Dear Dr. Presanna, the patient could be managed clinicaly by Syptoms & Signs by jaundice risk of canalicular obtruction and chollangitis if association with infection, while Image & Laboratory management could be acompanied by abdominal Ultrasound, MRCP & cholangiography, Hepatic & billiar  function enzymes by Transaminases & Alcaline Fosfatase. 

Honourable Colleague

You could try to detect with flexible endoscope the new "choledochus" and at the same time by minimal invasive surgery put a drainage to this place into the bowle for some weeks. Than this "emergency-exit" can be slowly retracted and biology could obliterate this

Difficult scenario! Good news is that patient is not septic. I guess this is because he has a well positioned abdominal drain which acts like a controlled fistula. Priority now is to divert bile for the time it takes to make the hepaticojejunal anastomosis heal.

In this scenario, I would go for a PTC stent and also request the radiologist to traverse the anastomosis and enter the jejunum if possible. This should act as an internal conduit and encourage healing of the anastomosis provided the leak is from the suture line of the anastomosis and not from any freely open duct elsewhere.

Obviously internalising the drain is not an option because it is a Roux loop.

You haven't mentioned the volume of the bile leak. If it's high volume the patient will need PTBD. If the volume is small and reducing I would not intervene unless the patient becomes septic or it persists beyond about 4-6 weeks. The hepaticojejunostomy you have described sounds like it is placed low on the bile duct and is insufficient for good drainage long term.  If possible wait for 6 to 12 weeks and redo the HJ after evaluation of the biliary anatomy and vasculature. By the time you operate the bile leak is likely to have healed - either spontaneously or with PTBD. if it has healed spontaneously you are likely to have some biliary dilatation to help you.

This is a difficult case .I will do nothing for the next 4 weeks  unless the patient is jandice or septic After that time I will study the anatomy of biliary tree and the  posibility of arterial damage and after all if the patient still have colestase or biliary leak i will offer a new operation .In this procedure you may have several possibiloties : the  junction of rigth and left main biliary ducts are still present -we can perform a Couinaud procedure ;the right and left ducts are separated  ;we can  perform  two  separeted anastomosis

In the most serous cases there is   also rigth hepatic artery damage in this case a right hepatectomy may be needed  with  left duct jejunun anastomosis In all these case I never used transanastomotic drains

Dear sir,

its a difficult situation indeed. 

First point would be is it a low or high output fistula

if it's low, and there is no jaundice and no intra abdo collection-then we are lucky then it's about- enteral nutrition, control of sepsis and protection of skin and wound and wait for the output to decrease before we start withdrawing drain. All the time building up the chest with breathing exercises.

worst scenario- a high output fistula. Will require intervention question is when....

if patient is not jaundiced no intrabdo collection or sepsis then we build up the patient... Do imaging try to understand the anatomy before we decide to go back in. We may need to add par enteral nutrition and consider refeeding  of bile as well . In this scenario PTCD may not work as the biliary system will not be dilated.

if the patient is jaundiced.... It may be associated with sepsis this makes it pretty complicated... PTCD may help if system dilated otherwise will need early operative intervention needs a very experienced team with imaging modalities at disposal

l am sorry. l so gynecologist surgeon.

Greetings

Thankyou,Biliary output at the time of admission was 300 mls in 24 hours.MRCP at our centre showed collapsed or non dilated system with high ductal injury at the hilum.Hilar area  is obscured by extravasation.ERCP showed complete obstruction of cbd with three clips. Dr Hans the test you mentioned is Spy Glass cholangioscopy,we did not do as it has no role in this scenario.Fistulogram was attempted through the drain,interestingly the drain has migrated to sub phrenic region, hence could not get any information.Patient is stable ,no fever started on diet. Blood and Bile culture reports are awaited.

Indeed, this is a tough case. The main reason for the failure of the repair is that the reoperation was done early and the surgeon couldn’t identify correctly the bile duct. Any repair in this situation is prone to fail. It seems by your initial report that Roux-en-y loop was anchored to the bile leak site. Therefore, bile leak will certainly continue. In my opinion the best course of action is to wait until postoperative inflammation and adhesions are completely gone. Meanwhile, clinical support care should keep this patient out of sepsis.

Your recent report mentioned that the hilar plate is obscured and the injury is at high level. Therefore, the Roux-en-Y was not effective. I would wait 4 to 6 weeks before definitive repair. Just be aware to check if the Roux-en-Y loop was properly done, otherwise the patient can experience postoperative cholangitis if a short or rotated loop is in place. For the repair it is of paramount importance to lower down the hilar plate.

MRI done at your center did show any vascular lesion? I hope not. It will be a difficult repair even in the absence of hepatic artery injury. Good luck.

 Interestingly not many of our Hepato Biliary RG colleagues have opined !

Relax then if patient stabilized try PTD several trials. If failed redo HJ.

If the 1st HJ was done by abdominal or gastric loops you can try ERCP

 Dear Dr Emad,probably my framing of the question was not clear.PTBD in collapsed ducts is difficult,In such a short period after Roux en Y HJ,do you think Redo will give atleast short term relief,of course identifying CHD bifurcation is going to be difficult again.

His main tube drain stopped draining and pt started feeling discofort.U/S screening showed large collection which was drained percutaniouly and the tube drain was removed.He is feeling well ,mobile and adviced discharge to his home country and review for surgery as discussed above.

Yet times Relaxing is a safer bet,

Again, I believe that if you redo HJ now you are going to have difficulty in identify and a new failure in HJ may compromise the future capacity of performing a definitive correction. Everytime you dissect the bifurcation you decrease the rate of success. If the patient tolerates this situation, wait and wait a little bit more.

WAIT n WAIT !!!

The best has already been done (drain the collection, lavage n keep fresh drain). Patient is now stable, ambulatory n oral. Let him build up nutritionally. A delayed repair after complete evaluation of biliary n vascular anatomy /injury is advised.

Just to note, its a delayed repair, NOT A LATE REPAIR....(after biliary cirhosis or other complications develop)

An attempt at  biliary-enteric anastomosis in the presence of inflammation and / or sepsis is doomed. Effective drainage, creation of a controlled fistula, perhaps a per-cutaneous biliary drainage (diversion) to permit the reduction of the cavity / collection might be helpful. Defining anatomy by imaging  would give confidence prior to any surgical intervention... the timing of the repair or re-anastomosis should be when biochemical and physiological (nutritional) parameters  are as 'normal' as possible in 3 to 6 months. 

Wait n careful watch is advised in such cases.

MRCP would help to determine the future course of action

Once inflammation settles further management options of PTBD/redo anastomosis 

Pt should be nutritionally build up before any redo surgery