Presentation Of Post Cholecystectomy Bile Duct Injuries In A Tertiary Care Hospital

Introduction: The occurrence of iatrogenic bile duct injuries is few, however potentially linked to life-threatening complications, particularly following the advent of laparoscopic cholecystectomy . Aims &Objectives: To evaluate the presentation of post-cholecystectomy bile duct injuries in a tertiary care hospital. Place and Duration of Study: This study was done in the Department of General Surgery at Combined Military Hospital Rawalpindi from Nov 2020 to Dec 2021. Material &Methods: This cross-sectional study was conducted on 15 subjects with post-cholecystectomy bile duct injuries.All the patients who presented to the emergency department and outdoor were included in the study and had post-cholecystectomy CBD injuries.Laparoscopic and open BDI were classified according to Strasberg classification. In descriptive statistics, mean, and standard deviation was used, and in qualitative analysis, frequency and percentages were calculated with the help of the SPSS 23 version, a p-value of (cid:148) 0.05 was considered significant . Results: In our study, 5 (33.3 %) males and 10 (66.7 %) were females, with a mean age of 47.27 ± 4.79.The presentation on the admission of patients was as follows, 3 (20.0 %) patients had biloma, 4 (26.7 %) had jaundice, 2 (13.3 %) had abdominal pain, 1 (6.7 %) had external biliary fistula, 3 (20.0 %) had Biliary peritonitis and 2 (13.3 %) had a fever. Conclusion: The most common consequence of cholecystectomy was complete resolution, but bile leak and major duct damage cause considerable morbidity, death, and healthcare expenditures. Better outcome was achieved when a nonprimary and skilled hepatobiliary surgeon repaired severe bile duct damage.


INTRODUCTION
One of the most frequent digestive health issues is gallstones.Laparoscopic cholecystectomy (LC) is the preferred method for removing the gallbladder in the treatment of symptomatic cholelithiasis due to its decreased postoperative mortality and morbidity rates 1 .Cholecystectomy is one of the most common gastrointestinal surgical procedures to be performed laparoscopically 2 .Compared to open cholecystectomy, bile duct injuries (BDI) are more prevalent and severe, with areported frequency of 0.6 % for laparoscopic and 0.1 % for open cholecystectomy.These injuries are a tragedy for surgeons and patients because of the accompanying morbidity,extended hospitalization, and death 3,4 .Bile duct injury (BDI) isa serious complication of laparoscopic cholecystectomy that can be fatal.A 0.5 % to 0.6 % rate of bile duct injuries (BDI) during laparoscopic cholecystectomy has been reported in several studies 3 .Patients with significant bile duct injuries provide a surgical challenge that is often best handled by the fellowship-trained specialists at tertiary referral centers.Surgeons, gastroenterologists, and interventional radiologists must work together to treat these types of injuries 1,3 .Bile duct injuries (BDI) may occur when any surgeon performs cholecystectomy surgery.Compared to open surgery, laparoscopic cholecystectomy is the most done procedure in the digestive tract, with a greater prevalence of BDI.Many people believe that this type of damage tarnishes the minimally invasive technique by delaying recovery times that could have been quicker and better and being extremely irritating for patients and doctors 5,6,7,8 .Bile duct injuries (BDI) after cholecystectomy is themain cause of early and long-term death and morbidity, lower quality of life, health-related and frequent legal action 9 .Early diagnosis, precise surgery scheduling, and proper reconstruction can help prevent major

INTRODUCTION
Globally, acute generalized peritonitis ranks among the top surgical emergencies 1 .It is more common in Third World nations.The prevalence of perforation is low (0.6% -4.9%) in developed nations but high (33% -63%) in West Africa 2 .554 persons were discovered to have peritonitis in a study that took place over three years in India 3 .Researchers in Pakistan have conducted studies with similar methods, with one study reporting 650 cases in a just 9 months 4 .Most cases of peritonitis are caused by a gastrointestinal perforation or anastomotic leak 5 .In the case of peritonitis, anaerobes and gramnegative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade brought on by the release of endotoxins 5 .Clinical evidence is used to identify peritonitis.Diagnosis can be achieved via upright plain x-ray of the abdomen, USG, or CT scan.This is often done through diagnostic laparoscopy nowadays 6 .Resuscitation, diagnosis, prompt exploration, treatment of the underlying cause, and extensive surgical peritoneal lavage have always been the cornerstones of peritonitis therapy regimens (IOPL) 7,8 .Regular IOPL is performed to lessen bacterial contamination and burden.Even though large volumes of normal saline are used in IOPL, the rates of sepsis, wound infection, and mortality remain alarmingly high.Another method consequences, including hepatic failure, biliary sepsis, and biliary cirrhosis, and improve recovery 10,11 .Surgical mediation aims to restore bile flow by a proper bilio-enteric reconstruction 11 .In patients with uncomplicated and early-stage BDI, endoscopic therapy with sphincterotomy and stent insertion is first indicated 5 .Surgical treatment is necessary when an endoscopic technique is impossible.Successful repair at a multidisciplinary facility by a competent hepatobiliary surgeon will minimize morbidity, cost and length of stay 12 .The surgical repair timing is debatable and relies on the kind and degree of the injury, the patient's overall health, sepsis presence, surgeons and resources of the hospital 11,13 .The most frequent causes of BDI, which are frequently ignored, are anatomical misunderstandings and technological mistakes.This delinquency can cause a delay in the patient's admittance to the hospital, which can subsequently cause a delay in diagnosis and care, affecting the repair's result.Many risk variables can be utilized as intraoperative guidance to help prevent BDI 14 .Our study aimed to evaluate the presentation of postcholecystectomy bile duct injuries in a tertiary care hospital.

MATERIAL AND METHODS
This cross-sectional study was conducted on 15subjects with post-cholecystectomy bile duct injuries from Nov 2020 to Dec 2021 at Combined Military Hospital, Rawalpindi.Data collection was done after approval from the Combined Military Hospital's Ethical Review Board, ref no 187/8/21.All the patients who presented to the emergency department and out door were included in the study and had post-cholecystectomy CBD injuries.The sample size of our study was 15 patients with bile duct injuries, which we calculated using the WHO sample size calculator.Laparoscopic and open BDI were classified according to Strasberg classification.The data on clinical presentation, demographic and biliodigestive reconstruction were measured and analyzed with the help of the SPSS 23 version.In descriptive statistics, mean, and standard deviation was used, and in qualitative analysis, frequency and percentages were calculated.

RESULTS
In our study, we enrolled 15 patients with bile duct injuries, of which 5 (33.3 %) were males and 10 (66.7 %) were females, with a mean age of 47.27 ± 4.79.The mean time of admission to patients was 18.07 ± 2.22 days, and the mean time of surgery of patients was 14.07 ± 1.44 days.Most of the patients had malnutrition.10 (66.7 %) cases of females occurred in the laparoscopic surgery procedure and 5 (33.3 %) of males cases were in the open surgery procedure.The presentation on the admission of patients was as follows, 3 (20.0%) patients had biloma, 4 (26.7 %) had jaundice, 2 (13.3 %) had abdominal pain, 1 (6.7 %) had external biliary fistula, 3 (20.0%) had Biliary peritonitis and 2 (13.3 %) had a fever.As a diagnostic tool in all patients, abdominal ultrasound was done in 15 (100 %) patients to identify and confirm the bile duct injury.MRCP in 7 patients,ERCP was done in 3 patients, and PTC in 1 patient.In follow-up of morbidity on outpatient, results showed one (1) patient had recurrent cholangitis, three (3) patients had surgical site infections (SSI), and one (1) had relaparotomy due to the burst abdomen and anastomosis leakage.In our study, the mean value of the length of stay was 29 days with no hospital mortality and stricture.in the open surgery procedure.These findings also matched with other studies 10,11 .A similar study was also conducted by Lalisang et al 5 .In which the total enrolled patients were 24 with a mean age of 45 years, and male to female ratio was 9/15.16 cases occurred in the laparoscopic surgery procedure and 8 in the open surgery procedure.These results were matched with the results of our study.A similar study 15 was also conducted in which the total enrolled patients were 97 with a mean age of 40.86 ± 13.45 years, and male to female ratio was 24/73.In another study by Pandit et al 4 ., the total number of patients enrolled was 18, with a mean age of 40.
The male-to-female ratio was 7/11.15 cases occurred in the laparoscopic surgery procedure and 3 in the open surgery procedure.These findings also matched our study results.The mean time of admission to patients was 18.07 ± 2.22 days, and the mean time of surgery of patients was 14.07 ± 1.44 days.Most of the patients had malnutrition.Compared to the bile leakage patients, people with obstructive jaundice present later.The average duration from diagnosis to treatment was 40.87 days, compared to 24.7 days for the bile leak patients 15,16 .The presentation on the admission of patients was as follows, 3 (20.0%) patients had biloma, 4 (26.7 %) had jaundice, 2 (13.3 %) had abdominal pain, 1 (6.7 %) had external biliary fistula, 3 (20.0%) had Biliary peritonitis and 2 (13.3 %) had a fever.In a study 17 , cystic duct leak (type A) was the main BDI form observed in 18 patients.In one patient, the stone of CBD was identified as the cystic duct leak factor, and in all other patients, failure of the clip was the causative factor.This contradicts the popular belief that an undetected stone of CBD is the most prevalent cause of cystic duct 'blow out.' Biliary leakage/fistula or obstructive biliary symptoms are the most common symptoms of bile duct injuries.These two groups may overlap.Although 15.5 per cent of our patients had obstructive jaundice and 84.5 per cent had bile leakage.At the time of presentation, several patients had jaundice, leakage, and intra-abdominal collection 15,18 .In our study, abdominal ultrasound was used as a diagnostic tool in all patients to identify and confirm the bile duct injury.ERCP was done in 3 patients, MRCP in 7 patients, and PTC in 1 patient.Transabdominal ultrasonography is frequently the first test performed when a patient has postsurgical biliary damage.Ultrasound can be used to check for ascites or billion and rule out CBD damage or retained stones; however, studies have shown that early ultrasound forbiliary leak is ineffective.Cholescintigraphy, CT abdomen, and MRCP are other diagnostic modalities.These modalities are 100 per cent, 95 per cent, and 95 per cent sensitive in detecting bile leakage 15,19 .In around 20% of the patients with leak cystic duct, a retained CBD stone has been recorded.EPT, ERC,alone for the leaks low-grade, or stenting bile duct are all options for treating type A damage.When there is an intraabdominal collection, a CT or US-guided percutaneously insertedcatheterisused to drain it.ERC is preceded by percutaneous catheter insertion, and laparoscopy is performed after ERC under the same anaesthetic 15,19,20 .The classification of Strasberg types E and A were the most common types found in this study, which was similar to other studies results 5,21 .According to a study, type A injury was more common with laparoscopic cholecystectomy, whereas type E3 was more common with open cholecystectomy 17 .This contradicts earlier research that connected laparoscopic surgery to more severe and complex BDI 22 .In a study 4 , the results of the classification of Strasberg showed that 9 (50 %) had type A, 1 (5.5 %) had type D, and 8 (44.5 %) had type E in which 5 (27.8 %) had E1, 1 (5.5 %) had E2 and 2 (11.1 %) had E3.No vasculobiliary injury or other organ injury was found.Hepaticojejunostomy was done in four (4) cases, Choledocho-duodenostomy was done in three (3) cases, Primary cystic duct ligation was done in six (6) patients and End to End repair over T tube was performed in two (2) patients.In a study 4 , the procedures done in 7 (70 %) patients were hepaticojejunostomy, 1 (10 %) patients were End to End anastomosis with a 't' tube and 2 (20 %) patients had laparotomy performed with and drainage.When there is a lot of tissue loss, a hepaticojejunostomy is indicated.Inflammation and adhesion can create small inaccuracies in damage categorization in BDI, particularly in early treated cases, and can also make it difficult to recognize healthy biliary tract remnants that will be utilized in the biliary-enteric anastomosis.Due to its flexibility in anastomosis of various sizes of the residual biliary system, hepaticojejunostomy is now regarded as the final treatment 5, 23 .Postoperative bile duct damage can be life-threatening for the patient and the physician.Only 30% are detected during operation and have a reasonable prognosis in skilled hands.The kind of damage, the patient's health, and the available facilities all influence how the injury is managed 15 .In follow-up, results showed one (1) patient had recurrent cholangitis, three (3) patients had surgical site infections, and one (1) had relaparotomy due to the burst abdomen and anastomosis leakage.In our study, the mean value of the length of stay was 29 days with no hospital mortality and stricture.No mortality was observed in the study 4 , and superficial SSI was observed in 2 (20 %) patients.The pillars of an excellent outcome are early detection and an appropriate interdisciplinary approach.The biliary tree and its vasculature are frequently damaged due to poor injury care.To ensure the best outcomes in the early tertiary care facility approach, experienced and trained surgeons of hepatobiliary and interventional trained radiologists must be involved.

CONCLUSION
The most common consequence of cholecystectomy is complete resolution, but bile leak and major duct damagecause considerable morbidity, death, and healthcare expenditures.Compared to findings of a decade ago, the rate of significant bile duct damage has decreased due to the implementation of safecholecystectomy culture.Similarly, from cystic ducts, bile leakage has become more common.A great outcome is achieved when a nonprimary and skilled hepatobiliary surgeon repairs severe bile duct damage. REFERENCES Sugrue M, Coccolini F, Bucholc M, Johnston A. Intra-operative gallbladder scoring predicts the conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study.World Journal of Emergency Surgery.2019;14(1):1-8.8. Stilling NM, Fristrup C, Wettergren A, Ugianskis A, Nygaard J, Holte K, et al.Long-term outcome after early repair of iatrogenic bile duct injury.A national Danish multicentre study.Hpb.2015;17(5):394-400.9. Patrono D, Benvenga R, Colli F, Baroffio P, Romagnoli R, Salizzoni M. Surgical management of post-cholecystectomy bile duct injuries: referral patterns and factors influencing early and long-term outcome.Updates in surgery.2015;67(3):283-91.10.Halbert C, Altieri MS, Yang J, Meng Z, Chen H, Talamini M, et al.Long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy.