Referral Pattern and Timing of Repair Are Risk Factors for Complications After Reconstructive Surgery for Bile Duct Injury

Bile duct injury (BDI) after laparoscopic cholecystectomy (LC) remains a major problem in current surgical practice. BDI is associated with poor survival, increased morbidity, and impaired quality of life.1,2 The incidence ranges from 0.3% to 1.4%3–7 and depends on the study population and the criteria used to define the injury. In the Netherlands, approximately 15,000 LCs are performed annually.8 As a result, around 50 to 150 patients will suffer from a serious biliary complication per year. Although it has been suggested that the incidence has been stabilized or declined at the end of the learning phase, still 35 to 40 patients are referred annually to our center without any sign of decrease over the last years. BDI requires a multidisciplinary approach by surgeons, gastroenterologists, and interventional radiologists. Cystic stump leakage, partial laceration of the bile duct, and even strictures can be successfully treated by endoscopic retrograde, or percutaneous stenting and dilatation.9–11 The most severe lesions such as bile duct transection or recurrent strictures generally need reconstructive surgery. However, the optimal surgical strategy in BDI is still debated.12,13 Although outcome has been reported excellent after surgical repair in major institutions,12–15 survival was relatively poor from a nationwide cohort of patients from the United States.1 Therefore, the referral pattern and the timing of referral might substantially effect the outcome after reconstructive surgery; however, this is only spuriously been investigated. Another point of controversy is the debate on the timing of the surgical reconstruction. Surgical reconstruction within 12 to 96 hours after the occurrence of the injury can be performed safely in experienced hands. However, a reconstruction performed several days or a few weeks after the injury, on nondilated bile ducts due to leakage and in particular an inflamed hepatoduodenal ligament with abscess formation, is more difficult and associated with more complications.12 In 2 recent series, an effect of timing of repair on outcome could not be shown, the authors however frequently used interventional radiology to control sepsis and treat biliary fistula and used an interval period to allow inflammation to subside before reconstruction.13,16 The aim of the present study is therefore to analyze the outcome after reconstructive surgery for BDI and in particular the influence of referral pattern and timing of repair.