Comparing early and delayed repair of common bile duct injury to identify clinical drivers of outcome and morbidity

Optimal Timing of Surgical Repair After Bile Duct Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Major bile duct injury during cholecystectomy often requires surgical reconstruction. The optimal timing of repair is debated.

OBJECTIVES

To assess the association between the timing of hepaticojejunostomy and postoperative morbidity, mortality, and anastomotic stricture.

METHODS

Systematic review and meta-analysis of observational studies comparing early (<14 days), intermediate (14 days-6 weeks), and late (>6 weeks) repair. Primary outcomes were postoperative morbidity, mortality, and stricture rates. Pooled risk ratios were calculated. A generalized linear model was used to estimate odds per time interval.

RESULTS

20 studies were included in the systematic review. Of these, data from 15 studies was included in the meta-analyses. The 20 included studies comprised a total of 3421 patients who underwent hepaticojejunostomy for bile duct injury. Early repair was associated with lower morbidity versus intermediate repair (RR 0.73, 95% CI 0.54-0.98). Delayed repair had lower morbidity versus intermediate (RR 1.50, 95% CI 1.16-1.93). Delayed repair had a lower stricture rate versus intermediate repair (RR 1.53, 95% CI 1.07-2.20). Mortality was not associated with timing.

CONCLUSIONS

Reconstruction between 2 and 6 weeks after bile duct injury should be avoided given the higher morbidity and stricture rates. Delayed repair after 6 weeks may be beneficial.

Bile duct injury with formation of right hepatic duct-duodenal fistula after cholecystectomy: A case report

RATIONALE

The management of bile duct injury (BDI) remains a considerable challenge in the department of hepatobiliary and pancreatic surgery. BDI is mainly iatrogenic and mostly occurs in laparoscopic cholecystectomy (LC). After more than 2 decades of development, with the increase in experience and technological advances in LC, the complications associated with the procedure have decreased annually. However, bile duct injuries (BDI) still have a certain incidence, the severity of BDI is higher, and the form of BDI is more complex.

PATIENT CONCERNS

We report the case of a patient who presented with bile duct injury and formation of a right hepatic duct-duodenal fistula after LC.

DIAGNOSES

Based on the diagnosis, a dissection was performed to relieve bile duct obstruction, suture the duodenal fistula, and anastomose the right and left hepatic ducts to the jejunum.

INTERVENTION

Based on the diagnosis, a dissection was performed to relieve bile duct obstruction, suture the duodenal fistula, and anastomose the right and left hepatic ducts to the jejunum.

OUTCOMES

Postoperative recovery was uneventful, with normal liver function and no complications, such as anastomotic fistula or biliary tract infection. The patient was hospitalized for 11 days postoperatively and discharged.

LESSONS

The successful diagnosis and treatment of this case and the summarization of the imaging features and diagnosis of postoperative BDI have improved the diagnostic understanding of postoperative BDI and provided clinicians with a particular clinical experience and basis for treating such diseases.

Post-cholecystectomy major bile duct injury: ideal time to repair based on a multicentre randomized controlled trial with promising results

BACKGROUND

Bile duct injury (BDI) is one of the serious complications of cholecystectomy procedures, which has a disastrous impact on long-term survival, health-related quality of life (QoL), healthcare costs as well as high rates of litigation. The standard treatment of major BDI is hepaticojejunostomy (HJ). Surgical outcomes depend on many factors, including the severity of the injury, the surgeons' experiences, the patient's condition, and the reconstruction time. The authors aimed to assess the impact of reconstruction time and abdominal sepsis control on the reconstruction success rate.

METHODS

This is a multicenter, multi-arm, parallel-group, randomized trial that included all consecutive patients treated with HJ for major post-cholecystectomy BDI from February 2014 to January 2022. Patients were randomized according to the time of reconstruction by HJ and abdominal sepsis control into group A (early reconstruction without sepsis control), group B (early reconstruction with sepsis control), and group C (delayed reconstruction). The primary outcome was successful reconstruction rate, while blood loss, HJ diameter, operative time, drainage amount, drain and stent duration, postoperative liver function tests, morbidity and mortality, number of admissions and interventions, hospital stay, total cost, and patient QoL were considered secondary outcomes.

RESULTS

Three hundred twenty one patients from three centres were randomized into three groups. Forty-four patients were excluded from the analysis, leaving 277 patients for intention to treat analysis. With univariate analysis, older age, male gender, laparoscopic cholecystectomy, conversion to open cholecystectomy, failure of intraoperative BDI recognition, Strasberg E4 classification, uncontrolled abdominal sepsis, secondary repair, end-to-side anastomosis, diameter of HJ (< 8 mm), non-stented anastomosis, and major complications were risk factors for successful reconstruction. With multivariate analysis, conversion to open cholecystectomy, uncontrolled sepsis, secondary repair, the small diameter of HJ, and non-stented anastomosis were the independent risk factors for the successful reconstruction. Also, group B patients showed decreased admission and intervention rates, decreased hospital stay, decreased total cost, and early improved patient QoL.

CONCLUSION

Early reconstruction after abdominal sepsis control can be done safely at any time with comparable results for delayed reconstruction in addition to decreased total cost and improved patient QoL.

Determinants, Costs, and Consequences of Common Bile Duct Injury Requiring Operative Repair Among Privately Insured Individuals in the United States, 2003-2020

Objective

Characterize the determinants, all-cause mortality risk, and healthcare costs associated with common bile duct injury (CBDI) following cholecystectomy in a contemporary patient population.

Background

Retrospective cohort study using nationwide patient-level commercial and Medicare Advantage claims data, 2003-2019. Beneficiaries ≥18 years who underwent cholecystectomy were identified using Current Procedure Terminology (CPT) codes. CBDI was defined by a second surgical procedure for repair within one year of cholecystectomy.

Methods

We estimated the association of common surgical indications and comorbidities with risk of CBDI using logistic regression; the association between CBDI and all-cause mortality using Cox proportional hazards regression; and calculated average healthcare costs associated with CBDI repair.

Results

Among 769,782 individuals with cholecystectomy, we identified 894 with CBDI (0.1%). CBDI was inversely associated with biliary colic (odds ratio [OR] = 0.82; 95% confidence interval [CI]: 0.71-0.94) and obesity (OR = 0.70, 95% CI: 0.59-0.84), but positively associated with pancreas disease (OR = 2.16, 95% CI: 1.92-2.43) and chronic liver disease (OR = 1.25, 95% CI: 1.05-1.49). In fully adjusted Cox models, CBDI was associated with increased all-cause mortality risk (hazard ratio = 1.57, 95% CI: 1.38-1.79). The same-day CBDI repair was associated with the lowest mean overall costs, with the highest mean overall costs for repair within 1 to 3 months.

Conclusions

In this retrospective cohort study, calculated rates of CBDI are substantially lower than in prior large studies, perhaps reflecting quality-improvement initiatives over the past two decades. Yet, CBDI remains associated with increased all-cause mortality risks and significant healthcare costs. Patient-level characteristics may be important determinants of CBDI and warrant ongoing examination in future research.

Iatrogenic Injury of Biliary Tree-Single-Centre Experience

Cholecystolithiasis is among the most prevalent gastrointestinal disorders requiring surgical intervention, and iatrogenic damage to the bile tree is a severe complication. We aimed to present the frequency of bile duct injuries and how our facility handles these complications. We retrospectively analyzed bile duct injuries in patients undergoing surgery. We concentrated on factors such as sex, age, indications for surgery, type of surgery, primary procedure, bile tree injury, repair, and timing as well as early and late complications. There were 22 cases of bile duct injury in the studied material, primarily affecting women-15 individuals (68.2%). Eleven cases (45.7%) of acute cholecystitis were the primary reason for surgery, and an injury to the common bile duct that extended up to 2 cm from the common hepatic duct was the most common complication (European Association for Endoscopic Surgery grade 2). Roux-en-Y hepaticojejunostomy was the most common repair procedure in 14 cases (63.6%). Eleven patients (50%) experienced early complications following reconstruction surgery, whereas five patients (22.7%) experienced late complications. An annual mortality rate of 22.7% (five patients) was observed. Iatrogenic bile duct injury is a severe complication of surgical treatment for cholecystolithiasis. Reconstruction procedures are characterized by high complication rates and high mortality.

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.

Management of Major Injuries to the Bile Duct at a Hepatobiliary Specialty Referral Center

INTRODUCTION

Aim is to evaluate geographical and demographic factors influencing management of bile duct injuries occurring during cholecystectomy in a tertiary hepato-pancreato-biliary center in Southeast US.

METHODS

All referrals for biliary injuries during cholecystectomy, between Jan 2017 and December 2020 were included.

RESULTS

19 patients were identified with a median age of 59 (47-65), average BMI of 30.3 (18-49), and the prevalence of diabetes mellitus, hypertension and cardiovascular disease of 11%, 47% and 16%, respectively. The average transfer distance was 76 miles (8-102) and median transfer time was 3 days (1-12). 16 (84%) had Strasberg E injury, with 4 (21%) having a concomitant vascular injury (3 - right hepatic artery, 1 - right portal vein). Two (10.5%) were managed non-operatively, immediate surgical repair was performed in 2 (10.5%) and 15 (78.9%) patients underwent a delayed repair with a median of 87 days (69-118) from injury to repair. Median operative time was 5 hours (4-7), blood loss was 150 mL (100-200) and hospital stay was 8 days (6-12).

DISCUSSION

Factors including distance between hospitals, delays in patient transfer due to bed availability and transportation, play a role in the decision-making towards delayed repair. The delayed repair has the benefit of medical optimization of our high-risk patients' population.

Risk factors for anastomotic stricture after hepaticojejunostomy for bile duct injury-A systematic review and meta-analysis

BACKGROUND

After major bile duct injury, hepaticojejunostomy can result in good long-term patency, but anastomotic stricture is a common cause of long-term morbidity. There is a need to assimilate high-level evidence to establish risk factors for development of anastomotic stricture after hepaticojejunostomy for bile duct injury.

METHODS

A systematic review of studies reporting the rate of anastomotic stricture after hepaticojejunostomy for bile duct injury was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses of proposed risk factors were then performed.

RESULTS

Meta-analysis included 5 factors (n = 2,155 patients, 17 studies). Concomitant vascular injury (odds ratio 4.96; 95% confidence interval 1.92-12.86; P = .001), postrepair bile leak (odds ratio: 8.03; 95% confidence interval 2.04-31.71; P = .003), and repair by nonspecialist surgeon (odds ratio 11.29; 95% confidence interval 5.21-24.47; P < .0001) increased the rate of anastomotic stricture of hepaticojejunostomy after bile duct injury. Level of injury according to the Strasberg Grade did not significantly affect the rate of anastomotic stricture (odds ratio: 0.97; 95% confidence interval 0.45-2.10; P = .93). Owing to heterogeneity of reporting, it was not possible to perform a meta-analysis for the impact of timing of repair on anastomotic stricture rate.

CONCLUSION

The only modifiable risk factor, repair by a nonspecialist surgeon, demonstrates the importance of broad awareness of these data. Knowledge of these risk factors may permit risk stratification of follow-up, better informed consent, and understanding of prognosis.

Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study

BACKGROUND

Bile duct injury (BDI) after cholecystectomy remains a significant surgical challenge. No guideline exists to guide the timing of repair, while few studies compare early versus late repair BDI. This study aimed to analyze the outcomes in patients undergoing immediate, intermediate, and delayed repair of BDI.

METHODS

We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020. The patients were divided into three groups based on the time of BDI reconstruction. Group 1 underwent an immediate reconstruction (within the first 72 hours post-cholecystectomy, n = 156); group 2 underwent an intermediate reconstruction (from 4 days to 6 weeks post-cholecystectomy, n = 75), and group 3 underwent delayed reconstruction (after 6 weeks post-cholecystectomy, n = 181).

RESULTS

Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3. Favorable outcome was observed in 111 (71.2%) patients in group 1, 31 (41.3%) patients in group 2, and 157 (86.7%) patients in group 3 (P = 0.0001). Multivariate analysis identified that complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1, the use of external stent was an independent factor of favorable outcome in group 2, and level E4 BDI was an independent factor of unfavorable outcome in group 3. Transected BDI and level E4 BDI were independent factors of unfavorable outcome.

CONCLUSIONS

Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI. Complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Biliary Enteric Reconstruction After Biliary Injury: Delayed Repair Is More Costly Than Early Repair

BACKGROUND

Bile duct injury (BDI) during cholecystectomy requiring biliary enteric reconstruction (BER) is associated with increased risk of postoperative mortality and substantive increases in costs of care. The impact of the timing of repair on overall costs of care is poorly understood.

MATERIALS AND METHODS

The Healthcare Cost and Utilization Project Florida State databases (2006-2015) were queried to identify patients undergoing BER within 1-y of cholecystectomy performed for benign biliary disease. Patients were then categorized by the time interval between cholecystectomy to BER: early (≤3 d), intermediate (4 d to 6 wk), or delayed (>6 wk). By repair timing strategy, 1-y outcomes were aggregated, including charges, inpatient costs, aggregate length of stay, and inpatient mortality.

RESULTS

Of 563,887 patients undergoing cholecystectomy, 1168 required a BER (0.21%) within 1-y of cholecystectomy. Early BER was performed in 560 patients (47.9%), intermediate BER in 439 patients (37.6%), and delayed BER in 169 (14.5%) patients. On multivariable analysis adjusting for patient, procedure, and facility factors, intermediate BER demonstrated an increased risk of mortality (odds ratio 2.04, 95% confidence interval [CI]: 1.16-3.56) and increased aggregate inpatient cost (+$12,472; 95% CI: $6421-$18,524) relative to early BER. There was no notable difference in adjusted risk of inpatient mortality between the early and delayed BER cohorts (odds ratio 0.90; 95% CI: 0.32-1.25), but delayed BER was associated with increased aggregate inpatient costs (+$45,111; 95% CI: $36,813-$53,409).

CONCLUSIONS

When compared with delayed BER, early repair was associated with shorter aggregate inpatient hospitalization without increased postoperative mortality. Intermediate timing of repair is associated with increased costs and risk of mortality.

Optimal timing for surgical reconstruction of bile duct injury: meta-analysis

Background

Major bile duct injury (BDI) after cholecystectomy generally requires surgical reconstruction by means of hepaticojejunostomy. However, there is controversy regarding the optimal timing of surgical reconstruction.

Methods

A systematic review was performed by searching PubMed, Embase and Cochrane databases for studies published between 1990 and 2018 reporting on the timing of hepaticojejunostomy for BDI (PROSPERO registration CRD42018106611). The main outcomes were postoperative morbidity, postoperative mortality and anastomotic stricture. When individual patient data were available, time intervals of these studies were attuned to render these comparable with other studies. Data for comparable time intervals were pooled using a random‐effects model. In addition, data for all included studies were pooled using a generalized linear model.

Results

Some 21 studies were included, representing 2484 patients. In these studies, 15 different time intervals were used. Eight studies used the time intervals of less than 14 days (early), 14 days to 6 weeks (intermediate) and more than 6 weeks (delayed). Meta‐analysis revealed a higher risk of postoperative morbidity in the intermediate interval (early versus intermediate: risk ratio (RR) 0·73, 95 per cent c.i. 0·54 to 0·98; intermediate versus delayed: RR 1·50, 1·16 to 1·93). Stricture rate was lowest in the delayed interval group (intermediate versus delayed: RR 1·53, 1·07 to 2·20). Postoperative mortality did not differ within time intervals. The additional analysis demonstrated increased odds of postoperative morbidity for reconstruction between 2 and 6 weeks, and decreased odds of anastomotic stricture for delayed reconstruction.

Conclusion

This meta‐analysis found that surgical reconstruction of BDI between 2 and 6 weeks should be avoided as this was associated with higher risk of postoperative morbidity and hepaticojejunostomy stricture.

Early Versus Delayed Surgical Repair and Referral for Patients With Bile Duct Injury: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study was to systematically review and meta-analyze the available evidence regarding the association between timing of repair or referral and clinical outcomes in bile duct injury (BDI).

BACKGROUND

Surgical repair is recommended for patients with complex BDI following laparoscopic cholecystectomy. However, consensus on the timing of surgery or referral to a specialist is lacking.

METHODS

We searched PubMed, Embase, Cochrane Library, and Scopus for eligible studies. The coprimary outcomes were repair failure in follow-up and postoperative complications. We pooled odds ratios (ORs) using random-effects models.

RESULTS

We included 32 studies. The rate of repair failure was significantly higher for early versus delayed repair [OR 1.65, 95% confidence interval (CI) 1.14-2.37, P= 0.007], lower for early versus delayed referral (OR 0.28, 95% CI 0.17-0.45, P < 0.001), but did not differ substantially for on-table versus postcholecystectomy repair (OR 2.06, 95% CI 0.89-4.73, P = 0.09). Regarding postoperative complications, early referral outperformed delayed referral (OR 0.24, 95% CI 0.09-0.68, P= 0.007); however, we found no significant differences between early and delayed repair (OR 1.34, 95% CI 0.96-1.87, P= 0.08), or between on-table and postcholecystectomy repair (OR 1.13, 95% CI 0.42-3.07, P= 0.81). At the cutoff time point of 6 weeks, early repair was associated with increased rates of repair failure (OR 4.03; P < 0.001), postoperative complications (OR 2.18; P < 0.001), and biliary stricture (OR 6.23; P < 0.001).

CONCLUSIONS

Among patients with BDI, early referral and delayed repair appear to confer favorable outcomes.

Risk factors and management of different types of biliary injuries in blunt abdominal trauma: Single-center retrospective cohort study

Background

Biliary injuries after blunt abdominal traumas are uncommon and difficult to be predicted for early management. The aim of this study is to analyze the risk factors and management of biliary injuries with blunt abdominal trauma.

Method

Patients with blunt liver trauma in the period between 2009 to May 2019 were included in the study. Patients were divided into 2 groups for comparison; a group of liver parenchymal injury and group with traumatic biliary injuries (TBI).

Results

One hundred and eight patients had blunt liver trauma (46 patients with liver parenchymal injury and 62 patients with TBI). TBI were; 55 patients with bile leak, 3 patients with haemobilia, and 4 patients with late obstructive jaundice. Eight patients with major bile leak and 12 patients with minor bile leak had been resolved with a surgical drain or percutaneous pigtail drainage. Nineteen patients (34.5%) with major and minor bile leak underwent successful endoscopic retrograde cholangiopancreatography (ERCP). Sixteen patients (29.1%) underwent surgical repair for bile leak. In Multivariate analysis, the possible risk factors for prediction of biliary injuries were central liver injuries (P = 0.032), high grades liver trauma (P = 0.046), elevated serum level of bilirubin at time of admission (P = 0.019), and elevated gamma glutamyl transferase (GGT) at time of admission (P = 0.017).

Conclusion

High-grade liver trauma, central parenchymal laceration and elevated serum level of bilirubin and GGT are possible risk factors for the prediction of TBI. Bile leak after blunt trauma can be treated conservatively, while ERCP is indicated after failure of external drainage.

Risk factors and management of different types of biliary injuries in blunt abdominal trauma: Single-center retrospective cohort study

Background

Biliary injuries after blunt abdominal traumas are uncommon and difficult to be predicted for early management. The aim of this study is to analyze the risk factors and management of biliary injuries with blunt abdominal trauma.

Method

Patients with blunt liver trauma in the period between 2009 to May 2019 were included in the study. Patients were divided into 2 groups for comparison; a group of liver parenchymal injury and group with traumatic biliary injuries (TBI).

Results

One hundred and eight patients had blunt liver trauma (46 patients with liver parenchymal injury and 62 patients with TBI). TBI were; 55 patients with bile leak, 3 patients with haemobilia, and 4 patients with late obstructive jaundice. Eight patients with major bile leak and 12 patients with minor bile leak had been resolved with a surgical drain or percutaneous pigtail drainage. Nineteen patients (34.5%) with major and minor bile leak underwent successful endoscopic retrograde cholangiopancreatography (ERCP). Sixteen patients (29.1%) underwent surgical repair for bile leak. In Multivariate analysis, the possible risk factors for prediction of biliary injuries were central liver injuries (P = 0.032), high grades liver trauma (P = 0.046), elevated serum level of bilirubin at time of admission (P = 0.019), and elevated gamma glutamyl transferase (GGT) at time of admission (P = 0.017).

Conclusion

High-grade liver trauma, central parenchymal laceration and elevated serum level of bilirubin and GGT are possible risk factors for the prediction of TBI. Bile leak after blunt trauma can be treated conservatively, while ERCP is indicated after failure of external drainage.

•

In most of the published series they discussed the iatrogenic biliary injuries or injuries after sharp trauma.

•

To our knowledge it is the largest series to discuss the biliary injuries with blunt liver trauma.

•

We can predict the possible risk factors for bile duct injury after blunt liver trauma.

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So we can diagnose and treat it properly and early before sepsis and biliary complications.

•

We can approach to the ideal treatment modality for each type of biliary injuries with prober timing.

Long-Term Impact of Iatrogenic Bile Duct Injury

BACKGROUND

Bile duct injury (BDI) is a devastating complication following cholecystectomy. After initial management of BDI, patients stay at risk for late complications including anastomotic strictures, recurrent cholangitis, and secondary biliary cirrhosis.

METHODS

We provide a comprehensive overview of current literature on the long-term outcome of BDI. Considering the availability of only limited data regarding treatment of anastomotic strictures in literature, we also retrospectively analyzed patients with anastomotic strictures following a hepaticojejunostomy (HJ) from a prospectively maintained database of 836 BDI patients.

RESULTS

Although clinical outcomes of endoscopic, radiologic, and surgical treatment of BDI are good with success rates of around 90%, quality of life (QoL) may be impaired even after "clinically successful" treatment. Following surgical treatment, the incidence of anastomotic strictures varies from 5 to 69%, with most studies reporting incidences around 10-20%. The median time to stricture formation varies between 11 and 30 months. Long-term BDI-related mortality varies between 1.8 and 4.6%. Of 91 patients treated in our center for anastomotic strictures after HJ, 81 (89%) were treated by percutaneous balloon dilatation, with a long-term success rate of 77%. Twenty-four patients primarily or secondarily underwent surgical revision, with recurrent strictures occurring in 21%.

CONCLUSIONS

The long-term impact of BDI is considerable, both in terms of clinical outcomes and QoL. Treatment should be performed in tertiary expert centers to optimize outcomes. Patients require a long-term follow-up to detect anastomotic strictures. Strictures should initially be managed by percutaneous dilatation, with surgical revision as a next step in treatment.

Difficult iatrogenic bile duct injuries following different types of upper abdominal surgery: report of three cases and review of literature

Background

Iatrogenic bile duct injuries (BDIs) are mostly associated with laparoscopic cholecystectomy but may also occur following gastroduodenal surgery or liver resection. Delayed diagnosis of type of injury with an ongoing biliary leak as well as the management in a non-specialized general surgical units are still the main factors affecting the outcome.

Case presentation

Herein we present three types of BDIs (Bismuth type I, IV and V) following three different types of upper abdominal surgery, ie. Billroth II gastric resection, laparoscopic cholecystectomy and left hepatectomy. All of them were complex injuries with complete bile duct transections necessitating surgical treatment. All were also very difficult to treat mainly because of a delayed diagnosis of type of injury, associated biliary leak and as a consequence severe inflammatory changes within the liver hilum. The treatment was carried out in our specialist hepatobiliary unit and first focused on infection and inflammation control with adequate biliary drainage. This was followed by a delayed surgical repair with the technique which had to be tailored to the type of injury in each case.

Conclusion

We emphasize that staged and individualized treatment strategy is often necessary in case of a delayed diagnosis of complex BDIs presenting with a biliary leak, inflammatory intraabdominal changes and infection. Referral of such patients to expert hepatobiliary centres is crucial for the outcome.

A comprehensive evaluation of the long-term economic impact of major bile duct injury

BACKGROUND

Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI.

METHOD

Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes.

RESULTS

Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates.

CONCLUSION

Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.

An Update on Iatrogenic Biliary Injuries: Identification, Classification, and Management

Common bile duct injury is a feared complication of cholecystectomy, with an incidence of 0.1% to 0.6%. A majority of injuries go unnoticed at index operation, and postoperative diagnosis can be difficult. Patient presentation can vary from vague abdominal pain to uncontrolled sepsis and peritonitis. Diagnostic evaluation typically begins with ultrasound or CT scan in the acute setting, and source control is paramount at time of presentation. In a stable patient, hepatobiliary iminodiacetic acid scan can be useful in identifying an ongoing bile leak, which requires intervention. A variety of diagnostic techniques define biliary anatomy. Treatment often requires a multidisciplinary approach.

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

Objectives

Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries.

Patients and methods

We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018.

Results

Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity.

Conclusion

Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures.

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

Objectives

Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries.

Patients and methods

We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018.

Results

Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity.

Conclusion

Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures.

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Sepsis at referral was associated with poor outcome after management of LC related MBDIs.

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Liver cirrhosis and operative bleeding were associated with poor outcome after management of these injuries.

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It is crucial to avoid these catastrophes when doing those major procedures.

Long-term follow-up and risk factors for strictures after hepaticojejunostomy for bile duct injury: An analysis of surgical and percutaneous treatment in a tertiary center

BACKGROUND

Hepaticojejunostomy is commonly indicated for major bile duct injury after cholecystectomy. The debate about the timing of hepaticojejunostomy for bile duct injury persists since data on postoperative outcomes, including postoperative strictures, are lacking. The aim of this study was to analyze short- and long-term outcomes of hepaticojejunostomy for bile duct injury, including risk factors for strictures.

METHOD

Analysis of outcome of hepaticojejunostomy in bile duct injury patients referred to a multidisciplinary team.

RESULTS

Between the years1991 and 2016, 281 patients underwent hepaticojejunostomy for bile duct injury. Clavien-Dindo grade III complications occurred in 31 patients (11%) and 90-day mortality occurred in 2 patients (0.7%). After a median follow-up of 10.5 years (interquartile range 6.7-14.8 years), clinically relevant strictures were found in 37 patients (13.2%). Strictures were treated with percutaneous dilatation in 33 patients (89.2%), and 4 patients (1.4%) were reoperated. The stricture rate in patients undergoing hepaticojejunostomy <14 days, between 14-90 days, and >90 days after bile duct injury was 15.8%, 18.7%, and 9.9%, respectively. The stricture rate for early versus intermediate and late repair did not differ (P = 0.766 and 0.431, respectively). The stricture rate for repair after 14-90 days, however, was higher compared with repair >90 days after bile duct injury (P = 0.045). In multivariable analysis male gender was the only independent variable associated with stricture formation (OR 6.7, 95% CI 1.8-25.4, P = 0.005).

CONCLUSION

Hepaticojejunostomy is a relatively safe treatment of bile duct injury. Timing of surgery and intermediate repair affect long-term stricture rate; most anastomotic strictures can be treated successfully with percutaneous dilation.

Surgical management for bile duct injury

The management of bile duct injury (BDI) remains a considerable challenge in hepatobiliary surgery. BDI is mainly iatrogenic, and mostly occurs in cholecystectomy. Laparoscopic cholecystectomy (LC) has been performed widely, however, the incidence of BDI associated with LC increases 2-3 times compared to that in open cholecystectomy (OC). BDI also occurs in robotic cholecystectomy. In China, the evidence-based Practice Guideline for Diagnosis and Treatment of BDI was published by the Biliary Surgery Group of Surgery Branch of Chinese Medical Association, with the purpose of reducing the incidence of BDI as well as promoting its optimal diagnosis and treatment. Surgery remains the mainstay of treatment for BDI and traumatic bile duct stricture. The definitive repair involves a series of procedures including exposing the proximal and distal bile duct, anastomotic bile duct tissue preparation, minimally invasive tissue anastomoses, and so on. Successful management is a surgical challenge requiring great specialized experience and precise surgical skill. The application of precision biliary surgery is recommended for promoting standardized management of BDI.