Factors Affecting Short-Term and Long-Term Outcomes After Bilioenteric Reconstruction for Post-cholecystectomy Bile Duct Injury: Experience at a Tertiary Care Centre.

Abstract

Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity, reduced long-term survival and quality of life. There has been little literature on the long-term outcomes after surgical reconstruction and factors affecting it. The aim of this study was to study factors affecting long-term outcomes following surgical repair of iatrogenic bile duct injury being referred to a tertiary care centre. Between January 2005 to December 2011, 138 patients with bile duct injury were treated in a single surgical unit in a tertiary care referral hospital. Preoperative details were recorded. After initial resuscitation, any intra-abdominal collection was drained and an imaging of biliary anatomy was done. Once the general condition of the patient improved, patients were taken up for a side-to-side extended left duct hepaticojejunostomy. The post-operative outcomes were recorded and a hepatobiliary iminodiacetic acid scan and liver function tests were done, and then the patients were followed up at regular intervals. Clinical outcome was evaluated according to clinical grades described by Terblanche and Worthley (Surgery 108:828-834, 1990). The variables were compared using chi-square, unpaired Student's t test and Fisher's exact test. A two-tailed p value of <0.05 was considered significant. One hundred thirty-eight patients, 106 (76.8%) females and 32 (23.2%) males with an age range of 20-63years (median 40.8 ± SD) with bile duct injury following open or laparoscopic cholecystectomy, were operated during this period. Majority of the patients [83 (60.1%)] had a delayed presentation of more than 3months. Based on imaging, Strasburg type E1 was seen in 17 (12.5%), type E2 in 30 (21.7%), type E3 in 85 (61.5%) and type E4 in 6 (4.3%). On multivariate analysis, only level of injury, longer duration of referral and associated vascular injury were independently associated with an overall poor long-term outcome. This study demonstrates level of injury at or above the confluence; associated vascular injury and delay in referral were associated with poorer outcomes in long-term follow-up; however, almost all patients had excellent outcome in long-term follow-up.