Abstract
Background
Right posterior sectoral bile duct (RPSD) anomalies seen in up to 8% of the population rarely are injured at laparoscopic cholecystectomy. Paucity of data on the management of these injuries led the authors to conduct this study aimed at reviewing management strategies for laparoscopic RPSD injuries at a specialist center.
Methods
Of 221 patients, 15 (6.7%; 4 men; mean age, 51 years; range, 21–75 years) treated between 1992 and 2009 for injuries to the RPSD were followed up for a median of 58 months (range, 7–208 months). Case notes, imaging, and follow-up data were reviewed.
Results
The RPSD injury was immediately recognized in 3 (20%) of the 15 patients, whereas in the remaining patients, biliary injury was suspected on day 1 (range, 1–18 days) due to bile leak/biloma. The diagnosis of RPSD injury was made by a combination of investigations including endoscopic retrograde cholangiopancreatography (ERCP) (n = 11), drain tube cholangiogram (n = 10), on-table cholangiogram (n = 3), and nuclear scan (n = 3). An intact common bile duct and absence of RPSD were identified on cholangiography (ERCP and on-table cholangiogram), whereas drain tube cholangiogram demonstrated a leaking RPSD in all cases. The majority of the patients (8/15, 53%) were managed nonoperatively with combined percutaneous drainage and endoscopic stenting, whereas six patients (40%) were managed with biliary reconstruction (immediate: n = 2; delayed 14–87 days: n = 4). Clinical and radiologic confirmation of complete cessation of bile leak was demonstrated 56 days (range, 7–62 days) after injury. The long-term outcome included a dilated right duct system with transient elevation of liver function tests in two patients (1 each in the nonoperative and surgical management groups), whereas the remaining patients all remain well at this writing.
Conclusion
Bile leak in the presence of an intact common duct shown on cholangiogram should raise the suspicion of an RPSD injury. Expertise is needed to interpret the absence of RPSD in these cases. Drain tube cholangiogram is an important adjunctive investigation. In selected cases, the results of nonoperative management alone is comparable with the results of reconstruction.
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References
de Reuver P, Sprangers M, Rauws E et al (2008) Impact of bile duct injury after laparoscopic cholecystectomy on quality of life: a longitudinal study after multidisciplinary treatment. Endoscopy 40:637
Walsh R, Henderson J, Vogt D, Brown N (2007) Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies. Surgery 142:450
Calvete J, Sabater L, Camps B et al (2000) Bile duct injury during laparoscopic cholecystectomy: myth or reality of the learning curve? Surg Endosc 14:608
Misra M, Schiff J, Rendon G, Rothschild J, Schwaitzberg S (2005) Laparoscopic cholecystectomy after the learning curve: What should we expect? Surg Endosc 19:1266
Georgiades C, Mavromatis T, Kourlaba G et al (2008) Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy? Surg Endosc 22:1959
Strasberg S (2002) Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 9:543
Strasberg S, Hertl M, Soper N (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101
Davidoff A, Pappas T, Murray E et al (1992) Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 215:196
Kullman E, Borch K, Lindström E, Svanvik J, Anderberg B (1996) Value of routine intraoperative cholangiography in detecting aberrant bile ducts and bile duct injuries during laparoscopic cholecystectomy. Br J Surg 83:171
Meyers W, Peterseim D, Pappas T et al (1996) Low insertion of hepatic segmental duct VII–VIII is an important cause of major biliary injury or misdiagnosis. Am J Surg 171:187
Babel N, Sakpal S, Paragi P, Wellen J, Feldman S, Chamberlain R (2009) Iatrogenic bile duct injury associated with anomalies of the right hepatic sectoral ducts: a misunderstood and underappreciated problem. HPB Surg 2009:153269. doi: 10.1155/2009/153269
Chapman W, Abecassis M, Jarnagin W, Mulvihill S, Strasberg S (2003) Bile duct injuries 12 years after the introduction of laparoscopic cholecystectomy. J Gastrointest Surg 7:412
Colovic R (2009) Isolated segmental, sectoral, and right hepatic bile duct injuries. World J Gastroenterol 15:1415
Perini R, Uflacker R, Cunningham J, Selby J, Adams D (2005) Isolated right segmental hepatic duct injury following laparoscopic cholecystectomy. Cardiovasc Interv Radiol 28:185
Silva M, Coldham C, Mayer A, Bramhall S, Buckels J, Mirza D (2008) Specialist outreach service for on-table repair of iatrogenic bile duct injuries: a new kind of “traveling surgeon”. Ann R Coll Surg Engl 90:243
Kaman L, Behera A, Singh R, Katariya R (2004) Management of major bile duct injuries after laparoscopic cholecystectomy. Surg Endosc 18:1196
Oh H, Lee S, Lee T et al (2007) Analysis of percutaneous transhepatic cholangioscopy-related complications and the risk factors for those complications. Endoscopy 39:731
Ohtsuka T, Chijiiwa K, Yamaguchi K, Akashi Y, Matsunaga H, Miyoshi A (1999) Posterior hepatic duct injury during laparoscopic cholecystectomy finally necessitating hepatic resection: case report. JSLS 3:323
Lillemoe K, Petrofski J, Choti M, Venbrux A, Cameron J (2000) Isolated right segmental hepatic duct injury: a diagnostic and therapeutic challenge. J Gastrointest Surg 4:168
Christensen R, vanSonnenberg E, Nemcek AJ, D’Agostino H (1992) Inadvertent ligation of the aberrant right hepatic duct at cholecystectomy: radiologic diagnosis and therapy. Radiology 183:549
Strasberg S, Picus D, Drebin J (2001) Results of a new strategy for reconstruction of biliary injuries having an isolated right-sided component. J Gastrointest Surg 5:266
Laurent A, Sauvanet A, Farges O, Watrin T, Rivkine E, Belghiti J (2008) Major hepatectomy for the treatment of complex bile duct injury. Ann Surg 248:77
Lichtenstein S, Moorman D, Malatesta J, Martin M (2000) The role of hepatic resection in the management of bile duct injuries following laparoscopic cholecystectomy. Am Surg 66:372
Thomson B, Parks R, Madhavan K, Garden O (2007) Liver resection and transplantation in the management of iatrogenic biliary injury. World J Surg 31:2363
Disclosures
M. T. P. R. Perera, A. Monaco, M. A. Silva, S. R. Bramhall, A. D. Mayer, J. A. C. Buckels, D. F. Mirza have no conflicts of interests or financial ties to disclose.
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Perera, M.T.P.R., Monaco, A., Silva, M.A. et al. Laparoscopic posterior sectoral bile duct injury: the emerging role of nonoperative management with improved long-term results after delayed diagnosis. Surg Endosc 25, 2684–2691 (2011). https://doi.org/10.1007/s00464-011-1630-4
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DOI: https://doi.org/10.1007/s00464-011-1630-4