Editorial
Hepatectomy for Bile Duct Injury – When Repair is not enough!
Vinay K. Kapoor*
Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, India
*Corresponding author: Vinay K Kapoor, Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, UP, India
Published: 05 Dec, 2016
Cite this article as: Kapoor VK. Hepatectomy for Bile Duct
Injury – When Repair is not enough!.
Clin Surg. 2016; 1: 1203.
Editorial
Laparoscopic cholecystectomy is associated with a 0.4-0.6% risk of bile duct injury (BDI). Early
surgical repair of an acute bile duct injury is not recommended [1]. Management of an acute bile
duct injury is non-surgical - percutaneous catheter drainage of the biloma and endoscopic stent
drainage of the bile duct; this converts the acute BDI into a controlled external biliary fistula which
closes to form a benign biliary stricture BBS [2]. Management of a post cholecystectomy iatrogenic
BBS is in the form a Roux-en-y hepatico-jejunostomy (HJ) at the hilum of the liver [3].
A vascular (hepatic artery and/ or portal vein) injury is associated with BDI in a significant
number of cases [4]. Reported vascular injury in as many 20/76 patients with BDI - more often
(11/33) with high BDI than with low BDI (9/43). The incidence may be higher if the vascular injury
is looked for e.g. by Doppler US, CT angiography or MR angiography.
Urgent hepatectomy may be required, though very rarely, in the early postoperative period
(within few weeks) for liver parenchymal necrosis and sepsis (liver abscess). As many as 5/10
hepatectomies in one report [4] and 2/11 in another [5] were urgent hepatectomies. Mortality of
early hepatectomy for massive hepatic necrosis is very high– in a review, 4 out of 9 patients who
underwent early hepatectomy died [6].
Vascular injury in itself is not an indication for hepatectomy in BDI; it is vascular injury along
with a high (Strasberg E4/E5) BDI/ (Bismuth Type IV) BBS which may require hepatectomy [7].
In a review of 99 hepatectomies among 1,756 BDIs reported in 31 publications, patients with
combined high (Strasberg E4/E5) BDI and hepatic arterial injury were 43 times more likely to need
hepatectomy [6]. Elective (planned) hepatectomy should be considered as an alternative option
to repair (HJ) in patients with complex BBS, i.e. proximal (high) BBS involving the biliary ductal
confluence associated with a vascular injury (bilio-vascular injury) because even if repair in the form
of HJ is technically feasible, the anastomosis, if done to ischemic and fibrosed ducts, is very likely
to stricture. Elective (planned) hepatectomy should also be considered in patients with isolated
stricture of segmental/ sectoral bile duct.
Patients who undergo HJ for BBS are prone to develop anastomotic stricture [8]. Treatment of
choice for an anastomotic stricture is percutaneous transhepatic balloon dilatation and long term
stenting; re HJ may be feasible in some patients with an available bile duct at the hilum. Delayed
hepatectomy may be required, especially after failed surgical repair of BBS, because of recurrent
cholangitis, cholangiolytic abscess and atrophy-hypertrophy complex. Atrophy hypertrophy results
in rotation of the hepatic hilum and makes repair of BBS technically difficult [5 and 9] Hepatectomy in
11 patients at a median of 58 months after BDI [7]. Hepatectomy in 9 (6%) of 148 BDIs but after
mean 2.4 attempts at surgical repair.br />
Truant reviewed 460 publications and found need for hepatectomy in 99 (5.6%) out of 1,756
patients with BDI reported in 31 publications. The largest experience is from Belghiti’s unit of 18
liver resections for BDI [9 and 10] need for hepatectomy in 10/355 (3%) patients who had undergone HJ
for BDI [11]. Hepatectomy in 10/76 (13%) patients with BDI managed from 1998-2007 in Tubingen
Germany; the high proportion of hepatectomies in this report probably reflects the referral bias of
a transplant center [5]. Report need for hepatectomy in 11/800 (1.4%) patients with BDI managed
from 1990-2012 at the Academic Medical Center, Amsterdam.
Most patients with BDI who require hepatectomy need right hepatectomy but few patients may
need left hepatectomy - 1/9 in one report [7] and 2/10 in another [9]. These are patients who have undergone HJ for BBS but develop recurrent anastomotic stricture causing recurrent cholangitis.
Right hepatectomy offers an advantage in that the exposure of the left
hepatic duct is very good and an adequate hepatico-jejunostomy can
be created.
Hepatectomy in patients with BBS is technically difficult
because of extensive inflammatory fibrosis at the hepatic helium
making isolation of the portal pedicles (especially right) difficult.
Hepatectomy for BDI is associated with significant mortality 1/10 [9],
1/10 [4], 2/11 in hospital + 1/11 long term [5]. Long term outcome of
hepatectomy is good. 8 out of 9 patients who underwent hepatectomy
were asymptomatic at a mean follow up of 69 months– 1 required
transplant [7]. 67% of 9 patients had no or only transitory symptoms
at a median follow up of 34 months [4].
There are several reports of patients with BDI requiring even liver
transplant. Commonest indication for liver transplant in patients with
BDI/BBS is secondary biliary cirrhosis (SBC) due to long standing
biliary obstruction, recurrent cholangitis and cholangiolytic abscess.
Rarely, urgent liver transplant may be required for fulminant liver
failure caused by massive liver necrosis [12]. 27 patients with BDI
listed for liver transplant between 1987 and 2010 in the Spanish Liver
Transplant Group including 24 units. 7 of these 27 patients needed
emergency transplant - 2 of these died while waiting for transplant
and 5 received an emergency transplant - 4 of these 5 died within 30
days of transplant and only 1 survived beyond 30 days. 20 patients
(13 with SBC) received elective liver transplant - 1 died within 30
days, 68% survived for 5 years [13]. 19 patients who received liver
transplant (1 for acute liver failure and 18 for end stage liver disease
at a median of 71 months) for BDI in 18 centers in Argentina– 5
year survival was 68% and 10 year survival 45% [14]. Reported that
5 (1.7%) out of 300 liver transplants performed at a center in Poland
between 2002 and 2011 were for SBC due to BDI.
Liver resection (and even transplant) may rarely be required on
an urgent basis in a very small number of patients with acute BDI.
Elective liver resection should be considered as an alternate option
to HJ in patients with complex bilio-vascular injury. Some patients
with anastomotic stricture and recurrent cholangitis may require
hepatectomy, during follow-up after HJ. Hepatectomy in BBS is
technically difficult resulting in high morbidity and significant
mortality but long term outcomes are good.
References
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