Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Oct 27, 2015; 7(10): 254-260
Published online Oct 27, 2015. doi: 10.4240/wjgs.v7.i10.254
Iatrogenic bile duct injury with loss of confluence
Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez
Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan México 14080, DF, México
Eduardo Cervantes-Alvarez, PECEM, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, México
Author contributions: Mercado MA, Leal-Leyte P and Cervantes-Alvarez E contributed to study conception and design; Mercado MA and Gonzalez BA contributed to the acquisition of data; Mercado MA, Vilatoba M, Contreras A, Leal-Leyte P, Cervantes-Alvarez E and Gonzalez BA contributed to analysis and interpretation; Mercado MA, Leal-Leyte P and Cervantes-Alvarez E contributed to drafting of manuscript; Mercado MA, Vilatoba M, Contreras A, Leal-Leyte P, Cervantes-Alvarez E and Gonzalez BA contributed to critical review; Arriola JC contributed to the figures.
Institutional review board statement: The study was reviewed and approved by the Research Committee and the Research Ethics Committee of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán.
Conflict-of-interest statement: None.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Miguel-Angel Mercado, MD, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Belisario Domínguez Sección XVI, Tlalpan México 14080, DF, México. mercadiazma@yahoo.com
Telephone: +52-55-54870900-7452
Received: June 5, 2015
Peer-review started: June 5, 2015
First decision: June 18, 2015
Revised: August 21, 2015
Accepted: September 1, 2015
Article in press: September 2, 2015
Published online: October 27, 2015
Processing time: 151 Days and 6.3 Hours
Abstract

AIM: To describe our experience concerning the surgical treatment of Strasberg E-4 (Bismuth IV) bile duct injuries.

METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo (median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study.

RESULTS: Patients were divided in three groups: G1 (n = 21): Construction of neoconfluence + Roux-en-Y hepatojejunostomy. G2 (n = 26): Roux-en-Y portoenterostomy. G3 (n = 6): Double (right and left) Roux-en-Y hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation.

CONCLUSION: Loss of confluence represents a surgical challenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis (neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.

Keywords: Bile duct injury; Hepatojejunostomy; Biliary repair; Portoenterostomy; Neoconfluence; Double-barrel anastomosis

Core tip: Strasberg E-4 (Bismuth IV) bile duct injuries represent a surgical challenge. These injuries which involve two separated right and left ducts are of multifactorial etiology, and may be the result of ischemic or thermal damage, an inflammatory reaction, or anatomical variants that predispose the patient to injury. The treatment options are many, mainly surgical. Best results are obtained with Roux-en-Y hepatojejunostomies, as we describe in this article.