Laparoscopic bile duct injuries: spectrum at a tertiary-care center

Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care Referral Centre of Nepal

Objective

With the adoption of safe cholecystectomy principles at an academic institute, the risk of major bile duct injury has decreased. This study aims at evaluating the present status of bile duct injury, compared to the study published in 2013 by index centre.

Methods

This is a retrospective review of a prospectively maintained database of bile leak and bile duct injury from 2014 to 2019. Patients who completed postcholecystectomy bile leak or bile duct injury treatment and were on regular follow-up were included.

Results

Eighteen patients (0.78%) among 2,300 consecutive cholecystectomies presented with bile duct injury, including 8 (0.35%) major bile duct injuries and 10 (0.43%) bile leaks compared to major bile duct injury rate of 0.68% (92/11,345 cholecystectomies) between 2001 and 2010. Injuries were classified as Strasberg's type A (52.9%), type D (5.9%), and type E (41.1%). Eight patients (47%) of bile leak were managed conservatively with drains, while two required laparotomy and lavage. The mean time for spontaneous closure of bile leak was 11 days. Intraoperative repair was done in three cases: Roux en Y hepaticojejunostomy in 2 and end-to-end repair over T-tube in 1 for sharp transection of the duct. Delayed repair (Roux-en-Y hepaticojejunostomy) was done in five patients. The median postcholecystectomy hospital stay was 8 days, with no mortality. There was no restricture at a median follow-up of 13 months.

Conclusion

With the adoption of a safe culture of cholecystectomy, the major bile duct injury rate has decreased currently. Repair of bile duct injury by experienced hepatobiliary surgeon results in excellent outcome.

Effect of institutional volume on laparoscopic cholecystectomy outcomes: Systematic review and meta-analysis

AIM: To determine whether institutional laparoscopy cholecystectomy (LC) volume affects rates of mortality, conversion to open surgery, bile leakage and bile duct injury (BDI).

METHODS: Eligible studies were prospective or retrospective cohort studies that provided data on outcomes from consecutive LC procedures in single institutions. Relevant outcomes were mortality, conversion to open surgery, bile leakage and BDI. We performed a Medline search and extracted data. A regression analysis using generalized estimating equations were used to determine the influence of annual institutional LC caseload on outcomes. A sensitivity analysis was performed including only those studies that were published after 1995.

RESULTS: Seventy-three cohorts (127404 LC procedures) were included. Average complication rates were 0.06% for mortality, 3.23% for conversion, 0.44% for bile leakage and 0.28% for bile duct injury. Annual institutional caseload did not influence rates of mortality (P = 0.142), bile leakage (P = 0.111) or bile duct injury (P = 0.198) although increasing caseload was associated with reduced incidence of conversion (P = 0.019). Results from the sensitivity analyses were similar.

CONCLUSION: Institutional volume is a determinant of LC complications. It is unclear whether volume is directly linked to complication rates or whether it is an index for protocolised care.

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

The clinical presentation, management and outcome of all patients with bile duct injury who presented to our tertiary care centre at various stages after cholecystectomy were analyzed. The patients were categorized into three groups: group A-patients in whom the injury was detected during cholecystectomy, group B-patients who presented within 2 weeks of cholecystectomy and group C-patients who presented after 2 weeks of cholecystectomy. Our team acted as rescue surgeons and performed 'on-table' repair for injuries occurring in another unit or in another hospital. Strasberg classification of bile duct injury was followed. In group A, partial and complete transections were managed by repair over T-tube and high hepaticojejunostomy, respectively. Patients in group B underwent endoscopic retrograde cholangiogram and/or magnetic resonance cholangiogram to evaluate the biliary tree. Those with intact common bile duct underwent endoscopic papillotomy and stenting in addition to drainage of intra-abdominal collection when present. For those with complete transection, early repair was considered if there was no sepsis. In presence of intra-abdominal sepsis an attempt was made to create controlled external biliary fistula. This was followed by hepatico jejunostomy at least after 3 months. Group C patients underwent hepaticojejunostomy at least 6 weeks after the injury. The outcome was graded into three categories: grade A-no clinical symptoms, normal LFT; grade B-no clinical symptoms, mild derangement of LFT or occasional episodes of pain or fever; grade C-pain, cholangitis and abnormal LFT; grade D-surgical revision or dilatation required. Fifty nine patients were included in the study and the distribution was group A-six patients, group B-33 patients and group C-20 patients. In group A, one patient with complete transection of the right hepatic duct (type C) and partial injury to left hepatic duct (LHD) underwent right hepaticojejunostomy and repair of the LHD over stent. Two patients with type D and three patients with type E 2 injury underwent repair over T-tube and hepaticojejunostomy, respectively. In group B, all except one of the 18 patients with type A injury underwent endoscopic papillotomy and stenting. The bile leak subsided at a mean interval of 8 days in all, except one patient who died of fulminant sepsis. Of the 15 patients with type E injury, five underwent hepaticojejunostomy after a minimum gap of 3 months. Early repair was considered in 10 patients. Twenty patients in group C underwent hepaticojejunostomy. In a mean follow-up of 40 months, the outcome was grade A in 54 patients, grade B in three patients (one from each of the three groups) and grade D in one patient (group C). The latter patient with a type E3 injury developed recurrent stricture and cholangitis necessitating percutaneous transhepatic dilatation. The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

Management of post-cholecystectomy benign bile duct strictures: review

Cholecystectomy is one of the common surgical procedure performed across the world and bile duct injury is a dreaded complication. The present review addresses the classification of injuries, preoperative preparation and evaluation of these patients and appropriate timing of surgery. A detailed preoperative evaluation combined with a meticulous wide anastomosis by experienced surgeons is the key in achieving long term success. Vascular injuries and its consequences on repair and outcome is also reviewed. Long term results of surgical repair and quality of life in these patients are excellent.

A safe laparoscopic cholecystectomy depends upon the establishment of a critical view of safety

Bile duct injuries (BDI) during a laparoscopic cholecystectomy (LC) occur more frequently than during an open cholecystectomy. Many expert surgeons learn to perform procedures safely based on their experience. Above all, the critical view of safety (CVS) introduced by Strasberg in 1995 is the standard practice to prevent BDI during an LC. The CVS is achieved by clearing all fat and fibrous tissue in Calot's triangle, after which the cystic structures can be clearly identified, occluded, and divided. Failure to successfully create this view may be an indication for conversion to an open cholecystectomy. The Japan Society for Endoscopic Surgery (JSES) introduced an accreditation examination in 2004. The critical view is an important factor used to judge a safe dissection. The annual ratios of successful applicants were 63% in 2004, 45% in 2005, 36% in 2006, 39% in 2007, and 44% in 2008. Biennial questionnaire surveys by JSES show that the laparoscopic BDI rates were 0.66% in 1990-2001, 0.79% in 2002, 0.77% in 2003, 0.66% in 2004, 0.77% in 2005, 0.65% in 2006, and 0.58% in 2007. Therefore, 2007 was the first year in which the rate was below 0.6%. A decreasing BDI rate is therefore expected because successful candidates will introduce technical improvements to colleagues in their hospitals and local regions.

Bile duct injury repair: when? what? who?

Laparoscopic cholecystectomy is associated with a two-to-four times higher risk of bile duct injury (BDI) than open cholecystectomy. BDI can lead to significant morbidity and even mortality. The first priority in BDI is to control peritoneal and biliary sepsis and to convert an acute BDI to a controlled external biliary fistula (EBF) - this can be achieved by endoscopic and/ or radiological intervention in most cases. This should be followed by assessment of the extent of injury - both biliary and vascular. Immediate management of BDI recognized during cholecystectomy depends on the type of injury, the condition of the patient, and the experience of the surgeon. For BDI recognized after cholecystectomy, early repair is not recommended, as the results are poor. The EBF may evolve into a benign biliary stricture (BBS), which should be electively repaired by a Roux-en-Y hepatico-jejunostomy. The use of an endoscopic stent as definitive management of BDI is not recommended. Long-term follow-up is essential after the repair of a BBS, as recurrence can occur several years after repair. Recurrent BBS is best treated with endoscopic balloon dilatation. Excellent early and long-term results can be obtained in specialized units at tertiary care referral centers.

Recurrent bile duct stricture: causes and long-term results of surgical management

BACKGROUND/PURPOSE

The management of recurrent bile duct strictures is a challenge for surgeons. This study reports the experience of revision surgery in patients referred following the failure of primary repair, and compares the outcome with that in patients who underwent management of recurrent stricture following primary repair at our institution.

METHODS

Over a period of 15 years, 300 patients with postcholecystectomy benign biliary stricture underwent surgical repair at our institution; 36 patients (12%) were referred after a failed primary repair.

RESULTS

In 25 (69%) patients, the primary repairs were done at peripheral hospitals. Twelve (33%) had had an early repair, at the time of cholecystectomy while 24 (67%) had a delayed repair at a later date; 83% and 67% of the patients who had undergone early and delayed repair, respectively, had not had a preoperative cholangiogram. Primary repairs performed were a bilioenteric anastomosis (22; 61%) or an end-to-end bile duct repair (14; 39%). Twenty-seven (75%) patients presented within 90 days after the primary repair, and the median interval to recurrent symptoms was 45 days (range, 1 day to 6.1 years). The median delay in referral after the development of symptoms of restricture was 175 days (range, 30 days to 22 years). Twenty-three (64%) patients had high strictures (Bismuth types III-V). All patients underwent a Roux-en-Y hepaticojejunostomy. At a median follow-up of 37 months (range, 12-144 months), 33 of 35 evaluable patients (94%) with recurrent stricture had an excellent/good outcome compared to 223 of 242 evaluable patients (92%) who had had their primary repair at our institution. Ten (4%) patients had a poor result following primary repair at our center. There was a significant difference in the stricture repair-to-recurrence interval between those patients referred to us with recurrent strictures and those who failed after primary repair at our institution (median interval, 1.5 vs 20 months; P = 0.001)

CONCLUSIONS

Patients referred with recurrent strictures had had their primary repair at peripheral settings; the failures were technical, presenting early (median, 1.5 months) with recurrent symptoms, compared to findings in patients with recurrent strictures following primary repair at our center. The long-term outcome following the repair of the primary and the recurrent strictures was no different in our experience.

Avoiding biliary injury during laparoscopic cholecystectomy: technical considerations

Experience alone is not sufficient to protect surgeons and their patients from biliary injury. This article suggests valuable technical considerations for the performance of laparoscopic cholecystectomy. Against the background of a widely accepted biliary injury classification system, the risk factors and causes of biliary injury are considered. The concept of the critical view exposure technique for Calot's triangle is emphasized from the practical standpoint of avoiding misidentified injuries.

Laparoscopic iatrogeny of the hepatic hilum as an indication for liver transplantation

The introduction of biliary laparoscopic surgery led to an increase in the incidence of liver hilum injuries. These types of lesions are very serious, because they can lead to secondary biliary cirrhosis or fulminant hepatic failure and the need for liver transplantation (LT). We present three cases of liver hilum injuries, which were treated with LT; one case was due to severe and persistent cholangitis, and two cases were due to fulminant hepatic failure. The world literature is also reviewed, and published cases of iatrogenic lesions of the liver hilum caused by laparoscopic surgery and requiring LT are presented. These iatrogenic lesions of the hepatic hilum are complex and technically demanding, due to their high morbidity and mortality and even the need for LT. In conclusion, these lesions must be always managed in centers with experience in hepatobiliary surgery.