Published online Oct 27, 2015. doi: 10.4240/wjgs.v7.i10.254
Peer-review started: June 5, 2015
First decision: June 18, 2015
Revised: August 21, 2015
Accepted: September 1, 2015
Article in press: September 2, 2015
Published online: October 27, 2015
AIM: To describe our experience concerning the surgical treatment of Strasberg E-4 (Bismuth IV) bile duct injuries.
METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo (median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study.
RESULTS: Patients were divided in three groups: G1 (n = 21): Construction of neoconfluence + Roux-en-Y hepatojejunostomy. G2 (n = 26): Roux-en-Y portoenterostomy. G3 (n = 6): Double (right and left) Roux-en-Y hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation.
CONCLUSION: Loss of confluence represents a surgical challenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis (neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.
Core tip: Strasberg E-4 (Bismuth IV) bile duct injuries represent a surgical challenge. These injuries which involve two separated right and left ducts are of multifactorial etiology, and may be the result of ischemic or thermal damage, an inflammatory reaction, or anatomical variants that predispose the patient to injury. The treatment options are many, mainly surgical. Best results are obtained with Roux-en-Y hepatojejunostomies, as we describe in this article.