title: Improved outcomes of bile duct injuries in the 21st century.
abstract: OBJECTIVE
  The objectives of this analysis were to compare the outcomes of bile duct injuries by specialist over time and the role of management timing and biliary stents.
  
  
  BACKGROUND
  Postoperative bile duct injuries require multidisciplinary management. In recent years, advancements have occurred in patient evaluation and in timing and type of therapy.
  
  
  METHODS
  A multidisciplinary team managed 528 patients over 18 years. Mean age was 52 years; 69% were women and 95% had a cholecystectomy and/or bile duct exploration. Patients were classified by the Strasberg system as having bile leaks (type A, n = 239, 45%) or bile duct injuries (types B-E, n = 289, 55%). Injury outcomes from 1993 to 2003 (n = 132) were compared with those from 2004 to 2010 (n = 157). A successful outcome was defined as no need for further intervention after the initial 12 months of therapy. Standard statistical methods were employed.
  
  
  RESULTS
  Patients with bile leaks were managed almost exclusively by endoscopists (96%) with a 96% success rate. Patients with bile duct injuries were managed most often by endoscopists (N = 115, 40%) followed by surgeons (N = 104, 36%) and interventional radiologists (N = 70, 24%). Overall success rates were best for surgery (88%, P < 0.05) followed by endoscopy (76%) and interventional radiology (50%) and improved over time (78% vs 69%). Outcomes were best for surgery in recent years (95% vs 80%, P < 0.05) and for patients stented for more than 6 months (P < 0.01).
  
  
  CONCLUSIONS
  Almost all bile leaks and many bile duct injuries can be managed successfully by endoscopists. Selected proximal injuries can be treated by interventional radiologists with modest success. Outcomes of bile duct injuries are best with surgical management and in patients who are stented for more than 6 months.
authors.affiliation: *Department of Surgery; †Division of Gastroenterology; ‡Department of Radiology, Indiana University School of Medicine, Indianapolis; and §Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, MA.
authors.forename: Henry A
authors.initials: HA
authors.lastname: Pitt
authors.forename: Stuart
authors.initials: S
authors.lastname: Sherman
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Johnson
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Hollenbeck
authors.forename: Jonathan
authors.initials: J
authors.lastname: Lee
authors.forename: Michael R
authors.initials: MR
authors.lastname: Daum
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
authors.forename: Glen A
authors.initials: GA
authors.lastname: Lehman
mesh_terms: D001646:Bile; D001652:Bile Ducts / Q000293:injuries*; D001662:Biliary Tract Surgical Procedures / Q000009:adverse effects*; D057186:Comparative Effectiveness Research; D016145:Endoscopy, Digestive System / Q000295:instrumentation / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D005762:Gastroenterology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team; D011183:Postoperative Complications / Q000628:therapy; D015642:Radiology, Interventional; D012189:Retrospective Studies; D013038:Specialization; D013043:Specialties, Surgical; D015607:Stents