Percutaneous Management of Hepatic Duct Injury Using Extra-Anatomic Biliary Catheters

Iatrogenic bile duct injury during laparoscopic cholecystectomy is a known complication of low incidence. The outcome can be devastating if not recognized and managed timely and properly. In cases of iatrogenic biliary injury due to cholecystectomy, the management depends on the level of injury, the timing of discovery (intraoperative or postoperative), and the patient's condition. If discovered intraoperatively, the injury should be managed immediately. In case expertise is lacking, a surgical drain with external biliary drainage can provide a temporary alternative solution to allow for referral to a tertiary care center. If the patient is septic or not fit for surgery, a percutaneous internal-external biliary drainage (PTBD) catheter can be placed until the patient’s condition improves. We report a case of complete transection of the common hepatic duct during laparoscopic cholecystectomy managed by extra-anatomic PTBD.


Introduction
Iatrogenic biliary injury is a recognized complication of cholecystectomy surgery [1], with potentially serious long-term consequences [2]. Whilst earlier studies reported the incidence of biliary injury at 0.6% for laparoscopic compared to 0.1% for open cholecystectomy [3], the more recent studies reported an overall incidence of 0.02%, particularly in high-volume centers [4].
Several strategies during laparoscopic cholecystectomy may help to reduce the incidence of biliary injury, including meticulous dissection of a distorted Calot's triangle, careful usage of the diathermy away from the bile ducts, and avoiding excessive traction on the gallbladder [5]. Better communication between the lead surgeon and the assisting surgeon during surgery and confirmation of the anatomy before dividing the cystic duct and cystic artery has also been shown to reduce the incidence of biliary injury [6].
When an inadvertent biliary injury is recognized during the surgery, corrective surgery (either by hepaticojejunostomy surgery or other surgical intervention depending on the findings) can be undertaken during the same surgery with a good outcome. However, if the injury is not recognized intraoperatively, the management depends on the time since the surgery, the presence of sepsis, and the patient's condition. In the absence of sepsis, corrective surgery is to be performed within 72 hours. After 72 hours, or in the presence of sepsis or other complications, the surgery can be deferred and sepsis management with the insertion of a percutaneous internal-external biliary drainage (PTBD) and collection drainage should be undertaken.

Case Presentation
An 85-year-old male with hypertension underwent laparoscopic cholecystectomy for biliary pancreatitis. During surgery, they converted from laparoscopic to open approach, due to the inflammation and omental adhesions. Bile leak was identified from the common hepatic duct (CHD), which was completely transected at the confluence (Bismuth type E4). Two 6 Fr. feeding tubes were inserted in each hepatic duct and externalized. A Jackson Pratt drain was placed in the subhepatic space and the patient was transferred to our institution seven days after the surgery (as he required tertiary center care). Upon admission, he was dehydrated, having pneumonia and acute kidney injury (not fit for surgical intervention). The magnetic resonance cholangiopancreatography (MRCP) demonstrated a complete transection of the CHD at the level of the hilum with biliary leak, perihepatic collection, porta-hepatis collection (biloma) ( Figures 1A, 1B) as well as non-dilated biliary ducts.  The left and right hepatic ducts were accessed separately from a right intercostal approach. Given the complete transection of the CHD, the wire inadvertently passed to the second part of the duodenum extraluminally/extra-anatomically, through a false tract from the porta-hepatic collection to the duodenum. Two internal-external 8.5 Fr. PTBDs were placed ( Figure 3) and connected to drainage bags for one week, then capped. The collection dried out and the drainage catheter was removed after two weeks. The patient was discharged home and the PTBDs were exchanged after three months. The patient continued to be unfit for surgery due to multiple comorbidities including a new stroke.
At five months, a cholangiogram was performed demonstrating patent mature extra-anatomic tracts with no evidence of leak. Therefore, both PTBDs were removed and two 7 Fr. plastic endoscopic biliary stents were placed percutaneously (Figure 4), to be exchanged endoscopically.

FIGURE 4: Placement of bilateral endoscopic plastic biliary stents percutaneously via the previous percutaneous internal-external biliary drainage (PTBD) accesses through extra-anatomical tracts to duodenum
At one year, the biliary stents were exchanged endoscopically and the patient's overall condition was improving with no complications. Figures 5A, 5B illustrate the procedure of PTBD and the biliary stenting.

Discussion
Management of patients following major bile duct injury poses a challenge and requires experienced hepatobiliary surgeons. Early recognition is important to prevent major morbidity. An atypical postoperative course with pain, sepsis, jaundice, or bile-stained dressing should raise the suspicion of leak. Elevated bilirubin and alkaline phosphatase may suggest ligation or clipping of the bile duct; while bile leak from the wound may suggest transection of the bile duct, or leak from the gall bladder bed due to transection of the duct of Luschka. Ultrasound, computed tomography, and MRCP may detect the collection and/or the biliary dilation. Our patient presented with pneumonia and comorbidities. Hence, we proceeded with the nonsurgical option. While placing the PTBDs intraluminally is ideal for biliary diversion and healing of the injury, the complete CHD transection forced us to go extra-anatomically. Despite that, the patient did well for one year with further stent internalization and endoscopic exchange. Eikermann et al. described that in some cases, the nonsurgical intervention can provide a definitive treatment option [7].
Extra-anatomic biliary drainage and stenting have been described for biliary drainage in the setting of palliation for inoperable cholangiocarcinoma, anastomotic recurrence of the periampullary lesion, and biliary trauma. These included trans-tumoral, trans-parenchymal, and hepato-gastrostomy [8].
Percutaneous dilatation of spontaneous hepatoduodenostomy and stenting has also been described for malignant tumors and occasionally for benign diseases or anatomic disruptions [9][10][11]. Extra-anatomic biliary stenting in the setting of iatrogenic biliary injury has not been previously described.

Conclusions
Iatrogenic biliary injury during laparoscopic cholecystectomy is a rare complication and may have lifechanging consequences without appropriate treatment. Recognition and timely treatment are critical. Surgical management should be carried out within 72 hours by a surgeon experienced in the procedure. Delayed surgical intervention is needed in patients where the biliary injury was unrecognized or immediate treatment was not possible. Extra-anatomic biliary catheters (EABS) offer a long-term alternative to surgical management and have some tangible benefits over hepaticojejunostomy in patients where surgery has concomitant elevated risk due to their poor performance status or comorbidities.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. King Faisal Specialist Hospital and Research Centre issued approval IRB 2022-CR-44. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.