Bile duct injury repair —— earlier is not better

Hepatico-Duodenal Fistula Following Iatrogenic Strasberg Type E4 Bile Duct Injury: A Case Report

INTRODUCTION

Gallstone disease (GSD) is among the most common disorders worldwide. Gallstones are established in up to 15% of the general population. Laparoscopic cholecystectomy (LC) has become the "gold standard" for treatment of GSD but is associated with a higher rate of certain complications, namely, bile duct injury (BDI). Biliary fistulas (BF) are a common presentation of BDI (44.1% of all patients); however, they are mainly external. Post-cholecystectomy internal BF are exceedingly rare.

CASE REPORT

a 33-year Caucasian female was admitted with suspected BDI after LC. Strasberg type E4 BDI was established on endoscopic retrograde cholangiopancreatography (ERCP). Urgent laparotomy established biliary peritonitis. Delayed surgical reconstruction was planned and temporary external biliary drains were positioned in the right and left hepatic ducts. During follow-up, displacement of the drains occurred with subsequent evacuation of bile through the external fistula, which resolved spontaneously, without clinical and biochemical evidence of biliary obstruction or cholangitis. ERCP established bilio-duodenal fistula between the left hepatic duct (LHD) and duodenum, with a stricture at the level of the LHD. Endoscopic management was chosen with staged dilation and stenting of the fistulous tract over 18 months until fistula maturation and stricture resolution. One year after stent extraction, the patient remains symptom free.

DISCUSSION

Management of post-cholecystectomy BDI is challenging. The optimal approach is determined by the level and extent of ductal lesion defined according to different classifications (Strasberg, Bismuth, Hannover). Type E BDI are managed mainly surgically with a delayed surgical approach generally deemed preferable. Only three cases of choledocho-duodenal fistulas following LC BDI currently exist in the literature. Management is controversial, with expectant approach, surgical treatment (biliary reconstruction), or liver transplantation being described. Endoscopic treatment has not been described; however, in the current paper, it proved to be successful. More reports or larger case series are needed to confirm its applicability and effectiveness, especially in the long term.

Actuarial Patency Rates of Hepatico-Jejunal Anastomosis after Repair of Bile Duct Injury at a Reference Center

Background: Bile duct injury complicates patients’ lives, despite the subsequent repair. Repairing the injury must restore continuity of the bile tree and bring the patient into a state of cure referred to as “patency”. Actuarial primary or actuarial secondary patency rates, depending on whether the patient underwent primary or secondary repair of injury, are proposed to be a proper metric in evaluating outcomes. This study was undertaken to assess outcomes of 669 patients with bile duct injuries Strasberg D and E type referred to the department from public surgical wards between 1990 and 2020. In 442 patients, no attempt was made to repair prior to a referral, and in 227 an attempt to repair was made which failed. Methods: Observations were summarized on December 31st, 2020. The retrospective analysis included: primary patency attained (Grade A result), secondary patency attained (Grade C result), patency loss, and actuarial patency rates of the bile tree at 2, 5, and 10 years. Results: Twenty-five (3.7%) patients died after repair surgery. Actuarial patency rates at 2, 5, and 10 years of follow-up were 93%, 88%, and 74% or 86%, 75%, and 55% in patients attaining Grade A and Grade C outcomes, respectively (p < 0.001). Conclusion: Bile duct injury stands out as a surgical challenge, requiring specialized management at a referral center. Improper proceeding after an injury is the factor leading to faster loss of anastomotic patency.

Timing of surgical repair of bile duct injuries after laparoscopic cholecystectomy: A systematic review

BACKGROUND

The surgical management of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC) is challenging and the optimal timing of surgery remains unclear. The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.

AIM

To assess timing of surgical repair of BDI and postoperative complications.

METHODS

The MEDLINE, EMBASE, and The Cochrane Library databases were systematically screened up to August 2021. Risk of bias was assessed via the Newcastle Ottawa scale. The primary outcomes of this review included the timing of BDI repair and postoperative complications.

RESULTS

A total of 439 abstracts were screened, and 24 studies were included with 15609 patients included in this review. Of the 5229 BDIs reported, 4934 (94%) were classified as major injury. Timing of bile duct repair was immediate (14%, n = 705), early (28%, n = 1367), delayed (28%, n = 1367), or late (26%, n = 1286). Standardization of definition for timing of repair was remarkably poor among studies. Definitions for immediate repair ranged from < 24 h to 6 wk after LC while early repair ranged from < 24 h to 12 wk. Likewise, delayed (> 24 h to > 12 wk after LC) and late repair (> 6 wk after LC) showed a broad overlap.

CONCLUSION

The lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC. This finding indicates an urgent need for a standardized reporting system of BDI repair.

Early Surgical Repair of Bile Duct Injuries following Laparoscopic Cholecystectomy: The Sooner the Better

Background  We aimed to investigate the outcomes of the immediate surgical repair of bile duct injuries (BDIs) following laparoscopic cholecystectomy. Materials and Methods  Between January 2012 and May 2017, patients, who underwent immediate surgical repair (within 72 hours) for postcholecystectomy BDI, by the same surgical team expert in hepatobiliary surgery, were enrolled into the study. Data collection included demographics, type of BDI according to the Strasberg classification, time to diagnosis, surgical procedures, and outcome. Results  There were 13 patients with a mean age of 43 ± 12 years. Classification of BDIs were as follows: type E in six patients (46%), type D in three patients (23%), type C in two (15%), and types B and A in one patient each (7.6%). Mean time to diagnosis was 22 ± 15 hours. Surgical procedures included Roux-en-Y hepaticojejunostomy for all six patients with type-E injury, primary repair of common bile duct for three patients with type-D injury, and primary suturing of the fistula orifice was performed in two cases with type-C injury. Other two patients with type-B and -A injury underwent removal of clips which were placed on common bile duct during index operation and replacing of clips on cystic duct where stump bile leakage was observed probably due to dislodging of clips, respectively. Mean hospital stay was 6.6 ± 3 days. Morbidity with a rate of 30% ( n  = 4) was observed during a median follow-up period of 35 months (range: 6-56 months). Mortality was nil. Conclusion  Immediate surgical repair of postcholecystectomy BDIs in selected patients leads to promising outcome.

Bile Duct Injury Repairs after Laparoscopic Cholecystectomy: A Five-Year Experience in a Highly Specialized Community Hospital

Bile duct injury represents a complication after laparoscopic cholecystectomy, impairing quality of life and resulting in subsequent litigations. A five-year experience of bile duct injury repairs in 52 patients at a community hospital was reviewed. Twenty-nine were female, and the median age was 51 years (range, 20–83 years). Strasberg classification identified injuries as Type A (23), B (1), C (1), D (5), E1 (5), E2 (6), E3 (4), E4 (6), and E5 (1). Resolution of the bile duct injury and clinical improvement represent main postoperative outcome measures in our study. The referral time for treatment was within 4 to 14 days of the injury. Type A injury was treated with endobiliary stent placement. The remaining patients required T-tube placement (5), hepaticojejunostomy (20), and primary anastomosis (4). Two patients experienced bile leak after hepaticojejunostomy and were treated and resolved with percutaneous transhepatic drainage. At a median follow-up of 36 months, two patients (Class E4) required percutaneous balloon dilation and endobiliary stent placement for anastomotic stricture. The success of biliary reconstruction after complicated laparoscopic cholecystectomy can be achieved by experienced biliary surgeons with a team approach in a community hospital setting.

Management of Segmental Bile Duct Injuries After Cholecystectomy: a Systematic Review

BACKGROUND

Injuries to segmental or aberrant bile ducts are encountered less commonly than their major bile duct counterparts and present a unique diagnostic and therapeutic challenge, since the nature of this injury involves a transected bile duct that loses its communication with the main ductal system. In this systematic review, we aim to pool available data on this particular type of biliary injury in an effort to outline available diagnostic and therapeutic modalities and evaluate their efficacy.

MATERIALS AND METHODS

An extensive literature search was performed on MEDLINE, Scopus, and Web of Science to identify isolated segmental or aberrant bile duct injuries.

RESULTS

A total of 21 studies were included in this systematic report. Ten studies reported non-operative management of patients, while 12 reported operative management of included patients. Outcomes of interest were the choice of treatment interventions and their success. Overall, 23 patients were managed non-operatively with a 91% success rate and 30 patients were managed operatively with a 90% success rate.

CONCLUSION

Non-operative management might be a viable alternative to surgery. Hepatobiliary surgeons should be encouraged to publish their results in treating these rare injuries to further elucidate the role and efficacy of such an approach.

Combined surgical and interventional radiological treatment for biliary leakage following iatrogenic biliary obstruction

Biliary leakage is a challenging complication when managing the bile duct strictures. The etiology of benign strictures of the biliary tree may have different etiologies but iatrogenic is the most common, with relevant increase after introduction of laparoscopic procedures.

Interventional radiologist plays a key role, both in diagnosis and treatment of biliary strictures and leakage.

We report on a case of a 39-year-old woman affected by abdominal pain and jaundice after laparoscopic cholecystectomy; jaundice was caused by surgical clipping of the common bile duct. The combined management by surgeon and interventional radiologist, consisting of removal of surgical clip and percutaneous management of biliary leakage, successfully resolved the leakage with clinical success.