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.