title: Iatrogenic bile duct injury with loss of confluence.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan México 14080, DF, México.
authors.forename: Miguel-Angel
authors.initials: MA
authors.lastname: Mercado
authors.affiliation: Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan México 14080, DF, México.
authors.forename: Mario
authors.initials: M
authors.lastname: Vilatoba
authors.affiliation: Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan México 14080, DF, México.
authors.forename: Alan
authors.initials: A
authors.lastname: Contreras
authors.affiliation: Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan México 14080, DF, México.
authors.forename: Pilar
authors.initials: P
authors.lastname: Leal-Leyte
authors.affiliation: Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan México 14080, DF, México.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Cervantes-Alvarez
authors.affiliation: Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan México 14080, DF, México.
authors.forename: Juan-Carlos
authors.initials: JC
authors.lastname: Arriola
authors.affiliation: Miguel-Angel Mercado, Mario Vilatoba, Alan Contreras, Pilar Leal-Leyte, Eduardo Cervantes-Alvarez, Juan-Carlos Arriola, Bruno-Adonai Gonzalez, Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan México 14080, DF, México.
authors.forename: Bruno-Adonai
authors.initials: BA
authors.lastname: Gonzalez
keywords: Bile duct injury; Biliary repair; Double-barrel anastomosis; Hepatojejunostomy; Neoconfluence; Portoenterostomy