum TM, Kim S, Dan D et al. Laparoscopic “Dome-down” cholecystectomy with the LCS-5 Harmonic scalpel. JSLS 2005; 9: 51–57. McMahon GS, Attar S, Dennison AR. Bile duct “clipstones”–why a stitch in time could save nine. Hepatogastroenterology 2010; 57: 1037–1039. Bernhardt GA, Kornprat P, Schweiger W et al. Late onset bile duct stricture caused by iatrogenic injury during laparoscopic cholecystectomy, mimicking cholangiocellular carcinoma. Endoscopy 2010; 42 Suppl 2:E148–E149. Stewart L & Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 1995; 130: 1123–1128; discussion 1129. de Reuver PR, Grossmann I, Busch OR et al. Referral pattern and timing of repair are risk factors for complications after reconstructive surgery for bile duct injury. Ann Surg 2007; 245: 763–770.
Asian J Endosc Surg 6 (2013) 322–326 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
