Case Report
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World J Gastroenterol. Sep 28, 2013; 19(36): 6118-6121
Published online Sep 28, 2013. doi: 10.3748/wjg.v19.i36.6118
Isolated right posterior bile duct injury following cholecystectomy: Report of two cases
Maciej Wojcicki, Waldemar Patkowski, Tomasz Chmurowicz, Andrzej Bialek, Anna Wiechowska-Kozlowska, Rafał Stankiewicz, Piotr Milkiewicz, Marek Krawczyk
Maciej Wojcicki, Waldemar Patkowski, Rafał Stankiewicz, Piotr Milkiewicz, Marek Krawczyk, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland
Piotr Milkiewicz, Liver Research Laboratories, Pomeranian Medical University, 70-111 Szczecin, Poland
Tomasz Chmurowicz, Department of General Surgery and Transplantation, District Hospital, 71-455 Szczecin, Poland
Andrzej Bialek, Department of Gastroenterology, Pomeranian Medical University, 71-252 Szczecin, Poland
Anna Wiechowska-Kozlowska, Department of Endoscopy, MSW Hospital, 70-382 Szczecin, Poland
Author contributions: Wojcicki M and Krawczyk M designed the report; Wojcicki M and Patkowski W performed surgery; Chmurowicz T and Stankiewicz R were attending doctors for the patients; Bialek A performed and interpreted imaging diagnosis; Wojcicki M, Patkowski W, Chmurowicz T and Wiechowska-Kozlowska A wrote the paper; Milkiewicz P and Krawczyk M critically revised the manuscript.
Correspondence to: Maciej Wojcicki, MD, PhD, Professor, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097 Warsaw, Poland. drmwojcicki@wp.pl
Telephone: +48-22-5992546 Fax: +48-22-5991545
Received: April 4, 2013
Revised: July 7, 2013
Accepted: July 17, 2013
Published online: September 28, 2013
Abstract

Anatomic variations of the right biliary system are one of the most common risk factors for sectoral bile duct injury (BDI) during cholecystectomy. Isolated right posterior BDI may in particular be a challenge for both diagnosis and management. Herein we describe two cases of isolated right posterior sectoral BDI that took place during laparoscopic cholecystectomy. Despite effective external biliary drainage from the liver hilum in both cases, there was a persistent biliary leak observed which was not visible on endoscopic retrograde cholangiogram. Careful evaluation of images from both endoscopic and magnetic resonance cholangiograms revealed the diagnosis of an isolated right posterior sectoral BDI. These were treated with a delayed bisegmental (segments 6 and 7) liver resection and a Roux-en-Y hepaticojejunostomy respectively with good outcomes at 24 and 4 mo of follow-up. This paper discusses strategies for prevention of such injuries along with the diagnostic and therapeutic challenges it offers.

Keywords: Cholecystectomy, Bile duct injury, Sectoral bile duct, Hepaticojejunostomy, Liver resection

Core tip: Anatomic variations of the right biliary system are common but the low insertion of the right sectoral bile duct into the common hepatic duct (or the cystic duct) is rare. This is clinically important as places the patient at particular risk for its injury during cholecystectomy. Moreover, it can be very difficult to be diagnosed and managed properly. It often presents with a persistent biliary leak which is not visible on endoscopic retrograde cholangiogram. We describe two such cases, present the diagnostic imaging with two different treatment options and discuss preventive and management strategies. This can be of clinical value for both surgeons, gastroenterologists and endoscopists.