Isolated right segmental hepatic duct injury: A diagnostic and therapeuticchallenge

Biliary leaks and injuries are not an uncommon occurrence following laparos copic cholecystectomy. Bile leaks associated with the biliary anatomic vari ant of a low-inserting right segmental hepatic duct can be particularly dif ficult 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 ni ne patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of;he hospital records of all patients with bile duct injuries managed at a single institution bet ween 1980 and July 1998, inclusive, was performed. Nine patients were ident ified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a lapar oscopic cholecystectomy, whereas the remaining two patients (22%) had under gone an open cholecystectomy All of the patients had undergone endoscopic r etrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval fro m the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmental b iliary system, with placement of a percutaneous transhepatic stent. After t he biliary leak was controlled, all patients underwent Roux-en-Y hepaticoje junostomy to the isolated biliary segment. AIL patients had an uncomplicate d postoperative course. There were no postoperative anastomotic leaks. Post operative stenting was maintained for a mean of 8 months. Sis (67%) of the nine patients had a long-term successful outcome with minimal or no symptom s. Tn three patients, recurrent symptoms with pain and/or cholangitis devel oped at a mean of 34 months. All three patients underwent percutaneous chol angiography: which demonstrated an anastomotic stricture, and all were mana ged with percutaneous balloon dilatation with a successful outcome. Current ly 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 l eakage is an uncommon complication following laparoscopic cholecystectomy: A diagnostic dilemma is created by the presence of a bile leak with a norma l endoscopic retrograde cholangiogram. Management begins with percutaneous access of the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy.