Surgical Management of Postcholecystectomy Strasberg Type E4 Bile Duct Injuries

High-biliary injuries are associated with worse outcomes. Most series do not mention failure rates specific to the injury grade. In our experience, Strasberg E4 injuries are associated with a higher failure rate. This study shares our experience with the surgical management of postcholecystectomy Strasberg E4 injuries.

Patient demographics, radiological findings, operative details, and postoperative complications were collected for patients with Strasberg E4 injury from October 2003 to December 2020. Between 2003 and 2010, the preferred operation was Roux-en-Y hepaticojejunostomy (HJ). In cases of right lobe atrophy or an isolated right hepatic duct injury, a primary hepatic resection was considered. From 2010 onward, Strasberg E4 injuries were considered for a right hepatectomy with the left duct HJ. Patients were followed up at six monthly intervals with liver function tests and abdominal ultrasound.

Sixteen patients had Strasberg E4 injuries, thirteen presented with an external biliary fistula and three presented with obstructive jaundice. Nine of the ten patients who underwent HJ before 2010 developed cholangitis at a median follow-up of 14 months (2-28 months). Five of these subsequently underwent a hepatectomy, one underwent a liver transplant, and the other three underwent radiological dilatation of their anastomoses. From 2010 onward, six patients underwent an upfront right hepatectomy with left duct anastomosis. At a median follow-up of 40 months (10-74 months), 3 patients had minor derangement of liver enzymes, and none required an endoscopic or radiological intervention.

HJ in E4 injuries often produces poor long-term results. An upfront right hepatectomy with left duct anastomosis might be considered.