Post cholecystecomy biliary injury, management at various stages of presentation

Abstract

Introduction: The clinical presentation, management and outcome of patients with bile duct injury presenting to our tertiary care centre at various stages after cholecystectomy were analyzed. Method: 70 Patients were categorized into three groups: I (n = 6) - Injury detected during cholecystectomy, II (n = 33) - Patients presenting within 2 weeks of cholecystectomy & III (n = 31) - Presenting after 2 weeks of cholecystectomy. We were rescue surgeons for ‘on-table’ repair of injuries occurring in another unit of our / another hospital. Strasberg classification was followed. In group I, partial and complete transections were managed by repair over T-tube and hepaticojejunostomy, respectively. Group II patients underwent ERCP and/or MRCP for evaluation. Those with intact common bile duct underwent endoscopic papillotomy, stenting and drainage of intra-abdominal collection when present. For those with complete transection, early repair was considered in absence of sepsis/ vascular injury. In sepsis or vascular injury, an attempt was made to create controlled external biliary fistula, followed by hepaticojejunostomy after 3 months. Group III patients underwent hepaticojejunostomy at least 6 weeks after the injury. The outcome was graded as: grade A–no symptoms, normal LFT; grade B–no symptoms, mild derangement of LFT or episodic pain or fever; grade C–pain, cholangitis and abnormal LFT; grade D–surgical revision or dilatation required. Various surgical & interventional modifications in complex injuries were undertaken and documented. Result: In a mean follow-up of 4 years, the outcome was, grade A in 65 patients, grade B in three (one from each of the groups) and grade D in two (one each from II and III). One patient (group II) who underwent revision surgery died of liver failure (secondary biliary cirrhosis). Conclusion: The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.