'Minor' iatrogenic bile duct injuries can have major consequences

Last Updated: 2020-04-16

By Scott Baltic

NEW YORK (Reuters Health) - Bile duct injuries that are considered "minor," that is, those of Strasberg grades A to D, can nonetheless result in substantial long-term morbidity and costs, according to a new study from the UK.

Iatrogenic bile duct injury (BDI) affects only 0.1% to 0.8% of cholecystectomies, but can nonetheless be a potentially serious complication of such procedures, researchers note in Surgery. Outcomes following injuries of Strasberg grade E, considered "major," are much more commonly reported than those after grade-A to -D injuries, they add.

"Most studies fail to report on long-term outcomes and focus upon major bile duct injury," Dr. Keith J. Roberts of University Hospitals Birmingham told Reuters Health by email. "Our study is the only one we know of to report such long-term outcomes for 'minor' bile duct injury."

The researchers drew data on 120 patients (mean age, 52; 66% women) referred to their center for grade-A through -D BDIs, primarily bile leaks and biloma, between 1990 and 2015. In the Strasberg system, severity increases from grade A to grade E, which can include a transected main bile duct.

The median follow-up was 8.4 years. Thirty-one patients developed long-term biliary complications of BDI, with complication rates of 19%, 23% and 31% at one, five and 10 years, respectively. The estimated five-year complication rate for grade-D injuries was 40% versus 15% for grade-A injuries (P=0.010).

Based on data published by the same center in 2019, the estimated five-year biliary complication rate after grade-E injury was 28%. Given this, the authors suggested, "the long-term clinical burden of Strasberg grade A to D, traditionally thought of as 'minor' BDI, is comparable to 'major' Strasberg grade E injuries."

The costs associated with treatment and follow-up of "minor" injuries were also significant, at 10,612/US$13,689 for grade-B injuries and 11,048/US$14,252 for grade-D injuries. This compares to average treatment costs with grade-E injuries of 14,269 for specialist repairs to 25,814 for nonspecialist repairs, the authors report.

"This indicates that any BDI, however 'minor,' can still result in a considerable financial burden to the health service," Dr. Roberts and colleagues write.

In an email to Reuters Health, Dr. Steven M. Strasberg of Washington University School of Medicine in St. Louis, Missouri, originator of the Strasberg system, called this "a nice study" and said its "conclusions seem reasonable."

He cautioned, however, that its findings are limited by the small numbers of patients in the B and C groups, 13 and 20, respectively.

Dr. Strasberg added that grade-D injuries "have a considerable spectrum. They can be a minuscule tear in the bile duct or transection of 50% of a major bile duct, such as the common hepatic duct or the common bile duct."

In addition, he said," some of the D repairs were done by general surgeons rather than specialist surgeons, which as expected based on prior studies generally would not have as good a long-term outcome."

SOURCE: https://bit.ly/2UQW8VF Surgery, online March 14, 2020.