Post cholecystectomy bile duct injury: early, intermediate or late repair with hepaticojejunostomy - an E-AHPBA multi-center study

Is there a place for endoscopic management in post-cholecystectomy iatrogenic bile duct injuries?

In this editorial we comment on the article by Emara et al published in the recent issue of the World Journal of Gastrointestinal Surgery. Previously, surgery was the primary treatment for bile duct injuries (BDI). The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures. Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years. Patient management, including the specific technique, is typically impacted by local knowledge and the kind and severity of the injury. Endoscopic therapy is a highly successful treatment for postoperative benign bile duct stenosis and offers superior long-term outcomes compared to surgical correction. Based on the damage features of BDI, therapeutic options include endoscopic duodenal papillary sphincterotomy, endoscopic nasobiliary drainage, and endoscopic biliary stent implantation.

Textbook outcome in patients with biliary duct injury during cholecystectomy

BACKGROUND

Iatrogenic bile duct injury (BDI) during cholecystectomy is associated with a complex and heterogeneous management owing to the burden of morbidity until their definitive treatment. This study aimed to define the textbook outcomes (TOs) after BDI with the purpose to indicate the ideal treatment and to improve it management.

METHODS

We collected data from patients with an BDI between 1990 and 2022 from 27 hospitals. TO was defined as a successful conservative treatment of the iatrogenic BDI or only minor complications after BDI or patients in whom the first repair resolves the iatrogenic BDI without complications or with minor complications.

RESULTS

We included 808 patients and a total of 394 patients (46.9%) achieved TO. Overall complications in TO and non-TO groups were 11.9% and 86%, respectively (P < .001). Major complications and mortality in the non-TO group were 57.4% and 9.2%, respectively. The use of end-to-end bile duct anastomosis repair was higher in the non-TO group (23.1 vs 7.8, P < .001). Factors associated with achieving a TO were injury in a specialized center (adjusted odds ratio [aOR], 4.01; 95% CI, 2.68-5.99; P < .001), transfer for a first repair (aOR, 5.72; 95% CI, 3.51-9.34; P < .001), conservative management (aOR, 5.00; 95% CI, 1.63-15.36; P = .005), or surgical management (aOR, 2.45; 95% CI, 1.50-4.00; P < .001).

CONCLUSION

TO largely depends on where the BDI is managed and the type of injury. It allows hepatobiliary centers to identify domains of improvement of perioperative management of patients with BDI.

Catalysing global surgery: a meta-research study on factors affecting surgical research collaborations with Africa

INTRODUCTION

In December 2019, the COVID-19 pandemic highlighted the urgent need for rapid collaboration, research, and interventions. International research collaborations foster more significant responses to rapid global changes by enabling international, multicentre research, decreasing biases, and increasing study validity while reducing overall research time and costs. However, there has been low uptake of collaborative research by African institutions and individuals.

AIM

To systematically review facilitating factors and challenges to collaborative surgical research studies conducted in Africa.

METHODOLOGY

A meta-research review using PubMed®/MEDLINE and Embase on surgical collaboration in Africa from 1st of January 2011 to 31st of September 2021 in accordance to PRISMA guidelines. Surgical studies by collaborative groups involving African authors and sites were included (55 papers). Data on the study period, geographical regions, and research scope, facilitating factors, and challenges were extracted from the studies retrieved from the search.

RESULTS

Most of the collaborations in Africa occurred with European institutions (76%). Of the 54 African countries, 63% (34/54) participated in surgical collaborations. The highest collaboration frequency occurred in South Africa (11%) and Nigeria (8%). However, most publications originated from Eastern Africa (43%). Leveraging synergies between high- and low- to middle-income countries (LMICs), well-defined structures, and secure data platforms facilitated collaboration. However, the underrepresentation of collaborators from LMICs was a significant challenge.

CONCLUSION

Available literature provides critical insights into the facilitating factors and challenges of research collaboration with Africa. However, there is a need for a detailed prospective study to explore the themes highlighted further.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2022 CRD42022352115 .

Complete Common Bile Duct Injury after Laparoscopic Cholecystectomy in Situs Inversus Totalis: A Case Report, Review of the Literature and Illustrative Case Video

INTRODUCTION AND IMPORTANCE

Situs Inversus Totalis (SIT) is a rare condition characterized by the transposition of internal organs. Given the anatomical variations in SIT, surgeons must exercise extreme caution when performing laparoscopic cholecystectomy to avoid iatrogenic bile duct injury. Despite the high difficulty index associated with laparoscopic cholecystectomy in SIT, there is only one case report of common bile duct (CBD) injury in the English-language literature.

CASE PRESENTATION

A 41-year-old female patient, known to have Kartagener syndrome, underwent laparoscopic cholecystectomy for acute cholecystitis and was discharged home on post-operative day one. However, on post-operative day five, the patient presented to the emergency room with abdominal pain, fever, and jaundice. Laboratory tests revealed leukocytosis and hyperbilirubinemia. Radiological images revealed complete occlusion of the CBD. A delayed approach was chosen, and six weeks after her initial operation, a hepaticojejunostomy was performed.

CLINICAL DISCUSSION

Laparoscopic cholecystectomy is the standard operative procedure for gallbladder disease. The unique anatomy of SIT increases the risk of CBD injury during laparoscopic cholecystectomy. Surgeons are required to perform a mirror-image procedure and adhere to the basic principles of safe laparoscopic cholecystectomy in SIT. This is only the second reported case of CBD injury in SIT patients.

CONCLUSION

Laparoscopic cholecystectomy in SIT presents a significant challenge. In patients with SIT, preventing CBD injury is the best approach, and referral to an experienced hepato-pancreato-biliary (HPB) surgeon is recommended. A delayed approach to CBD injuries in SIT allows thorough planning and understanding of the complex anatomical variations in these patients.

Liver transplantation for iatrogenic bile duct injury: a systematic review

BACKGROUND

Bile duct injury (BDI) is an infrequent but serious complication of cholecystectomy, often with life-changing consequences. Liver transplantation (LT) may be required following severe BDI, however given the rarity, few large studies exist to guide management for complex BDI.

METHODS

A systematic review was performed to assess post-operative complications, 30-day mortality, retransplant rate and 1-year and 5-year survival following LT for BDI in Medline, EMBASE, Web of Science or Cochrane Clinical Trials Database.

RESULTS

Seven articles met inclusion criteria, describing 179 patients that underwent LT for BDI. Secondary biliary cirrhosis (SBC) was the main indication for LT (82.2% of patients). Median model for end-stage liver disease (MELD) scores at time of LT ranged from 16 to 20.5. Median 30-day mortality was 20.0%. The 1-year and 5-year survival ranges were 55.0-84.3% and 30.0-83.3% respectively, and the overall retransplant rate was 11.5%.

CONCLUSION

BDI is rarely indicated for LT, predominantly for SBC following multiple prior interventions. MELD scores poorly reflect underlying morbidity, and exception criteria for waitlisting may avoid prolonged LT waiting times. 30-day mortality was higher than for non-BDI indications, with comparable long term survival, suggesting that LT remains a viable but high risk salvage option for severe BDI.

Clinical presentation, management and outcomes of bile duct injuries after laparoscopic cholecystectomy: a 15-year single-center experience in Vietnam

Objectives

To evaluate the clinical presentation, management, and outcomes of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC).

Methods

This is a case series of 28 patients with BDIs after LC treated at a tertiary hospital in Vietnam during the 2006-2021 period. The BDI's clinical presentations, Strasberg classification types, management methods, and outcomes were reported.

Results

BDIs were diagnosed intraoperatively in 3 (10.7%) patients and postoperatively in 25 (89.3%). The BDI types included Strasberg A (13, 46.4%), D (1, 3.6%), E1 (1, 3.6%), E2 (4, 14.3%), E3 (5, 17.9%), D + E2 (2, 7.1%), and nonclassified (2, 7.1%). Of the postoperative BDIs, the injury manifested as biliary obstruction (18, 72.0%), bile leak (5, 20.0%), and mixed scenarios (2, 8.0%). Regarding diagnostic methods, endoscopic retrograde cholangiopancreatography (ERCP) was more useful in bile leak scenarios, while multislice computed tomography, magnetic resonance cholangiopancreatography, and percutaneous transhepatic cholangiography were more useful in biliary obstruction scenarios. All 28 BDIs were successfully treated. ERCP with stenting was very effective in the majority of Strasberg A BDIs. For more complex BDI types, hepaticocutaneous jejunostomy was a safe and effective approach. The in-hospital morbidities included postoperative pneumonia (2, 10.7%) and biliary-enteric anastomosis leakage (1, 5.4%). There was no cholangitis or anastomotic stenosis during the follow-up after discharge (median 18 months).

Conclusions

The majority of BDIs are type A and diagnosed postoperatively. ERCP is effective for the majority of Strasberg A BDIs. For major and complex BDIs, hepaticocutaneous jejunostomy is a safe and effective approach.

Bile duct injuries during laparoscopic cholecystectomies: an 11-year population-based study

PURPOSE

Iatrogenic bile duct injuries (BDI) following laparoscopic cholecystectomy (LC) result in major morbidity and incidental mortality. There is a lack of unselected population-based cross-sectional studies on the incidence, management, and outcomes of BDI. We hypothesised that due to improved imaging capabilities and collective laparoscopic experience, BDI incidence will decrease over the study period and compare favourably with contemporary literature.

METHODS

After IRB approval, all cholecystectomies performed at national public healthcare facilities between 2008 and 2018 were retrospectively reviewed. BDIs were classified according to the Strasberg classification. The follow-up period ranged from 36 to 156 months.

RESULTS

A total of 241 BDIs of 29,739 laparoscopic cholecystectomies (LC) resulted in overall, minor, and major BDI incidence rates of 0.81%, 0.68%, and 0.13%, respectively. No significant decline in the BDIs was noted during the study period. Drainage in 66 (42.6%) and cases ERCP stent placement in 65 (41.9%) cases were equally used in Strasberg A lesions. Suture over T-tube in 20 (42.6%) and ERCP stenting in 19 (40.4%) cases were used in Strasberg D lesions. Roux-en-Y hepatojejunostomy (RYHJ) was performed in 30 (88.9%) of Strasberg E lesions. There were 27 (11.2%) patients with long-term bile duct strictures after BDI management. The overall mortality rate of BDIs and subsequent complications was 4.6%.

CONCLUSIONS

The annual incidence of iatrogenic bile duct injury over an 11-years' time after laparoscopic cholecystectomy did not decline significantly. We noted an overall BDI incidence of 0.81% comprising of 0.68% minor and 0.13% of major lesions. The management of injuries met contemporary guidelines with comparable outcomes.

Bile duct injury after cholecystectomy: timing of surgical repair should be based on clinical presentation. The experience of a tertiary referral center with Hepp-Couinaud hepatico-jejunostomy

Impact of timing of repair on outcomes of patients repaired with Hepp-Couinaud hepatico-jejunostomy (HC-HJ) after bile duct injury (BDI) during cholecystectomy remains debated. This is an observational retrospective study at a tertiary referral hepato-biliary center. HC-HJ was always performed in patients without sepsis or bile leak and with dilated bile ducts. Timing of repair was classified as: early (≤ 2 weeks), intermediate (> 2 weeks, ≤ 6 weeks), and delayed (> 6 weeks). 114 patients underwent HC-HJ between 1994 and 2022: 42.1% underwent previous attempts of repair at referring institutions (Group A) and 57.9% were referred without any attempt of repair before referral (Group B). Overall, a delayed HC-HJ was performed in 78% of patients; intermediate and early repair were performed in 17% and 6%, respectively. In Group B, 10.6% of patients underwent an early, 27.3% an intermediate, and 62.1% a delayed repair. Postoperative mortality was nil. Median follow-up was 106.7 months. Overall primary patency (PP) attainment rate was 94.7%, with a 5- and 10-year actuarial primary patency (APP) of 84.6% and 84%, respectively. Post-repair bile leak was associated with PP loss in the entire population (odds ratio [OR] 9.75, 95% confidence interval [CI] 1.64-57.87, p = 0.012); no correlation of PP loss with timing of repair was noted. Treatment of anastomotic stricture (occurred in 15.3% of patients) was performed with percutaneous treatment, achieving absence of biliary symptoms in 93% and 91% of cases at 5 and 10 years, respectively. BDI can be successfully repaired by HC-HJ regardless of timing when surgery is performed in stable patients with dilated bile ducts and without bile leak.

BILE: A Literature Review Based Novel Clinical Classification and Treatment Algorithm of Iatrogenic Bile Duct Injuries

PURPOSES

The management of patients with iatrogenic bile duct injuries (IBDI) is a challenging field, often with dismal medico legal projections. Attempts to classify IBDI have been made repeatedly and the final results were either analytical and extensive but not useful in everyday clinical practice systems, or simple and user friendly but with limited clinical correspondence approaches. The purpose of the present review is to propose a novel, clinical classification system of IBDI by reviewing the relevant literature.

METHODS

A systematic literature review was conducted by performing bibliographic searches in the available electronic databases, including PubMed, Scopus, and the Cochrane Library.

RESULTS

Based on the literature results, we propose a five (5) stage (A, B, C, D and E) classification system for IBDI (BILE Classification). Each stage is correlated with the recommended and most appropriate treatment. Although the proposed classification scheme is clinically oriented, the anatomical correspondence of each IBDI stage has been incorporated as well, using the Strasberg classification.

CONCLUSIONS

BILE classification represents a novel, simple, and dynamic in nature classification system of IBDI. The proposed classification focuses on the clinical consequences of IBDI and provides an action map that can appropriately guide the treatment plan.

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.

Vascular injury during laparoscopic cholecystectomy: An often-overlooked complication

Laparoscopic cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery worldwide. Bleeding complications due to vascular injuries represent an important cause of morbidity and mortality, especially when facing major bleeding during laparoscopy, where bleeding control can be technically challenging in inexperienced hands. Interestingly, the reported incidence rate of conversion to open surgery due to vascular lesions is approximately 0%-1.9%, with a mortality rate of approximately 0.02%. The primary aim of this article was to perform an up-to-date overview regarding the incidence and surgical management of vascular injuries during laparoscopic cholecystectomy according to the available scientific evidence.

Bile duct injury following cholecystectomy: delayed referral to a tertiary care center is strongly associated with malpractice litigation

BACKGROUND

Bile duct injury (BDI) following cholecystectomy is associated with malpractice litigation. Aim of this study was to evaluate risk factors for litigation in patients with BDI referred in a tertiary care center.

METHODS

Patients treated for BDI between 1994 and 2016. Stabilized inverse probability therapy weighting was used and multivariable logistic regression analysis identified risk factors for malpractice litigation.

RESULTS

Of the 211 treated patients, 98 met the inclusion criteria: early-referral group (<20 days; 51.0%), late-referral (≥20 days; 49.0%). 36 patients (36.7%) initiated malpractice litigation with verdict in favor of plaintiff in 86.7% of cases (median payment = €90 500, up to €600 000). Attempts at surgical and endoscopic repair before referral were significantly higher in late-referral group. Failed postoperative management (delayed referral, attempts at repair before referral) was one of the strongest predictors for litigation. Risk of litigation progressively increased from 23.8%, when referral time was within 19 days, to 54.5% (61-120 days), to 60.0% (121-210 days) and to 65.1% (211-365 days).

DISCUSSION

Litigation rate after BDI was 37%. Delayed referral to tertiary care center was one of the strongest predictors for litigation. Prompt referral to tertiary experienced centers without any attempt at repair may reduce the risk of litigation.

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.

Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama

BACKGROUND

The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery.

METHODS

This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes.

RESULTS

A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died.

CONCLUSION

Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.

Simultaneous early surgical repair of post-cholecystectomy major bile duct injury and complex abdominal evisceration: A case report

BACKGROUND

Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk.

METHODS & CASE REPORT

We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh.

DISCUSSION & CONCLUSION

The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.

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.

Percutaneous transhepatic cholangiography in the era of magnetic resonance cholangiopancreatography: A prospective comparative analysis in preoperative evaluation of benign biliary stricture

Background and Aim

Accurate anatomical delineation is the key before definitive repair for benign biliary stricture (BBS). The role of percutaneous transhepatic cholangiography (PTC) as a road map is less studied in the era of magnetic resonance cholangiopancreatography (MRCP).

Methods

A prospective observational study, performed between July 2012 and December 2013. All patients of post‐cholecystectomy BBS were evaluated with MRCP and PTC prior to definitive repair. Findings of MRCP and PTC were compared with intraoperative details.

Results

Thirty patients with BBS were included in the study. MRCP was performed in all but PTC was amenable in 28 of 30 (93.3%) patients. PTC was comparable to MRCP in diagnosing stricture type (96.4% vs 89.3%), intrahepatic stones (75% vs 75%), and biliary anomalies (95.6% vs 100%). Additionally, PTC revealed internal biliary fistula in 4 (85.7% vs 61.4%; P value 0.04). PTC‐related minor complications were noted in 2 (7.1%) patients.

Conclusion

PTC is comparable to MRCP in diagnosing the stricture type, intrahepatic biliary stones, and biliary anomalies. Though comparable to MRCP, the authors could not reveal any additional information that could change the course of management in BBS.

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.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Mechanism of scar formation following Roux-en-Y choledochojejunostomy in a novel rat model of obstructive jaundice

Background

The present study aimed to analyze the scar formation mechanism following Roux-en-Y choledochojejunostomy (CJS) in a novel rat model of obstructive jaundice.

Methods

The biliary obstruction model of Sprague-Dawley (SD) rats was established in advance, and 24 rats were randomly divided into 4 groups (control group, 1-day ligation group, 3-day ligation group, and 5-day ligation group). Changes in postoperative weight, common bile duct diameter, and laboratory indexes were analyzed to determine the best operation time. Roux-en-Y CJS in rats was studied based on the model, and the rats were randomly divided into 4 groups [control group, 3-day choledochojejunostomy (CJS) group, 7-day CJS group, and 30-day CJS group]. The same indexes were analyzed, and the characteristics of scar formation were evaluated by histopathology and polymerase chain reaction examination.

Results

The third day after common bile duct ligation is the best time for a Roux-en-Y CJS. The common bile duct diameter expands to 4.2 mm on average, and these physiological characteristics are consistent with current standard clinical findings. After completing CJS, the rats’ weight returned to normal levels, and alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TB), direct bilirubin (DB), and C-reactive protein (CRP) indexes gradually decreased (P<0.05). Anastomotic stoma diameter tended to narrow with time and was significantly narrower on day 30 than preoperation. After CJS, the expression of α-smooth muscle actin (α-SMA) peaked in the early stage and was still higher than that of the control group in the bile duct wall 1 month postoperatively (P<0.05). Transforming growth factor-β1 (TGF-β1) expression gradually increased and was higher than that of the control group at each stage postoperatively (P<0.05).

Conclusions

The rat Roux-en-Y CJS model is more in line with our surgical model, and the clinical condition has potential applicability for the study of CJS scar formation. Scar formation following CJS in rats is characterized by the activation of fibroblasts caused by early inflammatory stimulation, which leads to the proliferation of collagen and smooth muscle fibers, resulting in scars.

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.

Quality-of-life after bile duct injury repaired by hepaticojejunostomy: a national cohort study

OBJECTIVES

Reports on quality-of-life (QoL) after bile duct injury (BDI) show conflicting results. The aim of this cohort study was to evaluate QoL stratified according to type of treatment.

METHODS

QoL assessment using the SF-36 (36-item short form health survey) questionnaire. Patients with post-cholecystectomy BDI needing hepaticojejunostomy (HJ) were compared to all other treatments (BDI repair) and to patients without BDI at cholecystectomy (controls).

RESULTS

Patients needing a HJ after BDI reported reduced long-term QoL irrespective of time for diagnosis and repair in both the physical (PCS; p < .001) and mental (MCS; p < .001) domain compared to both controls and patients with less severe BDI. QoL was comparable for BDI repair (n = 86) and controls (n = 192) in both PCS (p = .171) and MCS (p = .654). As a group, patients with BDI (n = 155) reported worse QoL than controls, in both the PCS (p < .001) and MCS (p = .012). Patients with a BDI detected intraoperatively (n = 124) reported better QoL than patients with a postoperative diagnosis. Patients with an immediate intraoperative repair (n = 99), including HJ, reported a better long-term QoL compared to patients subjected to a later procedure (n = 54).

CONCLUSIONS

Patients with postoperative diagnosis and patients with BDIs needing biliary reconstruction with HJ both reported reduced long-term QoL.

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.