Cholangiojejunal fistula caused by bile duct stricture after intraoperative injury to the common hepatic artery

Abstract

A 68-year-old man, admitted for the treatment of recurrent cholangitis after a pancreatoduodenectomy (PD) performed 3 years previously was diagnosed as having multiple hepaticolithiasis. On laparotomy, the hepatic artery was not recognized. The anastomosed common hepatic duct was obstructed, and a fistula had been formed between the right hepatic duct and the Roux limb of the jejunum. Lithotripsy was performed from this fistula and it was reanastomosed. Angiography was performed postoperatively and it revealed common hepatic artery injury, most likely to have occurred during the previous PD. The patient's postoperative course was uneventful and he has been asymptomatic for 8 months after the operation, indicating that reanastomosis of the fistula can be an effective method. The stricture of the anastomosis was suspected to be mainly due to cholangial ischemia, because no episode of anastomotic leak or retrograde biliary infection had occurred during the PD perioperative period. There are several reports of late stricture of anastomosis 5 or more years after cholangiojejunostomy. This patient, therefore, requires further long-term follow up.

Management of hepatic artery trauma during hepato-pancreato-biliary procedures: Evolving approaches, clinical outcomes, and literature review

“…As a result of HA trauma, liver abscess, liver failure, anastomotic leakage, late liver atrophy, and bile duct stenosis are the most common complications. [3,4,[24][25][26] In eight series in which Landen et al [3] detected HA trauma in PubMed screening; complications (liver necrosis/abscess [n=14], liver failure [n=3], and anastomotic dehiscence [n=6]) were reported in 16 (76%) of 21 cases, three of which had artery variations. It was found that 11 of the patients were reoperated, and 5 (24%) of them died.…”

“…Due to ischemia of the bile duct wall caused by HA trauma, anastomotic leakage may develop in the early period, and biliary stricture may develop in the long term. [ 10 , 26 ] While mucosal damage due to ischemia in the bile duct mucosa heals with inflammation and fibrosis also causes stricture. Recurrent cholangitis and hepatolithiasis can also be seen in patients with a stricture.…”

“…The presence of hypovolemia, dehydration, anemia, lung problems, pain, excessive sedation, limitation of movement, or heart problems will further increase the risks associated with artery ligation. [ 26 ] Struggle with shock and providing oxygenation are the first preventive and therapeutic procedures.…”

Dealing with hepatic artery traumas: A clinical literature review

“…As a result of HA injury, liver abscess, liver failure, anastomosis opening, late liver atrophy, and bile duct stenosis are the most common complications[ 3 , 9 , 35 , 41 , 44 ]. In the HA injury series of 21 cases, Landen et al [ 3 ] detected in the PubMed screen complications: Liver necrosis/abscess ( n = 14), liver failure ( n = 3), and anastomotic dehiscence ( n = 6) were reported in 16 patients (76%), 3 of which had artery variations.…”

“…In a patient with impaired hemodynamics, the portal vein's oxygen parameters deteriorate further, and the liver's oxygenation is disrupted. The presence of hypovolemia, dehydration, anemia, lung problems, pain, excessive sedation, limitation of movement, or heart problems will further increase the risks associated with artery ligation[ 44 , 58 ]. Struggle with shock and providing oxygenation are the first protective and therapeutic procedures.…”