Standardizing Diagnostic And Surgical Approaches To Management Of Bile Duct Injuries After Cholecystectomy: Long Term Outcomes Of 107 Patients Treated At A High Volume Hepato-Biliary Center

Abstract

Presenter: Mohammad Raheel Jajja MD | Emory University Background: There is still debate regarding optimal diagnostic and surgical approaches for a patient presenting with a bile duct injury (BDI). We present the Results from our standardized approach over 15 years managing more than one hundred such injuries at our institution. Methods: Data for patients undergoing repair for bile duct injuries between January 2003 and December 2018 at Emory University were reviewed retrospectively. Demographic data and clinical notes were reviewed. Kaplan-Meir survival curves were constructed for determining primary and secondary biliary patency rates. All cases were performed solely by the senior author JMS. Results: 123 patients underwent a biliary repair with the senior author over the study period. Of these 16 were excluded as they had BDIs secondary to previous hepatic resections. The remaining 107 consecutive patients had BDIs all secondary to cholecystectomy induced injury. Of these 42 (39%) were identified intra-op by the index surgeon, while the remaining 65 (61%) were identified in the post-operative period (median time 10 days (IQR 3-174)). 16 (15%) patients had an attempted repair of this injury and 9 (8%) patients had been noted to have a cholangiogram performed by the index surgeon. Magnetic Resonance Imaging (MRI) (n=80, 75%) with selective angiography (n=48, 45%) was the routine diagnostic approach to these patients in our clinic. ERCP (n= 23, 21%) was used selectively if MR quality was suboptimal or the patient needed a therapeutic intervention. MR was omitted if cholangiogram images were available at time of consult. Bismuth I-V classification of all 107 injuries respectively: 9 (8%), 35 (33%), 30 (28%), 11 (10%), 11 (10%). Concomitant hepatic arterial injuries were identified in 30 (28%) patients (Angiography identified 28 of 28, MR identified 3 of 30, while CTA identified 2 of 16 such injuries). 15 patients had their injuries repaired within 4 days of index procedure, while the remaining had at least a 3-week interval (median time to repair 65 days (IQR 42-213)). Hepp-Couinad procedure was employed as first choice for bile duct repair (n=89, 84%). Overall 18 patients required a liver resection as part of their surgical management. 27 (25%) patients experienced a Clavien I-II and 3 (3%) experienced a Clavien III-V grade complication within 30 days. Primary patency was 100% at 30 days (Figure 1) and 91% at 15 years. Overall 10 patients required a redo-biliary anastomosis during this period. Conclusion: Our data demonstrates that a standardized approach to diagnostic modalities reliably identified biliary and concomitant arterial injuries. We recommend that MRI be used as first imaging modality for patients suspected of having BDI and should be supplemented with angiography. ERCP use should only be considered for specific therapeutic intervention or if MR quality is subpar. The overall role of CT/CTA is limited in defining either biliary or arterial injuries. In our experience CT use should be reserved for follow-up of bile leaks or PTC placements. A standardized surgical approach, using Hepp-Couinad as procedure of choice with appropriate liver resection for BDI management can lead to greater than 90% primary patency rates at 15 years.