Korean J Hepatobiliary Pancreat Surg.  2011 Aug;15(3):189-193. 10.14701/kjhbps.2011.15.3.189.

Therapeutic induction of hepatic atrophy for isolated injury of the right posterior sectoral duct following laparoscopic cholecystectomy

• Hwang S
• Yoon SY
• Jung SW
• Namgoong J
• Park GC
• Gwon DI
• Lee SG

• KMID: 2130992
• DOI: http://doi.org/10.14701/kjhbps.2011.15.3.189

Abstract

Laparoscopic cholecystectomy has resulted in various bile duct injuries. Treatment of these injuries is usually difficult and often leads to an intractable clinical course. We herein present a case of isolated right anterior sector (RAS) duct injury induced by laparoscopic cholecystectomy. The bile duct injury was successfully treated by hepatic atrophy induction. Imaging studies revealed that the RAS duct was severed, probably due to rare anatomical variations. Considering the difficulty in surgical reconstruction, atrophy induction of the involved hepatic parenchyma was attempted. This treatment consisted of embolization of the RAS portal branch to inhibit bile production, induction of heavy adhesion at the bile leak site to ensure percutaneous pigtail clamping, and sequential clamping and removal of pigtail catheters. This procedure took 3 months prior to pigtail catheter removal. She was free from other complications during the first 12 months and to date. She will be followed up for 5 years overall including surveillance for hepatobiliary complications. Although this therapeutic induction of atrophy approach is not universally applicable, it can be considered to be a feasible option in unique situations such as this one.

Keyword

Laparoscopic cholecystectomy; Sectoral bile duct injury; Liver atrophy; Portal vein embolization

MeSH Terms

Atrophy
Bile
Bile Ducts
Catheters
Cholecystectomy, Laparoscopic
Constriction
Dietary Sucrose
Dietary Sucrose

Figure

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  Fig. 1 Laparoscopic findings of the gallbladder (A) and gallbladder bed after cholecystectomy (B). Only the cystic duct stump was ligated except for small clips applied to the cystic artery. There was no evidence of bile leak from the dissected surface.

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  Fig. 2 Abdomen computed tomography scan showing progressive accumulation of abnormal fluid collection in the subhepatic and subphrenic areas at 1 week (A and B) and 2 weeks (C and D) after laparoscopic cholecystectomy.

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  Fig. 3 Endoscopic retrograde cholangiography images showing no evidence of bile leak. Each was taken at 1 week (A) and 3 weeks (B) after laparoscopic cholecystectomy. Subhepatic pigtail catheters are shown together (B). There is an abnormal finding showing only one right sectoral duct.

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  Fig. 4 Magnetic resonance cholangiography images showing the extent of bile duct injury. Bile is leaking from the right anterior sectoral duct and scattered to the subhepatic and subphrenic areas (A). The missed portion of the right anterior segmental duct (red) and its imaginary insertion into the cystic duct (green) are illustrated (B).

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  Fig. 5 Hepatobiliary scan images taken before (A) and 6 months after (B) embolization of the portal branch of the right anterior sector. The territory of the right anterior sector appears to be deficient in bile production.

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  Fig. 6 Sequences of liver computed tomography scans showing progressive atrophy of the right anterior sector. The images were taking before (A), and 1 week (B), 1 month (C), and 6 months (D) after segmental portal vein embolization.

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  Fig. 7 Percutaneous direct portogram images taken before (A) and after (B) embolization of the portal branch of the right anterior sector.

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