Optimal timing for surgical reconstruction of bile duct injury: meta-analysis

Abstract

Background Major bile duct injury (BDI) after cholecystectomy generally requires surgical reconstruction by means of hepaticojejunostomy. However, there is controversy regarding the optimal timing of surgical reconstruction. Methods A systematic review was performed by searching PubMed, Embase and Cochrane databases for studies published between 1990 and 2018 reporting on the timing of hepaticojejunostomy for BDI (PROSPERO registration CRD42018106611). The main outcomes were postoperative morbidity, postoperative mortality and anastomotic stricture. When individual patient data were available, time intervals of these studies were attuned to render these comparable with other studies. Data for comparable time intervals were pooled using a random‐effects model. In addition, data for all included studies were pooled using a generalized linear model. Results Some 21 studies were included, representing 2484 patients. In these studies, 15 different time intervals were used. Eight studies used the time intervals of less than 14 days (early), 14 days to 6 weeks (intermediate) and more than 6 weeks (delayed). Meta‐analysis revealed a higher risk of postoperative morbidity in the intermediate interval (early versus intermediate: risk ratio (RR) 0·73, 95 per cent c.i. 0·54 to 0·98; intermediate versus delayed: RR 1·50, 1·16 to 1·93). Stricture rate was lowest in the delayed interval group (intermediate versus delayed: RR 1·53, 1·07 to 2·20). Postoperative mortality did not differ within time intervals. The additional analysis demonstrated increased odds of postoperative morbidity for reconstruction between 2 and 6 weeks, and decreased odds of anastomotic stricture for delayed reconstruction. Conclusion This meta‐analysis found that surgical reconstruction of BDI between 2 and 6 weeks should be avoided as this was associated with higher risk of postoperative morbidity and hepaticojejunostomy stricture.

Timing of surgical repair of bile duct injuries after laparoscopic cholecystectomy: A systematic review

“…Hence, two studies included in this review proposed the early[ 25 , 26 ], while another two recommended the delayed[ 27 , 28 ] approach as treatment of choice. This goes in line with the findings of two recent meta-analyses that BDI repair should be undertaken either early or in a delayed fashion after 6 wk, whereas the time frame between 2-6 wk seems to be associated with increased morbidity[ 23 , 24 ].…”

“…Alongside the extent of injury and surgical experience of those managing BDI, it has been suggested that timing of BDI repair may be a significant prognostic factor for clinical outcomes[ 10 , 20 - 24 ]. To date, the timing of BDI repair is controversial, with discussions in the literature failing to reach clear recommendations.…”

Optimal Time for Bile Duct Injury Reconstruction. Early Does Not Mean Better: a Multicenter Retrospective Analysis of a Hepato-pancreatic-biliary Group

“…As well, Stewart and Way found in a multivariate analysis that the time of reconstruction was not an important factor [37]. However, Schreuder et al show that reconstruction between 2-6 weeks has an increased rate of postoperative morbidity and hepaticojejunostomy stricture [33]. Therefore, based on our data, the timing of reconstruction it's not related to increased postoperative complications, mortality, or anastomotic stricture, and suggests that early does not mean better in BDI reconstruction, however, a delay of more than 4 weeks could be detrimental in postoperative outcomes [33,36].…”

“…As Halle-Smith et al describe, reconstruction performed by a non-hepatobiliary surgeon increases a 4-time risk to present postoperative complications [21]. Among those relevant factors, time of reconstruction rises in literature as a key component of reduced morbidity and mortality [33]. Early reconstruction is associated with a shorter hospital stay, costs reduction, and reduced burden of the patient.…”

“…Early reconstruction is associated with a shorter hospital stay, costs reduction, and reduced burden of the patient. On the contrary, delaying surgical reconstruction allows for optimization of the clinical condition, sepsis control, and delimitation of bile duct ischemia, eventually in uencing long-term strictures and bile duct leak [33]. Some reports describe no relevance in the time of reconstruction for the early and delayed complication rates [34,35].…”