Early versus late repair of bile duct injuries

Abstract

Biliary injuries associated with laparoscopic cholecystectomy occur at a constant rate of 0.3% to 0.6%. The spectrum of injures ranges from small leaks of bile to complete section of the main ducts requiring bilioenteric reconstruction. The goal of biliary reconstruction is to obtain a high-quality bilioenteric anastomosis that will not malfunction for a long time. No prospective, controlled, randomized trial (evidence level 1) has been conducted that shows whether an early repair is better than a late one. The timing of the operative procedure should be individualized. A complete examination of the patient should be performed to identify the type of injury and coexistent comorbidities. For septic patients and those with multiple organ dysfunction syndrome, the repair should be delayed. Maneuvers to drain the bile ducts can be performed to relieve jaundice and cholangitis in these patients. For these cases, the surgery should be delayed. If a stable patient is found, without comorbidities, the operation can be scheduled earlier. Subhepatic drains should not be left for a long period because of the risk for intestinal fistulization. If needed, they should be changed for transhepatic stents. High-quality bilioenteric anastomoses are performed with fine absorbable sutures for healthy ducts (nonscarred, noninflamed, nonischemic) in a wide opening, with anastomosis of a (tension-free) defunctionalized jejunal limb. Individualization of the patient is the best rule.

Management of iatrogenic bile duct injury in cholecystectomy: a single centre experience

“…There are studies which highlighted the role of early repair in select group of patients. 17,18 There were 4 type D injuries. 2 recognized intraoperatively were immediately dealt by on table repair.…”

Management of Bile Duct Injury at Various Stages of Presentation: Experience from a Tertiary Care Centre

“…Notwithstanding the conventional practice, some recent studies have highlighted the role of early repair of BDI in a select group of patients [6,24,25]. The result of early repair was comparable to the delayed approach in a stable patient in whom intra-abdominal sepsis, vascular and cautery injury could be excluded and more importantly when the surgery was performed by 'specialist hepatobiliary surgeon'.…”

Spontaneous hepaticoduodenal fistula functioning like a bilioenteric anastomosis following bile duct injury: Case report

“…If the patient is unstable with fluid and electrolyte imbalance or sepsis, biliary reconstruction should be delayed until a more stable condition is achieved. Treatment of sepsis, regulation of fluid-electrolyte imbalance and percutaneous drainage or limited surgery including biliary decompression and abdominal drainage should be performed (10). This waiting period also allows resolution of inflammatory reaction and provides healthier ducts in which a high quality repair can be performed (10).…”

“…Treatment of sepsis, regulation of fluid-electrolyte imbalance and percutaneous drainage or limited surgery including biliary decompression and abdominal drainage should be performed (10). This waiting period also allows resolution of inflammatory reaction and provides healthier ducts in which a high quality repair can be performed (10). On the first admission of the patient, hepatostomy was preferred as the patient was unstable because of biliary peritonitis and sepsis.…”