Management of a patient with a bile leak from hepatico-jejunostomy performed for bile duct injury

Management of a patient with a bile leak from hepatico

International Archives of Integrated Medicine, Vol.

Copy right © 2015, IAIM, All Rights Reserved.

Case Report

Management of a patient with a bile leak

from hepatico

A.J. Thanenthiran, K.B. Galketiya

Teaching Hospital,

*Corresponding author email:

How to cite this article: A.J. Thanenthiran

a bile leak from hepatico-jejunostomy performed for bile duct injury

Available online at

Received on: 17-12-2014

Abstract

Bile leak is a known complication following hepatico

presented a case history where a leak was successfully managed with an open abdomen which

allowed sepsis to settle and facilitate natural healing

Key words

Bile leak, Hepatico-jejunostomy, Bile duct

Introduction

Iatrogenic bile duct injuries are more common in

laparoscopic (0.3-0.5%) than open

cholecystectomy. Strasberg, et

bile duct injuries into five classes which is a

modified version of Bismuth classification

has five classes from A-E. Among those, class E

includes damage to the common hepat

or major hepatic ducts with or without stricture.

We reported a case of 44 year

admitted with complete transection of common

hepatic duct in the hilum (Bismuth

Class E 3) following laparoscopic

Management of a patient with a bile leak from hepatico-jejunostomy

International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015.

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from hepatico-jejunostomy performed for

bile duct injury

A.J. Thanenthiran, K.B. Galketiya*, MVG Pinto

Teaching Hospital, Peradeniya, Srilanka

*Corresponding author email: [email protected]

Thanenthiran, K.B. Galketiya, MVG Pinto. Management of a patient with

jejunostomy performed for bile duct injury. IAIM, 2015; 2(1

Available online at www.iaimjournal.com

2014 Accepted on:

Bile leak is a known complication following hepatico-jejunostomy performed for bile duct injury. We

a case history where a leak was successfully managed with an open abdomen which

allowed sepsis to settle and facilitate natural healing.

jejunostomy, Bile duct injury.

Iatrogenic bile duct injuries are more common in

0.5%) than open (0.1-0.2%) [1]

al. classified the

bile duct injuries into five classes which is a

modified version of Bismuth classification [2]. It

E. Among those, class E

includes damage to the common hepatic ducts

with or without stricture.

years old female

admitted with complete transection of common

hepatic duct in the hilum (Bismuth-Strasberg

Class E 3) following laparoscopic

cholecystectomy. She developed a bile leak on

the tenth post-operative day which was

managed with an open abdomen.

Case report

A 44 years old woman underwent laparoscopic

cholecystectomy for gallbladder neck calculus

with distended gallbladder. S

leak on the fourth postoperative day and was

transferred to our unit for further management.

On admission, pulse rate was 100/min, b

pressure was 120/80 mmHg, r

was 24/minute, and abdomen was slightly

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Page 100


jejunostomy performed for

, MVG Pinto

Management of a patient with

5; 2(1): 100-102.

Accepted on: 26-12-2014

performed for bile duct injury. We

a case history where a leak was successfully managed with an open abdomen which

cholecystectomy. She developed a bile leak on

perative day which was

managed with an open abdomen.

old woman underwent laparoscopic

cholecystectomy for gallbladder neck calculus

with distended gallbladder. She developed bile

leak on the fourth postoperative day and was

rred to our unit for further management.

, pulse rate was 100/min, blood

mmHg, respiratory rate

was 24/minute, and abdomen was slightly




distended with localized tenderness over right

hypochondrium. On Ultrasound scan abdomen

distal common bile duct was unable to visualize

and there was a localized collection seen in the

hepatorenal pouch. Endoscopic Retrograde

Cholangio Pancreatography (ERCP) showed

evidence of a common bile duct injury. Her total

bilirubin was 29.82 umol/l (1-17 umol/l).

spectrum antibiotics were started and prepared

for laparotomy.

Emergency laparotomy was done which

revealed complete transection of common

hepatic duct just after the confluence of major

hepatic ducts. Roux En Y loop was created from

the proximal jejunum and End to Side Hepatico

Jejunostomy was performed. A feeding tube was

placed across the anastomotic site, ex

via the jejunal loop. The proximal end of the

Roux loop was anastomosed to the stomach as

an access path to the anastomosis. A large bore

drainage tube was placed in the sub hepatic

space.

Patient was transferred to intensive care unit

(ICU) and was extubated on first post

day. Patient recovered from biliary peritonitis

with bilirubin levels becoming normal

was transferred back to ward on post

day 6 and was on a normal diet by the seventh

post-operative day, oral sips

established from the third day.

The abdominal drain was removed on day 8

which had no drainage from day four. Tw

later a bile leak was noted through the

laparotomy incision. Contrast study was done

through the feeding tube which revealed that it

had fallen back in to the jejunum. Therefore the

degree of anastomotic breakdown could not be

interpreted. Ultrasound scan

generalized free fluid in the abdomen.



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distended with localized tenderness over right

hypochondrium. On Ultrasound scan abdomen,

distal common bile duct was unable to visualize

and there was a localized collection seen in the

hepatorenal pouch. Endoscopic Retrograde

Cholangio Pancreatography (ERCP) showed

evidence of a common bile duct injury. Her total

17 umol/l). Broad

spectrum antibiotics were started and prepared

Emergency laparotomy was done which

revealed complete transection of common

hepatic duct just after the confluence of major

hepatic ducts. Roux En Y loop was created from

the proximal jejunum and End to Side Hepatico

Jejunostomy was performed. A feeding tube was

placed across the anastomotic site, exteriorized

. The proximal end of the

Roux loop was anastomosed to the stomach as

stomosis. A large bore

drainage tube was placed in the sub hepatic

Patient was transferred to intensive care unit

(ICU) and was extubated on first post-operative

day. Patient recovered from biliary peritonitis

with bilirubin levels becoming normal. Patient

ransferred back to ward on post-operative

ay 6 and was on a normal diet by the seventh

operative day, oral sips has been

The abdominal drain was removed on day 8

which had no drainage from day four. Two days

later a bile leak was noted through the

laparotomy incision. Contrast study was done

through the feeding tube which revealed that it

had fallen back in to the jejunum. Therefore the

degree of anastomotic breakdown could not be

d scan showed

generalized free fluid in the abdomen.

A relaparotomy was done on post

11 which revealed a bile leak into the peritoneal

cavity (about 1 litre). Peritoneal cavity was

thoroughly washed out with normal Saline. The

site of the anastomosis was not disturbed. A

large bore drain tube was replaced close to the

hepatorenal pouch. The abdomen was kept

open as a laparostomy bowel loops being

protected using uribag.

Daily washout of the peritoneal cavity with

Normal Saline was done thro

and abdominal dressing was changed twice

daily. The leak through the open abdomen

gradually declined and repeat Ultrasound scan

showed no collections and no intra

dilatation. Abdomen was closed after two

weeks.

Discussion

Strasberg-Bismuth class E3 is a major bile duct

injury with a higher morbidity and mortality rate

due to biliary peritonitis. Roux

jejunostomy is the accepted treatment

Following hepatico-jejunostomy

known complication and strictures may occur

later on [4]. Having a large bore drain placed in

the sub hepatic space for at least one week will

help to drain if a bile leak occurs. Having an

access loop allows endoscopic dilatation of

anastomotic strictures [5].

In this patient, the drain tube was removed on

day 8 and developed a leak 2

reopening was needed as it was a large leak. The

anastomotic site was not disturbed and drainage

to the exterior was achieved with a sub hepatic

drain and leaving the abdomen open.

drainage of leak minimized biliary peritonitis

allowing natural healing of the anastomotic

dehiscence. Open abdomen is well recognized to

be life saving in patients with adverse intra

abdominal conditions like infection, leaks,

ISSN: 2394-0026 (P)

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Page 101

A relaparotomy was done on post-operative day

11 which revealed a bile leak into the peritoneal

(about 1 litre). Peritoneal cavity was

thoroughly washed out with normal Saline. The

nastomosis was not disturbed. A

large bore drain tube was replaced close to the

hepatorenal pouch. The abdomen was kept

open as a laparostomy bowel loops being

the peritoneal cavity with

ormal Saline was done through the drain tube

and abdominal dressing was changed twice

daily. The leak through the open abdomen

radually declined and repeat Ultrasound scan

showed no collections and no intra-hepatic duct

dilatation. Abdomen was closed after two

class E3 is a major bile duct

injury with a higher morbidity and mortality rate

due to biliary peritonitis. Roux-en-Y hepatico

jejunostomy is the accepted treatment [3].

jejunostomy bile leak is a

strictures may occur

. Having a large bore drain placed in

the sub hepatic space for at least one week will

help to drain if a bile leak occurs. Having an

access loop allows endoscopic dilatation of

the drain tube was removed on

day 8 and developed a leak 2 days later. A

reopening was needed as it was a large leak. The

anastomotic site was not disturbed and drainage

to the exterior was achieved with a sub hepatic

drain and leaving the abdomen open. The

drainage of leak minimized biliary peritonitis

allowing natural healing of the anastomotic

dehiscence. Open abdomen is well recognized to

be life saving in patients with adverse intra-

abdominal conditions like infection, leaks,




trauma and increased intra-abdominal pressure

[6]. Various methods of temporary c

described and we used uribag, which is readily

available and low cost [7]. Ultrasound scan

done before closure of the laparostomy and

revealed no intra hepatic duct dilatation with no

free fluid in the hepatorenal pouch or pelvis.

Conclusion

In face of a major anastomotic dehiscence,

drainage and use of open abdomen

(laparostomy) along with intensive care allowed

sepsis to settle facilitating natural healing of the

leak. The gastric access loop is useful which will

allow endoscopic dilatation of stricture, if it

occurs.

References

1. Pekolj J, Alvarez FA, Palavecino M, et al.

Intraoperative management and repair

of bile duct injuries sustained during

10,123 laparoscopic cholecystectomi

in a high-volume referral center. J Am

Coll Surg, 2013; 216(5): 894

Source of support: Nil



Rights Reserved.

abdominal pressure

. Various methods of temporary cover are

bag, which is readily

Ultrasound scan was

done before closure of the laparostomy and

hepatic duct dilatation with no

free fluid in the hepatorenal pouch or pelvis.

In face of a major anastomotic dehiscence,

drainage and use of open abdomen

(laparostomy) along with intensive care allowed

sepsis to settle facilitating natural healing of the

access loop is useful which will

allow endoscopic dilatation of stricture, if it

Pekolj J, Alvarez FA, Palavecino M, et al.

Intraoperative management and repair

of bile duct injuries sustained during

10,123 laparoscopic cholecystectomies

volume referral center. J Am

894-901.

2. Strasberg SM, Hertl M, Soper NJ. An

analysis of the problem of biliary injury

during laparoscopic cholecystectomy. J

Am Coll Surg, 1995;

3. Connor S, Garden OJ. Bile duct

the era of laparoscopic

cholecystectomy. Br J Surg

158e-68.

4. Lillemoe KD, Melton GB, Cameron JL, et

al. Postoperative bile duct strictures:

management and outcome in the 1990s.

Ann Surg, 2000; 232: 430e

5. Mohan De Silva. Management

iatrogenic bile duct injuries;

learned. R A Navaratne oration,

2010.

6. Demetriades D, Salim A

the open abdomen.

2014; 94(1): 131-53.

7. Maddah G, Shabahang H

Zehi V, Abdollahi M

abdominal closure in the critically ill

patients with an open abdomen

Med Iran, 2014; 52(5):

Nil Conflict of interest:

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ISSN: 2394-0034 (O)

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Strasberg SM, Hertl M, Soper NJ. An

analysis of the problem of biliary injury

during laparoscopic cholecystectomy. J

180: 101-25.

Connor S, Garden OJ. Bile duct injury in

the era of laparoscopic

cholecystectomy. Br J Surg, 2006; 93:

Lillemoe KD, Melton GB, Cameron JL, et

al. Postoperative bile duct strictures:

management and outcome in the 1990s.

232: 430e-41.

Mohan De Silva. Management of

iatrogenic bile duct injuries; the lessons

R A Navaratne oration, CSSL,

Salim A. Management of

. Surg Clin North Am.,

53.

Shabahang H, Abdollahi A,

Abdollahi M. Temporary

abdominal closure in the critically ill

patients with an open abdomen. Acta

52(5): 375-80.

Conflict of interest: None declared.

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Management of a patient with a bile leak from hepatico-jejunostomy performed for bile duct injury