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-jejunostomy ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O)Management of a patient with a bile leakfrom hepatico-jejunostomy performed for bile duct injury A.J. Thanenthiran, K.B. Galketiya*, MVG Pinto Teaching Hospital, Peradeniya, Srilanka *Corresponding author email: [email protected] to cite this article: A.J. Thanenthiran, K.B. Galketiya, MVG Pinto. Management of a patient witha bile leak from hepatico-jejunostomy performed for bile duct injury. IAIM, 2015; 2(1): 100-102. Available online at www.iaimjournal.comReceived on: 17-12-2014 Accepted on: 26-12-2014AbstractBile leak is a known complication following hepatico-jejunostomy performed for bile duct injury. Wepresented a case history where a leak was successfully managed with an open abdomen whichallowed sepsis to settle and facilitate natural healing.Key wordsBile leak, Hepatico-jejunostomy, Bile duct injury.Introduction cholecystectomy. She developed a bile leak on the tenth post-operative day which wasIatrogenic bile duct injuries are more common in managed with an open abdomen.laparoscopic (0.3-0.5%) than open (0.1-0.2%) [1]cholecystectomy. Strasberg, et al. classified the Case reportbile duct injuries into five classes which is amodified version of Bismuth classification [2]. It A 44 years old woman underwent laparoscopichas five classes from A-E. Among those, class E cholecystectomy for gallbladder neck calculusincludes damage to the common hepatic ducts with distended gallbladder. She developed bileor major hepatic ducts with or without stricture. leak on the fourth postoperative day and wasWe reported a case of 44 years old female transferred to our unit for further management.admitted with complete transection of common On admission, pulse rate was 100/min, bloodhepatic duct in the hilum (Bismuth-Strasberg pressure was 120/80 mmHg, respiratory rateClass E 3) following laparoscopic was 24/minute, and abdomen was slightlyInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 100Copy right © 2015, IAIM, All Rights Reserved.

Management of a patient with a bile leak from hepatico-jejunostomy ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)distended with localized tenderness over right A relaparotomy was done on post-operative dayhypochondrium. On Ultrasound scan abdomen, 11 which revealed a bile leak into the peritonealdistal common bile duct was unable to visualize cavity (about 1 litre). Peritoneal cavity wasand there was a localized collection seen in the thoroughly washed out with normal Saline. Thehepatorenal pouch. Endoscopic Retrograde site of the anastomosis was not disturbed. ACholangio Pancreatography (ERCP) showed large bore drain tube was replaced close to theevidence of a common bile duct injury. Her total hepatorenal pouch. The abdomen was keptbilirubin was 29.82 umol/l (1-17 umol/l). Broad open as a laparostomy bowel loops beingspectrum antibiotics were started and prepared protected using uribag.for laparotomy. Daily washout of the peritoneal cavity withEmergency laparotomy was done which Normal Saline was done through the drain tuberevealed complete transection of common and abdominal dressing was changed twicehepatic duct just after the confluence of major daily. The leak through the open abdomenhepatic ducts. Roux En Y loop was created from gradually declined and repeat Ultrasound scanthe proximal jejunum and End to Side Hepatico showed no collections and no intra-hepatic ductJejunostomy was performed. A feeding tube was dilatation. Abdomen was closed after twoplaced across the anastomotic site, exteriorized weeks.via the jejunal loop. The proximal end of theRoux loop was anastomosed to the stomach as Discussionan access path to the anastomosis. A large boredrainage tube was placed in the sub hepatic Strasberg-Bismuth class E3 is a major bile ductspace. injury with a higher morbidity and mortality ratePatient was transferred to intensive care unit due to biliary peritonitis. Roux-en-Y hepatico(ICU) and was extubated on first post-operative jejunostomy is the accepted treatment [3].day. Patient recovered from biliary peritonitis Following hepatico-jejunostomy bile leak is awith bilirubin levels becoming normal. Patient known complication and strictures may occurwas transferred back to ward on post-operative later on [4]. Having a large bore drain placed inday 6 and was on a normal diet by the seventh the sub hepatic space for at least one week willpost-operative day, oral sips has been help to drain if a bile leak occurs. Having anestablished from the third day. access loop allows endoscopic dilatation of anastomotic strictures [5].The abdominal drain was removed on day 8 In this patient, the drain tube was removed onwhich had no drainage from day four. Two days day 8 and developed a leak 2 days later. Alater a bile leak was noted through the reopening was needed as it was a large leak. Thelaparotomy incision. Contrast study was done anastomotic site was not disturbed and drainagethrough the feeding tube which revealed that it to the exterior was achieved with a sub hepatichad fallen back in to the jejunum. Therefore the drain and leaving the abdomen open. Thedegree of anastomotic breakdown could not be drainage of leak minimized biliary peritonitisinterpreted. Ultrasound scan showed allowing natural healing of the anastomoticgeneralized free fluid in the abdomen. dehiscence. Open abdomen is well recognized to be life saving in patients with adverse intra- abdominal conditions like infection, leaks,International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 101Copy right © 2015, IAIM, All Rights Reserved.

Management of a patient with a bile leak from hepatico-jejunostomy ISSN: 2394-0026 (P)trauma and increased intra-abdominal pressure ISSN: 2394-0034 (O) 2. Strasberg SM, Hertl M, Soper NJ. An[6]. Various methods of temporary cover are analysis of the problem of biliary injurydescribed and we used uribag, which is readily during laparoscopic cholecystectomy. Javailable and low cost [7]. Ultrasound scan was Am Coll Surg, 1995; 180: 101-25.done before closure of the laparostomy and 3. Connor S, Garden OJ. Bile duct injury inrevealed no intra hepatic duct dilatation with no the era of laparoscopicfree fluid in the hepatorenal pouch or pelvis. cholecystectomy. Br J Surg, 2006; 93: 158e-68.Conclusion 4. Lillemoe KD, Melton GB, Cameron JL, et al. Postoperative bile duct strictures:In face of a major anastomotic dehiscence, management and outcome in the 1990s.drainage and use of open abdomen Ann Surg, 2000; 232: 430e-41.(laparostomy) along with intensive care allowed 5. Mohan De Silva. Management ofsepsis to settle facilitating natural healing of the iatrogenic bile duct injuries; the lessonsleak. The gastric access loop is useful which will learned. R A Navaratne oration, CSSL,allow endoscopic dilatation of stricture, if it 2010.occurs. 6. Demetriades D, Salim A. Management of the open abdomen. Surg Clin North Am.,References 2014; 94(1): 131-53. 7. Maddah G, Shabahang H, Abdollahi A,1. Pekolj J, Alvarez FA, Palavecino M, et al. Zehi V, Abdollahi M. Temporary Intraoperative management and repair abdominal closure in the critically ill of bile duct injuries sustained during patients with an open abdomen. Acta 10,123 laparoscopic cholecystectomies Med Iran, 2014; 52(5): 375-80.in a high-volume referral center. J AmColl Surg, 2013; 216(5): 894-901.Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 102Copy right © 2015, IAIM, All Rights Reserved.