Timing of repair in Bile Duct Injury
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Timing of repair in bile duct injury is still debated and questioned. Delayed repair is considered standard practice whereas early repair in selected patients in specialist HPB units.
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Timing of repair in Bile Duct Injury
- 1. TIMING OF REPAIR OF BILE DUCT INJURY DR AMIT DANGI DEPARTMENT OF SURGICAL GASTROENTEROLOGY KING GEORGE MEDICAL UNIVERSITY
- 2. •ETIO-PATHOGENESIS •RISK FACTORS •DEFINITE REPAIR •PREVENTION •LONG TERM OUTCOMES QUESTIONS WELL SETTLED AND ANSWERED •TIMING OF REPAIR •ROLE OF TRANSANASTOMOTIC STENTS OR BILIARY DRAINAGE •IMPACT OF VASCULAR INJURY •WHO SHOULD REPAIR STILL DEBATED
- 3. SUCCESS OF THE INITIAL REPAIR IS THE MOST IMPORTANT VARIABLE INFLUENCING THE LENGTH OF ILLNESS Davidoff AM, ET AL 1992 Ann Surg 215:196–202.
- 4. CONTROL OF INTRA-ABDOMINAL INFECTION COMPLETE PREOPERATIVE CHOLANGIOGRAPHY SURGICAL TECHNIQUE SURGICAL EXPERIENCE OF THE SURGEON INCOMPLETE EXCISION OF THE SCARRED DUCT, NONABSORBABLE SUTURE MATERIAL USE OF 2 LAYER ANASTOMOSIS FAILURE TO ERADICATE SUBHEPATIC INFECTION BEFORE THE ATTEMPTED REPAIR (STEWART-WAY 1996) FACTORS THAT CONTRIBUTE TO SUCCESS OF BILIARY RECONSTRUCTIONS STEWART AND WAY. HPB 2009, 11, 516–522FACTORS THAT CONTRIBUTE TO UNSUCCESSFUL OUTCOME FOLLOWING BILIARY RECONSTRUCTIONS
- 5. LEVEL OF STRICTURE NUMBER OF PRIOR ATTEMPTS AGE AT REPAIR DURATION OF STENTING PORTAL HYPERTENSION ASSOCIATED CHRONIC LIVER DISEASE TYPE OF RECONSTRUCTION (CHOLEDOCHOJEJUNOSTOMY VS. HJ) BILIRUBIN AND ALBUMIN LEVELS S.S. Sikora B. Pottakkat et al. Dig Surg 2006;23:304–312 FACTORS THAT CONTRIBUTE TO POOR OUTCOME FOLLOWING BILIARY RECONSTRUCTIONS
- 6. NO CONSENSUS, HOWEVER, ON WHETHER THE TIMING OF THE OPERATION IS IMPORTANT STEWART AND WAY. HPB 2009, 11, 516–522
- 7. Others have claimed, however, that the timing of the repair has an effect. Sicklick JK, et al 2005. Ann Surg 241:786–792. Schmidt SC, Br J Surg 92:76–82. Thomson BN, Parks RW, Madhavan KK, Wigmore SJ, Garden OJ. (2006) Early specialist repair of biliary injury. Br J Surg 93:216–220. de Reuver PR, et al. Referral pattern and timing of repair are risk factors for complications after reconstructive surgery for bile duct injury. Ann Surg 245:763–770.
- 8. A number of series have reported worse outcomes for biliary reconstructions performed at Less than1 week de Reuver PR, Ann Surg 245:763–770) Within 6 weeks of injury Thomson BN, et al. 2006 Br J Surg 93:216–220. Walsh RM, et al. 2007 Surgery 142:450–456; discussion 456–457). .
- 9. Whereas others report no differences in outcomes related to the timing of the repair. Lillemoe KD, et al. 2000 Ann Surg 232:430–441. Sicklick JK, et al 2006 Ann Surg 241:786–792. Schmidt SC, et al. Br J Surg 92:76–82
- 10. Although many routinely allow 5–12 weeks for intra- abdominal inflammation to subside. Thomson BN. Early specialist repair of biliary injury. Br J Surg 93:216–220. Lillemoe KD, et al. Ann Surg 232:430–441. Johnson SR, Surgery 128:668–677.
- 11. EARLY REPAIR (WITHIN DAYS, 48 HRS) INTERMEDIATE REPAIR (2-6 WEEKS) LATE REPAIR (AFTER 6-8 WEEKS) RESULTS WELL KNOWN GOOD RESULTS NO ADDED MORBIDITY ONLY SELECTED CASES WITH MINIMAL OR NO INFLAMMATION ONLY AT SELECT CENTRES WELL ESTABLISHED RESULTS OF EARLY REPAIR COMPARED WITH DELAYED REPAIR STANDARD PRACTICE ALL OVER WORLD NON HPB SURGEONS ✘ HPB SURGEONS ✔
- 12. Multivariate analysis, however, showed that the timing of the repair was unimportant (P = 0.572). Instead, success correlated with: Eradication Of Intra-abdominal Infection (P = 0.0001); Complete Preoperative Cholangiography (P = 0.002); Use Of Correct Surgical Technique (P = 0.0001), And Repair By A Biliary Surgeon (P = 0.0001).
- 13. They analysed 307 cases of major BDI following LC 137 injuries : initially repaired by a biliary surgeon and 163 injuries were initially repaired by the primary surgeon;
- 14. 3 groups were defined based on the level of inflammatory manifestations at the time of injury recognition: 1 Operative recognition; 26% 2 None/No SIRS: (65% of post op recognition) no inflammatory manifestations or SIRS manifestations: (fever [ 38 °C]; leucocytosis [white blood cells 11 k/cm2]; respiratory rate 20/min; heart rate 90/min), and/or 3 Complicated (35%): cases with cholangitis (Charcot’s triad), peritonitis, sepsis (hypotension, shock, organ dysfunction) or abdominal abscess.
- 17. Timing of surgical repair and outcomes Timing as an individual variable had no effect
- 18. Bivariate and multivariate analysis of factors influencing the success of biliary repair in the entire group
- 19. Timing of Surgical Repair After Bile Duct Injury Impacts Postoperative Complications but Not Anastomotic Patency Ismael Dominguez-Rosado, MD, y Dominic E. Sanford, MD,y Jingxia Liu, MS, PhD,z William G. Hawkins, MD,y and Miguel A. Mercado, MD Annals of Surgery Volume 264, Number 3, September 2016
- 20. 30 DAYS COMPLICATIONS : PRIMARY REPAIR GROUP: SEPSIS CONTROL : Protective against complications [odds ratio, OR 1⁄4 0.36 (0.19 – 0.70), P 1⁄4 0.003]. INTERMEDIATE TIMING OF REPAIR : Nonsignificant trend towards complications in this group. OLDER AGE was predictive of complications within 30 days [OR 1⁄4 1.03, 95% confidence interval, CI, (1.01–1.04), P = 0.002].
- 21. SECONDARY REPAIR INTERMEDIATE TIMING OF REPAIR : Independent predictor of complications in the group [OR 1⁄4 3.7, 95% CI (1.3 – 10.2), P 1⁄4 0.012] FAILURE TO RECOGNIZE INJURY DURING CHOLECYSTECTOMY [OR 1⁄4 4.2, 95% CI (1.1–15.6), P 1⁄4 0.03]. AGE AND STRASBERG E1 – 2 INJURY showed marginally significant trends towards being independent risk and protective factors, respectively, for complications within 30 days Ismael Dominguez-Rosado, Annals of Surgery Volume 264, Number 3, September 2016
- 22. LONG-TERM ANASTOMOTIC OUTCOMES Anastomotic failure : 132/614 (21.5%). TIMING OF REPAIR HAS NO IMPACT ON LONG TERM OUTCOMES Repairs performed after 2004 had a lower rate of anastomotic failure compared with those performed before 2004. (17% vs 32%, P = 0.0001). The rate of anastomotic failure was not significantly different between primary and secondary repair (20% vs 24%, P = 0.2).
- 23. PRIMARY REPAIR GROUP 1. Sepsis control [OR 0.37 95% CI (0.17–0.78), P - 0.009], 2. No conversion to open [OR 0.30 95% CI (0.10–0.96), P - 0.042], 3. No post repair hepatectomy [hazard ratio, HR 0.19, 95% CI (0.04– 0.93), P -0.041], and 4. Avoidance of postoperative biliary stents [OR 0.31, 95% CI (0.16–0.61), P - 0.001] were associated with lower rates of anastomotic failure. SECONDARY REPAIR GROUP 1.ASA 2 [OR 0.28, 95% CI (0.13–0.60), P = 0.0003] 2.Avoidance of postoperative biliary stents [OR = 0.22, 95% CI (0.11 – 0.44), P- 0.0001] were associated with lower risk of anastomotic failure
- 25. Sepsis control is a significant protective factor for complications and anastomotic failure after primary repair, whereas among secondary repair patients, intermediate timing of repair was a predictive risk factor for complications, with no association to anastomotic failure.
- 26. Data from other series are mixed regarding timing of repair. Cho et al demonstrated a benefit to delay bile duct primary repair (>6 weeks) Cho JY, et al. J Am Coll Surg. 2015;221:678–688. A case series of 69 bile duct injuries reported a significant association between the time of repair (3 days to 6 weeks) and the occurrence of bile leak or anastomotic stricture. Sahajpal Ak et al. Arch Surg. 2010;145:757 – 763. In a French survey, Ianelli et al reported better outcomes in those who were repaired after 45 days after injury.
- 27. Another series of 157 patients observed better outcomes in the ‘‘on-table’’ repair and early repair (less than 3 weeks) groups compared with those in the late repair (> 3 weeks) group, with no difference in recurrent cholangitis or reoperation. Perera MTPR, et al. Ann Surg. 2011;253:553–560. Using a different definition for timing of repair (<1 month, 1– 12 months, and >12 months), Sicklick et al reported no association with postoperative complications. Sicklick JK, et al. Ann Surg. 2005;241:786 – 795.
- 28. Retrospective review of patients with CBDI managed surgically at a single center. N=61 EARLY REPAIR (<48 HRS): 27 DELAYED REPAIR (>48 HRS) : 34 No differences were found in patient demographics, injury classification subtype, VBI incidence, hospital length of stay, 30-day readmission rate, or 90-day mortality rate. Patients undergoing delayed repair exhibited increased chance of readmission
- 29. When the surgeon sees the patient days after the injury, he or she must evaluate whether an early or late repair should be done. No level 1 evidence to support either approach. In fact, it is very difficult (if not impossible) to develop a prospective, controlled, randomized trial to solve this question. Each patient has his or her own anatomy, systemic inflammatory response, and type of injury. Mercado, M.A. Surg Endosc (2006) 20: 1644. There are some conditions that allow an early repair. No sepsis, No multiple organ failure, No intestinal fistulas, and No abdominal collections, Preserved abdominal wall (no dehiscence or wall abscesses)
- 30. Early or late repair was done based on patient’s characteristics. Postoperative results were measured according to Lillemoe criteria. N = 75 Early repair : 45 : 38 (84%) had good results Late repair : 12 : 10 (85%) had good results
- 31. Early repair may be done in a patient with a ligated/ clipped duct after LC when there is no bile leak, no cholangitis, and good proximal dilatation. VK Kapoor. J Hepatobiliary Pancreat Surg (2007) The Edinburgh group reported equally good results after early (within 2 weeks) repair as after delayed repair in selected patients. Thomson BNJ, et al. Br J Surg 2006
- 32. The Mayo Clinic also has a similar philosophy of management for BDIs. Based their approach on patient’s clinical characteristics. • Complete occlusion • No bile leak • 10 mm dilated ducts Murr MM, Arch Surg 1995;134:604–10 EARLY REPAIR WITHIN 2 WEEKS
- 33. In JOHN HOPKINS SERIES series, N = 200 175 underwent definitive biliary reconstruction (172 HJ) 34 Early repair, 9 repair at time of LC The timing of operation, defined as Early (less than 1 month after referral), Intermediate (1–12 months after referral), and Delayed (more than 12 months after referral), The timing of operation (early, intermediate, delayed), presenting symptoms, and history of prior repair did not affect the incidence of the most common perioperative complications or length of postoperative hospital stay. Sicklick JK, Ann Surg 2005;241:786– 95.
- 35. Nationwide, retrospective multicentre study. N = 139 Median referral time : 3 days Median time to definite reconstruction : 5 days Bismuth Type 1 or 2: Ninety-eight patients (71%) Type 3 or 4 : 35 patients (25%) Nicolaj M. Stilling et al HPB 2015, 17, 394–400 .
- 36. No significant effect on the stricture rate was observed in relation to Timing of reconstruction (within versus after 2 weeks of injury, P = 0.48), Concomitant vascular injury (P = 0.07), Level of injury (Bismuth 1–2 versus 3–5, P = 0.44), Place of reconstruction (between the 5 HPB centres, P = 0.17), The presence of perioperative complications
- 37. N = 640 IMMEDIATE IN 194 CASES (35.7%)--- AT TIME OF SURGERY SUTURE REPAIR 157(81%),BILIO-ENETRIC 37 (19%) EARLY IN 216 CASES (39.8%) --- 1-45 DAYS SUTURE REPAIR IN 119 CASES (55.1%) AND A BILIO-DIGESTIVE ANASTOMOSIS IN 96 CASES (44.9%) LATE IN 133 CASES (24.5%) --- AFTER 45 DAYS BILIO-DIGESTIVE RECONSTRUCTION IN 129 CASES (97%) AND A SUTURE REPAIR IN 4 CASES (3%)
- 39. Conclusion: The timing of surgical repair for a bile duct injury sustained during a cholecystectomy influences significantly the rate of a second procedure and a late repair should be preferred option. Antonio Iannelli et al. HPB 2013, 15, 611–616
- 40. Kaplan-Meier curves: stricture-free rate and time of repair following laproscopic cholecystectomy, P 0.053. Walsh et al Surgery 2007;142:450-7
- 42. PRIMARY SURGEON : 0.53 QALYs ($120,000/QALY) LATE REPAIR BY HBS : 0.74 QALYs ($74,000/ QALY) EARLY REPAIR BY HBS : 0.82 QALYs ($48,000/QALY) EARLY REPAIR BY HBS ; Associated with lower costs, earlier return to normal activity, and better quality of life. This cost-effectiveness model demonstrates that early repair by a HBS is the superior strategy for the treatment of BDI in properly selected patients. Leigh Anne Dageforde J Am Coll Surg 2012
- 43. STEWART AND WAY N= 137 EARLY REPAIR BY PRIMARY SURGEON EARLY REPAIR BY BILIARY SURGEON LATE REPAIR BY BILIARY SURGEON SIMILAR OUTCOMES WITH EARLY REPAIR BY BILIARY SURGEON DOMINGUEZ ET AL N = 586 PRIMARY GROUP/ SECONDARY GROUP: EARLY (<7 DAYS) INTERMEDIATE (8 DAYS-6 WEEKS) LATE (>6 WEEKS) NO IMPACT OF TIMING ON LONF TERM OUTCOME. DELAYED REAPIR PREFFERRED IN REOPEARTIVE (SECONDARY) GROUP SAHAJPAL ET AL N= 69 3 DAYS- 6 WEEKS : MORE STRICTURES PERERA ET AL. N=157 NO DIFFERENCE IN PATIENTS OPERATED < OR > 3 WEEKS SICKLICK ET AL (JOHN HOPKINS) N+200 34 EARLY SIMILAR PERIOPERATIVE OUTCOME
- 44. KIRK ET AL N= 61 < 48 HRS : 27 > 48 HRS : 34 SIMILAR OUTCOME THOMSEN BML ET AL < 2WEEKS : 25 2-6 WEEKS : 22 SIMILAR OUTCOME STILLING ET AL N= 139 MEDIAN OPERATIVE TIME : 5 DAYS 30% STRICTURE RATE SGPGIMS N = 300 (ONLY 11 TILL 2005) NO COMMENTS LATE REPAIR RECOMMENDED GIPMER N = 137 EARLY REPAIR : 5 NO COMMENTS SGE, KGMU (UNPUBLISHED) N = 147 (FROM 2011) 2 ON TABLE REPAIR : TYPE D 2 EARLY REPAIR (TYPE 3 AND TYPE 4)
- 45. The ultimate goal of biliary reconstruction is to obtain a high- quality bilio-enteric anastomosis that will not malfunction over a long period. This should be the surgeon aim in every scenario that involves a bile duct injury. No prospective, controlled, randomized trial (evidence level 1) has shown whether an early repair is better than a late one. The timing of the operative procedure should be individualized
- 46. OUR EXPERIENCE N = Early repair 2 Case 1 : Case 2 :
Editor's Notes
- Uniformity in literature. Debates/questions well settled and answered. However timing of repair is still an issue / question open to debate. No RCTs to settle this debate. Previous studies of CBDI have iden- tified several factors associated with successful repair. These include treatment by an experienced hepatopancreatobiliary (HPB) surgeon and specialized center as well as multidisciplinary perioperative care Surgeons who are not experienced in the management of bile duct injuries should not attempt primary repair, as the rate of failure in this situation is extremely high. Bile duct injury repair by the primary surgeon has been reported to be success- ful in only 10–17 % of cases versus over 90–94 % when performed by a special- ist HPB surgeon in a dedicated center
- here is heterogeneity in the literature regarding the optimal timing of surgical repair, and it remains unclear to what extent timing determines postoperative morbidity and long- term anastomotic function.
- No prospective, controlled, randomized trial (evidence level 1) has been conducted that shows whether an early repair is better than a late one. The timing of the operative procedure should be individualized. A complete examination of the patient should be performed to identify the type of injury and coexistent comorbidities. For septic patients and those with multiple organ dysfunction syndrome, the repair should be delayed. No optimal period of waiting for performance of an elective repair has been established, but Strasberg advises a wait of 3 months.
- No optimal period of waiting for performance of an elective repair has been established, but Strasberg advises a wait of 3 months. Resolution of bilomas, collections, and concomitant inflammation is expected after this period. Once the injury has reached its maxi- mum level of ischemia, the lesion is set to be stable. Elective surgical treatment then is recommended.
- The success of biliary reconstruction for iatrogenic bile duct injuries depended on com- plete eradication of abdominal infection, complete cholangiography, use of correct surgical technique, and repair by an experienced biliary surgeon. If these objectives were achieved, the repair could be performed at any point with the expectation of an excellent outcome. We see no reason to delay the repair for some arbitrary period
- Class I injuries (5% of cases) involved an incision in the common bile duct with no loss of duct. Class II injuries (24% of cases) consisted of lateral damage to the hepatic duct with a resultant stenosis and/or fistula. Class III injuries, the most common (61% of cases), involved transec- tion and excision of a variable length of the duct, which always included the cystic duct–common duct junction. Class III injuries were subdivided based on the proximal extent of the injury as follows: in class IIIa injuries, a remnant of the common bile duct or common hepatic duct remained; in class IIIb injuries, the proximal transaction was at the bifurcation at the common hepatic duct; in class IIIc injuries, the bifurcation of the common hepatic duct had been excised, and in class IIId injuries, the proximal line of resection was above the first bifurcation of the lobar ducts (into segmental ducts). Class IV injuries (10% of cases) involved damage (transection or injury) of the right hepatic duct (or a right segmental duct), often combined with injury to the right hepatic artery.
- 74% had post op recognition of BDI Cases with a complicated clinical presentation underwent a longer period of preoperative preparation for control of abdominal inflammation than those recognized at the index operation or those with none/SIRS
- Cases with a complicated clinical presentation underwent a longer period of preoperative preparation for control of abdominal inflammation than those recognized at the index operation or those with none/SIRS However, this varied by treating surgeon (Fig. 1): the period of preoperative prepara- tion for these complicated cases was longer among patients cared for by biliary surgeons than for those under the care of primary surgeons (33 vs. 4 days, biliary vs. primary surgeons; P < 0.0001, t-test). Complete imaging of the biliary tree was obtained before the repair in 32% of cases recognized in the postoperative period. Complete imaging of the biliary tree was obtained before the repair in all cases initially repaired by a biliary surgeon
- Overall, rates for primary success and success with post-repair interventional radiology (IR) dilatation were 21% for primary surgeons and 95% for biliary surgeons
- In general, repairs by primary surgeons were performed earlier than those by biliary surgeons (11 vs. 59 days; P < 0.0001), principally because of obvious logistical factors associated with referral and because biliary surgeons took the time to achieve eradication of intra-abdominal inflammation. a large number of injuries were repaired early by biliary surgeons: 23% were repaired within the first week and 44% were repaired within the first 2 weeks. When each repair interval was examined (<1 week, <2 weeks, 3-6 weeks, and >6 weeks), outcomes were nearly identical (Table 3). Outcomes were better for biliary surgeons, but outcomes were not influenced by the timing of repair in either Neither did the timing of the biliary reconstruction influence the length of postoperative course.
- Bivariate analysis (Table 4) suggested that later repairs were more successful than those carried out earlier (17 vs. 50 days; P = 0.003), but this was because repairs by primary surgeons were generally performed earlier than those by biliary surgeons (Figs 1 and 2). Multivariate analysis demonstrated that the timing of repair was not significant (P = 0.572). Likewise, success was unaffected by the level of injury (P = 0.197) or associated right hepatic artery injury (P = 0.918). For the cases repaired by the primary surgeon, factors associ- ated with success (multivariate analysis) included: the eradication of intra-abdominal infection (P = 0.004); the provision of com- plete preoperative cholangiography (P = 0.018); the use of the correct surgical technique (P < 0.0001), and Stewart–Way injury class (P < 0.0001). The timing of the repair, level of injury, and associated right hepatic artery injury did not correlate with sur- gical outcomes (P > 0.371). For the cases repaired by a biliary surgeon, eradication of intra- abdominal infection, complete preoperative cholangiography, and correct surgical technique were standard therapy, so, on bivariate analysis, these factors did not correlate with outcomes. Among the other factors analysed (timing of repair, Stewart–Way injury class, level of injury, associated right hepatic artery injury), only level of injury was associated with success on bivariate analysis (P = 0.014). Concomitant right hepatic artery injury showed a trend towards significance on bivariate analysis (P = 0.06). On multi- variate analysis, no factors independently correlated with out- comes, although level of injury showed a trend (P = 0.062). However, in cases referred early, with good control of intra- abdominal inflammation, we found no need to delay operative repair. In the current study 44% of cases were repaired in the first 2 weeks with good outcomes.
- This study was a retrospective review of a prospectively maintained database. The database includes all patients who under- went surgical repair of biliary injuries at the Instituto Nacional de Ciencias Medicas y Nutricion ‘‘Salvador Zubiran’’ (INCMNSZ) at Mexico City from January 1989 to December 2014 Time of repair from bile duct injury to primary or secondary repair was defined as early when performed during the first 7 days, intermediate timing if done between 8 days and 6 weeks, and late if performed after 6 weeks of injury.
- Nonsignificant trend towards being a risk factor for complications in this group.
- Adequate sepsis control and delayed repair of biliary injuries should be considered for patients presenting between 8 days and 6 weeks after injury to prevent complications, if a previous bile duct repair was attempted.
- Ninety-two (14%) patients had cholangitis that required intervention, and 85 (13%) patients had stenosis. Reoperation was required in 46 (7%) patients, and the median time from repair to first anastomotic failure was 5.8 months (range, 1 – 156 months) TIMING OF REPAIR HAS NO IMPACT ON LONG TERM OUTCOMES
- TIMING OF REPAIR HAS NO IMPACT PRIMARY GP: multivariate analysis revealed that sepsis no conversion to], no postrepair hepatectomy [hazard ratio, HR 1⁄4 0.19, 95% CI (0.04– 0.93), P 1⁄4 0.041], and avoidance of postoperative biliary stents [OR 1⁄4 0.31, 95% CI (0.16–0.61), P 1⁄4 0.001] were associated with lower rates of anastomotic failure. Among patients in the secondary repair group, only ASA 2 and avoidance of postoperative biliary stents] were associated with lower risk of anastomotic failure
- First, this was a retro- spective study and therefore subject to selection bias. Confounding unmeasured variables, not included in the database, could result in inadequate risk adjustment. First, the most obvious difference is that the majority of cholecystectomies, 61%, began as open cholecystectomy, whereas that number would be probably less than 10% in the United States. Biliary injury was recognized at the time of cholecystectomy in less than 10% of your patients whereas in the United States, laparoscopic cholecystectomy injuries are recognized about 30% to 40% of the time. Your patients most commonly presented with sepsis or chol- angitis with only 20% having a bile leak, whereas in the United States, with most bile duct injuries at the index operation following laparoscopic cholecystectomy, the most common presentation is with a bile leak or jaundice without cholangitis depending on whether the proximal duct has been clipped.
- SECONDARY GROUP is a higher risk population with unresolved inflammation/infection at the time of definitive bile duct repair. Moreover, this unresolved inflammatory state could be further aggravated if repair is performed between 8 days and 6 weeks after injury. Similar to the manage- ment of enterocutaneous fistulas, where operating during the period of time between 10 days and 6 weeks is avoided to control sepsis, improve nutritional status, and reduce adhesions,17 delayed bile duct repair may allow for better operative planning and improved outcomes, particularly in secondary repairs.
- Heterogeniety in literature regarding early and delayed repair. Out of 122 repairs performed, only 4 (3.3%) cases were operated on between 8 days and 6 weeks. Those with arterial injuries were repaired after 3 months, when a complete diagnosis of the injury and control of sepsis was achieved.13
- Using this defi- nition they compared the extremes in the scenario of bile duct repair without exploring the outcomes of an intermediate time frame where an unsolved inflammatory state and high technically demanding surgical procedure are likely. Different results regarding the timing of repair in the literature may be explained by variations in definitions of complications and anastomotic failure and by underpowered and heterogenous case series that include injuries that are not surgically treated.20 – 24
- While early repair is variably described and suggested to be feasible up to 5 days or 7 days after injury, delay in injury recognition accounted for approximately 35% of patients who underwent delayed repair. The selection of 48 h as the differentiation between early and delayed repair was based on a clear point of differentiation at the 48-h timepoint, beyond which few repairs occurred prior to 4 – 6 weeks following injury. Large reviews of CBDI suggest that concomitant vascular injury is present in approximately 25% of these patients.10,11,14 While arterial injury may be considered an indication to delay repair given concern for biliary or bilioenteric anastomotic structure,8,10,11,22,23 liver transplantation may be required for catastrophic vasculobiliary injuries.11,14,24 The present series includes 4 patients with VBI who underwent early repair: three tangential hepatic vascular injuries requiring intervention to prevent ongoing hemorrhage and a single extreme VBI with segmental portal vein and proper hepatic artery excision. This patient underwent emergent venous allograft reconstruction of the hepatic vasculature within hours of injury as hepatic infarction was considered imminent, with liver transplantation In conclusion, these data suggest that equivalent perioperative clinical outcomes can be achieved for early and delayed repair of CBDI by experienced surgeons and an experienced center with an algorithm for assessment and management of CBDI;
- The patientÕs general condition must be carefully evaluated at his or her presentation. Some patients are quite stable, whereas others suffer from an important systemic inflammatory response. A broad individual response to abdominal collections or biliperitoneum can be observed. An evaluation for early repair can be performed. If abdominal cavity exploration shows limited inflam- mation and peritonitis, and if adequate ducts are found for a high-quality anastomosis, an early repair can be performed. By doing this, a complete resolution of the problem is achieved, with results similar to those in the acute and elective setting.
- These criteria describe good results in terms of asymptomatic patients without obstruction or cho- langitis and bad results in terms of the opposite.
- Immediate or early repair (<1 week) is favored when a complete diagnosis is achieved for a stable patient without any intra-abdominal bile collection and without associated vascular injury. SGPGI ; We do not recommend early repair and have performed early (within 4 weeks) repair in only 11 out of 362 patients in whom we have performed HJ for BDI between 1989 and 2005 (unpublished data) the early repair could, however, be done in only 25 out of 47 patients and follow up is short — only 33 months
- “Philosophy is surgery; surgery is philosophy.” PERCUTANEOUS TUBES CAN BE INTERMITENTLY CLAMPED TO ALLOW DUCT DILATATION UPTO 10 MM. BILE LEAK, FISTULA, BILIARY PERITONITIS, CHOLANGITIS : DELAYED REAPIR
- In total, 139 patients had an HJ repair. The median time from the BDI to reconstruction was 5 days. Forty-two patients (30%) had a stricture of the HJ. No association was found between timing of repair, concomitant vascular injury, level of injury and stricture formation. Conclusion: In this national, unselected and consecutive cohort of patients with BDI repaired by early HJ we found a considerable risk of long-term complications (e.g. 30% stricture rate)
- In Denmark, all confirmed major bile duct injuries requiring reconstruction with HJ or other complex surgical procedures are treated in one of the aforementioned HPB centres or by a HPB surgeon travelling to the referring hospital. The overall approach was to reconstruct the patient as soon as possible after referral. Only 12 patients were reconstructed more than 2 months after the primary bile duct injury, and this included the five afore- mentioned patients with primary surgical repair attempts Overall, 49 patients (36%) were reconstructed within 2 days and 115 patients (83%) within 2 weeks from the BDI. Only 12 patients were not reconstructed with a HJ within 1 week of referral
- We observed an overall 30% biliary stricture rate which was somewhat higher than reported by others. Schmidt16 and Holte17 found stricture rates of 19.6% and 24%, respectively, whereas the reported stricture rates varied between 0 and 19% in other dedicated HPB centres.12,14,18,19 As an example, Strasberg’s group19had a stricture/failure rate of only 5% during a median follow-up period of 4.9 years in 113 patients. They advocate for the Hepp–Couinaud technique with side-to-side HJ to the left hepatic duct when possible and a late repair, if ischaemia is suspected due to vascular injury to the liver arteries.
- A retrospective national French survey was conducted to compare the results of immediate (at time of cholecystectomy), early (within 45 days after a cholecystectomy) and late (beyond 45 days after a cholecystectomy) surgical repair for BDI sustained during a cholecystectomy. An open cholecystectomy was undertaken in 83 cases (15.3%), and a laparoscopy in the remaining cases of which 205 (44.6%) underwent conversion to open surgery
- ON TABLE REPAIRS DONE BY PRIMARY SURGEON OR NOT KNOWN. A second procedure was required in 110 cases (56.7%) for immediate repair, 80 cases (40.7%) for early repair (P < 0.05) and in 9 cases (6.8%) for late repair (P < 0.001). FAILURE OF DIRECT REPAIR IN IMMEDIATE AND EARLY REPAIR.
- Immediate and early repair resulted in a 39.2% and 28.7% rate of post-operative complications, respectively (P < 0.05). The rate of post-operative complications was 14.3% in patients undergo- ing a late repair (P < 0.01). As expected, the best results in this series were found in patients undergoing a late repair. Three main reasons may account for these data. First, all of these patients were managed in tertiary hepatobiliary referral centres. Second, when the repair is made beyond 45 days after the BDI the local inflammatory phenomena accompanying the injury have regressed and the evolution of the damage to the biliary tree vascular supply have stabilized and the level of the injury can be then reliably assessed.30 Third, the RYHJJ, which is considered as the procedure of choice, was performed in almost all the cases providing the lowest rate of post-operative complications and the highest success rate. In conclusion, this large French national survey, although biased by its retrospective nature, indicates that the best timing to repair a BDI is beyond 45 days and the best results can be expected in the hands of experienced hepatobiliary surgeons with bilio- enteric repair in the form of the RYHJJ.
- The objective of this study was to evaluate the cost- effectiveness of repair by a primary nonhepatobiliary surgeon, late repair by a hepatobiliary surgeon, and early repair by a hepatobiliary surgeon. The Markov decision analytic technique is used to model outcomes for groups of hypothetical patients and analyze time, value, and costs of patients in each state of health The base case patient was defined to be a 42-year- old woman employed outside of the home, which describes the typical patient undergoing laparoscopic cholecystec- tomy We assumed that patients did not have septic physiology and therefore were candidates for any of the 3 approaches of surgical repair
- quality adjusted life years (QALYs) Specifically, 1 year after repair, PSR yielded 0.53 quality adjusted life years (QALYs) ($120,000/QALY) and LHBS yielded 0.74 QALYs ($74,000/ QALY); EHBS yielded 0.82 QALYs ($48,000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities. Although there is little clinical difference between early and late repair, there is a great difference in cost and quality of life. Ideally, costs and quality of life should be considered in decisions regarding strategies of repair of injured bile ducts.