Dear Editor:

We have read the article “Relationships of hepatic histopathological findings and bile microbiological aspects with bile duct injury repair surgical outcomes: A historical cohort” by Callejas et al. [1] in the November 2022 issue of the journal. We congratulate the authors for having undertaken this interesting study on patients undergoing repair for post-cholecystectomy bile duct strictures (PCBDS). Sikora et al. [2] have looked into this very aspect and reported important findings (vide infra) previously. It is well known that higher grades of liver fibrosis will lead to worse outcomes following PCBDS repair.

The authors claim that “little is currently known on the potential associations of hepatic histopathological findings... in individuals undergoing surgical bile duct injury repair.” They seem to have overlooked relevant important work on the histological grading system used previously in patients with PCBDS [2,3].

Evaluation of liver histological changes in patients with PCBDS have been reported previously by Johnson et al. [4]. A liver biopsy was performed in 16 of 21 patients (76.2%) who underwent surgical repair of PCBDS. They documented marked fibrosis in five of these 16 patients (31.2%). Sikora et al. [2] made the first systematic effort to use a scoring system to categorize the severity of liver fibrosis in patients with PCBDS in 2008. Important findings of that study were as follows: 1) grades 1, 2, and 3 fibrosis were seen the earliest at 10, 14, and 20 weeks, respectively, highlighting the need for undertaking the repair at the earliest time to avoid irreversible liver damage; 2) prolonged duration from injury to repair and portal hypertension were significantly correlated with severe liver fibrosis/secondary biliary cirrhosis on a univariate analysis; 3) deranged liver function during follow-up of patients in the absence of demonstrable stricture on radiological and scintigraphic evaluation could be a reflection of background liver fibrosis at the time of repair; 4) a successful surgical repair and relief of biliary obstruction could halt or reverse pathological changes in the liver.

While the modest number in the study “Relationships of hepatic histopathological findings and bile microbiological aspects with bile duct injury repair surgical outcomes: A historical cohort” by Callejas et al. [1] showed a direct correlation between greater severity of fibrosis and prolonged injury repair, adding to available data on PCBDS, their study failed to provide long-term follow-up data in a manner that would allow a better understanding of implications of liver fibrosis. These aspects are covered in greater depth in other studies.