Differences in Post-Cholecystectomy Bile Duct Injury Care: A Comparative Analysis of 2 Different Health-Care Public Institutions in a Low- and Middle-Income Country: Southeast Mexico

Abstract

Background: Mexican health system structure allows us to study the differences in bile duct injury (BDI) management. The study aimed to assess the differences in patients with complex BDI in 2 different public sector institutions using a new proposed standard terminology. Methods: Retrospective review (2008-2019) in 2 public institutions (IMSS/SES-VER). Bismuth-Strasberg E injuries with hepaticojejunostomy were included. Data are presented in a tabular reporting system. The outcomes were percent of patients attaining primary patency, loss of primary patency, and actuarial primary patency rate. Results: Seventy-eight patients (IMSS: n = 37; SESVER: n = 41) without differences in demographic and preoperative assessment were studied. BDI occurred mostly in outside hospitals. Open cholecystectomy was the most common index operation in SESVER (73%, p = 0.02). IMSS had more surgeries (p = 0.007) and repair attempts (p = 0.06) prior to referral. Magnetic resonance cholangiopancreatography was more commonly used in IMSS patients. Biliary stents (45%) and cholangitis (29%) were more common in IMSS (p < 0.05). IMSS patients had longer follow-up than SESVER (p < 0.05). No differences in primary patency rates (IMSS: 89%, SESVER: 97%) and actuarial patency rates were noted. Discussion: Despite differences in referral, preoperative, and operative events, good BDI repair outcomes can be achieved. Longer follow-up is needed to monitor these outcomes.

Actuarial Patency Rates of Hepatico-Jejunal Anastomosis after Repair of Bile Duct Injury at a Reference Center

“…The rate of attaining primary patency was assessed at 98%. The result corresponds to some other recently published studies [ 21 , 22 , 23 , 24 , 29 , 30 , 31 , 32 , 33 ]. Two hundred twenty-seven patients of Group II did not have this chance at all.…”

“…The new method of reporting outcomes of bile duct repair is based on the concept of “patency” of the bilo-jejunal anastomosis [ 20 , 21 , 22 ], unlike previous evaluations that were based mostly on clinical symptoms and biochemical tests [ 4 , 5 , 6 , 12 , 13 , 14 , 15 , 20 , 21 , 22 , 23 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ]. However, it is stressed in most such reports that it is not the severity of the injury that is responsible for bad outcomes of repair.…”

“…Decision toward re-repair was taken with the belief that secondary patency could not be achieved and maintained by endoscopic, IR, or other treatment, even if stents or bouginage procedures will be retained up to 18 months, or longer, from the failure of primary repair. In other words, it was impossible to achieve a result of Grade B in any of the considered patients [ 20 , 21 , 22 , 30 , 31 , 32 , 33 ]. Preparing for surgery was challenging in most septic and complicated cases but did not exceed 5 weeks.…”

“…The experience presented here is in line with some recent studies on this subject. Martínez-Mier et al determined the percentage of primary patency at 93.4% by the initial surgical treatment [ 29 , 30 ]. In the study by Lindemann et al, primary and secondary patency were determined at 98.1% and 96.4%, respectively [ 22 ].…”

“…Cuendis-Velázquez et al recently published outcomes after minimally invasive bile duct injury repair of Strasberg type E in Mexico also and reported 100% attained primary patency rate and a Grade A result in 93% of patients undergoing laparoscopic repair at a median 49-month follow-up and 100% in patients undergoing robotic repair at a median 16-month follow-up [ 32 ]. In the other study from Mexico, patency rates of 83% and 63% were reported in patients attaining a Grade A result at 10-year follow-up [ 29 , 30 ]. Lindemann et al found primary and secondary patency at 98.1% and 96.4%, respectively, with no differences in 30-day complications [ 32 ].…”