The treatment of isolated segmental,sectoral and right hepatic bile duct injuries is controversial.Nineteen patients were treated over a 26-year period.Group one was comprised of 4 patients in whom the injury was prim...The treatment of isolated segmental,sectoral and right hepatic bile duct injuries is controversial.Nineteen patients were treated over a 26-year period.Group one was comprised of 4 patients in whom the injury was primarily repaired during the original surgery;3 over a T-tube,1 with a Roux-en-Y.These patients had an uneventful recovery.The second group consisted of 5 patients in whom the duct was ligated;4 developed infection,3 of which required drainage and biliary repair.Two patients had good long-term outcomes;the third developed a late anastomotic stricture requiring further surgery.The fourth patient developed a small bile leak and pain which resolved spontaneously.The fifth patient developed complications from which he died.The third group was comprised of 4 patients referred with biliary peritonitis;all underwent drainage and lavage,and developed biliary fistulae,3 of which resolved spontaneously,1 required Roux-en-Y repair,with favorable outcomes.The fourth group consisted of 6 patients with biliary fistulae.Two patients,both with an 8-wk history of a fistula,underwent Roux-en-Y repair.Two others also underwent a Roux-en-Y repair,as their fistulae showed no signs of closure.The remaining 2 patients had spontaneous closure of their biliary fistulae.A primary repair is a reasonable alternative to ligature ofinjured duct.Patients with ligated ducts may develop complications.Infected ducts require further surgery.Patients with biliary peritonitis must be treated with drainage and lavage.There is a 50% chance that a biliary fistula will close spontaneously.In cases where the biliary fistula does not close within 6 to 8 wk,a Roux-en-Y anastomosis should be considered.展开更多
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 th...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 fistulaethat 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.展开更多
文摘The treatment of isolated segmental,sectoral and right hepatic bile duct injuries is controversial.Nineteen patients were treated over a 26-year period.Group one was comprised of 4 patients in whom the injury was primarily repaired during the original surgery;3 over a T-tube,1 with a Roux-en-Y.These patients had an uneventful recovery.The second group consisted of 5 patients in whom the duct was ligated;4 developed infection,3 of which required drainage and biliary repair.Two patients had good long-term outcomes;the third developed a late anastomotic stricture requiring further surgery.The fourth patient developed a small bile leak and pain which resolved spontaneously.The fifth patient developed complications from which he died.The third group was comprised of 4 patients referred with biliary peritonitis;all underwent drainage and lavage,and developed biliary fistulae,3 of which resolved spontaneously,1 required Roux-en-Y repair,with favorable outcomes.The fourth group consisted of 6 patients with biliary fistulae.Two patients,both with an 8-wk history of a fistula,underwent Roux-en-Y repair.Two others also underwent a Roux-en-Y repair,as their fistulae showed no signs of closure.The remaining 2 patients had spontaneous closure of their biliary fistulae.A primary repair is a reasonable alternative to ligature ofinjured duct.Patients with ligated ducts may develop complications.Infected ducts require further surgery.Patients with biliary peritonitis must be treated with drainage and lavage.There is a 50% chance that a biliary fistula will close spontaneously.In cases where the biliary fistula does not close within 6 to 8 wk,a Roux-en-Y anastomosis should be considered.
文摘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 fistulaethat 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.
