Systematic Review of Non-Traumatic Bile Duct Perforation in Adults: From Traditional to Minimally Invasive Approach

Abstract

Background

Non-traumatic bile duct perforation in adults is a rare and often under-recognized surgical emergency. Its non-specific clinical presentation and variable etiologies pose significant diagnostic and therapeutic challenges. This systematic review synthesizes existing data on clinical presentation, diagnostic strategies, management approaches, and outcomes.

Methods

This systematic review followed PRISMA 2020 guidelines. Initially prepared as a narrative review and subsequently advanced to systematic methodology, this study was not prospectively registered. A comprehensive search of English-language publications from 1882 to 2024 was performed in PubMed, EMBASE, Cochrane Library, and reference lists. All studies reporting adult cases (≥18 years) of non-traumatic bile duct perforation were included. Exclusion criteria were pediatric cases, traumatic/iatrogenic perforations, non-English language, and unavailable full text. Data extraction included demographics, etiology, presentation, diagnosis, management, and outcomes. Missing data were documented and reported for each variable. ASA classification was retrospectively assigned based on clinical descriptions when not explicitly stated, representing a study limitation. Management approaches were categorized by temporal era to assess the evolution from traditional to minimally invasive techniques. Mortality risk factors were analyzed using chi-square test with P < 0.05 considered significant.

Results

From 102 eligible studies containing 223 reports, 124 adult cases of non-traumatic bile duct perforation met inclusion criteria (median age 56 years, IQR 38-68; 71.4% female). Stone-related etiology was identified in 54.0% (n = 67): choledocholithiasis (36.3%, n = 45) and cholelithiasis without choledocholithiasis (21.8%, n = 27). Clinical presentation was characterized by abdominal pain (99.1%, n = 112/113), tenderness (96.5%, n = 109/113), and vomiting (87.6%, n = 99/113). Median time to diagnosis was 3 days (IQR 1-7). Diagnostic modalities evolved significantly across eras: from 0 modalities (1880-1940) to 3.4 modalities (2010-2023). Ultrasonography (42.1%, n = 45/107) and CT (31.8%, n = 34/107) were most frequently used. Paracentesis demonstrated 91% positivity when performed (n = 38/97). Surgical treatment, primarily cholecystectomy with T-tube placement (72.8%, n = 83/114), was performed in 73.7% (n = 84/114). Preoperative ERCP was performed in 23.2% (n = 13/56). Overall mortality was 17.7% (n = 20/113), showing dramatic improvement from 45.7% (1880-1940) to 0% (2011-2023). Preoperative ERCP demonstrated a protective effect (0% vs 17% mortality). Hypotension at presentation (P = 0.086) and elevated WBC (P = 0.051) showed trends toward increased mortality.

Conclusions

Non-traumatic bile duct perforation carries considerable morbidity and mortality. The evolution from purely surgical to combined endoscopic-surgical approaches has dramatically improved outcomes. A high index of suspicion and prompt use of paracentesis or cholangiographic studies (ERCP, MRCP) are critical for timely diagnosis. Treatment should be tailored to patient stability and perforation characteristics, with ERCP-based interventions favored in stable patients and immediate surgical intervention reserved for unstable or extensive cases. Early recognition and individualized, minimally invasive management strategies are key to improving patient outcomes.