Hepatectomy as an Upfront Surgical Modality for Strasberg E4 Biliary Injuries

Abstract

Introduction: High biliary injuries are associated with worse outcomes. Overall success following Roux-en-Y hepatico-jejunostomy (HJ) ranges between 85-95% over 55-110 months. Failure rates specific to injury grade are rarely discussed. In our experience, Strasberg-E4 injuries, are associated with a higher failure rate. This study shares our experience with the surgical management of Strasberg-E4 injuries. Methods: Between October 2003 and December 2020, 119 operations for post-cholecystectomy biliary injuries were performed. Between 2003 and 2010, the preferred operation was an HJ. When possible, the right and left ducts were approximated to construct a single anastomosis. If tension-free approximation was not possible, separate anastomoses were constructed. From 2010 onwards, Strasberg-E4 injuries were considered for a right hepatectomy with left duct HJ. Patients were followed up at 6 monthly intervals with liver functions and abdominal ultrasound. Results: Sixteen(13.4%) patients had Strasberg-E4 injuries, thirteen presented with an external biliary fistula and three with obstructive jaundice. Of the ten patients who underwent HJ before 2010, nine developed cholangitis, median follow-up of 14 months (2-28months). Five of these, subsequently underwent a hepatectomy, one, a liver transplant and other three, radiological dilatation of their anastomoses. From 2010 onwards, six, underwent an upfront right hepatectomy with left duct HJ. At a median follow up of 40 months (10-74months), 3 developed minor derangement of liver enzymes, none required an additional intervention. Conclusion: Poor long-term results are seen with E4 injuries. An upfront right hepatectomy with left duct anastomosis might yield better long-term results than Roux en Y HJ.Tabled 1Follow upInitial Roux en Y HJ (n=10)Upfront hepatectomy (n=6)Success rate (Terblanche grades 1,2)1/10, 84 months5/6, 40 months (10 – 74)Time to cholangitis9/10, 20 months (4 – 28)-Time to first intervention (Radiological or Surgical )9/10, 24 months (10 – 35)-Time for re-do surgery6/10, 26 months (16 – 28)-Need for liver transplant1/10, 16 months- Open table in a new tab