Delayed-onset isolated injury of the right posterior segment duct after laparoscopic cholecystectomy: a report of hepatic segmental atrophy induction

Variant Biliary Anatomy in Biological Siblings

Laparoscopic cholecystectomy is the standard of care for cholecystolithiasis but carries an increased risk of biliary injury compared to open cholecystectomy. Complications from laparoscopic cholecystectomy can be related to several factors. These include - (i) technical factors that depend on the skill of the surgeon, (ii) pathologic factors such as associated inflammation and adhesions, and (iii) anatomic factors such as biliary anatomy. Aberrant biliary anatomy is a major cause of bile duct injury during surgery. To the best of our knowledge familial aberrant biliary anatomy has not been previously reported in the literature. We report a case series of two biological sisters with isolated posterior right duct syndrome and present a brief literature review of this medical condition.

Thermal Processes in Bile Ducts During Laparoscopic Cholecystectomy with Monopolar Instruments. Experimental Study Using Real-Time Intraluminal and Surface Thermography

Introduction. A significant rate of complications during laparoscopic cholecystectomy (LC) occurs due to thermal injury caused by monopolar electrosurgery (MES) equipment. Most of them manifest weeks and months after surgery with the common bile duct (CBD) and large duodenal papilla strictures, some in the early postoperative period with bile leaks. Objective. To study thermal processes occurring in the lumen and on the surface of the bile ducts during monopolar coagulation in a porcine model of LC. Methods. The temperature of the bile ducts was measured using instrumentation consisted of biliary stent with temperature sensors, which was inserted in the porcine CBD, signal amplifier, and current sense transformer. Surface temperature was measured with a scientific grade thermal camera. Cholecystectomy was performed using a standard "critical view of safety" (CVS) approach with 5 mm monopolar laparoscopic instruments. Results. Application of MES caused significant tissue heating. Lateral thermal spread and the rate of tissue heating depended on the duration of energy application and the initial tissue temperature. In 5 out of 6 experiments, the intraluminal temperature rose up to the critical threshold, and the exposure time ranged from 54 to 560 seconds. A sensor positioned at the papilla site was heated in all the experiments but still below the cell damage inducing threshold. The analysis of thermographic charts revealed the presence of the "current channeling" effect and the pedicle effect. Conclusion. There is a possibility of a direct and delayed thermal injury to the bile ducts during LC.

Necrosectomy of hepatic left lateral section after blunt abdominal trauma in a patient who underwent central hepatectomy and bile duct resection for perihilar cholangiocarcinoma

When the liver is divided into the right and left halves after central hepatectomy, a serious injury to the one half of the liver can destroy the ipsilateral half. We report a case showing total necrosis of the hepatic left lateral section (LLS) caused by blunt abdominal trauma in a patient who had undergone central hepatectomy and bile duct resection for perihilar cholangiocarcinoma. A 47-year-old female patient was transferred because of postoperative status following blunt abdominal trauma. Five years before, she had been diagnosed with perihilar cholangiocarcinoma. Since the tumor extent was compatible with Bismuth-Corlette type IV, she underwent central hepatectomy and bile duct resection. After five years, she experienced an industrial safety accident, in which a heavy refrigerator fell over her body. She underwent emergency duodenal diversion surgery with distal gastrectomy and Roux-en-Y gastrojejunostomy. During this surgery, serious ischemic injury of the LLS with occlusion of the left portal vein and hepatic artery was identified, but not treated. After three weeks, LLS necrosectomy with repair of the jejunal limb was done. Postoperative bile leak developed and required supportive care for two months for its healing. She is currently doing well without any physical discomfort four months after the necrosectomy. Our experience with this case suggests that an injury to the afferent jejunal limb requires an individualized treatment strategy including long-standing waiting with effective drainage for spontaneous healing. The experience of this case appears to be theoretically matched with late-stage resection of LLS following central hepatectomy and bile duct resection.

Hepatic atrophy treatment with portal vein embolization to control intrahepatic duct stenosis-associated cholangitis

We present two cases of hepatic atrophy treatment with portal vein embolization (PVE) to control intractable cholangitis. The first case was a 60-year-old male who was admitted for repeated episodes of cholangitis. He had undergone cholecystectomy and Roux-en-Y choledochojejunostomy 2 years earlier. Imaging studies showed left intrahepatic duct dilatation and anastomotic site stricture. The patient was reluctant to undergo another surgery. Thus, we decided to perform left PVE to induce atrophy of the left liver. The left liver shrank and stayed silent for 5 years, but a radiological intervention was necessary to treat symptomatic anastomotic stenosis. The patient has done well for 12 years after PVE. The second case was a 51-year-old female who was also admitted for repeated episodes of cholangitis. She had undergone excision of type I choledochal cyst 2 years earlier. Imaging studies showed right hepatic duct stenosis. Cholangitis developed repeatedly. Thus, radiologic interventions were performed 8 times over 9 years. Finally, she was referred for surgery, but she was very reluctant to undergo another surgery. We planned a wait-and-see strategy following right PVE. After PVE, the right liver progressively shrank. Three months after PVE, we decided to wait for a longer period until further atrophy of the right liver. The patient has been doing well for 14 months after PVE without any episode of cholangitis. In conclusion, experience from our two cases suggests that hepatic parenchymal induction therapy through percutaneous PVE can be a therapeutic option for patients with perihilar biliary stenosis-associated cholangitis.

Management of Segmental Bile Duct Injuries After Cholecystectomy: a Systematic Review

BACKGROUND

Injuries to segmental or aberrant bile ducts are encountered less commonly than their major bile duct counterparts and present a unique diagnostic and therapeutic challenge, since the nature of this injury involves a transected bile duct that loses its communication with the main ductal system. In this systematic review, we aim to pool available data on this particular type of biliary injury in an effort to outline available diagnostic and therapeutic modalities and evaluate their efficacy.

MATERIALS AND METHODS

An extensive literature search was performed on MEDLINE, Scopus, and Web of Science to identify isolated segmental or aberrant bile duct injuries.

RESULTS

A total of 21 studies were included in this systematic report. Ten studies reported non-operative management of patients, while 12 reported operative management of included patients. Outcomes of interest were the choice of treatment interventions and their success. Overall, 23 patients were managed non-operatively with a 91% success rate and 30 patients were managed operatively with a 90% success rate.

CONCLUSION

Non-operative management might be a viable alternative to surgery. Hepatobiliary surgeons should be encouraged to publish their results in treating these rare injuries to further elucidate the role and efficacy of such an approach.

Hepatic segmental atrophy and nodular elastosis: imaging features

PURPOSE

To evaluate the imaging features of hepatic segmental atrophy and nodular elastosis.

MATERIALS AND METHODS

In this Institutional review board (IRB)-approved, HIPAA-compliant study, we reviewed imaging features in six cases of histologically confirmed hepatic segmental atrophy (HSA) and nodular elastosis (NE). Retrospective review of ultrasound (US) in 2 patients, computed tomography (CT) in 5 patients, magnetic resonance imaging (MRI) in 4 patients, and positron emission tomography (PET) in 2 patients was performed. Location, size, and attenuation/density/signal intensity of these lesions were evaluated. Clinical presentation and coexistent conditions were also recorded.

RESULTS

All six patients were females. Mean age of presentation was 58.3 years (range 37-80). A single HSA and NE lesion in each patient was found. The mean size of the lesion was 18 mm (range: 3 mm to 36 mm). Most lesions were detected incidentally (5/6). On contrast-enhanced single-phase (portal venous) CT, most lesions were hypodense (4/5) and one lesion was hyperdense to fatty liver parenchyma. On MRI, the lesions were iso- to hyperintense on T2-weighted images, T1 hypointense, and hyperintense on diffusion-weighted images (DWI). Three lesions were hypointense on arterial, portal venous, and delayed phases. One lesion occurring in fatty liver appeared hyperintense on all three phases. Gd-EOB-DTPA-enhanced images were available in 2 patients and lesions were hypointense on the 20-min hepatobiliary phase. On PET, two lesions were isometabolic to the background hepatic parenchyma. On ultrasound, one lesion appeared hypoechoic and another lesion isoechoic to hepatic parenchyma.

CONCLUSIONS

Hepatic segmental atrophy and nodular elastosis is an uncommon benign lesion and can simulate metastases due to variable imaging features. Lack of FDG uptake on PET/CT may be a clue to the benign nature of the lesion and may suggest the possibility of HSA and NE.

Acetic acid sclerotherapy for treatment of biliary leak from an isolated right posterior sectoral duct after cholecystectomy

Bile duct injury is one of the most serious complications of both laparoscopic and open cholecystectomy. Isolated bile duct injury can occur from the misidentification of aberrant right hepatic ducts, and it is troublesome because the early diagnosis is easy to miss and the definite treatment is controversial. We report a case of an isolated right posterior sectoral duct injury following cholecystectomy managed successfully with acetic acid sclerotherapy combined with coil embolization for a fistula tract.

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 retrograde cholangiogram. 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.

Therapeutic induction of hepatic atrophy for isolated injury of the right posterior sectoral duct following laparoscopic cholecystectomy

Laparoscopic cholecystectomy has resulted in various bile duct injuries. Treatment of these injuries is usually difficult and often leads to an intractable clinical course. We herein present a case of isolated right anterior sector (RAS) duct injury induced by laparoscopic cholecystectomy. The bile duct injury was successfully treated by hepatic atrophy induction. Imaging studies revealed that the RAS duct was severed, probably due to rare anatomical variations. Considering the difficulty in surgical reconstruction, atrophy induction of the involved hepatic parenchyma was attempted. This treatment consisted of embolization of the RAS portal branch to inhibit bile production, induction of heavy adhesion at the bile leak site to ensure percutaneous pigtail clamping, and sequential clamping and removal of pigtail catheters. This procedure took 3 months prior to pigtail catheter removal. She was free from other complications during the first 12 months and to date. She will be followed up for 5 years overall including surveillance for hepatobiliary complications. Although this therapeutic induction of atrophy approach is not universally applicable, it can be considered to be a feasible option in unique situations such as this one.

Non-operative management of right posterior sectoral duct injury following laparoscopic cholecystectomy

OBJECTIVE

The purpose of this study is to describe the outcomes of conservative management for patients with right posterior sectoral bile duct injury acquired during laparoscopic cholecystectomy.

METHODS

This retrospective, consecutive case series reviews seven patients with an isolated injury to the right posterior or right hepatic duct occurring during laparoscopic cholecystectomy.

RESULTS

Seven patients with an isolated right sectoral duct injury were studied, six women and one man aged 22 to 71 years (mean age, 43.6 years). Diagnosis of bile duct injury occurred between 1 day and 13 weeks after the initial cholecystectomy. Three patients had plastic biliary stents placed and six patients had JP drains placed. All patients in this series were managed conservatively, with no reoperation for formal repair of the bile duct. Length of follow-up ranged from 2 to 14 months (mean, 8.2 months). At last follow-up, all patients were asymptomatic with no biliary drainage.

CONCLUSIONS

Conservative management is an important option for patients with an isolated right posterior bile duct injury.

Surgical management of segmental and sectoral bile duct injury after laparoscopic cholecystectomy: a challenging situation

BACKGROUND

Injury to a segmental or sectoral bile duct is a rare event in laparoscopic cholecystectomy; its diagnosis and management may be difficult.

PATIENTS AND METHODS

Between April 1998 and December 2006, 73 patients referred to the author's tertiary center for management of postcholecystectomy biliary complications were studied. The patients with segmental/sectoral bile duct injury were divided into two groups: injury to a duct which drains at least one Couinaud segment (type 1) or injury to a minor biliary radical in the gallbladder fossa (type 2). Beside the management of concomitant vascular or other biliary injury, type 1 segmental/sectoral duct injury was repaired by biliary-enteric anastomosis and type 2 by oversewing.

RESULTS

Ten out of 73 referred patients had segmental/sectoral duct injuries (eight type 1, two type 2). Despite multiple radiological imaging and endoscopic procedures, in seven patients, the lesion was identified only by precise surgical dissection. The median length of hospital treatment was 26 (range 9-47) days. One patient died due to sepsis before any definitive treatment. During the mean follow-up of 43 (range 27-111) months, seven patients remained asymptomatic while two patients developed biliary anastomotic strictures requiring intervention.

CONCLUSION

Segmental/sectoral duct injury is difficult to be assessed by conventional radiological diagnostics and should be taken into consideration in every case of bile leakage. Surgical treatment, adapted to the type of lesion, generally results in a favorable outcome.

Monopolar electrosurgery on the extrahepatic bile ducts during laparoscopic cholecystectomy: an experimental controlled trial

INTRODUCTION

The purpose of this study is to investigate the occurrence of thermal injury in the extrahepatic bile ducts when monopolar electrosurgery is used to perform dieresis of the cystic duct and cystic vessels in laparoscopic cholecystectomy.

METHODS

Female pigs (n=40) of the Large White breed were separated into 2 groups of 20 animals. In the experimental groups, dieresis of the cystic duct and cystic vessels was performed with monopolar electrosurgery using a hook-like dissector using a power setting of 20 W, whereas in the control group this procedure was performed with a pair of Metzenbaum scissors disconnected from any kind of thermal energy source. Occurrence of distal thermal injury was evaluated on 2 occasions, on the 3rd and 28th days postoperatively. It consisted of exploratory laparotomy, cholangiography and both macroscopic and microscopic examination of the surgical specimen, which included cystic duct stump, hepatic duct and choledochus.

RESULTS

The presence of distal thermal injury, classified as second degree, 1.2 mm in the portion near the clipping area, was observed in only one of the cystic duct stumps after microscopic examination, without statistical significance. No thermal injury was observed in the extrahepatic bile ducts.

CONCLUSIONS

Monopolar electrosurgery produced negligible thermal injury in the extrahepatic bile ducts after laparoscopic cholecystectomy.