title: Surgical management of post-cholecystectomy bile duct injuries: referral patterns and factors influencing early and long-term outcome.
abstract: Cholecystectomy-related bile duct injuries (BDI) remain a cause of significant morbidity and debate concerning optimal management is ongoing. We reviewed our experience with surgical management of BDI to assess patterns of referral along with postoperative and long-term outcomes. During September 1996-August 2013, 35 patients were operated in our tertiary care center for a Bismuth-Strasberg grade >A BDI after a cholecystectomy performed elsewhere. Injury grade distribution was as follows: D, n = 3; E1, n = 4; E2, n = 15; E3, n = 5; E4, n = 5; E5, n = 3. Four patients (11.4%) had an associated vascular injury (arterial, n = 2; portal, n = 1; both, n = 1). Treatment was direct repair + Kehr drain placement (n = 1), hepaticojejunostomy (n = 28), hepaticojejunostomy + hepatic resection (n = 5), and liver transplantation (n = 1). There was one postoperative death (2.8%) due to hepatic failure after liver resection; severe (Dindo-Clavien grade ≥3b) complications were observed in 12 (34.3%) patients. Sepsis at referral (OR 17.33, p = 0.007) and laparotomy prior to definitive repair (OR 14, p = 0.04) were the factors associated with severe complications. Median follow-up was 81 (range 12-182) months; two patients were lost to follow-up. Treatment failure (defined as need for reoperation or interventional radiology procedure during follow-up) was observed in 7/32 (21.9%) patients. No association between baseline variables and treatment failure was observed. Post-cholecystectomy BDI represent a heterogeneous entity. The whole armamentarium of the hepatobiliary surgeon is required to achieve proper management. Patients referred with sepsis and requiring laparotomy prior to definitive repair are more prone to develop severe complications.
authors.affiliation: General Surgery 2U and Liver Transplantation Center, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Corso Bramante 88 - 90, 10126, Turin, Italy.
authors.forename: Damiano
authors.initials: D
authors.lastname: Patrono
authors.forename: Rosa
authors.initials: R
authors.lastname: Benvenga
authors.forename: Fabio
authors.initials: F
authors.lastname: Colli
authors.forename: Paolo
authors.initials: P
authors.lastname: Baroffio
authors.forename: Renato
authors.initials: R
authors.lastname: Romagnoli
authors.forename: Mauro
authors.initials: M
authors.lastname: Salizzoni
mesh_terms: D000328:Adult; D000368:Aged; D001652:Bile Ducts / Q000293:injuries* / Q000601:surgery*; D002763:Cholecystectomy / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007431:Intraoperative Complications / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome