Bile Duct Injury: A Novel Risk Stratification System for the Timing of Repair

BackgroundBile duct injuries (BDI) occur in 0.2%-0.6% of cholecystectomies. Early definitive repair prevents clinical deterioration, reduces hospital stays, and cuts costs, while delayed repairs may reduce postoperative stricture rates. Currently, there are no guidelines to support early vs delayed repair. Using our institution's risk stratification, we hypothesize that low-risk patients can undergo early repair without increased postoperative complications.MethodsThis retrospective study reviewed 53 patients with BDI treated surgically from January 2014 to September 2023 at a non-university tertiary care center. Patients were classified as low-risk (score ≤2) or high-risk (score ≥3) based on four factors: index surgical approach, vascular injury, biloma, and sepsis.ResultsThe mean age was 58.3 years, with 49.1% women. Most BDI were diagnosed within one week (median 3 days) following laparoscopic cholecystectomy (83.6%). Biloma was present in 46% of cases, and 3.8% were septic. The majority (88.7%) of patients were classified as low-risk. Strasberg-Bismuth E2 (27.3%) and E3 (20%) injuries were the most common. Additionally, 92.7% of patients underwent end-to-side hepaticojejunostomy. Early (9 of 29; 31.0%) and late repairs (8 of 18; 44%) showed no significant difference in complication rates for low-risk patients (P = 0.35).DiscussionThis study proposes a scoring system to identify low-risk patients who can safely undergo early repair without increased complications. These findings highlight the potential for stratified decision-making to optimize outcomes, but prospective validation is needed to establish evidence-based guidelines for BDI management.