Pesce A, et al. Iatrogenic bile duct injury: impact and management challenges. Clin Exp Gastroenterol. 2019 Mar 6;12:121-128. Free full-text.
“Iatrogenic BDIs represent a serious complication which can be brought on by cholecystectomy. The errors leading to laparoscopic bile duct lesions stem principally from misperception of the biliary anatomy. Any effort toward the reduction of the risk profile of everyday cholecystectomy is appreciated. The key points to successful treatment are characterized by early recognition, control of any intra-abdominal fluid collection and infection, nutritional balance, multidisciplinary approach, and surgical repair by an experienced surgeon in biliary reconstruction.”
Pekolj J, et al. Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center. J Am Coll Surg. 2013 May;216(5):894-901. Full-text for Emory users.
Results: Among 10,123 LC performed during the study period, 19 patients had a BDI sustained during the procedure. Intraoperative cholangiography was routinely used. Bile duct injury was diagnosed intraoperatively in 17 patients (89.4%). Mean age was 56.4 years (range 18 to 81 years) and 15 patients were women (88%). According to the Strasberg classification of BDI, there were 3 type C lesions, 12 type D lesions, and 2 type E2 lesions. There were no associated vascular injuries. Twelve cases (71%) were converted to open surgery. The repairs included 10 primary biliary closures, 4 Roux-en-Y hepaticojejunostomies, 2 end to end anastomosis, and 1 laparoscopic transpapillary drainage. Postoperative complications occurred in 5 patients (29.4%). During the follow-up period, early biliary strictures developed in 2 patients (11.7%) and were treated by percutaneous dilation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.
Conclusions: The current series represents one of the largest single-center experiences in terms of intraoperative repair of BDI sustained during LC. The results suggest that a high level of intraoperative diagnosis is possible, where intraoperative cholangiography is a useful tool. The intraoperative repair of BDI sustained during LC by experienced hepatobiliary surgeons either by open or laparoscopic approach appears of paramount importance to assure optimal results.
Ahmad DS, Faulx A. Management of Postcholecystectomy Biliary Complications: A Narrative Review. Am J Gastroenterol. 2020 Aug;115(8):1191-1198. Full-text for Emory users.
“Cholecystectomy-related biliary injuries lead to increased morbidity, mortality, and a significant financial burden. Those patients frequently require complex management. Biliary injuries requiring operative intervention are associated with 20.8% long-term all-cause mortality, an increase of 8.8% in the rate of death, and liver transplant rate of 0.8 % (4).”
Cholecystectomy-related biliary injuries occur because of the inability to avoid the biliary tract and its blood supply during dissection. Several factors have been associated with increased risk of cholecystectomy-related CBD injury including:
- the inability to definitively identify the cystic duct before clipping or dividing
- operating on acute cholecystitis
- presence of choledocholithiasis
- anatomic variations in the anatomy of the biliary tree
- urgent surgery
See also: Warren Lecture: “Understanding and Preventing Bile Duct Injury”