Isolated Right Segmental Hepatic Duct Injury

A Diagnostic and Therapeutic Challenge

Keith D. Lillemoe, Jason A. Petrofski, Michael A. Choti, Anthony C. Venbrux, John L. Cameron

Research output: Contribution to journalArticle

51 Citations (Scopus)

Abstract

Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmental hepatic duct can be particularly difficult to diagnose in that results of endoscopic retrograde cholangiography (ERC) are usually interpreted as "normal" with no leaks demonstrated. The aim of this study was to describe a single institution's experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a laparoscopic cholecystectomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopic retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmental biliary system, with placement of a percutaneous transhepatic stent. After the biliary leak was controlled, all patients underwent Roux-en Y hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67%) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89%) of the nine patients are asymptomatic, with a mean followup of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental hepatic ductal injury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopic retrograde cholangiogram. Management begins with percutaneous access of the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy.

Original languageEnglish (US)
Pages (from-to)168-177
Number of pages10
JournalJournal of Gastrointestinal Surgery
Volume4
Issue number2
StatePublished - Mar 2000

Fingerprint

Common Hepatic Duct
Wounds and Injuries
Therapeutics
Cholangiography
Laparoscopic Cholecystectomy
Cholecystectomy
Bile
Pain
Anastomotic Leak
Cholangitis
Hospital Records
Liver Function Tests
Biliary Tract
Bile Ducts

Keywords

  • Bile duct injury
  • Biliary fistula
  • Cholecystectomy

ASJC Scopus subject areas

  • Surgery

Cite this

Lillemoe, K. D., Petrofski, J. A., Choti, M. A., Venbrux, A. C., & Cameron, J. L. (2000). Isolated Right Segmental Hepatic Duct Injury: A Diagnostic and Therapeutic Challenge. Journal of Gastrointestinal Surgery, 4(2), 168-177.

Isolated Right Segmental Hepatic Duct Injury : A Diagnostic and Therapeutic Challenge. / Lillemoe, Keith D.; Petrofski, Jason A.; Choti, Michael A.; Venbrux, Anthony C.; Cameron, John L.

In: Journal of Gastrointestinal Surgery, Vol. 4, No. 2, 03.2000, p. 168-177.

Research output: Contribution to journalArticle

Lillemoe, KD, Petrofski, JA, Choti, MA, Venbrux, AC & Cameron, JL 2000, 'Isolated Right Segmental Hepatic Duct Injury: A Diagnostic and Therapeutic Challenge', Journal of Gastrointestinal Surgery, vol. 4, no. 2, pp. 168-177.
Lillemoe, Keith D. ; Petrofski, Jason A. ; Choti, Michael A. ; Venbrux, Anthony C. ; Cameron, John L. / Isolated Right Segmental Hepatic Duct Injury : A Diagnostic and Therapeutic Challenge. In: Journal of Gastrointestinal Surgery. 2000 ; Vol. 4, No. 2. pp. 168-177.
@article{9d8fee02cfb6448e9c4f7b52a3cab472,
title = "Isolated Right Segmental Hepatic Duct Injury: A Diagnostic and Therapeutic Challenge",
abstract = "Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmental hepatic duct can be particularly difficult to diagnose in that results of endoscopic retrograde cholangiography (ERC) are usually interpreted as {"}normal{"} with no leaks demonstrated. The aim of this study was to describe a single institution's experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78{\%}) of the nine patients had undergone a laparoscopic cholecystectomy, whereas the remaining two patients (22{\%}) had undergone an open cholecystectomy. All of the patients had undergone endoscopic retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmental biliary system, with placement of a percutaneous transhepatic stent. After the biliary leak was controlled, all patients underwent Roux-en Y hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67{\%}) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89{\%}) of the nine patients are asymptomatic, with a mean followup of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental hepatic ductal injury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopic retrograde cholangiogram. Management begins with percutaneous access of the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy.",
keywords = "Bile duct injury, Biliary fistula, Cholecystectomy",
author = "Lillemoe, {Keith D.} and Petrofski, {Jason A.} and Choti, {Michael A.} and Venbrux, {Anthony C.} and Cameron, {John L.}",
year = "2000",
month = "3",
language = "English (US)",
volume = "4",
pages = "168--177",
journal = "Journal of Gastrointestinal Surgery",
issn = "1091-255X",
publisher = "Springer New York",
number = "2",

}

TY - JOUR

T1 - Isolated Right Segmental Hepatic Duct Injury

T2 - A Diagnostic and Therapeutic Challenge

AU - Lillemoe, Keith D.

AU - Petrofski, Jason A.

AU - Choti, Michael A.

AU - Venbrux, Anthony C.

AU - Cameron, John L.

PY - 2000/3

Y1 - 2000/3

N2 - Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmental hepatic duct can be particularly difficult to diagnose in that results of endoscopic retrograde cholangiography (ERC) are usually interpreted as "normal" with no leaks demonstrated. The aim of this study was to describe a single institution's experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a laparoscopic cholecystectomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopic retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmental biliary system, with placement of a percutaneous transhepatic stent. After the biliary leak was controlled, all patients underwent Roux-en Y hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67%) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89%) of the nine patients are asymptomatic, with a mean followup of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental hepatic ductal injury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopic retrograde cholangiogram. Management begins with percutaneous access of the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy.

AB - Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmental hepatic duct can be particularly difficult to diagnose in that results of endoscopic retrograde cholangiography (ERC) are usually interpreted as "normal" with no leaks demonstrated. The aim of this study was to describe a single institution's experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a laparoscopic cholecystectomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopic retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmental biliary system, with placement of a percutaneous transhepatic stent. After the biliary leak was controlled, all patients underwent Roux-en Y hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67%) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89%) of the nine patients are asymptomatic, with a mean followup of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental hepatic ductal injury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopic retrograde cholangiogram. Management begins with percutaneous access of the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy.

KW - Bile duct injury

KW - Biliary fistula

KW - Cholecystectomy

UR - http://www.scopus.com/inward/record.url?scp=0034145705&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0034145705&partnerID=8YFLogxK

M3 - Article

VL - 4

SP - 168

EP - 177

JO - Journal of Gastrointestinal Surgery

JF - Journal of Gastrointestinal Surgery

SN - 1091-255X

IS - 2

ER -