Outcomes of Complex Iatrogenic Biliary Tract Injuries: Retrospective Single-Center Experience from Pakistan

Abstract

Background & objective: Iatrogenic bile duct injury (IBDI) is a well-established complication of cholecystectomy. Effective management of this complex surgical complication necessitates early referral to high-volume hepatobiliary centers. The sequelae of this injury can lead to biliary peritonitis, recurrent cholangitis, biliary stricture, liver cirrhosis, sepsis, and even mortality. The aim of this study was to thoroughly examine the clinical presentation, injury grading, surgical approaches, and outcomes of patients with IBDI.

Methodology: Data of all IBDI patients were collected, and 79 patients were included who underwent surgery between 1st January 2019 to 31st January 2025 at Hepato pancreato biliary department Pakistan Kidney and Liver Institute and Research Centre. Our primary outcomes included the success rate of different surgical procedures, postoperative morbidity and mortality, need for hepatic resection or liver transplantation, and length of hospital stay. Categorical data such as age, gender, risk factors, and diagnosis were presented as frequencies and percentages. Crude odds ratios (ORs) with 95% confidence intervals were determined for the risk of death.

Results: A total of 79 patients met the selection criteria, including 18 (22.8%) males and 61 (77.2%) females. The median age of the patients was 43 years (IQR, 34-53 years). The majority of IBDI cases, 48 (60.8%), were treated with hepaticojejunostomy, followed by 16 (20.3%) with redo hepaticojejunostomy, and one patient underwent liver transplantation for secondary biliary cirrhosis. Right hepatectomy with biliary reconstruction was performed in 45.4% of cases with isolated RHA injury. The overall success rate was 96.2%, irrespective of the type of surgery performed. The median follow-up duration for the 77 patients was 20 months (IQR, 11-31 months). Two (2.5%) patients were lost to follow-up after the initial visit, and hospital mortality was observed in 2 (2.5%) patients. There was no statistically significant difference in postoperative complications across the different risk factors or surgical types. Postoperative morbidity occurred in 23 patients (29.1%), and these complications were more pronounced in E5 injuries associated with vascular involvement.

Conclusion: IBDI represents a complex surgical complication that demands expertise, and inadequate reconstruction by the index surgeon should not be attempted. Early referral to high-volume hepatobiliary centers is recommended. Complex biliary and vascular injury is an independent risk factor for hepatectomy and significantly prolongs postoperative recovery but does not substantially compromise the long-term outcomes when adequately treated.