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Introduction: Gall stone disease is common in north India and cholecystectomy is one of the commonest operations performed. Bile duct injury (BDI) is a not uncommon but dangerous complication of cholecystectomy, more so of laparoscopic cholecystectomy (LC). We have reviewed our experience with management of acute BDI.
Patients: Retrospective analysis of 146 patients with post-cholecystectomy acute BDI referred to and managed at a tertiary level healthcare facility over 18 years and in whom follow up information was available. Patients who presented with BDI due to non-cholecystectomy procedures and those with established benign biliary strictures (BBS) were excluded from this analysis.
Results: There were 47 males and 99 female patients with a mean age of 40 (range 12-71) years. The index surgery was open cholecystectomy in 103, open cholecystectomy with common bile duct (CBD) exploration in 9 and laparoscopic cholecystectomy in 34 patients. Patients were referred to us at a median of 20 (range 0-730) days after cholecystectomy. 51 out of 146 (35%) patients had one or more pre-referral interventions (surgical 26, percutaneous 17, endoscopic 2 and combinations 6). Based on isotope scintigraphy (58), cholangiography (52) or both (24), BDI could be classified as partial (n=46, 37%) or complete (80, 63%) in 126/146 patients. Based on their clinical presentation, the patients with BDI were classified into external biliary fistula EBF (n=69), biloma (n=49), bile peritonitis (n=21) and bile ascites (n=7). 52 patients were managed conservatively, 41 had percutaneous intervention, 7 had endoscopic intervention, 26 were operated and 20 had combination of these procedures. 8 (6%) patients (6 with bile peritonitis) died due to the complications of BDI. Fistula closed in 95/ 138 (69%) surviving patients and 104/ 138 (75%) formed a biliary stricture (37/44 88% and 20/44 45% in partial injury vs. 43/77 57% and 70/77 92% in complete injury). Open cholecystectomy as the index procedure, jaundice at presentation, complete injury, delayed (>20 days) referral and high (>350 ml) fistula output were predictors for persistence of fistula and development of biliary stricture. If more than 3 adverse factors were present, the biliary fistula persisted in more than 70% of the cases and biliary stricture developed in more than 90% of cases.
Conclusion: Post-cholecystectomy BDI is associated with significant morbidity and even mortality. Management and outcome of post-cholecystectomy BDI depends on the clinical presentation and whether the injury is partial or complete. The short term and long term outcome of the acute BDI in terms of fistula closure and development of biliary stricture could be predicted based on presence of adverse factors.
Outcome in the partial and complete injury groups

n=121	Partial injury n=44	Complete injury n=77	P value
Fistula closure	37 (84%)	43 (57%)	p =0.001
Stricture formation	20 (45%)	70 (92%)	p =0.000

* 5 out of the 126 patients whose injury could be classified as partial or complete died and are excluded.

Outcome based on adverse factors

No. of adverse factors	Fistula closure	Stricture formation
0 (n=9)	9 (100%)	1 (11%)
1 (n=18)	17 (94%)	9 (50%)
2 or 3 (n=77)	54 (70%)	64 (84%)
>3 (n=34)	15 (44%)	30 (91%)
Total (n=138*)	95 (69%)	104 (75%)

* 8 Patients died due to complications of acute BDI and are excluded