Background: Biliary system anatomical abnormalities can be preoperatively detected on magnetic resonance imaging; therefore, some presume that the number of bile duct injuries should decline. However, once a bile duct injury occurs, repair may be difficult. There are various ways to repair bile duct injuries, but successful repair may be exceptionally difficult. Case presentation: A 72-year-old Japanese man underwent a pancreaticoduodenectomy due to a diagnosis of middle bile duct cancer. We had a complication of an isolated posterior segmental biliary obstruction when pancreaticoduodenectomy was performed. We conducted a drip infusion cholecystocholangiography-computed tomography test to determine the positional relationship between his bile duct and elevated jejunum. To secure the bile duct we punctured the bile duct under computed tomography guidance, and the hepaticojejunal anastomosis site was visualized by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle and verified the vibrations with the endoscope. We observed a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope on insertion. We also successfully inserted an 8.5-Fr pigtail catheter into the elevated jejunum. We removed all drains after percutaneously inserting an uncovered metallic stent. Our patient’s subsequent clinical course was unremarkable. He visits our institution as an out-patient and has had no stent occlusion even after 6 months. Conclusions: When repairing bile duct injuries, it is important to accurately determine the positional relationships between the injured bile duct and the surrounding organs. Keywords: Bile duct injury, Internal bile duct drainage, Pancreaticoduodenectomy Background bile duct injuries should decline. However, once a bile Pancreaticoduodenectomy is one of the most difficult duct injury occurs, repair may be difficult. We report on surgeries. The incidence of postoperative complications a case of successful establishment of internal bile duct can be as high as 30–50%, depending on the case [1–4]. drainage, into the elevated jejunum, against an isolated Pancreatic fluid leakage is frequently observed [5, 6], posterior segmental biliary obstruction after pancreatico- and various complications such as intraabdominal duodenectomy. We discuss therapeutic approaches for abscess, hemorrhage, bile leakage, and bile duct injury bile duct injury repair as well as our method of estab- may occur. Because biliary system anatomical abnormal- lishing internal biliary drainage. ities can be preoperatively detected on magnetic reson- ance imaging (MRI), some presume that the number of Case presentation Our patient was a healthy 72-year-old Japanese man, * Correspondence: email@example.com with an unremarkable previous medical history. He was Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, referred to our institution due to jaundice and impaired 1838 Ishikawa, Hachioji, Tokyo 192-0032, Japan Full list of author information is available at the end of the article hepatic function found during a health examination. We © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Izumi et al. Journal of Medical Case Reports (2018) 12:156 Page 2 of 5 observed stenosis in the middle bile duct on a preopera- tive endoscopic retrograde cholangiopancreatography (ERCP) image (Fig. 1), whereas class V adenocarcinoma was detected by biliary abrasive cytology. The preopera- tive image indicated low bifurcation in the posterior seg- mental branch. A pancreaticoduodenectomy was conducted due to the diagnosis of middle bile duct can- cer. Because our patient had no post-surgical com- plaints, even given mildly increased inflammation, he was discharged on postoperative day 22. However, we found increased inflammation on blood withdrawal when he visited our institution on postoperative day 30. On computed tomography (CT) we observed abscess formation with suspected bile leakage around the hepati- Fig. 2 Postoperative computed tomography image: The black arrow cojejunal site and posterior segmental bile duct dilata- indicates a tumor, suggestive of bile leakage, and the white arrow tion (Fig. 2). We initially completed percutaneous indicates a dilated posterior bile duct transhepatic biliary drainage (PTBD). During contrast radiography with PTBD, only the posterior segmental branch was visualized, but there was no bile leakage into from the anterior segmental branch and left branch (Fig. 5; the elevated jejunum (Fig. 3). Later, we completed con- white arrow). We dorsally visualized the bile duct in the trast radiography from the hepaticojejunal anastomosis isolated posterior segmental branch (Fig. 5; black arrow). site with the use of an endoscope, and only the anterior From the DIC-CT test, we at that time detected an unclear segmental branch and left branch were visualized (Fig. 4). positional relation between elevated jejunum and posterior Thus, we concluded the damage was on the low bifur- segmental branch. We determined that there was no intru- cation in the posterior segmental branch. Bile (approxi- sion of other organs between the elevated jejunum and the mately 250 ml/day) was discharged by PTBD on bile duct. Consequently, percutaneous transhepatic internal consecutive days. drainage of the posterior isolated bile duct, to the elevated We conducted a drip infusion cholecystocholangiogra- jejunum, could be conducted. phy (DIC)-CT test to determine the positional relation- To secure the bile duct, we made a puncture in the bile ship between bile duct and elevated jejunum. We found duct (Fig. 5; black arrow) under CT guidance (Fig. 6), and contrast agent discharged into the elevated jejunum visualized the hepaticojejunal anastomosis site by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle, and verified the vibrations with the endoscope. We found a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope Fig. 3 Percutaneous transhepatic biliary drainage contrast Fig. 1 Preoperative endoscopic retrograde cholangiopancreatography radiography. Only bile ducts in the posterior segment were image visualized without a bile leakage Izumi et al. Journal of Medical Case Reports (2018) 12:156 Page 3 of 5 Fig. 6 Puncture with computed tomography guidance Fig. 4 Endoscopic contrast radiography. Only the anterior segmental Hardening and adhesion by an anomalous cystic duct, branch and left branch were visualized; the posterior segmental segmental bile duct branch anatomy, or pathological in- branch was not visualized flammation can cause bile duct injury . Preoperative detection of bile duct branch abnormalities is important on insertion (Fig. 7a, b). We also successfully inserted to help reduce complications. Unfortunately, our patient an 8.5-Fr pigtail catheter into the elevated jejunum experienced bile duct damage and dissection because we (Fig. 7c). We removed all drains after percutaneously failed to check the preceding bifurcation in the posterior inserting an uncovered metallic stent (5 cm 10 mm; segmental branch, although noticing it before surgery. Fig. 7d). Our patient’s subsequent clinical course was un- According to Kitami et al. , preceding bifurcation in remarkable, and he visits our institution on an out-patient the posterior segmental branch requires careful attention basis, without stent occlusion even after 6 months. due to its incidence (4.5–7.5%). The treatment method for bile duct injury can vary depending on the degree of injury or time of diagnosis . Discussion There are two main treatments for bile duct injury. In patients who undergo hepato-biliary-pancreatic sur- The first approach is to reduce biliary excretion. In these gery, postoperative bile leakage can be a frequent cases, hepatectomy may be the most reliable approach complication. Although the frequency of bile duct . However, it should not be selected in cases involv- injury leakage after hepatectomy has been reported ing large invasion. Alternatively, anhydrous ethanol [7–9], there is no report of bile duct injury after injection [13, 14] and selective portal vein embolization pancreaticoduodenectomy. [15, 16] can be considered. Becker et al.  and Majeed et al. reported that the use of anhydrous ethanol for the biliary system was effective for ablating the gall blad- der and cystic duct, but Kyokane et al. reported an indication relating to the intrahepatic bile duct. First, they confirmed the safety of the procedure during ani- mal experiments, and then conducted biliary ablation only for the hepatic lateral segment B2, against bile duct leakage, after hepatectomy for gallbladder cancer. Hepatic atrophy, at the site of biliary ablation, and hepatic enlargement, at the non-injection site, were confirmed [13, 14]. Selective percutaneous transhepa- tic portal embolization may be effective for promoting hepatic atrophy and fibrosis, as well as reducing bile production [15, 16]. Fig. 5 Drip infusion cholecystocholangiography-computed tomography The second method is to establish a new biliary excre- contrast agent (white arrow) discharged into the elevated jejunum from tion route. Bile duct reanastomosis  and magnet the anterior segmental branch and left branch. The black arrow indicates compression anastomosis (Yamanouchi’s method)  the posterior segmental branch are examples of these type of approaches. Bile duct Izumi et al. Journal of Medical Case Reports (2018) 12:156 Page 4 of 5 Fig. 7 a Puncture needle penetration into elevated jejunum. b X-ray at the time of penetration of puncturing needle into the elevated jejunum. c 8.5-Fr pigtail catheter was inserted into the elevated jejunum. d Uncovered metallic stent (5 cm 10 mm) was inserted percutaneously reanastomosis can be difficult to perform due to the thin Authors’ contributions HI, HY, DY, SU, RA, MM, EN, and HM performed surgery and postoperative diameter of the bile duct, particularly where anastomotic management. HI performed medical diagnoses and endoscopy. TM, TM, and stricture may also be present. Furthermore, identification TH performed puncture with CT guidance. All authors have read and of damaged site for the segmental bile duct branch can approved the final manuscript. be extremely difficult during a repeat surgery due to Ethics approval and consent to participate adhesion with surrounding tissue. This surgery can be ex- Not applicable. tremely difficult; therefore, it is not easily adopted [20, 21]. Yamanouchi’s method naturally forms an anastomosis by Consent for publication Written informed consent was obtained from the patient for publication of placing powerful magnets that make the targeted intestinal this case report and all accompanying images. A copy of the written consent lumens attract each other . Initially, the approach was form is available for review from the Editor-in-Chief of this journal. indicated for anastomosis of intestinal tract-to-intestinal tract at the time of intestinal obstruction, but it was re- Competing interests The authors declare that they have no competing interests. cently adapted for anastomosis of the bile duct-to-intestinal tract, where it was successful . Because the approach is less invasive and features a high success rate, it might be a Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in worthwhile procedure for many patients. published maps and institutional affiliations. Author details Conclusions Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, We report a successful case of treating isolated posterior 1838 Ishikawa, Hachioji, Tokyo 192-0032, Japan. Department of Internal bile duct injury with new internal drainage. Bile duct Medicine, Tokai University Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo 192-0032, Japan. Department of Diagnostic Radiology, Tokai University injury repair methods are varied; however, it is import- Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo 192-0032, Japan. ant to accurately determine the positional relationships between the injured bile duct and surrounding organs. Received: 13 October 2017 Accepted: 27 April 2018 Acknowledgements The authors would like to thank Enago for the English language review. References 1. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive Availability of data and materials pancreaticoduodenectomies in the 1990s: pathology, complications, and The photos used in this case report are published within the report. outcomes. Ann Surg. 1997;226:248–57. discussion 257-260 Izumi et al. Journal of Medical Case Reports (2018) 12:156 Page 5 of 5 2. Buchler MW, Wagner M, Schmied BM, et al. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg. 2003;138:1310–4. discussion 1315 3. Balcom JH 4th, Rattner DW, Warshaw AL, et al. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001;136:391–8. 4. Yeo CJ, Cameron JL, Lillemoe KD, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality. Ann Surg. 2002;236:355–66. discussion 366-358 5. Buchler MW, Friess H, Wagner M, et al. Pancreatic fistula after pancreatic head resection. Br J Surg. 2000;87:883–9. 6. Munoz-Bongrand N, Sauvanet A, Denys A, et al. Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy. J Am Coll Surg. 2004;199:198–203. 7. Miyagawa S, Makuuchi M, Kawasaki S, Kakazu T. Criteria for safe hepatic resection. Am J Surg. 1995;169:589–94. 8. Lo CM, Fan ST, Liu CL, et al. Biliary complications after hepatic resection: risk factors, management, and outcome. Arch Surg. 1998;133:156–61. 9. Yamashita Y, Hamatsu T, Rikimaru T, et al. Bile leakage after hepatic resection. Ann Surg. 2001;233:45–50. 10. Tantia O, Jain M, Khanna S, Sen B. Iatrogenic biliary injury: 13,305 cholecystectomies experienced by a single surgical team over more than 13 years. Surg Endosc. 2008;22:1077–86. 11. Kitami M, Takase K, Murakami G, et al. Types and frequencies of biliary tract variations associated with a major portal venous anomaly: analysis with multi-detector row CT cholangiography. Radiology. 2006;238:156–66. 12. Lichtenstein S, Moorman DW, Malatesta JQ, Martin MF. The role of hepatic resection in the management of bile duct injuries following laparoscopic cholecystectomy. Am Surg. 2000;66:372–6. discussion 377 13. Kyokane T, Nagino M, Oda K, Nimura Y. An experimental study of selective intrahepatic biliary ablation with ethanol. J Surg Res. 2001;96:188–96. 14. Shimizu T, Yoshida H, Mamada Y, et al. Postoperative bile leakage managed successfully by intrahepatic biliary ablation with ethanol. World J Gastroenterol. 2006;12:3450–2. 15. Yamakado K, Nakatsuka A, Iwata M, et al. Refractory biliary leak from intrahepatic biliary-enteric anastomosis treated by selective portal vein embolization. J Vasc Interv Radiol. 2002;13:1279–81. 16. Sadakari Y, Miyoshi A, Ohtsuka T, et al. Percutaneous transhepatic portal embolization for persistent bile leakage after hepatic resection: report of a case. Surg Today. 2008;38:668–71. 17. Becker CD, Fache JS, Malone DE, et al. Ablation of the cystic duct and gallbladder: clinical observations. Radiology. 1990;176:687–90. 18. Majeed AW, Reed MW, Stephenson TJ, Johnson AG. Chemical ablation of the gallbladder. Br J Surg. 1997;84:638–41. 19. Yamanouchi EKH, Endo I, et al. A New interventional method: magnetic compression anastomosis with rare-earth magnets. Cardiovasc Intervent Radiol (United States). 1998;21:S155. 20. McDonald ML, Farnell MB, Nagorney DM, et al. Benign biliary strictures: repair and outcome with a contemporary approach. Surgery. 1995;118:582–90. discussion 590-581 21. Tocchi A, Costa G, Lepre L, et al. 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Journal of Medical Case Reports – Springer Journals
Published: Jun 4, 2018
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