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Benign strictures of the common bile duct after surgery or due to gallstones may lead to obstruction and derangement of bile drainage in the extrahepatic biliary system. Although the treatment of choice in these situations is the endoscopic dilatation, in some cases with stenosis of a long segment of the bile duct a partial replacement with a vascularised jejunal patch may be possible and useful. To our knowledge, there are no reports on long-term results of the procedure. We describe the course, the surgical technique and long-term results of four patients with a jejunal patch reconstruction of the common bile duct. Ten years after surgery there were no radiologic or laboratory signs of a restenosis of the common bile duct.

Differences in outcome between patients undergoing laparoscopic (LC) vs. open cholecystectomy (OC) should be examined under objective and subjective aspects.We prospectively evaluated the postoperative course of 135 patients who underwent LC or OC in 1999. In the first step we examined the recover period with the help of the modified McPeek-Index. In the second phase during a 35 postoperative days-spanned analysis all patients noted there physical, emotional and social well-being in a circulating standard questionnaire, based on the modified Gastrointestinal Quality Life Index (GIQLI).Responses were obtained from 103 patients (76.3 %) undergoing 29 OC and 74 LC. 21.4 % of the patients aged 70 and older or had perioperative risksII in ASA-Classification (LC 19.8 vs. OC 30.1 %). The (objective) McPeek-Outcome was similar in both groups, with no statistical advantage for LC (best score: 69 % LC vs. 62 % OC). The subjective assessment of the patients showed that patients having LC felt fully fit 10.2 days earlier than patients after OC (23.9 vs. 34.1 days). Patients in the LC-group returned to work after an average of 24.7 days, compared with 42.2 days following OC. The main finding of the postal questionnaire was a significantly earlier recruitment in physical, emotional and social status following LC in the group of aged70 andASA II-Score-patients, in contrast to control-OC-group.The study suggests an additional advantage in surgical outcome after LC, in comparison to OC. The laparoscopic approach is the preferable procedure to treat especially older and comorbide patients, when local or anesthesiological contraindications are absent.

Biliary tract injury, although uncommon, is the most feared complication of laparoscopic cholecystectomy. Early identification or exclusion of such injury is essential for successful management. Over a two year period (1995-1996) twenty-one from a total of 413 ERCPs in this Surgical Endoscopy Unit were performed because of suspected biliary injury after laparoscopic cholecystectomy. 16 patients were referred from other units. No abnormality was demonstrated in two cases. A clip-related stenosis requiring reoperation was shown in twei patients. The remaining 17 cases had biliary leakage, related to an aberrant bile duct in 2 cases or a cystic duct leak in 15, all of which were treated endoscopically by nasobiliary tube (7), endoscopic papillotomy (5) or a combination of both (5). All of these biliary leaks healed uneventfully no ERCP-associated morbidity.

Minimal invasive methods compete with surgical treatment in the therapy of complications after cholecystectomy. We demonstrate our results of endoscopic therapy. 52 patients with postoperative complications (39 stenoses, 5 leakages, 6 stenoses and leakages, 2 complete obliterations of bile duct) were treated by transpapillary or transhepatic biliary drainage over a time period of 12 months. In 73% of patients who completed the therapy protocol successful treatment was possible. In 4 cases a restenosis occurred. 4 patients underwent surgical treatment. We think endoscopic management is the therapy of first choice for postoperative biliary complications. Biliary stricture should be dilatated for 12 months by biliary endoprosthesis, leakage can be drained for shorter time periods.

The postoperative complication rate of laparoscopic cholecystectomy (LC) is about 5-6%. The most frequent complications are residual gallstones in the common bile duct, biliary leckage, biliary fistula and duct stenosis. In the period between 01.11.94 and 01.04.96 we performed 1620 endoscopic retrograde cholangio pancreatographies including 410 papillotomies at the second Department of Medicine in the Clinic of Suhl. Thereby in 2.1% (34 cases) of patients a complication after laparosopic cholecystectomy was seen and endoscopically controlled. Residual bile duct stones were removed without any problems by papillotomy and stone extraction. Biliary leckage were brigded by stent implantation. In case of aberrant cystic duct it was also possible to implant a stent depending on anatomical situation. All patients were followed up over a period of 6 to 8 month after endoscopic procedure. All except two patients showed an occlusion of biliary leckage and the bile duct stent could be revved. In one case, a younger patient, with a failed endoscopic occlusion of biliary fistula had to undergo a further operation because of residual gallbladder tissue. In the other case, a 84-years old patient, we use a new method, developed at our department, for selective embolization of the cystic duct to prevent a relaparotomy. The leckage was sufficiently closed. Endoscopic intervention is indicated in case of postoperative complication after LC and successful in the majority of cases. This should primarily discussed between surgeon and physician. Only secondarily a relaparotomy should be performed, if endoscopic procedures have failed.

Occluding stones left in the stumpf of the cystic duct may account for between 17% and 25% of the cases of post-cholecystectomy syndrome. When acutely inflamed or empyemic gallbladders are removed, an occlusive cystic duct stone must almost always be expected. When performing laparoscopic cholecystectomy, therefore, care must be taken to ensure that any stone occluding the cystic duct are detected and removed. After completely freeing the cystic duct to the point of its junction with the common bile duct, it is carefully "palpated" with a 5 mm forceps for the presence of stones. Any such present are pressed out of the duct through a transverse incision, and retrieved. Bile reflux through the incision in the duct indicates freedom from stones. Finally, intraoperative cholangiography can be performed.