What is the occurrence rate of bile duct injury after a cholecystectomy?

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Fogel, Evan L., Sherman, Stuart (2024). In Goldman-Cecil Medicine (pp. 1049). DOI: 10.1016/B978-0-323-93038-3.00141-6

A biliary fistula represents an injury to the bile duct, most commonly seen as a complication of cholecystectomy, common bile duct exploration, or inadvertent operative injury of the bile duct or as a consequence of a local infection. Rarely, biliary fistulas result from long-standing untreated biliary tract disease. With more widespread use of laparoscopic cholecystectomy, the incidence of bile duct injury, including biliary fistula, has increased, but it remains less than 0.5% in most published series. Postoperative bile duct leaks are usually manifested within a week after surgery, with patients presenting with abdominal pain (90%), tenderness (80%), fever (75%), nausea and vomiting (50%), and jaundice (40%). Clinically detectable ascites is rare. Biochemical testing is usually nonspecific, with variable elevations in serum liver test values and the white blood cell count. Patients with suspected biliary fistulas often undergo abdominal ultrasonography or CT to look for evidence of a biloma as well as a hepatobiliary scan to diagnose the leak. However, ERCP is the most sensitive test to detect a biliary fistula. Treatment options for biliary leaks include percutaneously or endoscopically placed biliary drains or stents and surgical drainage and repair of the leak.

In patients with sickle cell disease (Chapter 149), for example, cholecystitis can precipitate a crisis with substantial operative risks. Large gallstones (>3cm) are more frequently associated with acute cholecystitis and gallbladder carcinoma. Because gallbladders containing stones that are larger than 3cm in diameter have a 10-fold greater risk for developing malignancy than do those containing stones that are smaller than 1cm, prophylactic cholecystectomy may also be indicated in these patients.Symptomatic Gallstones in OutpatientsAlthough initial conservative management followed by elective surgery is reasonable in patients with mild symptoms,early surgery within 24 hours is generally preferred for patients with uncomplicated biliary colic. If patients do not have severe pain that lasts for >15 minutes, is located in the epigastrium or right upper quadrant, radiates to the back, and responds to simple analgesics, a conservative strategy of delaying surgery may be a reasonable alternative.Day surgery is as safe and effective as an overnight stay.More than 95% of cholecystectomies are performed laparoscopically, with about 3% of elective procedures converted to an open procedure in the operating room. Contraindications to laparoscopic surgery include significant bleeding and Child class C cirrhosis (Chapter 139). Some patients with severe chronic obstructive pulmonary disease or heart failure may not tolerate the pneumoperitoneum required for laparoscopic surgery, and the prior upper abdominal surgery may increase the difficulty of or preclude laparoscopic cholecystectomy. Serious complications of laparoscopic cholecystectomy are rare, with a reported incidence of 0.6 to 1.5% for any bile duct leaks and 0.3 to 0.6% for a major bile duct injury. Although these risks are higher than for open surgery, the overall mortality rate (<0.3%) is lower for laparoscopic surgery, and the postoperative recovery is much easier. Outcomes for laparoscopic cholecystectomy are comparable among low- and high-volume centers.

Postoperative extrahepatic bile duct strictures occur after 0.25 to 1% of cholecystectomies. Most of these lesions are manifested as abnormal liver test results, obstructive jaundice, and cholangitis within 2 to 3 months postoperatively, although the presentation can be delayed. The cholangiogram commonly shows a short, smooth narrowing near the cystic duct stump with proximal duct dilation (Fig. 141-9). Strictures typically must be redilated, and stents are exchanged at 3- to 4-month intervals for 8 to 12 months until the stricture is nearly as open as the downstream bile duct. About 80% of patients will have a good result. Covered self-expandable metal stents are as good as multiple plastic stents for resolving strictures, with fewer ERCP procedures needed to achieve resolution.However, some patients will ultimately require a bilioenteric bypass. Strictures more than 2 cm in length, strictures with clips placed securely across the duct, or strictures associated with resected segments of duct require surgical intervention. Intrapancreatic common bile duct strictures, which may occur in 3 to 46% of patients with chronic pancreatitis, can lead to secondary biliary cirrhosis or recurrent cholangitis. With the complication of cholangitis or jaundice, intervention is clearly indicated, typically with ERCP and stent placement. In the absence of cholangitis or jaundice, either surgical repair or endoscopic biliary decompression with multiple plastic stents (Fig. 141-10) has traditionally been recommended when the alkaline phosphatase level is consistently more than twice the upper limit of normal during a 6-month period of observation. Biliary strictures that complicate liver transplantation (Chapter 140) are usually treated similarly with good results. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) frequently targets the liver, but a rapidly progressive cholangiopathy has also been reported.The pathogenesis of this disorder remains poorly understood, and no specific treatment options are currently available.

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Klos D, Gregořík M, Pavlík T, et al. Langenbeck's Archives of Surgery. 2023;408(1):154. doi:10.1007/s00423-023-02897-2. Copyright License: CC BY

Publish date: April 4, 2023.

PURPOSE: Bile duct injury (BDI) remains the most serious complication following cholecystectomy. However, the actual incidence of BDI in the Czech Republic remains unknown. Hence, we aimed to identify the incidence of major BDI requiring operative reconstruction after elective cholecystectomy in our region despite the prevailing modern 4 K Ultra HD laparoscopy and Critical View of Safety (CVS) standards implemented in daily surgical practice among the Czech population. METHODS: In the absence of a specific registry for BDI, we analysed data from The Czech National Patient Register of Reimbursed Healthcare Services, where all procedures are mandatorily recorded. We investigated 76,345 patients who were enrolled for at least a year and underwent elective cholecystectomy during the period from 2018-2021. In this... (truncated preview)

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de'Angelis N, Catena F, Memeo R, et al. World Journal of Emergency Surgery : WJES. 2021;16(1):30. doi:10.1186/s13017-021-00369-w. Copyright License: CC BY

Publish date: June 4, 2021.

When considering only the need for any type of surgical repair of the common bile duct, the rate ranged between 0.06% and 0.31% [73, 76, 82, 83, 85, 88]. The California Cholecystectomy Group analyzed 711,454 cholecystectomies (of which 95% were LCs) from the California Office of Statewide Health Planning and Development (COSHPD) database from 2005 to 2014. They found a bile leak rate of 0.5%, defined by the need for isolated endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) within 4 weeks after cholecystectomy [12]. Patients who underwent choledocho-enterostomy, common bile duct suture, hepatectomy, liver transplantation, more than 1 ERCP within a year, or 1 or more PTCs between 4 weeks and 1 year were considered to have a BDI. The rate of these major BDIs was 0.22%, and together, they accounted for 0.72% of patients requiring any ERCP, PTC, or surgical procedure after LC [12]. A higher incidence of BDIs can be expected in cases of inflammation (acute or chronic) [75, 78,79,80] or emergency cholecystectomy [75, 78, 79]. Based on the GallRiks database, patients with AC at the time of surgery or with a positive history of AC are at higher risk of BDI (odds ratios, ORs: 1.23 and 1.34, respectively), which can be reduced by performing IOC [78]. Mangieri et al. analyzed 217,774 LCs in the NSQIP database, 67% of which presented with AC. They found a small yet significantly higher incidence rate of BDIs in AC (0.21% vs. 0.18%) [84]. In a nationwide study of 572,223 LCs conducted in England, only a very small difference was reported concerning the need for reconstructive biliary surgery between patients presenting with AC on admission and patients operated on in the elective setting (0.09% vs. 0.11%) [74].