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World J Gastroenterol. May 21, 2008; 14(19): 3049-3053
Published online May 21, 2008. doi: 10.3748/wjg.14.3049
Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery: An algorithmic approach
Georgios Fragulidis, Athanasios Marinis, Andreas Polydorou, Christos Konstantinidis, Georgios Anastasopoulos, John Contis, Dionysios Voros, Vassilios Smyrniotis
Georgios Fragulidis, Athanasios Marinis, Andreas Polydorou, Christos Konstantinidis, Georgios Anastasopoulos, John Contis, Dionysios Voros and Vassilios Smyrniotis, Second Department of Surgery, Areteion University Hospital, Athens Medical School, University of Athens, 76 Vassilisis Sofia’s Ave., Athens 11528, Greece
Author contributions: Fragulidis G, Marinis A and Smyrniotis V wrote the paper; Konstantinidis C and Anastasopoulos G contributed equally to this work; Polydorou A, Fragulidis G, Contis J, Voros D and Smyrniotis V performed the operations, Polydorou A and Smyrniotis V reviewed the paper.
Correspondence to: Athanasios Marinis, MD, Second Department of Surgery, Areteion University Hospital, Athens Medical School, University of Athens, 40 Ptolemaidos str, 13674, Acharnes, Athens 11528, Greece. sakisdoc@yahoo.com
Telephone: +30-697-2335748
Fax: +30-210-2441689
Received: January 9, 2008
Revised: March 26, 2008
Published online: May 21, 2008
Abstract

AIM: To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed.

METHODS: During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography (E/MRCP), scintigraphy and fistulography.

RESULTS: Thirty (12.8%) patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants (mortality rate 28.5%).

CONCLUSION: Management of major biliary fistulae that are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.

Keywords: Biliary aberrations; Bile duct injury; Postoperative bile leakage; Hepatic duct confluence; Hepatectomy