Introduction 1 2 3 5 6 6 8 9 11 12 14 15 16 17 18 The aim of the present study was to analyze short- and long-term outcome in patients who are referred after failure of a primary EEA. Patients and Methods Patients Cohort and Data Collection 18 Data from the referring hospital included: indication for cholecystectomy, type of initial procedure, location of injury, type of repair including the use of a T-tube, the postoperative diagnostic interventions, and the therapeutic interventions before referral. Data from the present center included: symptoms at referral, diagnostic work-up, type of treatment, short-term, and long-term complications. Endoscopic, Radiological, and Surgical Treatment for complicated EEA Endoscopic treatment was performed by balloon dilatation or catheter dilatation before stent placement. The biliary stent is placed over the guide wire bridging the stenosis. Two or more stents were inserted if possible. For multiple stent insertion, an endoscopic sphincterotomy was performed to facilitate stent placement. Stents were replaced after 6 weeks and subsequently exchanged every 3 months to avoid cholangitis. Percutaneous transhepatic catheterization was performed by injecting the contrast medium from the right intercostal approach. A right or left approach for the percutaneous transhepatic biliary drainage was chosen depending on ultrasound images illustrating the biliary anatomy, and the possibility of puncturing a dilated intrahepatic bile duct. Catheterization of intrahepatic bile ducts was performed in standard fashion. A guide wire was advanced through the biliary stricture into the duodenum. When this was achieved, a biliary drainage catheter was inserted. All drainage procedures were performed with the administration of broad-spectrum antibiotics. In case of a surgical reconstruction, the procedure was performed via a Roux-en-Y hepaticojejunostomy. The stricture in the CBD is transected and the hilar plate is opened. The hepatic ducts of different segmental bile ducts are mobilized and from there opened over the left hepatic duct. Intrahepatic segmental ducts are mobilized and if possible sutured together before one or two jejunal anastomosis are made. A closed suction drain is placed during operation and removed 24–48 hours after surgery. Percutaneous transhepatic drains, when inserted before surgery are left in place and removed after 10 days till 6 weeks, depending on the clinical course, the level of anastomosis and the surgeons’ preference. Outcome Follow-up data was obtained through outpatient records and the records of the general practitioner. The outcome of treatment was analyzed by the number complications and late restenosis during follow-up. Failure of treatment was defined as recurrent stenosis after stent therapy followed by surgery or recurrent stenosis after surgical reconstruction followed by additional therapy. Statistical Analysis Data from patient characteristics, management, and outcome show descriptive statistics in number of patients and percentages. Mean and median values are given with a minimum and maximum. Long-term stricture-free survival was analyzed by Kaplan Meier Survival Analysis. Data analyses were performed using SPSS® software (SPSS, Chicago, Illinois, USA). Results Patients’ Characteristics at Referral n 1 1 n Figure 1 Referred patients for treatment of bile duct injury. Total number of referred patients (red), patients referred after a primary end to end anastomosis (blue), and patients referred after a primary biliodigestive reconstruction (green).  Table 1 Patient Characteristics   Primary EEA n % Age at cholecystectomy Mean (years) 52  Gender Female 43 77 Indication for cholecystectomy Symptomatic cholelithiasis 45 80 Cholecystitis 5 9 Cholecystitis a froid 6 1 Type of initial operation Open procedure 8 14 Laparoscopic to open procedure 48 86 Anastomosis over T-tube 49 88 Duration of T-tube in situ Days, median (range) 42(2–145)  2 2 n n n n n n Table 2 Referral Pattern   Primary EEA n % Time interval between injury and referral  Weeks, median (range) 16 (0–141)  Intervention after EEA and before referral  Explorative relaparotomy 2 4  Percutaneous drainage 5 9  Endoscopic stenting 12 21  Endoscopic papillotomy 9 16 a 2 4 Symptoms at referral  Cholestasis 14 25  Cholangitis/fever 10 18  Abdominal pain 15 27  Abces/biloma 4 7  Uncontrolled sepsis/peritonitis 3 5 Diagnosis at referral Stenosis 38 68 Leakage 10 18 Combination of stenosis and leakage 8 14 b   I 9 16   II 21 38   III 17 30   IV 7 12   V 2 4 a b Figure 2 ERCP showing successful (aggressive) stent therapy after primary EEA. a Stenosis of the common bile duct. b Stents in situ. c After stent removal within a year.  Management after Referral n n n 3 Figure 3 PTCD  Radiological and Endoscopic Treatment Three patients were successfully treated by PTCD. In two patients, a stenosis was treated by transhepatic dilatation and in one patient, bile leakage was treated by external transhepatic stent insertion. 2 n n n Surgical Treatment After referral and during the follow-up period, a new hepatobiliary anastomosis was performed by hepaticojejunostomy in 13 patients (23.2%). Mean duration of hospital stay was 9.1 ± 3.1 days. Postoperative complications occurred in one patient (7.6%) who underwent a PTC procedure after leakage of the anastomosis. No hospital mortality occurred in patients who underwent a reconstructive procedure after a previous EEA. Long-term Follow-up n n n n n The long-term results of surgical treatment after EEA are as follows; from 13 patients who underwent a HJ after work-up, a stenosis of the anastomosis occurred in two patients (15%). Both patients underwent successful percutaneous transhepatic dilatation, respectively 9 and 35 months after surgery. n 4 Figure 4 Kaplan–Meier plot showing proportion of patients without restenosis among 56 bile duct injury patients treated for complications after EEA.  Discussion The present study describes a selected group of BDI patients, who were referred for treatment after a complicated EEA. This group of patients is a negative selection, representing the worst complications of EEA; otherwise, patients were not referred for additional treatment. So, this study does not provide any information about the success rate of EEA. The present study shows a long-term stricture free survival of 91% in EEA patients after treatment in a tertiary center. The analysis showed that even the majority of complications after primary AEE in a general hospital can successfully be treated by endoscopic and radiological interventions. In only one-third of the patients, a secondary surgical repair is necessary. The surgical reconstruction after EEA was associated with acceptable morbidity and without mortality. 19 6 20  21 22 2 15 15 23 18 24 25 24 25 25 Of interest is the evaluation of the long-term stricture-free survival after treatment for complications after EEA. After a mean follow-up of 7.1 years, restenosis after treatment developed in 9% of the patients. In all patients who underwent initial endoscopic therapy, restenosis occurred a relatively short time after stent removal, diagnosed within 2 to 8 months follow-up. Therefore, endoscopic treatment is not associated with a high rate of long-term restenosis after stent removal. In two patients, a restenosis occurred within 3 years after a hepaticojejunostomy. Symptoms were cholestasis and cholangitis. In both patients, transhepatic dilatation was successful to resolve the stenosis. The long-term stricture-free survival of 91% in the present series provides evidence for a good outcome after treating complicated EEA patients. If BDI is detected during surgery, in particular if there is no extensive tissue loss, the local anatomy is clear and there is no inflammation, EEA could be considered as a sufficient treatment strategy. Patients with postoperative complications (stricture or leakage) should be treated by a multidisciplinary team of gastroenterologists, radiologists, and surgeons. Postoperative complications can adequately be managed by endoscopic or percutaneous drainage in two-third of the patients. Reconstructive surgery after a complicated EEA is associated with low morbidity and no mortality.