Management Of Bile Duct Injuries Research Articles

Iatrogenic Bile Duct Injuries: An Overview and A Review of Literature

Abstract​ Laparoscopic cholecystectomy (LC) is one of the most frequently performed surgical procedures worldwide. Iatrogenic bile duct injury (IBDI) is a serious complication of LC and has an incidence of 0.3 to 0.7%. Since it is associated with a significant and potentially lifelong morbidity as well as mortality, diagnosing IBDI as early as possible is of paramount importance. Management of bile duct injuries and prognosis of their surgical repair depend on the timing of its recognition, type and the extent of the injury. In this paper, we present a case of IBDI and attempt to discuss all its dimensions.

Standardizing Diagnostic and Surgical Approach to Management of Bile Duct Injuries After Cholecystectomy: Long-Term Outcomes of Patients Treated at a High-Volume HPB Center

BackgroundOptimal diagnostic and surgical approaches for patients with bile duct injuries (BDI) remain debated. This study reviews results from a standardized approach to management of high-grade BDIs at a North American center. DesignPatients undergoing surgical repair for BDIs over a 15-year period were included. Post-operative outcomes and biliary patency rates were calculated using imaging, laboratory values, and patient interviews. ResultsA total of 107 consecutive patients underwent repair for BDIs. Bismuth grade I/II injuries were identified in 46 patients (41%), grade III/IV in 41 (38%), grade V in 11 patients (10%), and 9 (10%) were unclassified. BDI anatomy was commonly identified using magnetic resonance imaging (MRI) (75%). Concomitant arterial injuries were identified in 30 (28 with formal angiography). Fifteen had early repairs (within 4 days) and remainder interval repairs (median: 65 days). Hepp-Couinaud repair was method of choice (83%). Estimated primary biliary patency was 100% at 30 days and 87% at 5 years. ConclusionWith appropriate referral to a specialist, surgical reconstruction of BDIs can have excellent outcomes, even with accompanying arterial injuries. Based on our experience, MR as first imaging modality and supplemental angiography served as the optimal diagnostic strategy. Delayed repair, using Hepp-Couinaud technique, with selective liver resection results in high long-term patency rates.

Retrospective Study of Common Bile Duct Injury after Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is one of commonest laparoscopic surgeries but carries out serious complications, one of them with high morbidity and mortality which is Bile Duct Injury. Biliary leak, biliary peritonitis and obstructive jaundice presents BDI with different management planes from ERCP and stent application up to abdominal exploration and roux-en-y hepatico-jeujenostomy to restore bile system continuity, this fact drove the attention of healthcare institutes to this problem. Is to assess different types of Bile duct injuries (BDI) after laparoscopic cholecystectomy and the outcome of different surgical procedures and recent radiological interventional procedures. This is a retrospective study carried on 50 patients underwent laparoscopic cholecystectomy and complicated by bile duct injury in benha university hospitals, after approval of local ethics committee, all patients included in the study were informed about the procedure and a written consent was obtained from every patient before carrying the different surgical procedures and recent radiological interventions. The study was done from January 2004 till January 2020. BDI during laparoscopic cholecystectomy occur more frequently when compared to open surgery. They occur twice to three times, more frequently than after an open surgery. Among early presentations is bile leak which occurred in (56%) who present early within first week. Different plans of management which differs from radiological intervention with (14%) up to abdominal exploration with (70%). Increased incidence of bile duct injury with laparoscopic cholecystectomy more than open cholecystectomy. Over confidence of some surgeons can cause serious damage. Roux en y Hepatico-jeujonostomy is the preferred surgical procedure. Intervention radiology plays important role in diagnosis and management of BDI.

Management of bile duct injuries in high-risk us population in unique referral settings - an experience of one HPB center

Management of bile duct injuries in high-risk us population in unique referral settings - an experience of one HPB center

Management of Bile Duct Injury Following Cholecystectomy.

Laparoscopic cholecystectomy is responsible for 80-85% of the bileduct injury, and twice as frequentcompared to open cholecystectomy.Injury affects the quality of life and overall survival of the patient. The management of these injuries is complex and challenging. There are few locally published reports regarding management of bile duct injury. The objective of this study is to evaluate the management of bile duct injury and its outcome Methods: This retrospective study includes patients bile duct injury following cholecystectomy who were managed at Dhulikhel Hospital, Nepal, during January 2014 to December 2016. The clinical features, type of injuries(Strasberg classification) management, outcome (as per McDonald and colleague grading system) and follow up were analyzed descriptively. Out of 35 bile duct injuries,only 3 (8.57%)occurred following open cholecystectomy. Three (8.7%) cases of bile duct injury were diagnosed intraoperatively and had primary biliary anastomosis over T-tube. Five (14.28%) were diagnosed postoperatively and underwent Roux-en-y hepatojejunostomy 6 weeks after index surgery. And, 27(77.14%) with type A injuries were treated by endoscopic retrograde cholangio-pancreatography and stenting. After surgical repair, 1 (2.85%) had transient biliary leak. One patient had grade B outcome. During 18 months follow up, no stricture or cholangitis were observed. Bile duct injury with intact continuity of the duct can be successfully managed with endoscopic stenting of the biliary tree. Intraoperative diagnosis of bile duct injury and immediate surgical management has good outcome.

Management of Bile Duct Injuries: A 6-year Experience in a High Volume Referral Center.

ABSTRACTObjectivesThe aim of our study was to determine operative and nonoperative treatments performed in bile duct injuries and the effect of a multidisciplinary approach on the treatment.BackgroundBile duct injuries may lead to morbidities such as biliary leakage, peritonitis, and mortality.Materials and methodsA total of 83 patients with biliary complications (37 patients with iatrogenic bile duct injury referred to our clinic from other centers were also included in this study) were evaluated.ResultsOf the operated 6,663 patients, iatrogenic bile duct injury occurred in 46 (0.69%) of these patients. The most common type of injury was Strasberg type A injury, which was found in 48 (57.83%) patients. The time interval between the diagnosis and initiation of treatment after the operation was shorter in patients with an inserted cavity drainage catheter (p < 0.05). Of the patients with bile duct injury, 32.6% received surgical and 62.6% endoscopic treatment, while 4.8% were followed-up without intervention. The rate of mortality was found to be 2.4%.ConclusionTime interval to diagnosis is of great importance for management of the patients.How to cite this articleÇavuşoğlu SD, Doğanay M, Birben B, et al. Management of Bile Duct Injuries: A 6-year Experience in a High Volume Referral Center. Euroasian J Hepato-Gastroenterol 2020;10(1):22–26.

Bile Duct Injuries: Outcome of Early and Delayed Repair at a Tertiary Care Centre

Bile duct injuries (BDIs) are fearsome complication following open or laparoscopic cholecystectomy (LC). Significant morbidity can accompany such injuries. Late complications such as anastomotic bile duct strictures or secondary biliary cirrhosis may result in lifelong disability. The aim of the study was to assess the outcome of early (up to 7 days) and delayed (after 6 weeks) definitive repair of BDIs. It was a prospective study from June 2015 to May 2017 done at a tertiary care centre. The patients who underwent surgical management of bile duct injuries were part of the study and were followed up until end of the study period and assessed for stricture as primary objective and other secondary objectives, e.g. post-op complications and grade of repair of bile duct injury. Stricture was defined as stricture causing sign and symptoms requiring surgical, percutaneous or endoscopic intervention. A total of 50 patients were part of the study, out of which 15 underwent early and 35 underwent delayed repair. Mean follow-up of patients was 10.8 months (1–24 months). Bile duct injuries were classified as per Strasberg classification. It included 7 patients with E1, 15 patients of E2, 20 patients of E3, 5 E4 and 3 patients with type D injuries. The surgical reconstruction done was hepaticojejunostomy (HJ) in 48 and primary repair in 2 patients. The post-op complication observed were post-op bile leak in 4 patients (3 in early and 1 in delayed group, p = 0.041) and cholangitis in 3 patients (1 in early group and 2 in delayed group, p = 0.897). On comparison of stricture rate with post-op bile leak and cholangitis, both variables had significantly high stricture rate (p = 0.014 and p = 0.002, respectively). The grades of repair as per Mc Donald’s grading was grade A in 30, B in 16, C in 1 and D in 3 patients. The stricture was seen in 2 patients of early group and 1 patient in delayed group (p = 0.153). Our result suggests that early repair has more post-op complication with comparable stricture rates in patients with no evidence of systemic sepsis and intra-abdominal collection. Such repairs should be done at specialized centres with surgeons having experience in managing these cases.

Bile Duct Injuries During Open and Laparoscopic Cholecystectomy

Abstract Background: Common Bile duct injury after cholecystec-tomy remains one of the most serious iatrogenic catastrophes associated with significant postoperative morbidity and may lead to death after a short period of systemic inflammatory response and multi-organ failure syndrome. Aim of Study: To study the diagnosis and management of bile duct injuries during open and laparoscopic cholecystec-tomy, to avoid further bile duct injuries and its morbidity and mortality. Patients and Methods: This Study was a prospective comparative study on iatrogenic bile duct injury (BDI) after laparoscopic and open cholecystectomy. The cases were performed in the period from April 2015 till February 2018. In which 40 patients with bile duct injuries, 20 after open cholecystectomy (OC) and 20 after laparoscopic cholecystec-tomy (LC) were managed. Results: The number of cases done was 40 patients: 20 patients; 7 (17.5%) males, 13 (32.5%) females post laparo-scopic cholecystectomy, Mean age was 44.3 while overall age range from 25-62 years. 20 patient 9 (22.5%) males, 11 (27.5%) females post open cholecystectomy, Mean age was 42.2 while overall age range from 27-65 years, Fifteen (37.5%) of them associated with diabetes mellitus. Management of BDI after open cholecystectomy was one conservatively, 14 by ERCP with stent, 3 by hepaticojejunos-tomy and 2 by Choledochojejunostomy. After laparoscopic cholecystectomy were managed 2 conservatively, 12 by ERCP and 6 by hepaticojejunostomy. Conclusion: CBD injury complication with early diagnosis and prompt treatment can save patient's life with subsequent few or no complication even after its reconstructive surgery. Training must be emphasized to find all possible ways of recognizing biliary tract anatomy during surgery and possess skills to overwhelm the primary and leading cause of bile duct injury i.e. the visual misperception.

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

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.

SELSI Consensus Statement for Safe Cholecystectomy — Prevention and Management of Bile Duct Injury — Part A

Cholecystectomy is one of the commonest general surgical procedures performed all over India. The risk of bile duct injury (BDI) during laparoscopic cholecystectomy is two to three times higher than during open cholecystectomy. The worldwide incidence of bile duct injury is 0.5% or 1 in 200 cases. BDI and its consequences result in significant morbidity and may even cause mortality. BDI increases the cost of treatment and is a common reason for a medicolegal suit against the surgeons. To minimize the incidence of BDI and to manage it timely and appropriately, a set of guidelines was deemed necessary by a group of senior surgeons during a Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) meeting in 2016. Guidelines for “Safe Laparoscopic Cholecystectomy” and bile duct injury management formulated by other international societies are already available. The applicability of these guidelines to Indian subjects especially in small peripheral centers was limited. Hence, a decision was taken to form a set of guidelines for general surgeons with basic laparoscopic skills with little or no advanced laparoscopic skills. Those working in a solo practice, nursing homes, and small private hospitals at talukas or districts should have “Safe Cholecystectomy” guidelines and management of BDI suitable to their situation. These guidelines were formed after three consensus meetings and have been approved by a SELSI Expert Group.

Iatrogenic Bile Duct Injury and Its Management with Intensive Care Unit Process: A Single-Center Experience

The delayed recognition of bile duct injury (BDI) and the challenges in its diagnosis lead to clinical variability. The management of BDI is complicated and ranges from ERCP to liver transplantation. But infections related to BDI and sepsis control, prior to the bile flow reestablishment, are the mainstay of the treatment. In this study, we aimed to report the clinical outcomes of iatrogenic BDI and intensive care unit (ICU) process in a tertiary state hospital.

Long-term results of secondary biliary repair for cholecystectomy-related bile duct injury: results of a tertiary referral center

Background: Management of bile duct injury (BDI) after cholecystectomy is challenging. The authors analyzed their center’s 49-year experience.Methods: From 1968 to 2016, 120 consecutive patients were managed in a tertiary HBP center, 105 referred from other centers (Group A), 15 from our center (Group B). Surgical strategies and long-term outcomes were retrospectively reviewed.Results: Primary cholecystectomy approach was open in 35% and laparoscopic in 65%. In Group A, intraoperative BDI diagnosis was made in 25/105 patients, including 13 via intraoperative cholangiography (IOC) which was used in 21% of cases. Median time from BDI to referral was 148 days (range 0–10,758), and 3 patients had BDI-related secondary cirrhosis. Ninety-four patients underwent secondary surgical repair, mostly a complex biliary procedure (97%). Postoperative overall and severe morbidity rates were 26% and 6%, respectively. One patient with biliary cirrhosis at referral died postoperatively from hepatic failure. Nine patients (9.6%) developed a secondary biliary stricture after a median of 54 months from repair (6–228 months). In Group B, IOC was performed in 14/15 in whom BDI were intraoperatively detected and immediately repaired. There were 13 minor and 2 major BDIs, all repaired by uncomplex procedures with uneventful postoperative course. One patient had a secondary biliary stricture after 5 months, successfully treated by temporary endoprosthesis.Conclusion: Late follow-up after primary or secondary repair of BDI is recommended to detect recurrent biliary stricture. Bile duct injuries may occur in a tertiary center, but are intraoperatively detected with routine IOC and immediately repaired resulting in satisfactory outcome.

Surgical Result and Outcome Of Bile Duct Injuries Following Cholecystectomy

Introduction: Iatrogenic bile duct injuries most frequently caused by cholecystectomy during laparoscopy or open procedure. The aim of this study was to evaluate the management of bile duct injuries following cholecystectomy procedure in a tertiary hospital referral from primary and secondary care. Method: The cross-sectional design was used. A total of 21 patients, who sustained extra hepatic bile duct injuries during open and laparoscopic cholecystectomy between January 2008 and December 2017 were retrospectively analyzed. Result: Median age of patient was 45 (21-58) years with a female preponderance. Seven patients sustained bile duct injury during open cholecystectomy while fourteen patients during laparoscopic procedure. Roux-en-Y hepaticojejunostomy was performed in fifteen cases, choledochoduodenostomy in two cases, and primary ligation cystic duct in four cases. Of these, two patient had recurrent cholangitis post operatively, 2 patients had superficial surgical site infection and two patients were performed re-operation related bile anastomosis leakage and burst abdomen. No hospital mortality was found, with length of hospital stay 38(14-53) days. Conclusion: The most frequent site of bile duct injury during cholecystectomy was the common bile duct, and Roux-en-Y hepaticojejunostomy was the procedure of choice for the management of such injuries.

MANAGEMENT OF BILE DUCT INJURIES; CONVENTIONAL AND SURGICAL METHODS AND THEIR SHORT OUTCOME.

22Dec 2018 MANAGEMENT OF BILE DUCT INJURIES; CONVENTIONAL AND SURGICAL METHODS AND THEIR SHORT OUTCOME. Fady m. Habib , hassan ashour , tamer mohamed el shahidy and loay m. Gertallah. Lecturers of General surgery, Faculty of Medicine, Zagazig University.

Postcholecystectomy bile duct injuries: diagnostics and surgical treatment

Introduction: Bile duct injuries (BDIs) still occur during laparoscopic cholecystectomy. We would like to present our 15 years' experience in the management of BDIs, evaluate our results of treatment. Methods: Medical records of 67 patients who have experienced BDIs after laparoscopic cholecystectomy were retrospectively reviewed. All injures were classified according to European Association for Endoscopic Surgery ATOM (anatomic, time of detection, mechanism) classification and investigated by manifestation of the injury, surgical repair technique, early and late complications. Results: In 28 (41,8 %) patients the surgical treatment of BDI was completed with ERCP and stenting, in 14 (20, 1%) cases defect of bile duct was closed by suture, end-to-end ductal anastomosis was performed for 6 (13,4%) patients and hepaticojejunostomy in 19 (28,3%) patients. Morbidity and mortality after surgical repair of bile duct injury according to Clavien Dindo classification was: I - 2 (3%), II - 1 (1,5%), III - 61 (91%) and mortality - V - 4 (6%). We followed up 58 patients (92.1%) of 63. Mean follow-up duration was 25,7±36,7 months. In late postoperative time 23 (39,7%) patients developed bile duct strictures. Therefore, 13 (56,5%) patients underwent restenting or balloon dilatation and 10 (43,5%) patients underwent hepaticojejunostomy. Conclusions: Endoscopic retrograde cholangiopancreatography (ERCP) is the main diagnostic tool for suspected injuries. Stenting with a covered self-expanding metal stent is a promising method for the patients with partial divisions or strictures of bile ducts. Both hepaticojejunostomy and end-to-end anastomosis showed good results while treating complete divisions of ducts.

Evolution of bile duct repair: comparison of diagnosis, referral, management and outcomes in repair of bile duct injury after laparoscopic cholecystectomy from 1991–2004 and 2005–2017

Bile duct injury continues to be a serious complication after laparoscopic cholecystectomy (LC). Few studies have analysed the evolution in the management of bile duct injury (BDI) over time. In this study we compared presentation, management and outcome in two time periods. A retrospective review of a prospectively maintained database for patients with BDI after LC was performed. All patients undergoing index hepaticojejunostomy repair from 1991-2017 were included and divided into two groups (1991-2004 and 2005-2017) for comparison. Time of diagnosis, referral and repair, pre-operative interventions and imaging, post-operative re-interventions, and complications (Accordion Classification) were analyzed. Three times more repairs were performed in the later period (93 vs 32). In the later group, there was a significant increase in referral delay (p = 0.031), as well as an increased use of cross-sectional pre-operative imaging (p = 0.006, p < 0.001) and percutaneous intervention (p < 0.001), and a significant increase in referral to repair time (p < 0.001). There was an increase in the number of complications in the later period (p = 0.038). In this analysis the number of BDIs requiring repair, as well as pre-operative and operative management has changed over time. The observed differences in the later group are due to a combination of changes in referral patterns, and increased pre-operative investigations and interventions, which influenced outcome.Tabled 1FP19-08 Table [BDI Repair 1991-2004 and 2005-2017]1991-2004 n=322005-2017 n=93p-valuePre-repair Intervention1991-2004 n=32 (%)2005-2017 n=93 (%)p-valueTime (days) - Diagnosis Median (IQR)5 (0.75-8)3 (0-8)0.443ERCP20 (62.5)46 (49.5)0.206Time - Referral1.5 (0-10.25)6 (1-15)0.031PTC17 (53.1)78 (81.3)<0.001Time - Repair2.5 (1-5.5)8 (4-43)<0.001Percutaneous Drain7 (21.9)17 (18.3)0.659Immediate repair (< 3 days) n (%)7 (21.9)11 (11.8)0.328Laparotomy8 (25)32 (34.4)0.329Early Repair (> 3, ≤ 14 days)11 (34.4)22 (23.7)0.239Laparoscopy2 (6.3)4 (4.3)0.660Intermediate Repair (> 14, ≤ 90 days)11 (34.4)38 (40.9)0.521MRCP7 (21.9)46 (49.5)0.006Late Repair (> 90 days)3 (9.4)22 (23.7)0.083CT3 (9.4)43 (46.2)<0.001Post-repair percutaneous intervention3 (9.4)4 (4.3)0.163Ultrasound2 (6.3)22 (23.7)0.002Post-repair operative intervention2 (6.3)2 (2.2)0.259Total Complications18 (56.3)50 (53.8)0.038 Open table in a new tab

Percutaneous-endoscopic rendezvous procedure for the management of bile duct injuries after cholecystectomy: short- and long-term outcomes.

Bile duct injury (BDI) remains a daunting complication of laparoscopic cholecystectomy. In patients with complex BDI, a percutaneous-endoscopic rendezvous procedure may be required to establish bile duct continuity. The aim of this study was to assess short- and long-term outcomes of the rendezvous procedure. All consecutive patients with BDI referred to our tertiary referral center between 1995 and 2016 were analyzed. A rendezvous procedure was performed when endoscopic or radiologic intervention failed, and when deemed feasible by a dedicated multidisciplinary team including hepatopancreaticobiliary surgeons, gastrointestinal endoscopists, and interventional radiologists. Classification of BDI, technical success of the rendezvous procedure, procedure-related adverse events, and outcomes were assessed. Among a total of 812 patients, rendezvous was performed in 47 (6 %), 31 (66 %) of whom were diagnosed with complete transection of the bile duct (Amsterdam type D/Strasberg type E injury). The primary success rate of rendezvous was 94 % (44 /47 patients). Overall morbidity was 18 % (10 /55 procedures). No life-threatening adverse events or 90-day mortality occurred. After a median follow-up of 40 months (interquartile range 23 - 54 months), rendezvous was the final successful treatment in 26 /47 patients (55 %). In 14 /47 patients (30 %), rendezvous acted as a bridge to surgery, with hepaticojejunostomy being chosen either primarily or secondarily to treat refractory or relapsing stenosis. In experienced hands, rendezvous was a safe procedure, with a long-term success rate of 55 %. When endoscopic or transhepatic interventions fail to restore bile duct continuity in patients with BDI, rendezvous should be considered, either as definitive treatment or as a bridge to elective surgery.

Role for laparoscopy in the management of bile duct injuries.

Common bile duct (CBD) injury is the most serious complication of laparoscopic cholecystectomy. Recently, laparoscopic techniques have been used in the management of postoperative bile leak and CBD injury; this literature has not been reviewed. We reviewed the literature on CBD injury, the approach to its diagnosis and management, and reports of laparoscopic management techniques. We combined this review with our experience in laparoscopic methods to highlight diagnostic and therapeutic options. Laparoscopic techniques can be used to prevent, diagnose and treat CBD injuries. Intraoperatively, CBD injury can be prevented in the case of short cystic duct with the use of a loop ligature or transfixing suture, and it can be diagnosed using intraoperative cholangiography or other visualization techniques. When CBD injury is suspected postoperatively, repeat laparoscopy can be used to control sepsis with abdominal washout; as a diagnostic tool to guide management; and, in some settings, as a therapeutic tool for suturing small duct leaks, drain insertion and postoperative endoscopic retrograde cholangiopancreatography with sphincterotomy. Definitive laparoscopic repair is possible when certain criteria are met. Open surgery should be considered when the CBD is small, the injury occurred more than 72 hours previously, injury or anatomy are complex, port positioning is awkward for repair, or local experience is limited with laparoscopic management. There is an emerging role for laparoscopy in the management of CBD injuries. More case reports and series are needed to show the safety and efficacy of this technique, encourage its wider adoption, and allow outcomes assessment on a larger scale.

Delayed referral to specialist centre increases morbidity in patients with bile duct injury (BDI) after laparoscopic cholecystectomy (LC)

BackgroundThere is still a debate regarding the optimal management of bile duct injury following cholecystectomy. Our aim was to ascertain if delayed referral influenced clinical outcomes for patients with BDI treated in our institution. Materials and methodsWe interrogated a prospectively maintained database, including all patients with BDI (Bismuth and Strasberg classifications) post LC managed in our unit from 2000-2014. Referrals were arbitrarily defined as early (<96 h from the injury) and delayed (>96 h). Results68 patients with BDI were managed. Patient demographics, referral time, level of injury and morbidity data was collected. 50 patients (77%) required a surgical bile duct reconstruction. The Early referral Group included 33 patients (52.4%) and Delayed referral group 30 (47.6%).The patients referred late had a significantly high incidence of right hepatic artery injury (23% vs. 3%) and the overall number of complications (0.0001). The average number of surgical interventions (2.5 vs 1.8, p < 0.05) and invasive procedures (4 vs. 2.5, p < 0.05) per patient was high in the late referral group.There was significant difference in the interval between BDI-to-reconstruction (median 3 vs. median 88 days, p < 0.05) and referral-to-hospital discharge (median 9 vs. median days 59, p < 0.05).On multivariate analysis only delayed referral (OR 7.58, 95% CI 2.1–26.6) and Strasberg-E injuries (OR 4.86, 95% CI 1.1–20.9) were significant. ConclusionA late referral was associated with a higher incidence of post-treatment complications, greater need for invasive procedures and a longer recovery period. These observations support the need for early patient transfer to a tertiary institution following BDI.

Percutaneous Treatment of Iatrogenic and Traumatic Injury of the Biliary System

Traumatic or iatrogenic bile duct injury (BDI) includes bile leaks, benign stenoses, and fistulae. These complications result in significant morbidity and mortality. This review will provide insight into the presentation, diagnosis, classification, and percutaneous management of BDI. Prompt diagnosis through non-invasive imaging and minimally invasive procedures is paramount to improved patient outcomes. Numerous classifications of BDI exist, although none are universally accepted. Percutaneous approaches to the management of BDI offer a minimally invasive alternative to traditional surgery. Bile leaks are primarily treated with drainage and decompression; however, adjunctive techniques such as embolization are also presented. Fistulae are routinely treated with embolization even though limited literature exists to provide a consensus treatment algorithm. Benign stenosis is primarily treated with balloon dilation with long-term biliary intubation while placement of bile duct stents is often reserved for patients with recurrent stricture. Iatrogenic or traumatic BDI typically requires a multidisciplinary team approach, although prompt diagnosis and advances in therapeutic approaches have improved patient outcomes.