Diminished Survival in Patients with Bile Leak and Ductal Injury: Management Strategy and Outcomes

Abstract

BACKGROUND The increased incidence of bile duct injuries (BDIs) after the adoption of laparoscopic cholecystectomy has been well documented. However, the longitudinal impact of bile leaks and BDIs on survival and healthcare use have not been studied adequately. The aims of this analysis were to determine the incidence, long-term outcomes, and costs of bile leaks and ductal injuries in a large population. STUDY DESIGN The California Office of Statewide Health Planning and Development database was queried from 2005 to 2014. Bile leaks, BDIs, and their management strategy were defined. Survival was calculated by Kaplan-Meier failure estimates with multivariable regression and propensity analyses. Cost analyses used inflation adjustments and institution-specific cost-to-charge ratios. RESULTS Of 711,454 cholecystecomies, bile leaks occurred in 3,551 patients (0.50%) and were managed almost exclusively by endoscopists. Bile duct injuries occurred in 1,584 patients (0.22%) with 84% managed surgically. Patients with a bile leak were more likely to die at 1 year (2.4% vs 1.4%; odds ratio 1.85; p < 0.001). Similarly, BDI patients had an increased 1-year mortality (7.2% vs 1.3%; odds ratio 2.04; p < 0.0001). Survival of BDI patients was better with an operative approach (odds ratio 0.19; p < 0.001) when compared with endoscopic management. Operatively managed BDIs were also associated with fewer emergency department visits and readmissions, as well as lower cumulative costs at 1 year ($60,539 vs $118,245; p < 0.001). CONCLUSIONS The 0.22% incidence of BDIs observed in California is lower than reported in the first decade after the introduction of laparoscopic cholecystectomy. Bile leaks are 2.3 times more common than BDIs. Patients with a bile leak or BDI have diminished survival. Surgical repair of a BDI leads to enhanced survival and reduced cumulative cost compared with endoscopic management.

Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care Referral Centre of Nepal

“…On the contrary, the rate of bile leak has increased in recent decades (1.5% to 3%) [4,11]. In the present study, the rate of bile leak and major duct injury was 0.43% and 0.35%, respectively, which is in line with the published international standard [5].…”

“…It significantly increases the morbidity, mortality, and costs of hospital stay and decreases the quality of life [5,9]. Furthermore, it is associated with litigations.…”

“…However, the data of risk stratification of bile duct injury are a decade old. Nowadays, with the adoption of principles of safe cholecystectomy and extravigilance at the academic institute, the risk of major bile duct injury has somehow decreased [5]. On the contrary, the incidence of bile leak following laparoscopic cholecystectomy has increased in recent days [4,6].…”

Complex bile duct injuries after laparoscopic cholecystectomy: a comparative outcomes analysis of patients treated in tertiary private and public health facilities in Cape Town, South Africa

“…The increasing use of LC was reported as being associated with higher rates of LC associated bile duct injuries (BDIs), although recent population-based studies suggest the incidence of BDI has returned to open cholecystectomy rates. 1,2 The overall incidence of BDI in South Africa is not known. In the only report on outcomes after LC in a South African population to date, Mbatha et al found an incidence of 1.2% for major BDIs in a single centre retrospective review of LCs over an 18-month period.…”

Systematic review of cystic duct closure techniques in relation to prevention of bile duct leakage after laparoscopic cholecystectomy

“…Adequate closure of the cystic duct is essential to prevent CDL, especially in patients with complicated gallstone disease having a higher risk of bile leakage. Although CDL is classified as a minor injury of the bile ducts, it is associated with significant re-intervention rate, increased morbidity and even mortality[ 6 - 8 ]. The most common closure technique during LC is by simple (non-locking) metallic clips.…”