Bile Duct Injuries: Comprehensive Review

Abstract

Bile duct injuries (BDIs) are critical complications of surgical interventions involving the biliary tract, primarily occurring post-cholecystectomy. With an incidence of 0.3%–0.6%, BDIs represent a substantial clinical challenge, and approximately 400 cases are reported annually in the United States. Hepaticojejunostomy is the recommended treatment due to its efficacy in achieving durable biliary drainage with minimal stenosis. However, outcomes can be adversely influenced by factors such as biliary peritonitis, localized inflammation, sepsis, and the timing of repair. BDIs are more common in women in their forties, correlating with the higher incidence of cholelithiasis in this demographic.

Laparoscopic cholecystectomy is widely recognized as the most effective intervention for treating cholelithiasis, yet open cholecystectomy remains a viable option in resource-limited settings where laparoscopic technology or expertise is unavailable. Roux-en-Y hepaticojejunostomy is the preferred approach for long-term management of BDIs due to its reliable outcomes and low risk of stricture formation. Nonetheless, complications such as biliary leakage, cholangitis, and abdominal sepsis remain significant challenges in managing these injuries.

In our analysis, BDIs were predominantly observed in women in their forties, consistent with existing literature attributing this trend to the high prevalence of cholelithiasis. While global studies, such as those by Bobkiewicz et al., report that 82.6% of BDIs occur during laparoscopic procedures, our findings highlight a contrasting trend. Up to 62% of BDIs in our context were associated with open cholecystectomy, reflecting the continued reliance on open procedures in settings with limited laparoscopic resources. This discrepancy emphasizes the importance of adapting global surgical trends to local capabilities.

Rystedt et al. report that up to 89% of BDIs can be identified intraoperatively, underscoring the critical role of thorough intraoperative assessments and experienced surgical teams. The Bismuth classification remains a cornerstone for categorizing these injuries, with types II and III being the most prevalent in our specialized hepatopancreatobiliary (HPB) center.

BDIs are associated with a range of complications, including biliary fistula, jaundice, cholangitis, peritonitis, and abdominal sepsis. The morbidity rates vary significantly across institutions, with high-volume HPB centers reporting better outcomes due to specialized care. For instance, biliary leakage rates can be reduced to 5.7% in expert centers.

Postoperative factors such as drain placement have been associated with increased biliary leaks and complications, while operative time and intraoperative hemorrhage have shown no significant impact on outcomes. The timing of definitive repair remains a contentious issue, particularly in cases complicated by sepsis or biliary peritonitis.

Effective management of BDIs requires a multidisciplinary approach, prompt referral to specialized centers, and meticulous intraoperative techniques. Timely intervention in cases of sepsis and biliary peritonitis is critical to improving outcomes and reducing mortality rates.

Bile duct injuries, affecting 0.3%–0.6% of cholecystectomy procedures, are significant complications that demand specialized care. Hepaticojejunostomy remains the gold standard for repair, offering reliable long-term outcomes. While laparoscopic cholecystectomy is the preferred treatment for cholelithiasis, open procedures continue to play a role in resource-limited environments. The timely referral of patients to HPB centers and the adoption of a multidisciplinary strategy are essential for minimizing morbidity and enhancing survival rates.