Discussion
We report a very rare presentation of recurrent bile leak after cholecystectomy in context of aberrant anatomy that failed conservative management and required surgical intervention with good patient outcome. The exact etiology of this delayed bile leak is unclear; however, we postulate that it may be secondary to a likely tangential thermal injury to a superficial right posterior sectoral duct during dissection at the gallbladder fossa during index laparoscopic cholecystectomy.
Timing of presentation of bile ducts injury after cholecystectomy can be variable. If the duct injury is not recognized intraoperatively, postoperative bile leaks result in patients’ reported symptoms of abdominal pain, nausea, loss of appetite and lethargy. Posterior sectoral duct injuries may escape detection and opacification on intraoperative cholangiogram or postoperative ERCP due to the lack of communication of the injured ducts with the main biliary channels, thereby rendering angiographic assessment challenging. Diagnosis presents the most significant barrier to prompt treatment and such injuries should be suspected when a bile leak persists despite “normal” cholangiography and there is a presumed failure of a “CD stump leak” closure after biliary stent placement2. In addition, anatomical variation of the biliary tree is not uncommon and can increase risk for ductal injuries3. Surgeon awareness of the variant biliary branching is essential to decrease risk of accidental damage during cholecystectomy and prevent it’s associated significant morbidity4.
While most bile leaks after cholecystectomy can be managed conservatively via ERCP and biliary stent placement, alternative treatment options must be explored when conservative managements fail. The case presentation in our patient and repeat ERCP was most consistent with leak from rare anatomic variations of the right posterior sectoral duct system, which denotes class V for individual right sectoral bile duct injury according to the Bismuth-Strasberg system for classifying iatrogenic bile duct injuries5.
Perera et al proposed that nonoperative management is feasible in the majority of patients with leaks secondary to right posterior sectoral duct injuries via percutaneous drain placement and endoscopic stenting6. In cases where the leak persists, operative intervention should be sought. Although hepatic abscess can be resulted with posterior sectoral bile duct ligation, it can be safely considered in small duct size as performed in our case6. Partial hepatic resection or biliary reconstruction via Roux-en-Y hepaticojejunostomy might be required based on intraoperative assessment, biliary anatomy, underlying liver disease and patient comorbidities7.