Conservative Management of Isolated Sectoral Duct Injury With Bile Leak (Type C Injury): Important and Essential Initial Step in the Management, Not an Option

Abstract

Dear Editor, We read the article by Mazer et al. with great interest. This study adds to the emerging evidence for the conservative management of isolated sectoral duct injury. Isolated injury to the right sectoral duct may (Strasberg type C) or may not (Strasberg type B) present with bile leak. There is no universally accepted single modality of treatment for these injuries. Detected intraoperatively, these ducts may be ligated safely, thus actually converting type C injury into type B injury, with the patient usually remaining asymptomatic and the undrained liver becoming atrophied without major sequelae. However, some advocate repair in all the cases irrespective of the size of the duct. Few points need to be clarified before it can be concluded that conservative management is an important option for patients with an isolated right posterior bile duct injury as suggested by Mazer et al. First, follow-up is very short with a mean of 8.2 months (2 to 14 months). Even after surgical repair, a minimum follow-up of 5 years is considered optimum. Second, three patients underwent biliary stenting. How stenting is useful in such cases, where by definition of Strasberg type B or C (all cases in this report), hepatoenteric continuity of aberrant sectoral or right hepatic duct is lost. These injuries are classically suspected when the biliary system is apparently normal on ERCP, in the presence of biliary leak. Did the biliary fistula respond to stenting in these cases? Third, results of this study are considered as “excellent”. Results of surgical repair are considered as excellent when liver enzymes and the biliary ductal system are normal in an asymptomatic patient. Three out of five patients had elevated serum alkaline phosphatase on follow-up. This may be due to ongoing liver atrophy, and in such cases, gamma glutamyl transpeptidase may be more informative regarding the development of biliary stricture. Lastly, it is concluded that the conservative management is an important option for patients with an isolated right posterior bile duct injury. In fact, conservative management with radiological and endoscopic interventions is an essential initial step in the management of all patients presenting with bile leak even if surgical repair is planned later on. This allows the local sepsis to subside allowing safe repair. In addition, delayed approach in such situation allows the fistula to close by itself, and if repair is deemed necessary, it can be performed on the dilated duct. In this series, all patients had bile leak, i.e. type C injury.