ARTICLE IN PRESS JID: HBPD [m5G;October 22, 2020;23:7] Hepatobiliary & Pancreatic Diseases International xxx (xxxx) xxx Contents lists available at ScienceDirect Hepatobiliary & Pancreatic Diseases International journal homepage: www.elsevier.com/locate/hbpd Original Article/Biliary Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study Ayman El Nakeeb a,∗ , Ahmad Sultan a , Helmy Ezzat a , Mohamed Attia a , Mohamed Abd ElWahab a , Taha Kayed b , Ayman Hassanen b , Ahmad AlMalki c , Ahmed Alqarni c , Mohammed M Mohammed b a Gastrointestinal Surgical Center, Mansoura University, Mansoura, Egypt b Minia University Hospital, Minia, Egypt c Aseer Central Hospital, Aseer region, Saudi Arabia a r t i c l e i n f o Article history: Received 24 February 2020 Accepted 9 October 2020 Available online xxx Keywords: Bile duct injury Hepaticojejunostomy Anastomotic stricture Biloma Biliary peritonitis a b s t r a c t Background: Bile duct injury (BDI) after cholecystectomy remains a significant surgical challenge. No guideline exists to guide the timing of repair, while few studies compare early versus late repair BDI. This study aimed to analyze the outcomes in patients undergoing immediate, intermediate, and delayed repair of BDI. Methods: We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020. The patients were divided into three groups based on the time of BDI reconstruction. Group 1 underwent an immediate reconstruction (within the first 72 hours post-cholecystectomy, n = 156); group 2 underwent an intermediate reconstruction (from 4 days to 6 weeks post-cholecystectomy, n = 75), and group 3 underwent delayed reconstruction (after 6 weeks post-cholecystectomy, n = 181). Results: Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cir- rhosis compared with groups 1 and 3. Favorable outcome was observed in 111 (71.2%) patients in group 1, 31 (41.3%) patients in group 2, and 157 (86.7%) patients in group 3 (P = 0.0001). Multivariate analysis identified that complete ligation of the bile duct, level E1 BDI and the use of external stent were inde- pendent factors of favorable outcome in group 1, the use of external stent was an independent factor of favorable outcome in group 2, and level E4 BDI was an independent factor of unfavorable outcome in group 3. Transected BDI and level E4 BDI were independent factors of unfavorable outcome. Conclusions: Favorable outcomes were more frequently observed in the immediate and delayed recon- struction of post-cholecystectomy BDI. Complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of a favorable outcome. © 2020 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved. Introduction Complex BDI is often more common after LC. BDI is the most serious morbidity during cholecystectomy which has a significant effect on long-term survival and quality of life, and is linked with high rates of subsequent legal action [1–5]. ∗ Corresponding author. E-mail addresses: elnakeebayman@mans.edu.eg, elnakeebayman@yahoo.com (A. El Nakeeb). Early detection of BDI is necessary for the best possible treat- ment to be started. The management of patients with BDI is a chal- lenge even for hepatobiliary surgeons [6–9]. These patients should always be referred to a specialized center for proper management due to the difficulty of these injuries. The experience of the center and the surgeon is the most prominent factor for the outcome. Be- sides, timely diagnosis and appropriate treatment also play great roles in the management of this complex complication [2–7]. A major factor affecting the timing of BDI reconstruction is that most BDIs are not diagnosed during the cholecystectomy and only present postoperatively, by which time the patient may be septic https://doi.org/10.1016/j.hbpd.2020.10.001 1499-3872/© 2020 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved. Please cite this article as: A. El Nakeeb, A. Sultan, H. Ezzat et al., Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study, Hepatobiliary & Pancreatic Diseases International, https://doi.org/10.1016/j.hbpd.2020.10.001