Since the first description of laparoscopic cholecystectomy in 1985, it has become the gold standard in care for patients with gallstones and acute cholecystitis. Despite the decrease in complications due to a steeper learning curve, the incidence of bile duct injury continues to be one of the most feared complications, currently occurring at 0.2 to 0.7% of patients undergoing surgery . The early diagnosis and optimal treatment are the cornerstones to prevent bad outcomes or major complications .
A controversial debate on the optimal timing of HJ for BDI still persists in the literature. A wide variety of cut-off times for “early” and “delayed” surgery has been described and no guidelines at present show the proper time of BDI repair . However, early reconstruction is always recommended in HPB centers around the world. In this study, we used the most common classification as early (first 72 hours of reconstruction after the BDI diagnosis) and delayed (after 72 hours) . In this study, no associations in complications rates were found between those cut-off values, and the complication rate was similar in those groups (Intraoperative Group p = 0.1, Early group p = 0.6, delayed group p = 0.5). Some recent reports support this finding, a collaborative retrospective study from the European-African HPB Association concluded that the timing of reconstruction did not have an impact on severe postoperative complications, reinterventions, or mortality . As well, Stewart and Way found in a multivariate analysis that the time of reconstruction was not an important factor . However, Schreuder et al show that reconstruction between 2–6 weeks has an increased rate of postoperative morbidity and hepaticojejunostomy stricture . Therefore, based on our data, the timing of reconstruction it’s not related to increased postoperative complications, mortality, or anastomotic stricture, and suggests that early does not mean better in BDI reconstruction, however, a delay of more than 4 weeks could be detrimental in postoperative outcomes[33, 36].
Several risk factors must be revised in the preoperative time to classify the risk of potential complications. There are well-described factors in literature such as acute cholecystitis and cholangitis that were associated with more complex injuries (Type E) with statistically significant value . In this group, there was a higher rate of biliary duct lesions in patients with acute cholecystitis; 78.3% of the cases had acute cholecystitis at the time of the injury. However, it was not clearly associated with the complexity of the CBD injury (p = 0.06). Reasons given for this association may be related to the degree of inflammation, the development of fibrosis, and adhesion processes, which hinder the adequate exposure of the surgical field and provide a modification in the anatomy that prevents an adequate identification of the structures that need surgical repair .
When occurred, identification of the bile duct injury is still an enormous concern, only one-quarter of injuries are recognized during surgery . In this case series, 40,54% of cases were identified in the intraoperative time. Most of the lesions were identified in the postoperative time, the presence of symptoms such as fever, postoperative jaundice, and unmanageable abdominal pain should alert the possibility of bile duct injury. . In this study, the most common symptom was unmanageable postoperative pain in 70.27% of the patients. Jaundice appeared in 67.5% of cases and only 21.62% of patients presented with cholangitis .
The experience of a hepatobiliary surgeon and a specialized group has proven to be of relevance to ensure optimal results. 75% of surgeons attempt to repair the injury on their own with a poor success rate of 17% . The impact of bile duct injuries is high, this generates an increase in hospital stay and care costs. Also, the emotional toll of this complication is high as any health worker who has been in relation to a case with bile duct injury clearly knows the emotional value that each case represents, not only for the patient and their family but also for all the nursing staff and the surgical team. . Therefore, based on a significant amount of publications, the international organizations for HPB surgeons (AHPBA, IHPBA) state that bile duct reconstruction must be performed only by HPB surgeons.
Long-term follow-up data for this type of lesions is scarce given the low frequency of presentation and the low publication of case series in our setting . In a series of 400,000 cholecystectomies, Sinha et al. found that biliary tree injuries had a 6-fold increased risk of mortality at 1 year compared to those without bile duct lesions . One of the most frequent complications in long-term follow-up is anastomotic stenosis. In our series, 7 patients presented biliary stricture in long-term follow-up established at two years.
The presence of biloma in early or late BDI detection showed statistical association with severity of the injury (p 0.02), with a 41.7 increased risk-fold to present highly complex common bile duct injuries defined in this study as type E3-5 Strasberg lesions.
Vascular compromise is a well-described characteristic associated with complications, however in our patients, there were only 2 cases with confirmed vascular compromise, this finding can be associated with an underreported description in the involved hospital.
Strengths identified in our study are management by the same hepatobiliary group in multiple institutions and the possibility of follow-up at 30 days and 24 months postoperatively. Results in this study should be interpreted in light of several limitations. Only surgical nature of patients undergoing reconstruction as we did not have data on the total incidence of bile duct lesions (lesions with endoscopic management or patients who died before reoperation), as well as the retrospective nature of the study and the small number of patients included. Finally, a possible underreported description of associated complications like the vascular compromise could influence the results.