Surgical management of post-cholecystectomy bile duct injuries: referral patterns and factors influencing early and long-term outcome

Abstract

Cholecystectomy-related bile duct injuries (BDI) remain a cause of significant morbidity and debate concerning optimal management is ongoing. We reviewed our experience with surgical management of BDI to assess patterns of referral along with postoperative and long-term outcomes. During September 1996-August 2013, 35 patients were operated in our tertiary care center for a Bismuth-Strasberg grade >A BDI after a cholecystectomy performed elsewhere. Injury grade distribution was as follows: D, n = 3; E1, n = 4; E2, n = 15; E3, n = 5; E4, n = 5; E5, n = 3. Four patients (11.4%) had an associated vascular injury (arterial, n = 2; portal, n = 1; both, n = 1). Treatment was direct repair + Kehr drain placement (n = 1), hepaticojejunostomy (n = 28), hepaticojejunostomy + hepatic resection (n = 5), and liver transplantation (n = 1). There was one postoperative death (2.8%) due to hepatic failure after liver resection; severe (Dindo-Clavien grade ≥3b) complications were observed in 12 (34.3%) patients. Sepsis at referral (OR 17.33, p = 0.007) and laparotomy prior to definitive repair (OR 14, p = 0.04) were the factors associated with severe complications. Median follow-up was 81 (range 12-182) months; two patients were lost to follow-up. Treatment failure (defined as need for reoperation or interventional radiology procedure during follow-up) was observed in 7/32 (21.9%) patients. No association between baseline variables and treatment failure was observed. Post-cholecystectomy BDI represent a heterogeneous entity. The whole armamentarium of the hepatobiliary surgeon is required to achieve proper management. Patients referred with sepsis and requiring laparotomy prior to definitive repair are more prone to develop severe complications.

Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study

“…Furthermore, inflammatory changes in the surgical bed produce tissue friability, resulting in increased technical difficulty at repair time [ 38 , 73 ]. In similar, in our study, sepsis at referral due to biliary peritonitis or severe cholangitis was significant predictor of early and late morbidities, despite our aggressive management of it before doing the definitive repair, similarly, it was independent predictor of complications and anastomotic failure after primary repair in Dominguez-Rosado et al, 2016 [ 19 ] study and was predictor of severe complications in Patrono et al, 2015 [ 4 ] study and it was the only independent predictor of major morbidity and a significant predictor of late biliary stricture in Sulpice et al, 2014 [ 31 ] study, in the same line, it was independent predictor of long-term complications in Huang et al, 2014 [ 38 ] study. In the same way, Schmidt et al, 2005 [ 21 ] found that the presence of active peritonitis was independently associated with long-term complications, such as anastomotic stricture, or secondary biliary cirrhosis.…”

“…Performing the definitive operation immediately (during the 1st 72 h), in the intermediate period (between 72 h and 1.5 months) or in the late period (after1.5 months) from injury, did not have any significant effect on our late biliary morbidity. Similarly, it did not influence postoperative morbidity in Pottakkat et al, 2010 [ 3 ], Patrono et al, 2015 [ 4 ], Bansal et al, 2015 [ 36 ], Huang et al, 2014 [ 38 ], Kirks et al, 2016 [ 83 ], and Perera et al, 2011 [ 84 ], studies. However, most authors advice late repair of LC-BDIs (≤6 weeks) from LC [ 29 , 53 , 85 ]; this allows the abdominal inflammation to subside prior to definitive repair leading to its success [ 50 , 86 ].…”

“…Despite increased surgical skills and experience regarding laparoscopic choelcystectomy (LC), the rate of LC related bile duct injury (BDI) is still higher in comparison to open cholecystectomy (0.2%–1.5% vs. 0.1–0.2% respectively) [ [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] ]. LC related BDIs range from minor injuries to complex hilar injuries as classified by Strasberg et al [ 9 , 10 ]; where the major types correspond to type E injuries including ongoing stricture, complete occlusion, resection or division of the bile ducts; [ [11] , [12] , [13] ].…”

“…Stents were internal or external; the internal stents were 4–7 French straight biliary stent (9–11 cm) or it was 4–7 French ureteric catheters that were placed into the common bile duct (CBD) and blindly directed across the ampulla of Vater. However, the external stent tip was positioned into the bile duct mostly the left one crossing the HJ anastomosis and pulled out of the jejunum [ 4 , 44 ]. They were removed 1.5–3 months from surgery after doing cholangiogram (ERCP or tube cholangiogram) and ensuring the absence of stricture or leak, Liver biopsy was obtained during operation to determine the presence of 2ry biliary cirrhosis, moreover, operative bleeding, blood transfusion and operative time were recorded.…”

Evaluating the Outcome of Direct Repair of Bile Duct Injury

“…1% of the whole cases which may indicate to be a risk factor for BDI. Patrono and his colleagues showed that acute cholecystitis is a nonsignificant trend in cases with BDI and biliary strictures [5] . This can be attributed to the difficulty in identifying the biliary anatomy and also the delay in conversion to open may play another role in BDI.…”