Introduction: The development of videolaparoscopic cholecystectomy (VLC) has represented an important achievement in the search for minimally invasive surgical procedures, and especially in the surgical management of such a common and costly disease as cholelithiasis. However, the literature shows that, while VLC carries a similar mortality rate to open surgery, it has a greater incidence (2-5 times) of iatrogenic injury to the biliary tract and hepatic hilum [3, 5, 10, 25, 28]; this incidence further increases in cases of so-called "hard cholecystis" [10, 13, 25, 28, 30]. An equally minimally invasive technique is therefore needed to treat these lesions; this technique should be effective and safe, allow for shorter hospital stays and lower costs, and be made available at all the centres where VLC is performed.
Material and methods: We evaluated 60 patients (28 women and 22 men, age range 41-71) with 24 peritoneal collections (14 bilomas, 10 abscesses), 35 biliary stenosis (clips, chronic-developing lesions), and 2 vascular lesions as direct iatrogenic post-LC injuries. The most frequent clinical symptoms were jaundice, pain, sepsis, abdominal distension, and abdominal colic due to retained common bile duct stones. We carried out 60 percutaneous biliary reconstruction procedures, 44 biliary drainages (4 internal, 4 external), 6 combined radiological-endoscopic approaches with the Rendez-Vous technique, and 2 embolisations.
Results: All procedures had 100% technical success; the biliary reconstruction procedures had a 2% morbidity rate (sepsis, cholangitis). The clinical emergencies (choleperitoneum, haemoperitoneum, severe jaundice) resolved in 72 hours for 55 of the 60 patients (92%). The combined percutaneous-endoscopic procedures with the biliary Rendez-Vous technique were successfully performed in 5 out of 6 cases, allowing reconstruction of bile duct continuity and remission of symptoms, without the need to resort to surgical anastomosis. At a recent follow-up of the patients who had been managed only percutaneously, one showed patency of the bile ducts and had the stent removed after 18 months, and two showed optimal functioning of the stent that was still in place after 5 and 8 months respectively; two patients were lost to follow-up. Primary biliary patency at 60 months from biliary reconstruction was 75%. Maximum and immediate dilatation was obtained at the first attempt in most cases. Reoperation was avoided in 59 out of 60 patients. Only one patient with full transection of the common bile duct was reoperated on after insertion of a biliary drainage catheter. The overall length of hospital stays was between 1 and 4 weeks.
Conclusions: Interventional radiology carried out according to indications seems to be the most natural way to treat the complications of VLC. It spares the patients, who opted for a minimally invasive technique like VLC, the need to undergo open surgery, and allows for shorter hospital stays and more efficient cost management for the hospital.