Bile duct injury repair — earlier is not better

Abstract

Bile duct injury is a common complication of cholecystectomy. The timing of bile duct injury repair remains controversial. A recent review conducted in France reported 39% complications and 64% failure after immediate repair in 194 patients compared with 14% complications and 8% failure after late repair in 133 patients. A national review of 139 consecutive early repairs conducted at five hepatopancreaticobiliary centers in Denmark reported 4% mortality, 36% morbidity, and 42 restrictures (30%) at a median follow-up of 102 months, and only 64 patients (46%) demonstrated uneventful short-term and long-term outcomes. Most patients with bile duct injury present with bile leak and sepsis; thus, early repair is not recommended. Percutaneous drainage of bile and endoscopic stenting are the mainstays of treatment of bile leak because they convert acute bile duct injury into a controlled external biliary fistula. The ensuing benign biliary stricture should be repaired by a biliary surgeon after a delay of 4–6 weeks once the external biliary fistula has closed.

Keywords

bile duct injury / cholecystectomy / laparoscopic cholecystectomy

Introduction

Bile duct injury (BDI) is a common complication of laparoscopic cholecystectomy (LC) and occurs in 0.2%−0.6% of cases. The timing of BDI repair, which is classified as immediate (intraoperative), early (postoperative), or late (delayed), remains unresolved. Various groups have used different definitions of early repair, ranging from within 2 weeks [ 1, 2] to 3 weeks [ 3] to 45 days [ 4].

Immediate repair

Successful immediate repair can result in minimum morbidity, short hospital stay, and low hospitalization costs. However, few LC BDIs are detected during the operation itself. In most cases, the surgeon is under the impression that the operation is uneventful. Only 170 of 741 BDIs (23%), which occurred during 51 041 cholecystectomies performed in Sweden, were detected intraoperatively [ 5]. The immediate repair could be a suture repair of a lateral injury and end-to-end anastomosis or hepatico-jejunostomy (HJ) for a complete transaction. De Reuver [ 6] reported 56 immediate repairs (49 over a T-tube) performed by injuring surgeons through end-to-end anastomosis of a divided bile duct; of these cases, 43 were managed endoscopically (38 were successful and 5 failed, which were salvaged by surgery) and 13 were managed surgically (11 were successful and 2 failed, which were salvaged by endoscopy). At a mean follow-up of 7 years, 51 patients (91%) were stricture free [ 6]. By contrast, a large study of 157 immediate repairs performed through end-to-end anastomosis reported a 64% failure rate [ 4]. Sahajpal [ 7] classified repair within 72 h as immediate repair and recommended it based on satisfactory results in 13 patients only. Meanwhile, a recent review by the French Surgical Association (AFC) reported 39% complications and 64% failure after immediate repair in 194 patients compared with 14% complications and 8% failure after late repair (i.e., beyond 45 days) in 133 patients [ 4].

Postoperative management

Most LC BDIs are diagnosed in the early postoperative period on the basis of bile leak and its complications of biloma and bile peritonitis. The treatment of choice is percutaneous catheter drainage of localized bile collections (bilomas) in the peritoneal cavity and endoscopic stenting of the common bile duct (CBD) in patients with incomplete (i.e., Strasberg A and D) BDI to control the source and decrease the ongoing bile leak. This combined radiological and endoscopic treatment controls intra-abdominal sepsis and converts acute BDI into a controlled external biliary fistula (EBF). In case of a minor injury, this treatment alone is sufficient because it stops bile leak and allows the patient to recover without any sequel. In case of a partial/lateral CBD injury, in which EBF closes over a few weeks, some patients develop a benign biliary stricture (BBS). In case of a complete (i.e., Strasberg E) CBD injury (i.e., clipping or transaction), endoscopic stent is not an option and the source control of bile leak may require percutaneous transhepatic biliary drainage. Moreover, the EBF may not close at all, and all patients form a BBS or require repair [ 8].

Early repair

Most patients with BDI, except those with complete clipping/ligation of the CBD, present with bile leak and consequent sepsis. Tissue is inflamed, edematous, vascular, and friable, and sutures of an early repair are likely to cut through with high risk of anastomotic leak, which is one of the most important factors for anastomotic (i.e., recurrent) stricture. An associated vascular injury, which occurs in a significant number of LC BDIs, is also a contraindication for early repair [ 9]. Several small individual series reported acceptable results of early repair. Thomson [ 1] reported success in 22/23 of early repairs (i.e., within 2 weeks) versus 20/22 of delayed repairs (i.e., 2 weeks to 6 months). Holte [ 2] also reported 32 early repairs (i.e., within 2 weeks), with complications occurring in 14 cases (34%); over a follow-up of 9.2 years, 10 patients (24%) developed anastomotic stricture requiring percutaneous balloon dilatation or surgery, including hepatectomy in 3 patients and liver transplant for secondary biliary cirrhosis in 1 patient. Basing on these findings, Holte [ 2] concluded that early repair provides acceptable outcomes. Moreover, Perera [ 3] reported 112 of 200 BDIs repaired by specialists, with results of early repair (i.e., within 3 weeks) in 43 cases similar to those of delayed repair (i.e., after 3 weeks) in 41 cases. Meanwhile, Felekouros [ 10] reported equal outcomes between early repair (i.e., less than 2 weeks) in 34 patients and late repair (i.e., over 12 weeks) in 22 patients. These results are contradicted by large multicenter reviews. An AFC review of 543 BDIs, including 216 early repairs (i.e., within 45 days) and 133 late repairs (i.e., after 45 days), reported complication rates of 29% and 14%, respectively, and failure rates of 43% and 8%, respectively [ 4]. Another large unselected national review of 139 consecutive early repairs (median= 5 days) performed in five hepatopancreaticobiliary centers in Denmark reported 4% mortality, 36% morbidity, and 42 restrictures (30%) at a median follow-up of 102 months; only 64 patients (46%) had uneventful short-term and long-term outcomes [ 11]. Nevertheless, early repair (postoperative) can be performed in cases with a ligated/clipped duct without bile leak and biliary sepsis (cholangitis) [ 1]. Nuzzo [ 12] also observed that repair can be performed within 2 weeks only in the presence of a clean surgical field. Furthermore, Stewart [ 13] reviewed the results of repair of 307 BDIs and reported that the timing of repair is not important, unless in the presence of infection.

Intermediate repair

The results of intermediate repair (i.e., 72 h − 6 weeks) in 34 patients were the worst, with 26% restricture rate [ 7]. Felekouros [ 10] also advised against repair in the intermediate period (i.e., 2−12 weeks).

Medico-legal aspects

BDI is a catastrophe during cholecystectomy. The immediate reaction of an injuring surgeon to a BDI is a mixture of remorse, guilt, depression, and fear, and the knee-jerk response of the surgeon to the event is to attempt to “fix the leak then and there.” However, repair by the injuring surgeon is more likely to result in failure than that performed by a biliary surgeon [ 14]. Repair by a non-specialist surgeon in 45 cases was considered an independent risk factor for morbidity, restricturing, recurrent cholangitis, and redo reconstruction compared with repairs by a specialist surgeon in 112 cases [ 3]. Moreover, an unsuccessful repair attempt renders future repair to be more difficult and less likely to be successful, even if performed by a biliary surgeon. BDI during cholecystectomy is one of the most common reasons for medico-legal suits against surgeons. These suits are more likely to occur [ 15] and be successfully decided against the surgeon [ 16] if the repair is attempted by an injuring surgeon or in an injuring hospital than if the patient is referred to a biliary surgeon or to a biliary center. In addition, BDI is a major drain on health care resources; repair by an injuring surgeon is less cost effective than that by a biliary surgeon because of the higher risk of failure and need for interventions [ 17].

Delayed repair

We followed a policy of delayed repair (i.e., at least 4 − 6 weeks after the BDI) with HJ once the EBF has closed and a BBS has formed. We reported our experience with 300 patients operated between 1989 and 2004 with excellent to satisfactory outcomes in 91% of patients at 2 years and 90% at 5 years in 225 and 149 eligible patients, respectively, as well as poor outcome requiring intervention in 11 patients (5%) [ 18]. Moreover, Lillemoe [ 19] reported 156 patients who underwent delayed repair, with 91% successful outcome at a mean follow-up of 58 months; the successful rate increased to 98% after reintervention.

Conclusions

BDIs continue to occur during LC, which is generally performed by a general or laparoscopic surgeon who has minimal to no experience in reconstructive biliary surgery, i.e., HJ. Intraoperative repair should be performed only if the injuring surgeon is a biliary surgeon or if the help of a biliary surgeon can be obtained, either from within the hospital or from outside the hospital, as an outreach service [ 20]. The philosophy of immediate repair can be extended to the first 48 − 72 h in the postoperative period before systemic sepsis sets in. The key to avoid mortality caused by BDI is a high index of suspicion and early detection. The mainstays of management in the postoperative period include interventional radiology and therapeutic endoscopy to convert acute BDI into controlled EBF. Most BDIs present with bile leak and sepsis. Therefore, early repair is not recommended even if performed by a biliary surgeon, except in the presence of a ligated/clipped duct without bile leak. The ensuing BBS should be repaired by a biliary surgeon after a delay of 4 − 6 weeks once the EBF has closed; this technique is called “drain now, fix later” [ 21].

Compliance with ethics guidelines

Vinay K. Kapoor declares no conflicts of interest. This manuscript is a commentary and does not involve a research protocol requiring approval by the relevant institutional review board or ethics committee.

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