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18 Posterior Right Disconnected Bile Duct 241
Fig. 18.3 Laparotomy with atrophic right posterior liver sector
An intraoperative US confirmed isolated right posterior bile duct dilatation with
a small hyperechoic intraductal mass. An aberrant low confluence of right and left
hepatic ducts was also evident.
A complex hilar dissection due to the previous biliary surgery was then performed, with palpatory evidence of a small mass apparently involving the right bile
duct. The common bile duct was sectioned above the duodenum. Cholangioscopy,
which was then performed, confirmed the anatomic variation, including a very low
bile duct confluence and a completely obstructing stricture of the right posterior
duct (Fig. 18.4).
The right periportal and common hepatic artery nodal sampling was negative for
malignant cells. The right portal and arterial branches were selectively encircled and
sectioned; the right hepatic vein was isolated and encircled.
A right posterior sectionectomy (S6-S7) with resection of the biliary aberrant
confluence was performed, due to the close proximity with the pseudonodular
obstruction of the right posterior duct. A bi-ductal Roux-en-Y hepatico-jejunostomy
was performed. The patient was uneventfully discharged on postoperative day 7.
The final pathology revealed a sectoral chronic aspecific cholangitis with
proximal duct inflammatory sclerotic stenosis that was negative for cancer cells.
The picture was compatible with an iatrogenic biliary injury.
242 U. Cillo et al.
Fig. 18.4 Common bile duct section with evidence of anomalous low confluence. Right posterior
duct (RPD) was disconnected at cholangioscopy as well as at surgical sampling; RAD right
anterior duct; LHD left hepatic duct
Overall Management
• A crucial role in the management of technically demanding intraoperative
scenarios involving the biliary tract is early referral to tertiary specialized
hepatobiliary high-volume centers.
• Given the difficulty in ruling out malignancy in the context of a probable
history of a iatrogenic lesion, an “oncologic” approach should always be
taken.
• Adequate morphologic patient evaluation is mandatory including: CT
scan, MRCP, ERCP with also specific endoscopic procedures (such as
EUS, IDUS or Cholangioscopy) and tissue sampling.
References
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18 Posterior Right Disconnected Bile Duct 243
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Management of Contralateral Bile Duct Injury Following Liver Resection
Michael McCall, Jean-Michel Aubin and Elijah Dixon
Case 1
A 78-year-old gentleman, known for a coronary artery bypass graft (CABG) nine
years prior, a right hemicolectomy for a large, benign polyp, and no known liver
disease, initially presented with weakness and fatigue and was found to be anemic.
He underwent upper and lower endoscopies, as well as cross-sectional imaging.
Imaging (computed tomography and contrast-enhanced ultrasound) revealed a
7.9 4.0 4.7 cm hypodense lesion bridging segments 4b and 5 of the liver and
abutting the fundus of the gallbladder, suggestive of an intrahepatic cholangiocarcinoma (Fig. 19.1). Given his exceptional functional status, excision was offered.
Intraoperatively, the lesion was found to encompass segment 4b and involve
segment 5, abut the gallbladder, and encroach on the hepatic hilum. A meso-axial
hepatectomy was carried out, with the use of the Aquamantys® (Medtronic;
Minneapolis, MN, USA) device for parenchymal dissection. Hemostasis and
absence of bile were confirmed at the end of the procedure. No drains were placed.
19
M. McCall
Department of Surgery, Division of General Surgery, Foothills Medical Centre,
University of Calgary, 1403 29th Street NW, T2N 2T9 Calgary, AB, Canada
e-mail: mmccall@ualberta.ca
J.-M. Aubin
Department of Surgery, Foothills Medical Centre, University of Calgary,
1403 29th Street NW, T2N 2T9 Calgary, AB, Canada
e-mail: jmraubin@gmail.com
E. Dixon (&)
Foothills Medical Centre, University of Calgary, EG - 26,
1403 29th Street NW, T2N 2T9 Calgary, AB, Canada
e-mail: Elijah.Dixon@albertahealthservices.ca
© Springer International Publishing AG 2017
T.M. Pawlik et al. (eds.), Case-Based Lessons in the Management of Complex
Hepato-Pancreato-Biliary Surgery, DOI 10.1007/978-3-319-50868-9_19
245
246 M. McCall et al.
Fig. 19.1 Preoperative axial CT image showing concerning hypodense lesion bridging segments
4b/5
Pathologic assessment of the hepatic lesion revealed a poorly differentiated
hepatocellular carcinoma, solid variant, with portal vein invasion. Resection margins were free of tumor.
Hyperbilirubinemia ensued early in the postoperative course (bilirubin POD 1:
125umol/L). The postoperative day 5 level was 44 and a nadir of 30 occurred on
POD 7 (Fig. 19.2a). His international normalized ratio (INR) did not follow a
similar trend (POD 1: 1.3; POD 5: 1.2; peak on POD 8: 1.5) (Fig. 19.2b). Following the development of fevers and a leukocytosis, cross-sectional imaging
revealed a collection in the resection bed (Fig. 19.3 ). A percutaneous drain was
placed and bilious fluid was noted.
Sequential imaging eventually revealed bile duct dilation. At this point, a percutaneous transhepatic cholangiogram (PTC) was obtained (Fig. 19.4a) to assess
the biliary tree and characterize the suspected strictur e. Once the cholangiogram
was obtained, the stricture was traversed with a guidewire and an internal/external
catheter was placed for biliary drainage and stenting of the stricture (Fig. 19.4b).
The bilirubin level gradually decreased, but never normalized (nadir post PTC
insertion of 48). The PTC was sequentially upsized to a 14Fr caliber to optimize
bilioenteric flow. Bilious drainage eventually ceased via the percutaneous drain in
the surgical bed.
19 Management of Contralateral Bile Duct Injury … 247
Fig. 19.2 Case 1
postoperative bilirubin (a) and
INR (b) values. Lines denote
(a) placement of percutaneous
drain, (b) placement of left
PTC, (c) upsizing of PTC to
12 Fr, and (d) upsizing of
PTC to 14 Fr
Case 2
A 58-year-old gentleman initially presented with hematochezia and was found to
have a large malignant polyp. Fo llowing completion of metastatic workup, he
underwent a laparoscopic anterior resection. Cross-sectional imaging of the abdomen revealed a large cystic lesion centr ally located in his liver (Fig. 19.5). A cystadenoma was suspected, and consequently surgical resection was recommended.
His colonic lesion proved to be a T2N0 low-grade adenocarcinoma. As no
systemic therapy was planned, focus shifted to his hepatic lesion. Enucleation was
pursued, due to intimate relation of the cystic lesion with the central Glissonian
sheath and hilar plate. Though tedious, careful dissection was employed, without
use of an energy device, in proximity of the central structures. Following resection,
248 M. McCall et al.
Fig. 19.3 Postoperative axial CT image demonstrating fluid collection in resection bed.
A percutaneous drain was subsequently placed
hemostasis and absence of bile leaks was confirmed. No drains were placed.
Pathologic assessment confirmed the diagnosis of cystadenoma, without dysplasia.
Unfortunately, this patient also developed fevers and leukocytosis, prompting
cross-sectional imaging. A fluid collection was also identified and drained percutaneously (Fig. 19.6). Clinical improvement was then observed, and the patient was
discharged home with drain in situ. He then presented to the Emergency Department eight weeks postoperatively with jaundice (bilirubin 152umol/L).
Given the delayed presentation, duct dilation was readily evident on imaging,
and was amenable to percutaneous access. Both biliary systems were initially
accessed and found to lead to inaccessible strictures at the proximal hepatic ducts
(Figs. 19.7A, B). Bilateral external drains were placed.
The finding of bilateral occlud ed hepatic ducts resulted in a challenging scenario.
Serial instrumentation of the bile ducts and attempts at traversing the stricture
resulted in the transgression of the bile duct wall and free communication of both
biliary systems with the central cavity initially drained postoperatively.
With technical expertise, a guidewire was eventually manipulated down the
biliary tree, through to the cavity and back into the common hepatic duct. Bilateral
PTCs were then placed well into the duodenum, to establish internal/external
drainage (Fig. 19.7C). Multiple peri-procedural episodes of low-grade cholangitis
were encountered and managed with antibiotics and external drainage .
19 Management of Contralateral Bile Duct Injury … 249
Fig. 19.4 Postoperative percutaneous transhepatic cholangiography demonstrating a complete
biliary stricture (arrow), and b passage of wire across stricture with distal filling
Both PTCs remained in place for an extended duration of time until the percutaneous drain output decreased and became less bilious. Following this, the PTCs
were sequentially closed, to allow internalized drainage. Cholangiograms and
cross-sectional imaging eventually confirmed resolution of the central collection, as
well as integrity of the bile ducts. The PTCs were then discontinued, at 7 and
8 months respectively. Follow- up is ongoing to monitor for further stricture
development.
250 M. McCall et al.
Fig. 19.5 Computed tomography coronal image showing central hepatic cystic lesion. Final
pathology revealed a cystadenoma
Fig. 19.6 Percutaneous drainage of a central hepatic fluid collection after liver resection