Timing and Surgical Strategies for Reconstruction of Iatrogenic Bile Duct Injury Following Cholecystectomy: A Retrospective Cohort Study
Description
We conducted a retrospective cohort study of 54 consecutive patients with major BDI (Strasberg D/E) at a tertiary hepatobiliary center (2014-2022). Management followed a predefined protocol stratified by presentation timing and clinical status: Immediate repair (<72 h; n=22), Early delayed repair (~2 weeks; n=12), or Late delayed repair (3 months after initial drainage; n=12). Critically ill patients (n=8) underwent resuscitation before any definitive repair. The primary outcome was treatment success, defined as absence of anastomotic stricture or recurrent cholangitis requiring intervention. Factors associated with outcome were investigated in regression analysis.
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Patient management adhered to a predefined institutional protocol, stratifying patients based on timing of injury diagnosis and clinical status. Hemodynamically stable patients with injuries recognized intraoperatively or within the first 72 hours underwent immediate definitive surgical reconstruction during the same admission. Those with delayed diagnosis beyond 72 hours but without active sepsis or significant inflammation received early delayed repair, consisting of elective Roux-en-Y hepaticojejunostomy approximately two weeks after initial presentation following nutritional optimization and preoperative workup. Patients presenting with delayed diagnosis accompanied by significant inflammation, localized infection, or biloma were initially managed with percutaneous or surgical drainage and underwent late delayed repair with hepaticojejunostomy typically three months later to allow inflammation to subside. Critically ill patients presenting with biliary peritonitis and multi-organ failure were admitted to the intensive care unit for resuscitation and urgent drainage, with definitive repair deferred either for three months or until full physiological recovery had been achieved. Surgical Technique All definitive surgical repairs were performed by a dedicated hepatopancreatobiliary surgeon. The surgical principle was a tension-free, mucosa-to-mucosa Roux-en-Y hepaticojejunostomy. In cases where the common hepatic duct stump exceeded 1 cm, a standard hepaticojejunostomy was carried out. Complex hilar injuries classified as Strasberg types E3 to E5, characterized by inadequate duct length or dense fibrosis, were managed using advanced techniques including liver segment IV resection to facilitate access to the biliary confluence and the Longmire procedure, which involves left hepatic lobectomy with anastomosis of the left hepatic duct to a jejunal limb. Outcome Measures The primary outcome was defined as success of the primary repair, characterized by the absence of anastomotic stricture or recurrent cholangitis requiring intervention throughout the follow-up period. Secondary outcomes included the incidence of long-term complications such as anastomotic strictures and recurrent cholangitis, the requirement for re-interventions—whether endoscopic stenting, percutaneous drainage, or surgical revision—progression to secondary biliary cirrhosis, and all-cause mortality.