Torsed Hepaticoileostomy - an Unusual Complication of Bile Duct Injury Repair David R. Wallace, David H. Ballard, Romulo Vea, Gazi B. Zibari, Hosein M. Shokouh-Amiri, Horacio B. D’Agostino PII: DOI: Reference:
S0899-7071(14)00318-0 doi: 10.1016/j.clinimag.2014.12.012 JCT 7748
To appear in:
Journal of Clinical Imaging
Received date: Revised date: Accepted date:
27 November 2014 10 December 2014 15 December 2014
Please cite this article as: Wallace David R., Ballard David H., Vea Romulo, Zibari Gazi B., Shokouh-Amiri Hosein M., D’Agostino Horacio B., Torsed Hepaticoileostomy an Unusual Complication of Bile Duct Injury Repair, Journal of Clinical Imaging (2014), doi: 10.1016/j.clinimag.2014.12.012
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Torsed Hepaticoileostomy - an Unusual Complication of Bile Duct Injury Repair
RI P
T
(Clean/Unmarked Version)
SC
David R. Wallace, MD1; David H. Ballard, MS2; Romulo Vea, MD1; Gazi B. Zibari, MD3; Hosein M. Shokouh-Amiri, MD3; Horacio B. D'Agostino, MD1
MA
NU
1- Department of Radiology; Louisiana State University Health Shreveport. 1501 Kings Highway, Shreveport, Louisiana, 71130 2- School of Medicine; Louisiana State University Health Shreveport. 1501 Kings Highway, Shreveport, Louisiana, 71130 3- John C. McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, LA.
Correspondence:
AC
CE
PT
ED
Horacio B. D'Agostino, MD, FSIR, FACR, FICS Professor of Radiology, Surgery, and Anesthesiology Chairman, Department of Radiology LSU Health Shreveport Department of Radiology 1501 Kings Highway Shreveport, LA 71130 Email: [email protected] Phone: (318) 675-6247 Fax: (318) 675-5580
Running Title: Inadvertent Hepaticoileostomy Disclosures
Dr. D’Agostino is a co-inventor for LSUHSCNO / ExploraMed - Vibrynt, Inc. and a consultant for Boston Scientific. All other authors claim no conflicts of interest or disclosures.
Category: Case Report Manuscript Word Count: 1340; Abstract Word Count: 98; Number of Figures: 3
1
ACCEPTED MANUSCRIPT
Abstract
T
We present the case of a 42-year-old male with recurrent cholangitis from a stricture of a
RI P
bilioenteric anastomosis repair performed for a bile duct injury. The patient improved clinically after balloon dilation of the stricture and percutaneous biliary drainage; however, there was
SC
persistent reflux of bile around the catheter insertion site. A biliary catheter cholangiogram was
NU
suggestive of an error in the enteric limb. Surgical exploration revealed that an ileal loop was used for the anastomosis and this ileal loop was torsed. This error was repaired surgically. The
MA
patient had immediate and long-term resolution of symptoms.
ED
Keywords: Hepaticoenterostomy complications; Bilioenteric anastomosis complications;
CE
1. Introduction
PT
Laparoscopic cholecystectomy; Bile duct injury; Bile duct injury complications
AC
Laparoscopic cholecystectomy (LC) is the standard operation for gallbladder removal and is among the most common surgical procedures worldwide. One of the most serious and feared complications of LC is injury of the bile duct, occurring in up to 0.5% of cases in some series [1, 2]. A bilioenteric anastomosis between the severed bile duct(s) to a Roux-en-Y jejunal loop is the standard repair of this type of injury. This operation effectively reestablishes the biliary drainage to the gastrointestinal tract. The most common complication of this type of repair is the development of an anastomotic stricture. This complication may cause jaundice and cholangitis and has an incidence that ranges from 3-12% [2 - 4]. Management of symptomatic anastomotic strictures may require percutaneous biliary drainage and dilation, repeated surgery, and/or liver
2
ACCEPTED MANUSCRIPT transplantation. Additionally, the enteric loop may malfunction due to technical errors in the selection and reconstruction. These events are infrequent and may present a diagnostic challenge
RI P
T
[5, 6].
2. Case Presentation
SC
The patient was a 42-year-old white male who had a three-year history of symptomatic
NU
cholelithiasis without any other remarkable comorbidities. He had an LC complicated by a bile duct injury. The injury was recognized intraoperatively and repaired by a bilioenteric
MA
anastomosis. Three months after the bile duct injury repair, the patient had progressive jaundice, abdominal pain, and several hospital admissions for cholangitis (managed with antibiotics and
ED
analgesics). Four months later (seven months after the initial surgery) the patient was admitted to
PT
a local hospital for increasing jaundice and abdominal pain. While in the hospital, he was diagnosed with cholangitis, and was treated with intravenous antibiotics for a week. He was
CE
discharged home on oral antibiotics. The patient returned to the hospital two weeks later with
AC
aggravation of his symptoms, and was transferred to our institution for further management.
On admission, his physical examination revealed a well-developed jaundiced male in moderate distress, icteric sclera, and tenderness to palpation of the right upper quadrant of the abdomen. Pertinent laboratory results yielded a direct hyperbilirubinemia and elevations in gamma-glutamyl transpeptidase, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase. Abdominal CT with intravenous contrast revealed mild dilation of the intrahepatic ducts. The patient was started on broad-spectrum intravenous antibiotics. The hepatobiliary multidisciplinary team evaluated this patient and the decision was made for
3
ACCEPTED MANUSCRIPT interventional radiology to perform percutaneous biliary drainage on a presumptive diagnosis of
T
biliary obstruction.
RI P
The patient was taken to the interventional suite where a transhepatic cholangiogram revealed a tight stricture of the hepaticoenterostomy that was dilated using an 8x40 mm balloon
SC
catheter (Figure 1). After the dilation, a 10.2-F locking pigtail catheter (Dawson-Mueller; Cook,
NU
Bloomington, IN) was placed for internal/external biliary drainage. The patient tolerated the procedure well and improved clinically over the next few days with resolution of
MA
hyperbilirubinemia. On daily catheter rounds, it was noticed that there was persistent bile reflux onto the skin around the catheter skin hole. The patient was again brought to the interventional
ED
suite, where a catheter cholangiogram revealed a dilated bowel loop with delayed distal
PT
progression. The anastomotic loop appeared short and to the right of the spine with opacification of the ascending colon (Figure 2A). The possibility of having chosen an inadvertent distal
AC
CE
enteric limb for the anastomosis was entertained.
Given this situation, surgical exploration was offered to the patient and he was amendable to this course of action. Intraoperatively, a partially torsed loop of ileum was identified at the bilioenteric anastomosis (Figure 2B). The ileal loop was severed 40cm distal to the hepaticoileostomy and anastomosed to the proximal jejunum. An end-to-end ileoileostomy was performed to reinstitute bowel continuity. The bilioenteric anastomosis was not explored because percutaneous management of the stricture was effective and challenging surgical dissection. The patient had an uncomplicated recovery from surgery and postoperative transhepatic cholangiogram showed good communication between the biliary system and enteric limb
4
ACCEPTED MANUSCRIPT (Figure 3). The biliary catheter was removed six months after its insertion on an outpatient basis. Long term follow up at 24 months revealed no recurrence of jaundice, pain, or discomfort and no
RI P
T
subsequent hospitalizations.
3. Discussion
SC
This case illustrates a LC bile duct injury repair in which an anastomotic stricture developed on a
NU
torsed hepaticoileostomy. Despite appropriate percutaneous management of the stricture, bile leakage from the biliary catheter skin hole ensued. The patient’s initial postoperative colicky
MA
pain and discomfort, accompanied by precocious cholangitis, were most likely caused by poor evacuation of the ileal loop. Transbiliary catheter cholangiography and study of the enteric loop
ED
showed delay in transit within the loop. The backflow of bile content leaking around the biliary
PT
drainage skin hole suggested poor emptying of the anastomotic loop. This led to the suspicion of malfunction of the anastomotic enteral loop. Additionally, the fact that the loop was seen to the
CE
right of the spine suggested that an ileal loop might have been used in the reconstruction. Usually
AC
a loop of proximal jejunum is selected for the anastomosis; in this case an ileal loop was inadvertently used. In addition to being an ileal loop, the loop was placed torsed at the time of the anastomosis. Unfortunately this type of complication cannot be managed through minimally invasive techniques and requires a major operation to repair.
For over two decades LC has replaced open cholecystectomy for symptomatic cholelithiasis. However, despite the many advantages of this minimally invasive surgery, the drawback of this laparoscopic appraoch is the increase in bile duct injuries that occur when compared with open cholecystectomy. LC bile duct injuries are usually more severe than those
5
ACCEPTED MANUSCRIPT caused by open cholecystectomy because they are high in the biliary tree, may involve multiple ducts, and have associated vascular injuries. Up to 75% of the bile duct injuries are repaired by
T
the surgeon who caused the injury [7]. Successful repair without restenosis of the bile duct injury
RI P
by the initial surgeon performing the LC occurs in only 17% of the cases [2]. When an experienced hepatobiliary surgeon performs the hepaticojejunostomy, the success rate has been
SC
shown to be greater than 90%. A reoperation of a stenotic hepaticojejunostomy has better
NU
outcome when the bile duct injury is distal (Bismuth 1 or 2). The more a patient undergoes biliary operations the greater the risk for vascular complications due to distortion of anatomy,
MA
and difficult dissection [8].
ED
Our patient had a bilioenteric anastomosis constructed with a torsed ileal loop further
PT
complicated by a stricture. Anastomotic stricture is the most common complication of bilioenteric anastomosis, however, anastomotic malfunction due to errors in enteral loop
CE
selection and placement are very infrequent. These reported cases are often errant antiperistaltic
AC
connections to the jejunal limb of the bilioenteric anastomosis. This surgical complication is reported with attempted Roux-en-Y limbs for both repairs of bile duct injuries and in gastric bypass surgeries [5, 6]. To the best of our knowledge, there has only been one other case [6] describing an inadvertent biliary anastomosis with the ileum, which was also following a bile duct injury following LC. In that reported case, the patient’s presentation was with postoperative sepsis and peritonitis. After surgical correction of this hepaticoileostomy, the patient faired well at long-term follow-up [6]. Our case differs from this reported case as our patient had their errant limb (ileal loop) torsed at the time of the reconstruction.
6
ACCEPTED MANUSCRIPT In conclusion, this case report focuses on a patient that suffered a LC bile duct injury and unexpected adverse effects from its operative repair. This patient’s misfortune was four-fold: bile
T
duct injury, torsed enteral anastomosis, inadvertent ileal loop selection and an anastomotic
RI P
stricture. Management by our institution’s multidisciplinary hepatobiliary team proved valuable
SC
in resolving the complex situation of this patient.
NU
References
1. Vollmer CM, Callery MP. Biliary injury following laparoscopic cholecystectomy: why still a
MA
problem? Gastroenterology 2007;133:1039–41.
2. Sicklick JK, Camp MS, Lillemoe KD, Melton GB, Yeo CJ, Campbell KA, et al. Surgical
ED
management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative
PT
results in 200 patients. Ann Surg 2005;241:786–92; discussion 793–5. 3. Selvakumar E, Rajendran S, Balachandar TG, Kannan DG, Jeswanth S, Ravichandran P, et al.
CE
Long-term outcome of gastric access loop in hepaticojejunostomy. HBPD INT 2008;7:152–5.
AC
4. House MG, Cameron JL, Schulick RD, Campbell KA, Sauter PK, Coleman J, et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg 2006;243(5):571– 576; discussion 576–578. 5. Bektas H, Schrem H, Lehner F, Schmidt U, Kreczik H, Klempnauer J, et al. The value of reoperative procedures after unusual reconstructions in the gastrointestinal tract associated with substantial morbidity. J Gastrointest Surg 2006;10:111–22. 6. Zorn GL, Wright JK, Pinson CW, Debelak JP, Chapman WC. Antiperistaltic Roux-en-Y biliary-enteric bypass after bile duct injury: a technical error in reconstruction. Am Surg 1999;65:581–5.
7
ACCEPTED MANUSCRIPT 7. Ahrendt SA, Pitt HA. Surgical therapy of iatrogenic lesions of biliary tract. World J Surg 2001;25:1360–5.
T
8. De Santibáñes E, Ardiles V, Pekolj J. Complex bile duct injuries: management. HPB (Oxford)
SC
RI P
2008;10:4–12.
NU
Figure Legends
Figure 1. A. Transhepatic cholangiogram revealing tight stricture of bilioenteric anastomosis
MA
(arrows). B. Balloon cholangioplasty, note the waist (arrows) on the ballon. C. Balloon
ED
completely open, demonstrating resolution of stricture.
PT
Figure 2. A. Transhepatic cholangiogram with opacification of anastomosed bowel loop to the right of the spine. Contrast is seen rapidly opacifying the ascending colon (arrows). B.
AC
CE
Intraoperative image portraying the torsed bowel loop (arrows).
Figure 3. Postoperative transhepatic cholangiogram with opacification of the anastomosed bowel loop end to side into the jejunum.
8
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CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
Fig. 1a
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ED
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ACCEPTED MANUSCRIPT
Fig. 1b
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ACCEPTED MANUSCRIPT
Fig. 1c
11
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ED
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ACCEPTED MANUSCRIPT
Fig. 2a 12
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Fig. 2b
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
Fig. 3
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S0899-7071(14)00318-0 doi: 10.1016/j.clinimag.2014.12.012 JCT 7748
To appear in:
Journal of Clinical Imaging
Received date: Revised date: Accepted date:
27 November 2014 10 December 2014 15 December 2014
Please cite this article as: Wallace David R., Ballard David H., Vea Romulo, Zibari Gazi B., Shokouh-Amiri Hosein M., D’Agostino Horacio B., Torsed Hepaticoileostomy an Unusual Complication of Bile Duct Injury Repair, Journal of Clinical Imaging (2014), doi: 10.1016/j.clinimag.2014.12.012
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Torsed Hepaticoileostomy - an Unusual Complication of Bile Duct Injury Repair
RI P
T
(Clean/Unmarked Version)
SC
David R. Wallace, MD1; David H. Ballard, MS2; Romulo Vea, MD1; Gazi B. Zibari, MD3; Hosein M. Shokouh-Amiri, MD3; Horacio B. D'Agostino, MD1
MA
NU
1- Department of Radiology; Louisiana State University Health Shreveport. 1501 Kings Highway, Shreveport, Louisiana, 71130 2- School of Medicine; Louisiana State University Health Shreveport. 1501 Kings Highway, Shreveport, Louisiana, 71130 3- John C. McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, LA.
Correspondence:
AC
CE
PT
ED
Horacio B. D'Agostino, MD, FSIR, FACR, FICS Professor of Radiology, Surgery, and Anesthesiology Chairman, Department of Radiology LSU Health Shreveport Department of Radiology 1501 Kings Highway Shreveport, LA 71130 Email: [email protected] Phone: (318) 675-6247 Fax: (318) 675-5580
Running Title: Inadvertent Hepaticoileostomy Disclosures
Dr. D’Agostino is a co-inventor for LSUHSCNO / ExploraMed - Vibrynt, Inc. and a consultant for Boston Scientific. All other authors claim no conflicts of interest or disclosures.
Category: Case Report Manuscript Word Count: 1340; Abstract Word Count: 98; Number of Figures: 3
1
ACCEPTED MANUSCRIPT
Abstract
T
We present the case of a 42-year-old male with recurrent cholangitis from a stricture of a
RI P
bilioenteric anastomosis repair performed for a bile duct injury. The patient improved clinically after balloon dilation of the stricture and percutaneous biliary drainage; however, there was
SC
persistent reflux of bile around the catheter insertion site. A biliary catheter cholangiogram was
NU
suggestive of an error in the enteric limb. Surgical exploration revealed that an ileal loop was used for the anastomosis and this ileal loop was torsed. This error was repaired surgically. The
MA
patient had immediate and long-term resolution of symptoms.
ED
Keywords: Hepaticoenterostomy complications; Bilioenteric anastomosis complications;
CE
1. Introduction
PT
Laparoscopic cholecystectomy; Bile duct injury; Bile duct injury complications
AC
Laparoscopic cholecystectomy (LC) is the standard operation for gallbladder removal and is among the most common surgical procedures worldwide. One of the most serious and feared complications of LC is injury of the bile duct, occurring in up to 0.5% of cases in some series [1, 2]. A bilioenteric anastomosis between the severed bile duct(s) to a Roux-en-Y jejunal loop is the standard repair of this type of injury. This operation effectively reestablishes the biliary drainage to the gastrointestinal tract. The most common complication of this type of repair is the development of an anastomotic stricture. This complication may cause jaundice and cholangitis and has an incidence that ranges from 3-12% [2 - 4]. Management of symptomatic anastomotic strictures may require percutaneous biliary drainage and dilation, repeated surgery, and/or liver
2
ACCEPTED MANUSCRIPT transplantation. Additionally, the enteric loop may malfunction due to technical errors in the selection and reconstruction. These events are infrequent and may present a diagnostic challenge
RI P
T
[5, 6].
2. Case Presentation
SC
The patient was a 42-year-old white male who had a three-year history of symptomatic
NU
cholelithiasis without any other remarkable comorbidities. He had an LC complicated by a bile duct injury. The injury was recognized intraoperatively and repaired by a bilioenteric
MA
anastomosis. Three months after the bile duct injury repair, the patient had progressive jaundice, abdominal pain, and several hospital admissions for cholangitis (managed with antibiotics and
ED
analgesics). Four months later (seven months after the initial surgery) the patient was admitted to
PT
a local hospital for increasing jaundice and abdominal pain. While in the hospital, he was diagnosed with cholangitis, and was treated with intravenous antibiotics for a week. He was
CE
discharged home on oral antibiotics. The patient returned to the hospital two weeks later with
AC
aggravation of his symptoms, and was transferred to our institution for further management.
On admission, his physical examination revealed a well-developed jaundiced male in moderate distress, icteric sclera, and tenderness to palpation of the right upper quadrant of the abdomen. Pertinent laboratory results yielded a direct hyperbilirubinemia and elevations in gamma-glutamyl transpeptidase, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase. Abdominal CT with intravenous contrast revealed mild dilation of the intrahepatic ducts. The patient was started on broad-spectrum intravenous antibiotics. The hepatobiliary multidisciplinary team evaluated this patient and the decision was made for
3
ACCEPTED MANUSCRIPT interventional radiology to perform percutaneous biliary drainage on a presumptive diagnosis of
T
biliary obstruction.
RI P
The patient was taken to the interventional suite where a transhepatic cholangiogram revealed a tight stricture of the hepaticoenterostomy that was dilated using an 8x40 mm balloon
SC
catheter (Figure 1). After the dilation, a 10.2-F locking pigtail catheter (Dawson-Mueller; Cook,
NU
Bloomington, IN) was placed for internal/external biliary drainage. The patient tolerated the procedure well and improved clinically over the next few days with resolution of
MA
hyperbilirubinemia. On daily catheter rounds, it was noticed that there was persistent bile reflux onto the skin around the catheter skin hole. The patient was again brought to the interventional
ED
suite, where a catheter cholangiogram revealed a dilated bowel loop with delayed distal
PT
progression. The anastomotic loop appeared short and to the right of the spine with opacification of the ascending colon (Figure 2A). The possibility of having chosen an inadvertent distal
AC
CE
enteric limb for the anastomosis was entertained.
Given this situation, surgical exploration was offered to the patient and he was amendable to this course of action. Intraoperatively, a partially torsed loop of ileum was identified at the bilioenteric anastomosis (Figure 2B). The ileal loop was severed 40cm distal to the hepaticoileostomy and anastomosed to the proximal jejunum. An end-to-end ileoileostomy was performed to reinstitute bowel continuity. The bilioenteric anastomosis was not explored because percutaneous management of the stricture was effective and challenging surgical dissection. The patient had an uncomplicated recovery from surgery and postoperative transhepatic cholangiogram showed good communication between the biliary system and enteric limb
4
ACCEPTED MANUSCRIPT (Figure 3). The biliary catheter was removed six months after its insertion on an outpatient basis. Long term follow up at 24 months revealed no recurrence of jaundice, pain, or discomfort and no
RI P
T
subsequent hospitalizations.
3. Discussion
SC
This case illustrates a LC bile duct injury repair in which an anastomotic stricture developed on a
NU
torsed hepaticoileostomy. Despite appropriate percutaneous management of the stricture, bile leakage from the biliary catheter skin hole ensued. The patient’s initial postoperative colicky
MA
pain and discomfort, accompanied by precocious cholangitis, were most likely caused by poor evacuation of the ileal loop. Transbiliary catheter cholangiography and study of the enteric loop
ED
showed delay in transit within the loop. The backflow of bile content leaking around the biliary
PT
drainage skin hole suggested poor emptying of the anastomotic loop. This led to the suspicion of malfunction of the anastomotic enteral loop. Additionally, the fact that the loop was seen to the
CE
right of the spine suggested that an ileal loop might have been used in the reconstruction. Usually
AC
a loop of proximal jejunum is selected for the anastomosis; in this case an ileal loop was inadvertently used. In addition to being an ileal loop, the loop was placed torsed at the time of the anastomosis. Unfortunately this type of complication cannot be managed through minimally invasive techniques and requires a major operation to repair.
For over two decades LC has replaced open cholecystectomy for symptomatic cholelithiasis. However, despite the many advantages of this minimally invasive surgery, the drawback of this laparoscopic appraoch is the increase in bile duct injuries that occur when compared with open cholecystectomy. LC bile duct injuries are usually more severe than those
5
ACCEPTED MANUSCRIPT caused by open cholecystectomy because they are high in the biliary tree, may involve multiple ducts, and have associated vascular injuries. Up to 75% of the bile duct injuries are repaired by
T
the surgeon who caused the injury [7]. Successful repair without restenosis of the bile duct injury
RI P
by the initial surgeon performing the LC occurs in only 17% of the cases [2]. When an experienced hepatobiliary surgeon performs the hepaticojejunostomy, the success rate has been
SC
shown to be greater than 90%. A reoperation of a stenotic hepaticojejunostomy has better
NU
outcome when the bile duct injury is distal (Bismuth 1 or 2). The more a patient undergoes biliary operations the greater the risk for vascular complications due to distortion of anatomy,
MA
and difficult dissection [8].
ED
Our patient had a bilioenteric anastomosis constructed with a torsed ileal loop further
PT
complicated by a stricture. Anastomotic stricture is the most common complication of bilioenteric anastomosis, however, anastomotic malfunction due to errors in enteral loop
CE
selection and placement are very infrequent. These reported cases are often errant antiperistaltic
AC
connections to the jejunal limb of the bilioenteric anastomosis. This surgical complication is reported with attempted Roux-en-Y limbs for both repairs of bile duct injuries and in gastric bypass surgeries [5, 6]. To the best of our knowledge, there has only been one other case [6] describing an inadvertent biliary anastomosis with the ileum, which was also following a bile duct injury following LC. In that reported case, the patient’s presentation was with postoperative sepsis and peritonitis. After surgical correction of this hepaticoileostomy, the patient faired well at long-term follow-up [6]. Our case differs from this reported case as our patient had their errant limb (ileal loop) torsed at the time of the reconstruction.
6
ACCEPTED MANUSCRIPT In conclusion, this case report focuses on a patient that suffered a LC bile duct injury and unexpected adverse effects from its operative repair. This patient’s misfortune was four-fold: bile
T
duct injury, torsed enteral anastomosis, inadvertent ileal loop selection and an anastomotic
RI P
stricture. Management by our institution’s multidisciplinary hepatobiliary team proved valuable
SC
in resolving the complex situation of this patient.
NU
References
1. Vollmer CM, Callery MP. Biliary injury following laparoscopic cholecystectomy: why still a
MA
problem? Gastroenterology 2007;133:1039–41.
2. Sicklick JK, Camp MS, Lillemoe KD, Melton GB, Yeo CJ, Campbell KA, et al. Surgical
ED
management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative
PT
results in 200 patients. Ann Surg 2005;241:786–92; discussion 793–5. 3. Selvakumar E, Rajendran S, Balachandar TG, Kannan DG, Jeswanth S, Ravichandran P, et al.
CE
Long-term outcome of gastric access loop in hepaticojejunostomy. HBPD INT 2008;7:152–5.
AC
4. House MG, Cameron JL, Schulick RD, Campbell KA, Sauter PK, Coleman J, et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg 2006;243(5):571– 576; discussion 576–578. 5. Bektas H, Schrem H, Lehner F, Schmidt U, Kreczik H, Klempnauer J, et al. The value of reoperative procedures after unusual reconstructions in the gastrointestinal tract associated with substantial morbidity. J Gastrointest Surg 2006;10:111–22. 6. Zorn GL, Wright JK, Pinson CW, Debelak JP, Chapman WC. Antiperistaltic Roux-en-Y biliary-enteric bypass after bile duct injury: a technical error in reconstruction. Am Surg 1999;65:581–5.
7
ACCEPTED MANUSCRIPT 7. Ahrendt SA, Pitt HA. Surgical therapy of iatrogenic lesions of biliary tract. World J Surg 2001;25:1360–5.
T
8. De Santibáñes E, Ardiles V, Pekolj J. Complex bile duct injuries: management. HPB (Oxford)
SC
RI P
2008;10:4–12.
NU
Figure Legends
Figure 1. A. Transhepatic cholangiogram revealing tight stricture of bilioenteric anastomosis
MA
(arrows). B. Balloon cholangioplasty, note the waist (arrows) on the ballon. C. Balloon
ED
completely open, demonstrating resolution of stricture.
PT
Figure 2. A. Transhepatic cholangiogram with opacification of anastomosed bowel loop to the right of the spine. Contrast is seen rapidly opacifying the ascending colon (arrows). B.
AC
CE
Intraoperative image portraying the torsed bowel loop (arrows).
Figure 3. Postoperative transhepatic cholangiogram with opacification of the anastomosed bowel loop end to side into the jejunum.
8
AC
CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
Fig. 1a
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ED
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ACCEPTED MANUSCRIPT
Fig. 1b
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ACCEPTED MANUSCRIPT
Fig. 1c
11
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Fig. 2a 12
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Fig. 2b
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ACCEPTED MANUSCRIPT
Fig. 3
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