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Meta-Analysis
. 2020 Oct;4(5):776-786.
doi: 10.1002/bjs5.50321. Epub 2020 Aug 27.

Optimal timing for surgical reconstruction of bile duct injury: meta-analysis

A M Schreuder  1 , B C Nunez Vas  1 , K A C Booij  2 , S van Dieren  1 , M G Besselink  1 , O R Busch  1 , T M van Gulik  1
Affiliations
Meta-Analysis

Optimal timing for surgical reconstruction of bile duct injury: meta-analysis

A M Schreuder et al. BJS Open. 2020 Oct.

Abstract
in English, Spanish

Background: Major bile duct injury (BDI) after cholecystectomy generally requires surgical reconstruction by means of hepaticojejunostomy. However, there is controversy regarding the optimal timing of surgical reconstruction.

Methods: A systematic review was performed by searching PubMed, Embase and Cochrane databases for studies published between 1990 and 2018 reporting on the timing of hepaticojejunostomy for BDI (PROSPERO registration CRD42018106611). The main outcomes were postoperative morbidity, postoperative mortality and anastomotic stricture. When individual patient data were available, time intervals of these studies were attuned to render these comparable with other studies. Data for comparable time intervals were pooled using a random-effects model. In addition, data for all included studies were pooled using a generalized linear model.

Results: Some 21 studies were included, representing 2484 patients. In these studies, 15 different time intervals were used. Eight studies used the time intervals of less than 14 days (early), 14 days to 6 weeks (intermediate) and more than 6 weeks (delayed). Meta-analysis revealed a higher risk of postoperative morbidity in the intermediate interval (early versus intermediate: risk ratio (RR) 0·73, 95 per cent c.i. 0·54 to 0·98; intermediate versus delayed: RR 1·50, 1·16 to 1·93). Stricture rate was lowest in the delayed interval group (intermediate versus delayed: RR 1·53, 1·07 to 2·20). Postoperative mortality did not differ within time intervals. The additional analysis demonstrated increased odds of postoperative morbidity for reconstruction between 2 and 6 weeks, and decreased odds of anastomotic stricture for delayed reconstruction.

Conclusion: This meta-analysis found that surgical reconstruction of BDI between 2 and 6 weeks should be avoided as this was associated with higher risk of postoperative morbidity and hepaticojejunostomy stricture.

Antecedentes: La lesión mayor de la vía biliar (bile duct injury, BDI) después de la colecistectomía generalmente requiere reconstrucción quirúrgica mediante una hepaticoyeyunostomía. Sin embargo, existe controversia en relación al momento óptimo para la reconstrucción quirúrgica. MÉTODOS: Se realizó una revisión sistemática mediante la búsqueda en las bases de datos de Pubmed, Embase y Cochrane de los estudios que proporcionaban información sobre el momento de la realización de la hepaticoyeyunostomía por la BDI, publicados entre 1990-2018 (registro PROSPERO: CRD42018106611). Los resultados principales fueron la morbilidad postoperatoria, la mortalidad postoperatoria y las estenosis de la anastomosis. Cuando se disponía de datos individuales de los pacientes, los intervalos de tiempo de estos estudios se ajustaron para hacerlos comparables con otros estudios. Los datos de los intervalos de tiempo comparables se agruparon utilizando un modelo de efectos aleatorios. Además, los datos de todos los estudios incluidos se agruparon mediante un modelo lineal generalizado.

Resultados: Se incluyeron 21 estudios con un total de 2.229 pacientes. En estos estudios, se utilizaron 15 intervalos de tiempo diferentes. Ocho estudios utilizaron los intervalos de tiempo < 14 días (precoz), 14 días-6 semanas (intermedio) y > 6 semanas (tardío). El metaanálisis reveló un mayor riesgo de morbilidad postoperatoria en el intervalo intermedio (precoz versus intermedio: riesgo relativo, RR 0,73; i.c. del 95%: 0,54-0,98; intermedio versus tardío RR 1,50, 1,16-1,93). La tasa de estenosis fue más baja en el grupo del intervalo tardío (RR intermedio versus tardío, RR 1,50, 1,07-2,20). La mortalidad postoperatoria no difirió entre los distintos intervalos de tiempo. El análisis adicional demostró mayores probabilidades de morbilidad postoperatoria para la reconstrucción entre 2-6 semanas y menores probabilidades de estenosis anastomóticas en el caso de reconstrucción tardía. CONCLUSIÓN: Este metaanálisis muestra que la reconstrucción quirúrgica de la BDI entre 2 y 6 semanas debe evitarse, ya que este intervalo se asoció con un mayor riesgo de morbilidad postoperatoria y estenosis de la hepaticoyeyunostomía.

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Figures

Fig. 1
Fig. 1
PRISMA diagram for the review HJ, hepaticojejunostomy.
Fig. 2
Fig. 2
Data for primary outcomes according to time intervals, as provided by the studies a Postoperative morbidity; b postoperative mortality; c anastomotic stricture. Values in parentheses are percentages. OR, odds ratio. The key indicates the conclusion as provided by the studies.
Fig. 3
Fig. 3
Forest plots comparing risk ratios for early (less than 14 days), intermediate (14–42 days) and delayed (more than 42 days) reconstruction of bile duct injury a Postoperative morbidity; b postoperative mortality; c anastomotic stricture. An inverse‐variance random‐effects model was used for meta‐analysis. Risk ratios are shown with 95 per cent confidence intervals. E, early reconstruction; I, intermediate reconstruction; D, delayed reconstruction.
Fig. 4
Fig. 4
Estimated odds for the association between time from injury to repair and postoperative morbidity and anastomotic stricture a Postoperative morbidity; b anastomotic stricture. Mean odds with 95 per cent c.i. values are shown. HJ, hepaticojejunostomy.
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