Suspected Bile Duct Injuries and Appropriate Early Referral Can Reduce Chances of Litigation
Emily A. Rogers, MD; Shou-jiang Tang, MD; John Porter MD, FACS; Naveed Ahmed MD, FACS

Introduction
Bile duct injury following laparoscopic cholecystectomy is one of the most feared complications related to performing a cholecystectomy. Early identification and repair can be life saving for patients with bile duct injuries. Since the early 1990s, laparoscopic cholecystecomy (LC) has replaced open cholecystectomy as the preferred treatment of symptomatic cholethiasis, biliary dyskinesia, and cholecystitis. LC has decreased the length of hospital stay and post-operative pain and resulted in a subsequent faster return to normal daily activities; nonetheless, LC has a higher incidence in bile duct injury as compared to open cholecystectomy. Nearly all studies report the incidence of bile duct injury following open cholecystectomy between 0.1% and 0.2%. In comparison, LC has a reported incidence of bile duct injury between 0.4% and 0.7%.¹

The aim of this article is to review our initial experience with work-up and repair of bile duct injuries following LC performed at outside facilities and referred to the University of Mississippi Medical Center (UMMC) for definitive therapy. We will also review the classification of these injuries, preferred methods of diagnosis, and benefits of early treatment as well as factors that frequently lead to litigation following bile duct injury.

Methods
We review four patients referred to us in the last year (Jan 1, 2010- Dec 31, 2010) with suspected bile duct injuries. Our review examines the types of duct injuries identified, the severity of duct injuries, and the time after LC to diagnosis of injury. We also discuss the patients’ opinion of care provided by both the referring physician and the accepting surgeon at UMMC. Over the period of 1 year, 4 patients were seen for suspected bile duct injuries: 3 patients were referred by their physicians and 1 patient came for a second opinion.

The injuries in our patients fell into three categories:
1) No injuries
2) Early referrals
3) Late referrals

Results
No injury category
This patient had persistent jaundice after LC and was transferred from an outside emergency department. The work- ing diagnosis on arrival was bile duct injury. A computed tomography (CT) scan was obtained which was suspicious for an E4 duct injury. The original surgeon was contacted and reported that an intraoperative cholangiogram (IOC) was performed and was normal. A diagnostic laparoscopy was then performed at UMMC which revealed no adverse changes. Intraoperatively, an endoscopic retrograde cholangiopancreaticography (ERCP) was performed by our advanced GI colleague who demonstrated normal post-operative anatomy. The procedure was terminated after a laparoscopic liver biopsy.

Early Category
Two patients with suspected bile duct injuries were referred in by their original operating surgeons with suspected bile duct injuries within 72 hours of completion of the original operation. Both of these patients had E4 injuries and underwent a Roux-en-Y Hepaticojejunostomy (HJ) with no post-operative complications. Both patients were upset with this complication but understood that this was a known complication of LC and had no interest in litigation.

Late Category
This patient was referred five days after LC and presented with biliary ascites and jaundice. An ERCP completed by our advanced GI associate showed complete transection of the common bile duct (Figure 1). This patient had CT guided drainage and percutaneous transhepatic cholecystomy (PTC) tube placement for worsening sepsis (Figure 2). This patient was treated conservatively for eight weeks and then a Roux-en-Y HJ was completed. Post-operatively, we had a lengthy conversation with this patient regarding common bile duct injuries. We discussed openly that a common bile duct injury is a known complication of LC and that at least one of the UMMC staff surgeons has had a bile duct injury in their career; however, even after frank discussion, this patient fails to understand and wants to pursue a legal route.

Discussion
Bile duct injuries following LC, while not common, do occur and can lead to litigation in specific situations. Early referral to a tertiary center with a trained hepatobiliary specialist improves patient morbidity and reduces the incidence of litigation. It is reported that 32% of patients who have a major bile duct injury pursue litigation.² There are two factors associated with an increased likelihood of litigation by patients with major bile duct injuries: first, patient age younger than 52 years and second, immediate repair performed by the referring surgeon rather than a hepatobiliary specialist.²

Management of bile duct injuries following LC is dictated by two major factors – type and severity of injury and time to diagnosis of the injury. Early recognition of bile duct injuries, either intraoperatively or immediately postoperatively, led to improved outcomes and reduced morbidity for these patients. Unfortunately, only 35% of bile duct injuries are recognized intraoperatively.³ If there is suspicion for an injury intraoperatively, conversion to open cholecystecomy should be performed as well as a cholangiogram to determine the location and extent of injury. At this point, the surgeon has the option to place drains and transfer the patient to a tertiary referral center or repair the injury independently. Retrospective reviews demonstrate a 17% success rate following repair by the primary surgeon compared to a 94% success rate when the injury was repaired by a tertiary care hepatobiliary specialist.⁴


After identifying the location and extent of the injury, operative repair should be planned. If this is within the first 24-48 hours following LC, then proceeding with a Roux-N-Y HJ is the best course of action after defining the anatomy with an ERCP or MRCP. Since success rates following repair of bile duct injuries without obtaining a cholangiogram are poor, ranging from 4 to 31%, it is definitely beneficial to get proper imaging.^4,5,6 In comparison, there is a reported 84% success rate when a cholangiogram is completed preoperatively. If the time to diagnosis is longer than 48 hrs, PTC placement with ad- equate drainage for 6-8 weeks is the best option with eventual return to the operating room for HJ. Injuries are typically classified using the Bismuth-Strasburg classification system (Table 1). This identifies the injury based on the surgical injury site and provides a system for clear surgeon communication.

With respect to litigation following bile duct injury after LC, the biggest risk factors identified in a recent study are young age (patient age less than 52 years), related vascular injury, and immediate repair by the primary surgeon rather than a hepatobiliary specialist.² The results of our case series yield similar results with one out of the three patients referred with bile injuries pursuing litigation. Early consultation for possible bile duct injuries will improve the outcome of these patients.

References
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6. Strasberg SM, Hertl M, Soper NJ. Analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101-25.