DISCUSSION LC has become the operation of choice for a variety of gallbladder disorders, most commonly symptomatic cho- lelithiasis. 1-3 Although LC has an acceptable safety profile, it could result in major complications with high rates of morbidity and mortality. 2,5 One of the most common major complications of LC is IBDI. 2,5 Aberrant biliary tract anatomy is one of themajor risk factors for IBDI during LC. 2,3 Misiden- tification of the aberrant bile ducts as the cystic duct is the cause of 70%-80% of all IBDIs during LC. 2 Therefore, proper identification of biliary anatomy before clipping, ligating, or dividing the structures during LC is of utmost importance. 2 Although direct drainage of aberrant right bile ducts into the cystic duct has been previously reported, 4 to our knowledge, our case is the first report of direct drainage of an aberrant left main bile duct into the cystic duct or gallbladder. Only 25%-32%of IBDIs are recognized during LC. 5 Most IBDIs are diagnosed after LC. 2,5 Radiological investigations for evaluation of IBDIS include HIDA scan, ERCP, percuta- neous transhepatic cholangiography (PTC), and magnetic resonance cholagniopancreatography (MRCP). 2 PTC is help- ful in evaluating the biliary tract anatomy proximal to the site of injury. 2 ERCP can demonstrate the injured bile ducts and be used to stent the injuries of major hepatic ducts if the common bile duct is not completely transected or ligated. 2,5 MRCP can be useful for preoperative evaluation of IBDI in patients requiring surgical reconstruction by providing an excellent delineation of biliary anatomy. 2,5 However, MRCP can miss small biliary leaks. 5 In this case, T-tube cholangi- ography and ERCP did not initially diagnose the aberrant left main hepatic duct that was cut during LC. Looking retrospectively at this case, it could be observed that the left biliary system is actuallymissing in T-tube cholangiography and ERCP images (Figures 1A and 1B). Also, the branches of the biliary system, which were mistakenly interpreted as left biliary system, are, in reality, the branches of the right posterior biliary system. Furthermore, the fact that no leak from the biliary system during ERCP and T-tube cholangiogramwas observedmade this scenario evenmore complicated. These findings should have raised the possi- bility of an existing aberrant biliary ductal system draining directly into either the cystic duct or the gallbladder. The final diagnosis in our case resulted from a high index of suspicion and a cholangiography via J-P drain. Usually, a false tract forms around the J-P drain and the site of the transected bile duct that facilitates cholangiogram through the J-P drain. We suggest that our approach should be used for cases of IBDI inwhomERCP, T-tube cholangiography, or PTC do not show the location of bile duct injury. It should be mentioned that the transection of this type of bile duct anomaly is unavoidable during either open or LC. There- fore, time and accuracy of diagnosis plays a major role in the management of transection of this type of complication. There is controversy about the role of routine cholangi- ography during cholecystectomy in the prevention of IBDI. Although some studies suggest that intraoperative cholangi-
ography during cholecystectomy may reduce the chance of IBDI, 6 in a recent population-based data study by Sheffield et al., 7 which retrospectively evaluated 92,932 patients with cholecystectomy, intraoperative cholangiography was not found to be effective in the prevention of IBDI. There is a growing body of evidence demonstrating the importance of early referral of IBDI patients to tertiary care centers, which provide a multidisciplinary approach to treat IBDIs. 5,8 Besides being helpful in diagnosis, endoscopic and percutaneous radiological techniques can be used for primary treatment of IBDIs. 2 Surgical management of IBDIs is usually reserved for the cases that do not respond to or are not suitable candidates for radiological or endoscopic techniques. 2,5 A transected bile duct draining a segment or a smaller part of the liver can be safely ligated before it becomes colonized with bacteria and fungi. Subsequently, the draining segment of the liver will be atrophied without any significant sequelae. However, if the transected bile duct is colonized, ligation of the duct is contraindicated because it could lead to segmental cholangitis with the need for prolonged antibiotic therapy, significant morbidity, and even resection of the affected segment of the liver. In our case, since the left main hepatic duct was transected for an extended period of time and was most probably colonized, we decided to do selective left Roux-en-Y hepaticojejunos- tomy. Roux-en-Y hepatico/choledoco jejunostomy is the most widely used surgical operation for reconstruction of IBDIs. 1,2,5 Roux-en-Y hepaticojejunostomy has been reported to have favorable success rates with good short- and long- term outcomes if done at specialized hepatobiliary surgery centers. In a study by Schmidt et al., 9 successful long-term results were achieved in 50 (93%) out of 54 patients with major bile duct injuries who underwent roux-en-Y hepa- tiocojejunostomy. However, biliary reconstruction in the presence of peritonitis, combined vascular and bile duct injuries, and injury at or above the level of the biliary bifur- cation were among the major predictors of poor outcome after roux-en-Y hepatiocojejunostomy. Liver resection has been rarely used in the management of patients who have combined IBDI and major vascular injury. 10,11 Liver trans- plantation has been used for treatment of a small number of patients who develop acute or chronic liver failure due to the catastrophic complication of IBDI, such as hepatic necrosis in the presence of concomitant portal vein and/ or hepatic artery damage or secondary biliary cirrhosis as a consequence of inappropriate management of transected bile duct with too lengthy stent placement or inadequate treatment of stenotic hepaticojejunostomy. 8 We are reporting an extremely rare anatomical varia- tion of biliary system for the first time. We hope that the diagnostic andmanagement approach used in this case will help other physicians to identify and manage their patients should they face such a rare anatomy. REFERENCES
1. Sicklick JK, CampMS, Lillemoe KD, et al. Surgical management of
J La State Med Soc VOL 166 September/October 2014 205
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