Algorithms for management of patients with iatrogenic bile duct injury: a single-center experience

Iatrogenic bile duct injury (BDI) remains a serious complication and global health problem with high morbidity, posing challenges for diagnosis and management. This study aims to evaluate the effectiveness of management algorithms for BDIs and assess the clinical outcomes at a single tertiary referral center. A retrospective, cross-sectional study was conducted on 142 patients diagnosed with iatrogenic BDI from July 2017 to January 2024. Management algorithms were developed based on intra- and postoperative decision points, including patient condition, timing of repair, and referral to specialized centers. Clinical outcomes including postoperative complications and anastomotic stricture rates were analyzed. Of the 142 patients (mean age of 46.76 ± 15.03 years, 66.9% women), 26.1% diagnosed intraoperatively, while the majority were identified postoperatively based on subjective symptoms (abdominal pain, jaundice) or objective signs (bile leakage from a surgical drain). The most common injury type was type E (85.7%). A total of 7.74% required ICU admission, and there was no perioperative mortality. Associated injuries were common, with right hepatic artery injury occurring in 19.7% of cases and a few patients (2.1%) experienced combined hepatic artery and portal vein injuries that three of them required hepatectomy and one patient required liver transplantation. Postoperative complications, including anastomotic stricture, were notably lower compared to the literature. The majority of BDIs were repaired with hepaticojejunostomy, and the outcomes were favorable, even in re-operated patients that initially repaired by the index surgeon and no significant difference was observed in long-term outcomes of both groups. It suggests that optimal timing of operation is crucial for success. Our study highlights the importance of a structured, algorithm-based approach in the management of iatrogenic BDIs. Early referral to a specialized hepatobiliary center, timely intervention, and the use of hepaticojejunostomy significantly reduce postoperative complications and improve outcomes.