Management Algorithm for Biliary Complications (Graphic-1)
(I) Majority of the LLDs who had a radiological perihepatic bilioma with findings of cholangitis or abscess without acute abdomen underwent percutaneous transhepatic drainage and in rare occasions (Fig.1a), a percutaneous transperitoneal (non-hepatic) drainage was performed (Fig.1b). A drainage catheter was not placed in the perihepatic fluid collections or perihepatic abscess like fluid collections without abdominal findings when there is no bile in the aspirated fluid and these cases were generally followed-up with US. In rare cases with recurrent collection, the procedure was repeated. LLDs who received a drainage catheter were controlled with pouchography following couple of days to provide a decrease of pressure in the collection and reduction of the edema. In cases without any bile duct connection, “wait and see” strategy was chosen (Fig.1c). In majority of these cases the bilioma was caused by minor bile duct draining the caudate lobe (Fig.1d). Cases with a bile duct connection were evaluated and treated according to the communication of the bile leaks either to the main or isolated major segmental branches of hepatic duct (Fig.2). Cases with a communication with the main bile ducts were treated primarily with ERCP+ sphincterotomy ± stent placement. If ERCP failed due to technical reasons or bile leaks persisted despite ERCP, an external-internal or external PTBD catheter was inserted. In LLDs with bile leaks from an isolated segmental bile duct located on the cut surface of remnant liver without any communication with a major bile duct, treatment method is chosen according to daily amount of bile drainage. In LLDs with bile drainage less than 50 mL/day are mostly related to minor segmental bile duct; thus close follow-up without any invasive intervention is preferred but very rarely fibrin glue plug is applied to the bile duct through percutaneous placed catheter in cases with prolonged low volume drainage less than 20ml/days. In LLDs with prolonged bile drainage more than 50 ml/days can be related to major segmental bile duct which require PTBD catheter. If bile leaks was communicated with major segmental bile duct in PTC, PTBD assisted HJ can be considered. Even if the external-internal PTBD catheter is inserted, the most appropriate approach is PTBD guided HJ in cases with persistent bile leaks from the site of bile duct stumps. The reason for this is due to the fact that ischemic defects in the bile duct stump that often unsuitable for primary repair.
(II) For LLDs with a biliary drainage from the perihepatic surgical drain without acute abdomen, wait and see for first postoperative five days is the preferred management strategy. Early relaparotomy is beneficial in cases with pure bile flow more than 300 ml/day within the postoperative first two days, which we preferred in two cases in the present study. In LLDs with persistent biliary drainage prolonged (≥5 days), bile duct injury is usually evaluated with MRCP and/or occasionally with fluoroscopy enhanced with contrast media delivered from surgical drain where placed in the perihepatic space. In patients whose MRCP was unsuccessful to show the remnant biliary tract, diagnostic ERCP was considered and, stent was inserted in necessary cases. Wait and see strategy was chosen in LLDs without any evident relation with the bile ducts. If any relation with the bile ducts was diagnosed, first column of the algorithm was chosen (see Graphic-1).
(III) For LLDs with isolated enzyme elevation and without any clinical or ultrasonographic findings, MRCP is utilized to evaluate the biliary tract. LLDs without any biliary stricture diagnosed with MRCP require further investigation for evaluation of any possible parenchymal disease (transient elastography, biopsy, genetic analysis etc). LLDs with biliary stricture on MRCP undergo ERCP± sphincterotomy and a stent is inserted for the treatment of the stricture. In LLDs whom ERCP failed, PTBD is performed and external-internal PTBD catheter is inserted and during the follow-up period stent ‘renewal is performed with ERCP. If external-internal PTBD procedure failed to pass through the stricture, external PTBD catheter is inserted and re-evaluated a few days later. If the repeated attempt fails again, PTBD catheter assisted HJ is performed.
(IV) Relaparotomy was performed for LLDs with acute abdomen. Following irrigation of abdominal cavity, cut surface of remnant liver, left or right hepatic duct stumps, cystic duct stump and main bile duct are evaluated thoroughly and minor bile leaks points on cut surface of the remnant liver are sutured with polypropylene. Cholangiography is performed via catheter inserted into cystic duct. When major bile leaks are detected during cholangiography, catheter is sent through the cystic duct to the remnant liver bile ducts. After this procedure, bile leaks points are repaired with polypropylene suture materials. Postoperative cholangiography is performed two to four weeks later and catheter was withdrawn if no bile leak is observed.