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Emergency liver resection for combined biliary and vascular injury following laparoscopic cholecystectomy: case report and review of the literature.

Abstract: A 75-year-old woman suffering from symptomatic cholelithiasis was admitted to our hospital for elective laparoscopic cholecystectomy (LC). Intraoperatively, because of severe inflammation and dense adhesions in the region of the Calot triangle and bleeding arising from the porta hepatis which obscured the operating field, the method was converted to a conventional open approach. Copious hemostasis was achieved using sutures, clips and diathermy, and no bile duct or vascular injuries were recognized intraoperatively. Because of severe right upper quadrant abdominal pain and significant deterioration of the liver function tests (LFTs) on the first postoperative day, the patient underwent a Doppler ultrasound scan which showed absence of blood flow at the level of porta hepatis. Urgent relaparotomy revealed an ischemic liver on the right, a transected common bile duct at the level of its confluence, a divided and ligated right hepatic artery and thrombosed portal vein down to its confluence. Thrombectomy and reconstruction of the portal vein were performed to salvage the left hemiliver, and after restoration of blood flow to the left hemiliver, a right hemihepatectomy and a Roux-en-Y hepaticojejunostomy on the left were performed.

Liver resection serves an important role in the case of parenchymal necrosis due to combined biliary, hepatic artery and portal vein injury following laparoscopic cholecystectomy and moreover, the operation can be safely performed in the acute setting.

Key Words: laparoscopic cholecystectomy, bile duct injury, hepatic artery injury, portal vein injury, hepatectomy, liver resection

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Laparoscopic cholecystectomy (LC) constitutes the operation of choice for symptomatic gallstone disease. (1) Meanwhile, a 0.62% incidence of postcholecystectomy biliary injury has been reported. (2) Concomitant vascular injuries complicate the course of these patients with an incidence of 47%. (3)

The combination of biliary and vascular injury following LC contributes significantly to the postoperative morbidity and mortality, particularly in cases of delayed diagnosis. (4-7) The degree of the hepatic damage, the need for liver resection, or even liver transplantation are also contributing factors of the morbidity and mortality. (4,5,8)

Case Report

A 75-year-old female patient suffering from symptomatic cholelithiasis underwent elective laparoscopic cholecystectomy (LC). Because of severe inflammation and dense adhesions at the region of Calot triangle and bleeding arising from the porta hepatis which obscured the operating field, LC was converted to an open procedure through a standard right subcostal incision. Copious hemostasis was achieved using sutures, clips and diathermy, and no bile duct injury was recognized intraoperatively. On the first postoperative day, the patient complained of constant and severe right upper quadrant abdominal pain, while liver function tests (LFTs) were significantly elevated: aspartate aminotransferase (AST) 5250 IU/L (normal: 5-40 IU/L), alanine aminotransferase (ALT) 4672 IU/L (normal: 5-40 IU/L), total bilirubin 2.7 mg/dL (normal: 0.2-1.0 mg/dL). Evaluation with Doppler ultrasonography showed no portal flow due to occlusive thrombus of the portal axis down to the splenomesenteric confluence.

Urgent relaparotomy revealed an ischemic liver, especially on the right. The common bile duct was found to be transected and suture ligated at the level of its confluence. The right hepatic artery was also found to be divided between clips. The left and proper hepatic arteries were found to be intact, both by palpation and intraoperative Doppler ultrasound. The right portal vein was suture ligated while its main tract was thrombosed down to the splenomesenteric confluence. The bowel wall did not show any signs of ischemia or congestion.

Thrombectomy and reconstruction of the portal vein were performed to salvage the left hemiliver. After restoration of the blood flow to the left liver, right hemihepatectomy and an end-to-side Roux-en-Y hepaticojejunostomy on the left were performed (Fig.).

Postoperatively, the patient was transferred to the ICU. Her postoperative recovery was complicated by pneumonia and Acinetobacter baumanni was isolated from sputum cultures. Despite normal liver function tests and Doppler ultrasound findings, as well as proper antibiotic therapy administration, the patient died on the 16th postoperative day due to uncontrolled sepsis.

Literature Review

A MEDLINE database search was conducted using the following key words: laparoscopic cholecystectomy, bile duct injury (BDI), hepatic artery injury (HAI), (2) portal vein injury (PVI), hepatectomy, and liver resection. References were limited to articles of which the abstract at least was in the English language. Liver resections were classified according to the International Hepato-Pancreato-Biliary Association (IHPBA) recommendations. (9)

Discussion

Isolated BDI rarely requires liver resection for management of its long-term complications. (10) However, the simultaneous presence of vascular injury worsens the clinical course of the patient because of the development of complications such as liver necrosis and biliary stricture. (4,8,11)

As right hepatic artery (RHA) frequently runs closely and parallel to the cystic duct, it is more vulnerable to injury (12,13) and can be easily ligated if the structures in the Calot triangle are not clearly identified. (14) Although occlusion of the RHA is usually well tolerated because collaterals from the diaphragm and retroperitoneum support the liver, (11,15) the development of intrahepatic abscess, (11) ischemic necrosis of the right hepatic lobe, (11) recurrent episodes of cholangitis and subsequent secondary biliary cirrhosis, (11) as well as liver atrophy, have been reported as long-term complications, which might require liver resection for successful treatment. The incidence of liver necrosis with or without abscess formation has been reported to be as high as 75% (16) in patients with BDI and arterial injury. Almost half of such patients who underwent bilioenteric anastomosis for the BDI treatment developed postoperative biliary leak due to either primary hepaticojejunostomy failure (17) or late peripheral biliary duct stenosis of ischemic origin. (17) Thus, patients with confirmed bile duct injury should be evaluated for concomitant hepatic arterial injury and if this is present, should be treated immediately. (6) The literature addresses that hepatectomy is more common when a BDI is combined with an RHA injury, compared with isolated BDI. (12) Combined biliary duct and hepatic artery injury require various types of hepatic resections to treat mainly secondary biliary cirrhosis (Table 1). (3,6,10-12,18-22)

[FIGURE OMITTED]

Since an intact portal circulation is mandatory for hepatic parenchyma oxygenation in cases of hepatic artery injury and is a prerequisite for successful reconstruction in a dearterialized hepatic parenchyma, (6) the portal blood flow should be thoroughly examined in any case of BDI and RHA injury following LC. In fact, 9 cases of combined biliary duct, hepatic artery and portal vein injury following LC requiring liver resections have been previously reported (3,4,8,23) (Table 2).

Patients with biliovascular injuries status post LC, involving both the hepatic artery and portal vein branches, as compared with biliovascular injuries involving the hepatic artery branch alone present earlier (median time interval: 17.5 d versus 97.5 d, respectively) and are most likely to have undergone formal hepatectomies rather than partial liver resections.

The liver resection may be performed in an acute (minutes to hours after injury), late acute (days after the injury) or late (weeks after injury) setting. (21,24) The majority of the reported combined injuries (BDI + RHA [+ or -] PVI) (Tables 1 and 2) were recognized neither at the time of the LC, nor during the early postoperative period.

To our knowledge, the present case is the first reported in the English literature in which liver resection was done in an acute setting (20 hour). The dry operative field, the immediate identification of the injured structures, as well as the absence of severe inflammatory reaction, contributed to the immediate restoration of the blood flow to the liver and the salvage of the left hemiliver.

The elapsed period between the time of a bile duct injury and the time of referral has been proposed as a significant predictor of outcome (6) since delay in the diagnosis of a combined vascular injury, as well as long-term conservative management, makes the situation more burdensome for the surgeon. (8,12,25,26) Delayed diagnosis of vascular lesions leads to difficulty with revascularization and reconstruction, resulting in hepatic necrosis and liver cirrhosis. (6)

In conclusion, liver resection may serve an important role in cases of parenchymal necrosis, liver atrophy, massive bleeding or intraparenchymal bile duct injuries in cases of complicated biliovascular injury, including PVI, following LC. The present case suggests that major liver resection status post combined BDI and vascular injury can be safely performed in an acute setting.

References

1. McMahon AJ, Russell IT, Baxter JN, et al. Laparoscopic versus mini-laparotomy cholecystectomy: a randomised trial. Lancet 1994;343:135-138.

2. Diamantis T, Tsigris C, Kiriakopoulos A, et al. Bile duct injuries associated with laparoscopic and open cholecystectomy: an 11-year experience in one institute. Surg Today 2005;35:841-845.

3. Alves A, Farges O, Nicolet J, et al. Incidence and consequence of an hepatic artery injury in patients with postcholecystectomy bile duct strictures. Ann Surg 2003;238:93-96.

4. Madariaga JR, Dodson SF, Selby R, et al. Corrective treatment and anatomic considerations for laparoscopic cholecystectomy injuries. J Am Coll Surg 1994;179:321-325.

5. Robertson AJ, Rela M, Karani J, et al. Laparoscopic cholecystectomy injury: an unusual indication for liver transplantation. Transpl Int 1998;11:449-451.

6. Frilling A, Li J, Weber F, et al. Major bile duct injuries after laparoscopic cholecystectomy: a tertiary center experience. J Gastrointest Surg 2004;8:679-685.

7. Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 1992;215:196-202.

8. Nishio H, Kamiya J, Nagino M, et al. Right hepatic lobectomy for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 1999;6:427-430.

9. Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 2005;12:351-355.

10. Perini RF, Uflacker R, Cunningham JT, et al. Isolated right segmental hepatic duct injury following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 2005;28:185-195.

11. Schmidt SC, Langrehr JM, Raakow R, et al. Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases. Langenbecks Arch Surg 2002;387:183-187.

12. Stewart L, Robinson TN, Lee CM, et al. Right hepatic artery injury associated with laparoscopic bile duct injury: incidence, mechanism, and consequences. J Gastrointest Surg 2004;8:523-530; discussion 530-521.

13. Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003;237:460-469.

14. Scott-Conner CE, Hall TJ. Variant arterial anatomy in laparoscopic cholecystectomy. Am J Surg 1992;163:590-592.

15. Mays ET, Wheeler CS. Demonstration of collateral arterial flow after interruption of hepatic arteries in man. N Engl J Med 1974;290:993-996.

16. Gupta N, Solomon H, Fairchild R, et al. Management and outcome of patients with combined bile duct and hepatic artery injuries. Arch Surg 1998;133:176-181.

17. Koffron A, Ferrario M, Parsons W, et al. Failed primary management of iatrogenic biliary injury: incidence and significance of concomitant hepatic arterial disruption. Surgery 2001;130:722-728; discussion 728-731.

18. Uenishi T, Hirohashi K, Tanaka H, et al. Right hepatic lobectomy for recurrent cholangitis after bile duct and hepatic artery injury during laparoscopic cholecystectomy: report of a case. Hepatogastroenterology 1999;46:2296-2298.

19. Kayaalp C, Nessar G, Kaman S, et al. Right liver necrosis: complication of laparoscopic cholecystectomy. Hepatogastroenterology 2001;48:1727-1729.

20. Sekido H, Matsuo K, Morioka D, et al. Surgical strategy for the management of biliary injury in laparoscopic cholecystectomy. Hepatogastroenterology 2004;51:357-361.

21. Soderlund C, Frozanpor F, Linder S. Bile duct injuries at laparoscopic cholecystectomy: a single-institution prospective study: acute cholecystitis indicates an increased risk. World J Surg 2005;29:987-993.

22. Slater K, Strong RW, Wall DR, et al. Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy. ANZ J Surg 2002;72:83-88.

23. Heinrich S, Seifert H, Krahenbuhl L, et al. Right hemihepatectomy for bile duct injury following laparoscopic cholecystectomy. Surg Endosc 2003;17:1494-1495.

24. Mercado MA, Chan C, Orozco H, et al. Bile duct reconstruction after iatrogenic injury in the elderly. Ann Hepatol 2004;3:160-162.

25. Kaman L, Behera A, Singh R, et al. Management of major bile duct injuries after laparoscopic cholecystectomy. Surg Endosc 2004;18:1196-1199.

26. Johnson SR, Koehler A, Pennington LK, et al. Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery 2000;128:668-677.

Evangelos Felekouras, MD, Thomas Megas, MD, Othon P. Michail, MD, Ioannis Papaconstantinou, MD, Nikolaos Nikiteas, MD, Dimitrios Dimitroulis, MD, John Griniatsos, MD, Anastasios Tsechpenakis, MD, and Gregorios Kouraklis, MD

From the Department of Surgery, University of Athens, Medical School, LAIKO Hospital, Athens, Greece.

Reprint requests to Dr. Othon P. Michail, 30 Roumbessi str, Halandri, Athens, Greece. Email: omichail@yahoo.com

Accepted July 13, 2006.

RELATED ARTICLE: Key Points

* Combined biliary, hepatic artery and portal vein injury at the level of porta hepatis can occur following laparoscopic cholecystectomy.

* Liver resection in the acute setting (20 h after laparoscopic cholecystectomy) can be safely performed.
Table 1. Hepatic resections for combined biliary and hepatic artery
injuries following laparoscopic surgery

 No. of
Reference patients Elapsed period Type of injury

Alves (3) 8 361 days mean BDI + HAI
Stewart et al (12) 4 NA Various types of
 BDI + RHA
Schmidt et al (11) 2 1st pt: 4 months RHD + RHA
 2nd pt: 8 months RHD + RHA
Uenishi et al (18) 1 13 months Hilar BD + RHA
Kayaalp et al (19) 2 1st pt: 2 weeks BD + RHA
 2nd pt: 4 days CBD + RHA
Sekido et al (20) 2 1st pt: 2, 5 months CHD + RHA
 2nd pt: 5 months CBD + RHA
Soderlund et al (21) 2 1st pt: 4 months CHD + RHA
 2nd pt: 8 months HC + RHA
Frilling et al (6) 5 Median interval: Various types of
 12 days BDI + RHA
Slater et al (22) 8 1 to 8 months
Perini et al (10) 2 Median interval: RHD + RHA
 32 days

 Treatment/liver
Reference resection Outcome

Alves (3) RHHx + R-en-Y HJ Well, mean 56 months
Stewart et al (12) 3 pts: Partial RHHx Well, time NA
 1 pt: RHHx Well, time NA
Schmidt et al (11) RHHx + LHJ Well, 31 months
 RHHx + LHJ Well, 54 months
Uenishi et al (18) RHHx + LHJ Well, 25 months
Kayaalp et al (19) RHHx Died, 22 p.o day
 RHHx + LHJ Well, 36 months
Sekido et al (20) RHHx Well, 36 months
 RHHx Well, 16 months
Soderlund et al (21) RHHx + LHJ Well, 31 months
 RHHx + LHJ Well, 54 months
Frilling et al (6) 5 pts: RHHx Well, median 16 months
Slater et al (22) 5 pts: RHHx Well, median 60 months
 1 pt: Resection segment 4
 1 pt: LHHx
 1 pt: Right Anterior
 Sectionectomy
Perini et al (10) 2 pts: RHHx Well, median 44 months

BDI, bile duct injury; CBD, common bile duct; RHD, right hepatic duct;
CHD, common hepatic duct; HC, hepatic confluence; RHA, right hepatic
artery; HAI, hepatic artery injury; RHHx, right hemihepatectomy; LHJ,
left hepaticojejunostomy; p.o., postoperative; R-en-Y HJ = Roux-en-Y
hepaticojejunostomy; LHHx, left hemihepatectomy.

Table 2. Hepatic resections for combined biliary, hepatic artery and
portal vein injuries following LC

 No. of
Reference patients Elapsed period Type of injury

Alves et al (3) 4 361 days 3 pts: BDI + RHA + PV
 1 pt: BDI + PV
Nishio et al (8) 1 135 days HC + RHA + Right
 anterior PVB
Madariaga et al (4) 2 1st pt: 5 days CHD + RHA + PV
 2nd pt: 21 days CHD + RHA + Right
 posterior PVB
Heinrich et al (23) 1 2 weeks RHD + RHA + RPV
Present case 1 20 hrs CBD + RHA + RPV

 Treatment/liver
Reference resection Outcome

Alves et al (3) Right hepatectomy + Well, mean 56 months
 R-en-Y HJ
Nishio et al (8) RHHx Well, 25 months
Madariaga et al (4) RHHx + LHJ and PVR Well, 16 months
 RHHx, LHJ and CHJ Well, 14 months
Heinrich et al (23) RHHx Well, 11 months
Present case RHHx + LHJ Died, 16th day in ICU

CBD, common bile duct; HC, hepatic confluence; RHD, right hepatic duct;
RHA, right hepatic artery; PVB, portal vein branch; PV, portal vein;
RHHx, right hemihepatectomy; LHJ, left hepaticojejunostomy; CHJ, caudate
hepaticojejunostomy; R-en-Y HJ = Roux-en-Y hepaticojejunostomy; RPV,
right portal vein.
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Title Annotation:Case Report
Author:Kouraklis, Gregorios
Publication:Southern Medical Journal
Date:Mar 1, 2007
Words:2690
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