Isolated right posterior bile duct injury following cholecystectomy:Report of two cases

Anatomic variations of the right biliary system are one of the most common risk factors for sectoral bile duct injury(BDI)during cholecystectomy.Isolated right posterior BDI may in particular be a challenge for both diagnosis and management.Herein we describe two cases of isolated right posterior sectoral BDI that took place during laparoscopic cholecystectomy.Despite effective external biliary drainage from the liver hilum in both cases,there was a persistent biliary leak observed which was not visible on endoscopic retrogradecholangiogram.Careful evaluation of images from both endoscopic and magnetic resonance cholangiograms revealed the diagnosis of an isolated right posterior sectoral BDI.These were treated with a delayed bisegmental(segments 6 and 7)liver resection and a Roux-en-Y hepaticojejunostomy respectively with good outcomes at 24 and 4 mo of follow-up.This paper discusses strategies for prevention of such injuries along with the diagnostic and therapeutic challenges it offers.     

Microsurgical technique used in right anterior segmentectomy and pancreatoduodenectomy with reconstruction of the right posterior hepatic artery for widespread bile duct cancer involving the hepatic hilus

A microsurgical technique was used in performing anterior hepatic segmentectomy and pancreatoduodenectomy with reconstruction of the posterior hepatic artery in a 64-year-old man with widespread bile duct cancer from the intrapancreatic bile duct over the hepatic hilus. The anterior hepatic artery was obviously involved and the posterior hepatic artery just behind common hepatic duct was very close to the cancer. Microsurgical anastomosis between the remnant gastroduodenal artery and the posterior hepatic artery at the hepatic hilus made it possible to preserve the posterior segment of the liver and to perform a curative resection of the cancer. The patient had pyrexia because of suprahepatic abscess after the operation, but the abscess drained spontaneously. Postoperative arteriogram showed neither obstruction nor kinking of the reconstructed artery. He was discharged 2 months after surgery and has been enjoying a normal quality of life for 10 months since, with no signs of recurrence. It is suggested that a microsurgical technique is useful for performing an accurate anastomosis with good patency that allows not only a safe but also a highly curative operation for advanced bile duct cancer.     

The right hepatic artery syndrome

Various benign and malignant conditions could cause biliary obstruction. Compression of extrahepatic bile duct (EBD) by right hepatic artery was reported as a right hepatic artery syndrome but all cases were compressed EBD from stomach side. Our case compressed from dorsum was not yet reported, so it was thought to be a very rare case. We present here the first case of bile duct obstruction due to the compression of EBD from dorsum by right hepatic artery.     

Complex bile duct injuries: management

BACKGROUND: Laparoscopic cholecystectomy is the present treatment of choice for patients with gallbladder stones, despite its being associated with a higher incidence of biliary injuries compared with the open procedure. Injuries occurring during the laparoscopic approach seem to be more complex. A complex biliary injury is a disease that is difficult to diagnose and treat. We considered complex injuries: 1) injuries that involve the confluence; 2) injuries in which repair attempts have failed; 3) any bile duct injury associated with a vascular injury; 4) or any biliary injury in association with portal hypertension or secondary biliary cirrhosis. The present review is an evaluation of our experience in the treatment of these complex biliary injuries and an analysis of the international literature on the management of patients.     

Management of bile duct injuries combined with accessory hepatic duct during laparoscopic cholecystectomy

Bile duct injuries (BDIs) are difficult to avoid absolutely when the biliary tract has a malformation, such as accessory hepatic duct. Here, we investigated the management strategies for BDI combined with accessory hepatic duct during laparoscopic cholecystectomy.     

Results of surgical treatments and prognostic factors for hepatic hilar bile duct cancer

Results of surgical treatments for 57 patients who underwent resection for hepatic hilar bile duct cancer between 1984 and 1997 were studied. Bile duct resection was performed in eight patients, and combined resection of bile duct and liver was performed in 49 patients, of whom vascular reconstruction was added in 15 patients and pancreatoduodenectomy (PD) in six patients. All the operations of bile duct resection that were not combined with hepatectomy were non-curative. In the patients who underwent combined resection of the bile duct with liver, outcomes of the patients with well-differentiated adenocarcinoma were better than those with other lower-grade tumors. The factors related to the degree of tumor extension, such as serosal invasion, lymph node metastasis, lymphatic vessel invasion, perineural invasion, venous vessel invasion, and vascular involvement, were other factors which significantly influenced the survival. Curative resection yielded significantly better results than non-curative resection. Of all these variables, good tumor differentiation and vascular involvement were recognized as important prognostic factors by multivariate analysis. Most of the postoperative deaths were encountered in patients who underwent additional operations to hepatectomy, such as vascular reconstruction or PD. Improvement of surgical techniques and perioperative care has yielded better outcomes of vascular reconstruction. However, the application of hepatopancreatoduodenectomy should be limited due to poor outcomes of widespread bile duct cancer of which the histological grade is usually low. Whereas prognosis of bile duct cancer involving the hepatic hilus is mainly determined by the biologic characteristics of the tumor, surgeons should consider the fact that most patients die of local recurrence regardless of the biologic character of the tumor when curative resection is not performed.     

Management of excluded segmental bile duct leakage following liver resection

Background:

Postoperative bile leak secondary to a fistula is a known complication of hepatic surgery. Four different biliary fistula sub-types have been described: type A refers to minor leakage from the bile duct stump; type B to major leakage caused by insufficient closure of the bile duct stump; type C to major leakage caused by injury to the bile duct, and type D (the rarest) to the division and exclusion of a bile duct. This complication results from functional liver parenchyma in which bile drainage is excluded from the main duct.

Methods:

A retrospective review of the database for 163 patients diagnosed with post-hepatic surgery bile leak from April 1992 to June 2007 was performed.

Results:

Three patients were found to have type D biliary fistula, with durations of 3–21 months. The bile leak developed after a right hepatectomy in two patients and a right hepatectomy extending to segment IV in one patient. All three patients were rescheduled for surgical exploration, following failure of medical treatment. The procedure consisted of repeat resection of the independent liver parenchyma containing the fistula. One patient developed a postoperative leak from a hepaticojejunal anastomosis (treated conservatively) and the other two patients had an uneventful recovery. No recurrence of bile leak was encountered during their follow-up.

Conclusions:

Our experience indicates that conservative treatment is deceptive and not efficacious. For this condition, surgical intervention is the treatment of choice because it is very effective and is associated with a low morbidity.     

Rupture of the hepatic artery after left hemihepatectomy for hilar bile duct carcinoma

Hilar bile duct carcinoma has a poor prognosis, but this has been improved in recent years by an aggressive surgical approach. We treated a 73-year-old woman who had obstructive jaundice due to bile duct carcinoma at the hepatic hilum. The jaundice decreased after percutaneous transhepatic biliary drainage. The tumor was resected with the left and caudate lobe of the liver and a part of portal vein. The right hepatic artery was located behind the common hepatic duct, and was suspected to be invaded by the tumor. We dissected the tumor from the arterial wall without carrying out combined resection of the hepatic artery. On the 6th postoperative day, the hepatic artery ruptured and the patient suffered hypovolemic shock. Resection of the hepatic artery and reconstruction were done, but the patient died 2 days later. Histological examination of the resected artery showed that the tumor had been curatively removed by dissection and that no tumor remained at the arterial wall. The rupture of the right hepatic artery was thought to have been caused by damage to the wall during the dissection procedure.     

腹腔镜胆囊切除术中肝外胆管横断损伤原因及对策

目的　探讨腹腔镜胆囊切除术中肝外胆管横断损伤发生的原因及预防措施。方法　回顾分析了６ ０００ 例腹腔镜胆囊切除术中９例肝外胆管横断损伤的原因,探讨了预防肝外胆管横断损伤的措施。结果　指出Ｃａｌｏｔ三角解剖结构不清或存在解剖变异,误把胆总管当胆囊管钳夹、切断是肝外胆管横断损伤的主要原因。结论　严格掌握手术适应证,沿胆囊壶腹向下分离,仔细辨别Ｃａｌｏｔ三角解剖结构,术中始终想着Ｃａｌｏｔ三角解剖结构存在的变异,避免盲目自信、莽撞行事是预防肝外胆管横断损伤的关键。     

Iatrogenic bile duct injuries from biliary tract surgery

BACKGROUND:Cholecystectomy is the most commonly performed procedure in general surgery.However,bile duct injury is a rare but still one of the most common complications.These injuries sometimes present variably after primary surgery.Timely detection and appropriate management decrease the morbidity and mortality of the operation. METHODS:Five cases of iatrogenic bile duct injury(IBDI) were managed at the Department of Surgery,First Affiliated Hospital,Xi'an Jiaotong University.All the cases who underwent both open and laparoscopic cholecystectomy had persistent injury to the biliary tract and were treated accordingly. RESULTS:Recovery of the patients was uneventful.All patients were followed-up at the surgical outpatient department for six months to three years.So far the patients have shown good recovery. CONCLUSIONS:In cases of IBDI it is necessary to perform the operation under the supervision of an experienced surgeon who is specialized in the repair of bile duct injuries,and it is also necessary to detect and treat the injury as soon as possible to obtain a satisfactory outcome.     

First jejunal artery,an alternative graft for right hepatic artery reconstruction

Common bile duct cancer invading right hepatic artery is sometimes diagnosed intraoperatively. Excision andsafe reconstruction of the artery with suitable graft is essential. Arterial reconstruction with autologous saphenous vein graft is the preferred method practiced routinely. However the right hepatic artery reconstruction has also been carried out with several other vessels like gastroduodenal artery, right gastroepiploic artery or the splenic artery. We report a case of 63-year-old man presenting with history of progressive jaundice, pruritus and impaired appetite. Following various imaging modalities including computed tomography, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, intraductal ultrasound extrahepatic bile duct cancer was diagnosed; however, none of those detected vessel invasion. Intraoperatively, right hepatic artery invasion was revealed. Right hepatic artery was resected and reconstructed with a graft harvested from the first jejunal artery(JA). Postoperative outcome was satisfactory with a long-term graft patency. First JA can be a reliable graft option for right hepatic artery reconstruction.     

Delayed presentation of bile duct injuries after laparoscopic cholecystectomy

Bile duct injury is a serious complication of laparoscopic cholecystectomy, with 50% of bile duct injuries showing a delayed presentation. We experienced four patients (one male and three female) with bile duct injuries after laparoscopic cholecystectomy performed and referred by a local practitioner. The patients' ages ranged from 34 to 63 years. Symptoms included abdominal pain, anorexia, jaundice, ascites, ileus, fever, and tarry stool. Ductal injuries were a result of electrocautery burn in two patients and biliary strictures were due to malapplication of endoclips in the remaining two. The observed bile duct injuries, confirmed by ultrasonography, computed tomography (CT) scanning, and cholangiographic studies, were successfully treated by choledochotomy with a silastic T-tube stent. To avoid bile duct injuries, laparoscopic cholecystectomy should be performed by a well trained and experienced hepatobiliary surgeon, who should ensure accurate identification of the anatomical structures of Calot's triangle, careful dissection and management of intraoperative bleeding, and a lower threshold for conversion to open surgery.     

小儿肝胆超声声像图特点

小儿肝胆疾病,究其病因、先天发育特点、以及病理生理特点有其特殊性,不同于成人肝胆疾病,其超声影像学检查因此亦不同于成人超声影像特点。根据病因分为5类。（1）感染相关疾病;（2）先天发育异常疾病;（3）代谢性疾病;（4）肝脏占位性病变;（5）肝脏血管疾病。本文从这5个方面系统回顾儿科肝胆疾病超声特点,并对特征性疾病超声特点给予阐述。     

肝外胆管癌外科治疗与预后关系的临床探讨

目的探讨肝外胆管癌外科治疗与预后之间的临床关系。方法回顾性分析1984年1月-1993年12月收治的经病理和临床证实的肝外胆管癌55例,并对其不同的手术方法与生存情况进行了随访、比较。结果本组上、中、下段胆管癌分别占43.6%,21.8%,34.6%;有42例得到病理诊断,其中腺癌占绝大多数。癌肿根治性切除11例(26.2%),“减黄”手术30例(包括胆肠内引流14例,外引流16例),单纯剖腹、PTCD 和非手术治疗分别为1,6,7例。48例得到了1—62个月的随访(87.3%),平均生存时间10.8±9.7月,;其中癌肿根治性切除组生存时间最长(21.4±16.7月。P<0.01),生存率最高(P<0.05);胆肠内引流组的生存时间(12.2±6.8月)和生存率亦明显高于其它各组(P<0.05);外引流与单纯剖腹、永久 PTCD、保守治疗组间及术前是否施行 PTCD 间生存时间和生存率均无差异(P>0.05)。结论本组肝外胆管癌的治疗,以癌肿根治性切除的疗效及预后最好,胆肠内引流组次之。作者认为,对有条件的肝外胆管癌,应争取早期作肿瘤根治性切除 胆管空肠吻合,并酌情切除受累肝脏;即使无根治条件,亦应尽可能作胆肠内引流。     

Hilar bile duct resection for bile duct carcinoma at the hilus of the liver

Hilar bile duct resection, by which only the bile duct is resected, was carried out in 31 patients with bile duct carcinoma at the hepatic hilus. However, curative resection was possible in only 4 patients (12.9%). The postoperative 1-, 3-, and 5-year survival rates were 58.1%, 19.4%, and 7.7%, respectively. These results indicate that treatment of this hilar bile duct carcinoma by hilar bile duct resection is of limited value. We believe that this operative procedure should be used only for papillary or nodular carcinoma at the hepatic confluence at relatively early stages of Bismuth's type I or II.     

Hepatic resection for post-cholecystectomy bile duct injuries: a literature review

Objectives:

This study seeks to identify factors for hepatectomy in the management of post-cholecystectomy bile duct injury (BDI) and outcome via a systematic review of the literature.

Methods:

Relevant literature was found by searching the PubMed database and the bibliographies of extracted articles. To avoid bias selection, factors for hepatectomy were analysed in series reporting both patients undergoing hepatectomy and patients undergoing biliary repair without hepatectomy (bimodal treatment). Relevant variables were the presence or absence of additional hepatic artery and/or portal vein injury, the level of BDI, and a previous biliary repair.

Results:

Among 460 potentially relevant publications, only 31 met the eligibility criteria. A total of 99 hepatectomies were reported among 1756 (5.6%) patients referred for post-cholecystectomy BDI. In eight series reporting bimodal treatment, including 232 patients, logistic regression multivariate analysis showed that hepatic arterial and Strasberg E4 and E5 injuries were independent factors associated with hepatectomy. Patients with combined arterial and Strasberg E4 or E5 injury were 43.3 times more likely to undergo hepatectomy (95% confidence interval 8.0–234.2) than patients without complex injury. Despite high postoperative morbidity, mortality rates were comparable with those of hepaticojejunostomy, except in urgent hepatectomies (within 2 weeks; four of nine patients died). Longterm outcome was satisfactory in 12 of 18 patients in the largest series.

Conclusions:

Hepatectomies were performed mainly in patients showing complex concurrent Strasberg E4 or E5 and hepatic arterial injury and provided satisfactory longterm outcomes despite high postoperative morbidity.     

“三管一孔一脏器”显露在预防腹腔镜胆囊切除术胆管损伤的价值

目的研究胆囊各种病理形态、胆囊动脉变异和胆囊管变异情况下，腹腔镜胆囊切除术（ＬＣ）胆管损伤防治预案．方法ＬＣ患者１０６５例，急诊ＬＣ２０７例，择期ＬＣ８５８例，在全麻、ＣＯ２气腹状态下，采用经Ｃａｌｏｔ’ｓ三角后侧径路方法，显露“三管一孔一脏器”（ＴＯＯ）作为胆囊切除术的安全标志．结果“ＴＯＯ”显露１０２１例，占９５８６％，未显露４４例，占４１４％．胆囊动脉变异１４０例，胆囊管变异１５２例，均经ＬＣ顺利完成．全组无胆管损伤等并发症和死亡．结论“三管一孔一脏器”显露在ＬＣ预防胆管损伤起着重要作用．