Should we stent bilioenteric anastomosis after complex iatrogenic bile duct injury?

Abstract

Introduction: Iatrogenic bile duct injuries after cholecystectomy are challenging complications that often require multidisciplinary approach. Placement of an anastomotic stent is a matter of debate especially when a vascular injury is associated. Methods: We report two cases referred to our HPB Unit presenting with sepsis secondary to biliary peritonitis following laparoscopic cholecystectomy. Both cases consisted on complex bile duct injury (Strasberg E4) associated to vascular injury (right hepatic artery). The first patient was initially treated with percutaneous drainage of multiple intraabdominal collections and bilobar percutaneous transhepatic biliary drainage (PTBD). Intraoperatively, no viable bile ducts could be identified. Following source control of sepsis, the patient underwent a portoenterostomy and PTBDs were utilized to stent the anastomosis. In the second patient, no PTBD were placed preoperatively because an urgent laparotomy was needed due to biliary peritonitis. Intraoperatively, three small ischemic ducts could be identified (right, segment 4 and segment 2-3 bile ducts). The portoenterostomy was stented with three transjejunal tubes. Results: In both cases, the catheters were removed three months after surgery following a cholangiography demonstrating absence of leak or strictures. At 12-month follow-up, no biliary complications were detected. Conclusion: In case of hilar bile duct injuries associated with vascular injury, stenting of bilioenteric anastomosis can be helpful to avoid postoperative bile leak and late biliary complications.