title: Laparoscopic posterior sectoral bile duct injury: the emerging role of nonoperative management with improved long-term results after delayed diagnosis.
abstract: BACKGROUND
  Right posterior sectoral bile duct (RPSD) anomalies seen in up to 8% of the population rarely are injured at laparoscopic cholecystectomy. Paucity of data on the management of these injuries led the authors to conduct this study aimed at reviewing management strategies for laparoscopic RPSD injuries at a specialist center.
  
  
  METHODS
  Of 221 patients, 15 (6.7%; 4 men; mean age, 51 years; range, 21-75 years) treated between 1992 and 2009 for injuries to the RPSD were followed up for a median of 58 months (range, 7-208 months). Case notes, imaging, and follow-up data were reviewed.
  
  
  RESULTS
  The RPSD injury was immediately recognized in 3 (20%) of the 15 patients, whereas in the remaining patients, biliary injury was suspected on day 1 (range, 1-18 days) due to bile leak/biloma. The diagnosis of RPSD injury was made by a combination of investigations including endoscopic retrograde cholangiopancreatography (ERCP) (n = 11), drain tube cholangiogram (n = 10), on-table cholangiogram (n = 3), and nuclear scan (n = 3). An intact common bile duct and absence of RPSD were identified on cholangiography (ERCP and on-table cholangiogram), whereas drain tube cholangiogram demonstrated a leaking RPSD in all cases. The majority of the patients (8/15, 53%) were managed nonoperatively with combined percutaneous drainage and endoscopic stenting, whereas six patients (40%) were managed with biliary reconstruction (immediate: n = 2; delayed 14-87 days: n = 4). Clinical and radiologic confirmation of complete cessation of bile leak was demonstrated 56 days (range, 7-62 days) after injury. The long-term outcome included a dilated right duct system with transient elevation of liver function tests in two patients (1 each in the nonoperative and surgical management groups), whereas the remaining patients all remain well at this writing.
  
  
  CONCLUSIONS
  Bile leak in the presence of an intact common duct shown on cholangiogram should raise the suspicion of an RPSD injury. Expertise is needed to interpret the absence of RPSD in these cases. Drain tube cholangiogram is an important adjunctive investigation. In selected cases, the results of nonoperative management alone is comparable with the results of reconstruction.
authors.affiliation: The Liver Unit, University Hospital Birmingham, Queen Elizabeth NHS Trust, Edgbaston, Birmingham, B15 2TH, UK.
authors.forename: M T P R
authors.initials: MT
authors.lastname: Perera
authors.forename: A
authors.initials: A
authors.lastname: Monaco
authors.forename: M A
authors.initials: MA
authors.lastname: Silva
authors.forename: S R
authors.initials: SR
authors.lastname: Bramhall
authors.forename: A D
authors.initials: AD
authors.lastname: Mayer
authors.forename: J A C
authors.initials: JA
authors.lastname: Buckels
authors.forename: D F
authors.initials: DF
authors.lastname: Mirza
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D001652:Bile Ducts / Q000293:injuries*; D017081:Cholecystectomy, Laparoscopic; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D055815:Young Adult