title: Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery: an algorithmic approach.
abstract: OBJECTIVE
  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%).
  
  
  CONCLUSIONS
  Management of major biliary fistulae that 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.
authors.affiliation: Second Department of Surgery, Areteion University Hospital, Athens Medical School, University of Athens, Acharnes, Athens 11528, Greece.
authors.forename: Georgios
authors.initials: G
authors.lastname: Fragulidis
authors.forename: Athanasios
authors.initials: A
authors.lastname: Marinis
authors.forename: Andreas
authors.initials: A
authors.lastname: Polydorou
authors.forename: Christos
authors.initials: C
authors.lastname: Konstantinidis
authors.forename: Georgios
authors.initials: G
authors.lastname: Anastasopoulos
authors.forename: John
authors.initials: J
authors.lastname: Contis
authors.forename: Dionysios
authors.initials: D
authors.lastname: Voros
authors.forename: Vassilios
authors.initials: V
authors.lastname: Smyrniotis
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D000714:Anastomosis, Surgical; D001658:Biliary Fistula / Q000209:etiology / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001662:Biliary Tract Surgical Procedures / Q000295:instrumentation / Q000379:methods; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects*; D004322:Drainage; D004444:Echinococcosis, Hepatic / Q000473:pathology / Q000601:surgery*; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects*; D006500:Hepatic Duct, Common / Q000293:injuries* / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome