TY - JOUR
AU - Poston, G J
AB - Abstract Background Combined vasculobiliary injury is a serious complication of cholecystectomy. This study examined medium- to long-term outcomes after such injury. Methods Patients referred to this institution with Strasberg type E bile duct injuries were identified from a prospectively maintained database (1990–2010). Long-term outcomes were evaluated by chart review. Results Sixty-three patients were referred with bile duct injury alone (45 patients) or vasculobiliary injury (18). Thirty patients (48 per cent) had septic complications before transfer. Twenty-six patients (41 per cent) had long-term biliary complications over a median follow-up of 96 (range 12–245) months. Nine patients (3 with bile duct injury, 6 with vasculobiliary injury) required further interventions after a median of 22 (8–38) months; five required biliary surgical revision and four percutaneous dilatation of biliary strictures. Vasculobiliary injury and injury-related sepsis were independent risk factors for treatment failure: hazard ratio 7·79 (95 per cent confidence interval 2·80 to 21·70; P < 0·001) and 4·82 (1·69 to 13·68; P = 0·003) respectively. Conclusion Outcome following bile duct injury repair was worse in patients with concomitant vasculobiliary injury and/or sepsis. Introduction Bile duct injury (BDI) is a serious complication of cholecystectomy, arising in 0·2–0·3 per cent of patients undergoing an open procedure1,2 and 0·5 per cent of those undergoing laparoscopic surgery3,4. Concomitant vasculobiliary injuries (VBIs) are present in 12–61 per cent of these patients5–17. Isolated vascular injuries (mostly to the right hepatic artery) are usually uncomplicated in otherwise healthy patients18,19, and discovered only as incidental findings at autopsy20. However, hepatic artery flow disruption presents a significant problem with BDI repair or reconstruction owing to relative duct ischaemia11,15. This study examined medium- to long-term outcomes following referral of VBI to a tertiary centre. Methods All patients referred to this institution with a Strasberg type E BDI (Fig. 1)2 or a type E biliary stricture following cholecystectomy were identified from a prospectively maintained database (1990–2010). The study was approved by the local ethics committee and those patients still alive gave their consent for inclusion in the study. The types of BDI and VBI were defined by surgical recognition, computed tomography with vascular reconstruction, magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography. Hepatic artery angiography was performed in high-risk patients (with significant haemorrhage at the time of cholecystectomy), in the earlier years. Bile duct injuries were categorized according to the Strasberg classification (Fig. 1)2. Patients with cystic duct leaks or isolated vascular injuries were excluded. The routine surgical approach employed for reconstruction was an end-to-side Roux-en- Y hepaticojejunostomy according to the Hepp–Couinaud technique21,22. Fig. 1 Open in new tabDownload slide Strasberg classification of bile duct injuries. Type A injuries originate from small bile ducts in the liver bed or cystic duct. Type B and C injuries almost always involve aberrant right hepatic ducts. The notations ≥ 2 cm and < 2 cm in types E1 and E2 indicate the length of remaining common duct. The corresponding Bismuth classifications are shown where possible as B1–5 (in parentheses); note that Strasberg types A and D do not exist in the Bismuth system, and Strasberg types B, C and E5 would be classified as B5. (Reproduced, with permission, from Surgical Management of Hepatobiliary and Pancreatic Disorders (2nd edn), Poston GJ, D'Angelica M, Adam R (eds). Informa Healthcare: London, 2010) Patients were seen in the clinic at 1, 3, 6 and 12 months, and annually thereafter. A symptom grading system was used at the last clinic visit or at the time of reintervention23. Results were considered excellent or good in patients without symptoms attributable to the biliary tract injury or reconstruction, with blood liver function test (LFT) results less than or equal to twice the upper limit of normal. Ultrasound, MRI and cholangiographic studies were performed when there was clinical or biochemical concern regarding anastomotic stricture. Statistical analysis Continuous data are presented as median (range). Data were analysed using the χ2 test and Mann–Whitney U test as appropriate. Factors with P < 0·050 in univariable analysis were included in Cox regression analyses. Statistical analysis was carried out by using SPSS® version 13 (SPSS, Chicago, Illinois, USA). Results Sixty-three consecutive patients who sustained a major (Strasberg E) BDI during cholecystectomy were referred during the study period. Their median age was 53 (20–82) years, with a male to female ratio of 1:2. Patient demographics were similar among the two (BDI versus VBI) groups. Indications for referral are listed in Table 1. The most common type of biliary injury was Strasberg E32 and 18 patients (29 per cent) sustained a VBI (Table 1). Of these, 15 patients had disruption of the right hepatic artery, two had disruption of the common hepatic artery, and one patient had a pseudoaneurysm of the right hepatic artery; in one patient there was combined right hepatic artery resection with a portal venous injury. The latter was repaired primarily on site before referral, with a surgical drain to the divided hepatic duct followed by a delayed hepaticojejunostomy because of concern that hepatic duct ischaemia would compromise immediate biliary repair. Table 1 Indications for referral and classification of biliary injury according to the Strasberg classification in 63 patients . No. of patients . Indication for referral  Excessive bile leakage 40  Bile duct stricture 6  Recurrent cholangitis 15  Intraoperative bleeding 2 Type of injury*  E1 0 (0)  E2 4 (0)  E3 42 (11)  E4 13 (6)  E5 4 (1) Time from injury to referral (days)† 20 (0–4200) . No. of patients . Indication for referral  Excessive bile leakage 40  Bile duct stricture 6  Recurrent cholangitis 15  Intraoperative bleeding 2 Type of injury*  E1 0 (0)  E2 4 (0)  E3 42 (11)  E4 13 (6)  E5 4 (1) Time from injury to referral (days)† 20 (0–4200) * Values in parentheses are numbers of patients with vasculobiliary injuries; † values are median (range). The Strasberg classification2 is illustrated in Fig. 1. Open in new tab Table 1 Indications for referral and classification of biliary injury according to the Strasberg classification in 63 patients . No. of patients . Indication for referral  Excessive bile leakage 40  Bile duct stricture 6  Recurrent cholangitis 15  Intraoperative bleeding 2 Type of injury*  E1 0 (0)  E2 4 (0)  E3 42 (11)  E4 13 (6)  E5 4 (1) Time from injury to referral (days)† 20 (0–4200) . No. of patients . Indication for referral  Excessive bile leakage 40  Bile duct stricture 6  Recurrent cholangitis 15  Intraoperative bleeding 2 Type of injury*  E1 0 (0)  E2 4 (0)  E3 42 (11)  E4 13 (6)  E5 4 (1) Time from injury to referral (days)† 20 (0–4200) * Values in parentheses are numbers of patients with vasculobiliary injuries; † values are median (range). The Strasberg classification2 is illustrated in Fig. 1. Open in new tab Diagnosis and management The initial management at the primary hospital for patients with BDI and those with VBI was compared (Table 2). BDIs were recognized during surgery in 24 patients, yet only two patients were referred promptly after intraoperative recognition of a concomitant vascular injury. Thirty-nine patients (62 per cent) were diagnosed at a median of 8 (1–4200) days after cholecystectomy. Primary end-to-end anastomosis was the most frequent type of repair carried out by the primary surgeon (12 patients); other procedures and complications occurring at the base hospital are described in Table 2. All patients underwent either primary or revisional hepaticojejunostomy at the authors' institution. The median interval between injury and repair was 6 (0–600) weeks. Table 2 Clinical details of 63 patients included in the study . BDI alone (n = 45) . VBI (n = 18) . Total (n = 63) . Surgical approach  Laparoscopy 31 6 37  Converted to open procedure 5 7 12  Open surgery 9 5 14 Intraoperative cholangiography 5 1 6 Diagnosis of biliary injury  Intraoperative 15 9* 24  Postoperative 30 9 39 Procedures performed before referral  Attempted intervention 31 15 46   Radiological drainage 14 4 18   Surgical repair 17 11 28   Repair of biliary injury    Primary end-to-end anastomosis 12    Hepaticojejunostomy 9    Suture repair of partial transection 7  Abdominal drainage 8 3 11  No invasive procedure 12 2 14 Septic complications† 30  Sepsis at time of referral 15  Surgical drainage of peritonitis 5  Multiple radiological procedures for peritonitis 4 . BDI alone (n = 45) . VBI (n = 18) . Total (n = 63) . Surgical approach  Laparoscopy 31 6 37  Converted to open procedure 5 7 12  Open surgery 9 5 14 Intraoperative cholangiography 5 1 6 Diagnosis of biliary injury  Intraoperative 15 9* 24  Postoperative 30 9 39 Procedures performed before referral  Attempted intervention 31 15 46   Radiological drainage 14 4 18   Surgical repair 17 11 28   Repair of biliary injury    Primary end-to-end anastomosis 12    Hepaticojejunostomy 9    Suture repair of partial transection 7  Abdominal drainage 8 3 11  No invasive procedure 12 2 14 Septic complications† 30  Sepsis at time of referral 15  Surgical drainage of peritonitis 5  Multiple radiological procedures for peritonitis 4 * Only two concomitant vascular injuries were diagnosed at operation. † Including peritonitis. BDI, bile duct injury; VBI, vasculobiliary injury. Open in new tab Table 2 Clinical details of 63 patients included in the study . BDI alone (n = 45) . VBI (n = 18) . Total (n = 63) . Surgical approach  Laparoscopy 31 6 37  Converted to open procedure 5 7 12  Open surgery 9 5 14 Intraoperative cholangiography 5 1 6 Diagnosis of biliary injury  Intraoperative 15 9* 24  Postoperative 30 9 39 Procedures performed before referral  Attempted intervention 31 15 46   Radiological drainage 14 4 18   Surgical repair 17 11 28   Repair of biliary injury    Primary end-to-end anastomosis 12    Hepaticojejunostomy 9    Suture repair of partial transection 7  Abdominal drainage 8 3 11  No invasive procedure 12 2 14 Septic complications† 30  Sepsis at time of referral 15  Surgical drainage of peritonitis 5  Multiple radiological procedures for peritonitis 4 . BDI alone (n = 45) . VBI (n = 18) . Total (n = 63) . Surgical approach  Laparoscopy 31 6 37  Converted to open procedure 5 7 12  Open surgery 9 5 14 Intraoperative cholangiography 5 1 6 Diagnosis of biliary injury  Intraoperative 15 9* 24  Postoperative 30 9 39 Procedures performed before referral  Attempted intervention 31 15 46   Radiological drainage 14 4 18   Surgical repair 17 11 28   Repair of biliary injury    Primary end-to-end anastomosis 12    Hepaticojejunostomy 9    Suture repair of partial transection 7  Abdominal drainage 8 3 11  No invasive procedure 12 2 14 Septic complications† 30  Sepsis at time of referral 15  Surgical drainage of peritonitis 5  Multiple radiological procedures for peritonitis 4 * Only two concomitant vascular injuries were diagnosed at operation. † Including peritonitis. BDI, bile duct injury; VBI, vasculobiliary injury. Open in new tab Outcomes There were no perioperative deaths following referral to the North Western Hepatobiliary Unit. Median length of hospital stay after definitive repair was 9 (5–65) days in patients with BDI and 10 (7–91) days in patients with VBI. The overall postoperative in-hospital morbidity rate was 17 per cent (11 of 63), but this was significantly higher in patients who experienced sepsis (30 per cent, 9 of 30). Twenty-six patients (41 per cent) experienced long-term biliary complications over a median follow-up of 96 (range 12–245) months. Nine patients (3 with BDI, 6 with VBI) required further interventions after a median of 22 (8–38) months; five required biliary surgical revision and four percutaneous dilatation of biliary strictures. One patient was lost to follow-up at 54 months after repair with no biliary symptoms and normal LFT results. One patient died from severe biliary sepsis 3 years after initial biliary repair. During follow-up there were two other deaths, one from disseminated colorectal cancer and another following a stroke. Overall excellent and good outcomes were achieved in 45 patients (71 per cent). Prognostic factors On univariable analysis, VBI and sepsis were identified as factors for treatment failure (Table 3). However, among patients with BDI there was no statistical relationship between level of injury and outcome. Median time to treatment failure from repair was 28·5 (1–150) months overall, and was significantly shorter in the VBI group than in the BDI group (Table 3). VBI and sepsis were independent risk factors for treatment failure over time: hazard ratio 7·79 (95 per cent confidence interval 2·80 to 21·70; P < 0·001) and 4·82 (1·69 to 13·68; P = 0·003) respectively. Table 3 Prognostic factors for treatment failure . Treatment failure . χ2 . d.f. . P† . Overall 26 of 63 VBI versus BDI alone 12 of 18 versus 14 of 45 6·71 1 0·010 Sepsis, yes versus no 20 of 30 versus 6 of 33 15·24 1 < 0·001 Attempted primary repair, yes versus no 15 of 28 versus 11 of 35 3·15 1 0·076 Postop. complications, yes versus no 7 of 11 versus 19 of 52 2·75 1 0·097 Type of injury 5·32 3 0·150  E2 2 of 4  E3 16 of 42  E4 8 of 13  E5 0 of 4 Time to treatment failure following initial bile duct repair (months)* < 0·001‡  BDI 94 (12–150)  VBI 8 (1–24) . Treatment failure . χ2 . d.f. . P† . Overall 26 of 63 VBI versus BDI alone 12 of 18 versus 14 of 45 6·71 1 0·010 Sepsis, yes versus no 20 of 30 versus 6 of 33 15·24 1 < 0·001 Attempted primary repair, yes versus no 15 of 28 versus 11 of 35 3·15 1 0·076 Postop. complications, yes versus no 7 of 11 versus 19 of 52 2·75 1 0·097 Type of injury 5·32 3 0·150  E2 2 of 4  E3 16 of 42  E4 8 of 13  E5 0 of 4 Time to treatment failure following initial bile duct repair (months)* < 0·001‡  BDI 94 (12–150)  VBI 8 (1–24) * Values are median (range). VBI, vasculobiliary injury; BDI, bile duct injury. † χ2 test, except ‡ Mann–Whitney U test (Mann–Whitney U = 2). Open in new tab Table 3 Prognostic factors for treatment failure . Treatment failure . χ2 . d.f. . P† . Overall 26 of 63 VBI versus BDI alone 12 of 18 versus 14 of 45 6·71 1 0·010 Sepsis, yes versus no 20 of 30 versus 6 of 33 15·24 1 < 0·001 Attempted primary repair, yes versus no 15 of 28 versus 11 of 35 3·15 1 0·076 Postop. complications, yes versus no 7 of 11 versus 19 of 52 2·75 1 0·097 Type of injury 5·32 3 0·150  E2 2 of 4  E3 16 of 42  E4 8 of 13  E5 0 of 4 Time to treatment failure following initial bile duct repair (months)* < 0·001‡  BDI 94 (12–150)  VBI 8 (1–24) . Treatment failure . χ2 . d.f. . P† . Overall 26 of 63 VBI versus BDI alone 12 of 18 versus 14 of 45 6·71 1 0·010 Sepsis, yes versus no 20 of 30 versus 6 of 33 15·24 1 < 0·001 Attempted primary repair, yes versus no 15 of 28 versus 11 of 35 3·15 1 0·076 Postop. complications, yes versus no 7 of 11 versus 19 of 52 2·75 1 0·097 Type of injury 5·32 3 0·150  E2 2 of 4  E3 16 of 42  E4 8 of 13  E5 0 of 4 Time to treatment failure following initial bile duct repair (months)* < 0·001‡  BDI 94 (12–150)  VBI 8 (1–24) * Values are median (range). VBI, vasculobiliary injury; BDI, bile duct injury. † χ2 test, except ‡ Mann–Whitney U test (Mann–Whitney U = 2). Open in new tab Discussion Several classifications have been proposed for BDI2,24,25, but associated vascular injuries have only recently been considered7. The Hannover classification (Table 4)7, a modification of the Neuhaus and Strasberg systems2,26, aimed to classify combined vascular and biliary injury, but is complicated and requires further independent validation. The Hannover classification is intended to guide initial treatment strategy rather than give an indication of long-term outcome27. Vascular injuries are associated with tangential injuries (type C; Fig. 2) or complete transections (type D; Fig. 3) of the bile duct in the Hannover system. The proportion of VBIs in relation to BDIs in this series (18 of 63) is similar to that seen in the Hannover series (20 of 93). All of the present patients had either Hannover D2–4 or E2–4 injuries, with a similar anatomical distribution of vascular injuries (predominantly to the right hepatic artery). Fig. 2 Open in new tabDownload slide Type C bile duct injuries (tangential injuries) according to the Hannover classification7, with or without additional vascular injury (see Table 4) Fig. 3 Open in new tabDownload slide Type D bile duct injuries (complete ductal transection) according to the Hannover classification7, with or without additional vascular injury (see Table 4) Table 4 Hannover classification of vasculobiliary injury7 Type . Description . Peripheral bile leakage  A1 Cystic duct leak  A2 Leak in gallbladder fossa Bile duct stenosis  B1 Incomplete  B2 Complete Tangential injury  C1 < 5 mm injury  C2 > 5 mm injury below hepatic duct confluence  C3 Injury at hepatic duct confluence  C4 Injury above hepatic duct confluence Complete transection of duct  D1 Without defect below hepatic duct confluence  D2 With defect below hepatic duct confluence  D3 At hepatic duct confluence  D4 Above hepatic duct confluence Strictures of the duct  E1 Main duct < 5 mm  E2 Main duct > 5 mm  E3 Confluence of hepatic ducts  E4 Right hepatic/sectoral duct Type . Description . Peripheral bile leakage  A1 Cystic duct leak  A2 Leak in gallbladder fossa Bile duct stenosis  B1 Incomplete  B2 Complete Tangential injury  C1 < 5 mm injury  C2 > 5 mm injury below hepatic duct confluence  C3 Injury at hepatic duct confluence  C4 Injury above hepatic duct confluence Complete transection of duct  D1 Without defect below hepatic duct confluence  D2 With defect below hepatic duct confluence  D3 At hepatic duct confluence  D4 Above hepatic duct confluence Strictures of the duct  E1 Main duct < 5 mm  E2 Main duct > 5 mm  E3 Confluence of hepatic ducts  E4 Right hepatic/sectoral duct The type and site of injury is then linked to the specific vascular injury (d, right hepatic artery; s, left hepatic artery; p, proper hepatic artery; com, common hepatic artery; c, cystic artery; pv, portal vein) to complete the classification of the vasculobiliary injury. Open in new tab Table 4 Hannover classification of vasculobiliary injury7 Type . Description . Peripheral bile leakage  A1 Cystic duct leak  A2 Leak in gallbladder fossa Bile duct stenosis  B1 Incomplete  B2 Complete Tangential injury  C1 < 5 mm injury  C2 > 5 mm injury below hepatic duct confluence  C3 Injury at hepatic duct confluence  C4 Injury above hepatic duct confluence Complete transection of duct  D1 Without defect below hepatic duct confluence  D2 With defect below hepatic duct confluence  D3 At hepatic duct confluence  D4 Above hepatic duct confluence Strictures of the duct  E1 Main duct < 5 mm  E2 Main duct > 5 mm  E3 Confluence of hepatic ducts  E4 Right hepatic/sectoral duct Type . Description . Peripheral bile leakage  A1 Cystic duct leak  A2 Leak in gallbladder fossa Bile duct stenosis  B1 Incomplete  B2 Complete Tangential injury  C1 < 5 mm injury  C2 > 5 mm injury below hepatic duct confluence  C3 Injury at hepatic duct confluence  C4 Injury above hepatic duct confluence Complete transection of duct  D1 Without defect below hepatic duct confluence  D2 With defect below hepatic duct confluence  D3 At hepatic duct confluence  D4 Above hepatic duct confluence Strictures of the duct  E1 Main duct < 5 mm  E2 Main duct > 5 mm  E3 Confluence of hepatic ducts  E4 Right hepatic/sectoral duct The type and site of injury is then linked to the specific vascular injury (d, right hepatic artery; s, left hepatic artery; p, proper hepatic artery; com, common hepatic artery; c, cystic artery; pv, portal vein) to complete the classification of the vasculobiliary injury. Open in new tab Isolated arterial injuries are usually tolerated without clinical consequence28, but recent studies have questioned whether associated arterial injuries influence the outcome following bile duct repair10,11,14,29. Biliary complications occur in up to 75 per cent of patients with VBI undergoing biliary repair5,6,10,14,30. An associated arterial injury has been described as an independent predictor of poor outcome31, but not in every series15. Two recent reviews have disagreed on the effect of VBI on long-term outcome following BDI repair31,32. Over two-thirds of patients with VBI in some series required liver resection and revisional hepaticojejunostomy for liver atrophy after previous biliary repair, so worse outcome seems intuitive33. Anatomical orientation and recognition remains a major problem for non-hepatobiliary surgeons34. Although hepaticojejunostomy is the optimal technique for reconstruction35–37, this was employed in only one-third of patients initially treated by a non-specialist surgeon in the present study. Other types of attempted repair are associated with high failure and revision rates, especially when carried out by the primary surgeon3,38–40. In the present series, previous attempts at surgical repair were associated with poorer biliary outcome. Delay in referral to a specialist centre where multidisciplinary management is available should be minimized41–44. Since the 1990s, biliary repair in over half of patients in the UK has been attempted by non-specialist surgeons45. Only one-third of BDIs are recognized at the time of the index cholecystectomy46–49. The presence of biliary peritonitis was an independent predictor of poor outcome in the present series, as reported previously29. Following referral, the initial treatment of patients should focus on resuscitation, drainage of any collections, treatment of sepsis and nutrition50. In the present series, biliary repair was postponed intentionally in order to eradicate severe sepsis, and allow biliary revascularization in patients with VBI. The unit policy is to wait for collateral circulation within the hilar plate to provide an adequate arterial blood supply to the biliary confluence and the extrahepatic portion of the bile duct before performing the biliary repair. The authors believe that in the event of VBI it is preferable to wait until the patient is well and in an anabolic state51. Long-term follow-up following bile duct reconstruction is important as long-term patency rates are notably lower following VBI. Finally, these findings have significant implications for the settlement of future medicolegal claims following BDI due to cholecystectomy. Previous authors have reported lower rates of long-term complications following bile duct repair5–17, but these series included more patients with less serious injuries. No recognized quality-of-life tools were used prospectively during the course of the present study (1990 to present), so patient-reported symptoms and complications suffered after bile duct repair were identified from the database corroborated with case-note review. However, there are now numerous reports in the literature of poorer quality-of-life outcomes following BDI32,52–60. It may be that more long-term complications (41 per cent) were identified, and patients reported poorer outcomes (29 per cent, with 14 per cent requiring further surgical or radiological interventions) because the UK patient population is increasingly litigious compared with that of some other countries (such as Sweden where the process of handling compensation for such injuries does not involve the courts). 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Cholecystectomy-related bile duct and vasculobiliary injuries
JO - British Journal of Surgery
DO - 10.1002/bjs.8806
DA - 2012-07-04
UR - https://www.deepdyve.com/lp/oxford-university-press/cholecystectomy-related-bile-duct-and-vasculobiliary-injuries-ad0mg8J4H5
SP - 1129
EP - 1136
VL - 99
IS - 8
DP - DeepDyve
ER -