Post-cholecystectomy acute bile duct injury: Two decade experience from a tertiary hospital in India

Joji Abraham A, Dr, Vk Kapoor, Professor, Anand Prakash, Dr, Rk Singh, Dr, Ak Gupta, Professor, Anu Behari, Dr, R Saxena, Professor. Sanjay Gandhi Post-Graduate Institute of Medical Sciences(SGPGIMS).

Introduction: Post-cholecystectomy acute bile duct injuries have been addressed less frequently in the recent literature search. We analyzed our experience over the last two decades and report the short-term and long-term outcomes.

Patients: Retrospective analysis of prospectively kept data of 309 patients with post-cholecystectomy acute BDI that were managed in a single institution from January 1989 to Dec 2010 and in whom follow up information was available.

Results: There were 96 male & 213 female patients with a median age of 40(12-74) years. The index surgery was open cholecystectomy in 185, open cholecystectomy with common bile duct (CBD) exploration in 20 and laparoscopic cholecystectomy in 104 patients. Patients were referred to us at a mean 20(1-270) days after cholecystectomy. 136/309(44%) patients had single or multiple pre-referral interventions. Post-referral, 93 patients were managed conservatively, 134 had percutaneous intervention, 101 had endoscopic intervention attempted, 64 were operated and 43 required a combination of these procedures. 9/309(3%) patients died due to the complications of BDI. Acute BDI injury could be classified as partial (110/309) or complete (157/309) on the basis of scintigraphy or cholangiography (ERCP, fistulogram or MRCP). Of the 157 with complete injury, endoscopic stenting was attempted in 38 pts. but failed in 32/38(84%). Whereas in the 110 pts. with partial injury, endoscopic stenting was successful in 45 pts. out of the 58 attempted. In pts with complete injury, 89/157(57%) had persistent biliary fistula whereas 62/157(39%) had closure of fistula. In terms of long term outcome 132/157(84%) with a complete injury had biliary stricture that needed correction, whereas only 13/158(8%) had normal anatomy. In pts with partial injury, 89/110(81%) had closure of fistula as the short-term outcome and only 29/110(26%) had biliary stricture requiring intervention. Complete injury was one of the predictors for persistence of fistula and development of biliary stricture.

Conclusion: The management and prediction of outcome of the acute BDI could be based on whether the injury is complete or partial. While partial injuries are amenable to endoscopic management, the role of endoscopic stenting in complete injury is limited. Complete injury is associated with delayed fistula closure & high rates of stricture formation needing surgical intervention.
Key words: Bile duct injury, External biliary fistula, Bile ascites, Bile peritonitis, Biloma, Open Cholecystectomy, Laparoscopic cholecystectomy

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