Sicklick JK et al. (2005) Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg 241: 786–792

With the advent of laparoscopic technology, open cholecystectomy has been supplanted by laparoscopic cholecystectomy for the treatment of calculous biliary disease. Unfortunately, this has led to an increase in the incidence of major bile duct injuries (BDI). Several studies have evaluated the long-term management of patients with BDI but few have focused on their early perioperative management. Sicklick et al. prospectively studied 200 patients and analyzed the perioperative management of BDI following laparoscopic cholecystectomy.

The mean time from BDI to referral was 29.1 weeks, although this was variable depending upon patients' presentations. Twenty-five patients did not undergo surgical repair, including three who died because of uncontrolled sepsis after delayed referral. The remaining 22 patients underwent successful balloon dilation of an anastomotic stricture. Of the 175 patients that underwent biliary reconstruction, 172 had hepaticojejunostomies and 3 had end-to-end ductal repairs. Seventy-five patients had at least one postoperative complication, although all were managed nonoperatively. There were three deaths in the postoperative period.

In this study, the timing of the operation, presenting symptoms and history of previous attempts at BDI repair did not affect the incidence of the most common perioperative complications or the postoperative length of stay. The authors note that control of sepsis and bile leak are the primary goals of initial BDI management, whereas reconstruction can be carried out when the inflammation has subsided. This study supports the importance of early referral to a tertiary care hospital and definitive biliary reconstruction by an experienced hepatobiliary surgeon.