Abstracts
1999 Digestive Disease Week

# 3476 ISOLATED RIGHT SEGMENTAL HEPATIC DUCT INJURY: A DIAGNOSTIC AND THERAPEUTIC CHALLENGE:
K D Lillemoe, Jason A Petrofski, Michael A Choti, Anthony Venbrux, John L Cameron, Johns Hopkins Med Inst, Baltimore, MD

Objective: Biliary injuries and leaks are a not 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 endoscopic retrograde cholangiography is usually interpreted as "normal". Methods: A retrospective analysis was performed of the hospital records of patients with bile duct injuries managed at a single institution between 1980 and July of 1998, inclusive. Patients identified as having an isolated right segmental hepatic duct injury with a bile leak were identified and were included in this analysis. Results: Nine patients with bile leaks secondary to isolated right segmental hepatic duct injuries were identified. Seven of the 9 patients (78%) had undergone laparoscopic cholecystectomy, whereas the remaining 2 patients (22%) had undergone open cholecystectomy. All of the patients had undergone ERCP at outside institutions which had been interpreted as "normal". The median interval from the time of initial injury 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 with no cases of anastomotic leak. Postoperative stenting was maintained for a mean of eight months. Six of the nine patients (67%) have had a successful outcome with minimal to no symptoms. In 3 patients, recurrent symptoms of pain and/or cholangitis developed at a mean of 34 months. All 3 late recurrent strictures were managed with percutaneous balloon dilation with a successful outcome. Currently, 8 of the 9 patients (89%) are asymptomatic with a mean follow-up of 67 months (range 6 months to 18 years). One patient has intermittent right upper quadrant pain with normal liver function tests and has not required intervention. Conclusions: Isolated right hepatic ductal injuries with a biliary leak are an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created with the presence a bile leak with a "normal" endoscopic retrograde cholangiogram. Incomplete filling of the right hepatic lobe segments on ERCP is the key to diagnosis. Percutaneous access of the transected isolated ductal system is key for successful management, both for initial control of the biliary fistula and eventual reconstruction as a Roux-en-Y hepaticojejunostomy. Although an incidence of failure following initial surgical repair of 33% was noted, long-term outcome with primary biliary reconstruction and secondary balloon dilatation has led to successful long-term results in 100% of patients.

Copyright 1996 - 1999, SSAT, Inc.