Successful Repair of a Strasberg E4 Bile Duct Injury With Double-Barreled Dual Hepaticojejunostomy: A Case Report

Bile duct injury (BDI) is a catastrophic complication of cholecystectomy that can profoundly affect a patient's quality of life. While hepaticojejunostomy is the standard surgery for major BDI repair, reports of double-barreled dual hepaticojejunostomy following Strasberg E4 injury are limited. The complication rate of the repair of BDI above the bifurcation is very high, and very dismal outcomes are reported. We present a case of a 79-year-old male patient with multiple comorbidities who underwent laparoscopic cholecystectomy for acute gangrenous cholecystitis. He was transferred to our hospital on postoperative day (POD) 3 due to bile leak and sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) showed a large number of clips on the hilum of the liver and distal common bile duct obstruction. Exploratory laparotomy identified a missing common bile duct and hepatic duct above the confluence, with less than 5 mm extrahepatic left and right hepatic duct stumps left, which were occluded by multiple clips. Also, there was a sign of cauterization at the end of the stumps. Patient's condition did not permit safe intrahepatic dissection. Following the removal of clips and debridement of the hepatic duct stumps, a Roux-en-Y double-barreled dual hepaticojejunostomy was performed over stents. Postoperatively, the patient had a transient bile leak, tolerated diet, and was discharged to a skilled nursing facility on POD 12 and remained asymptomatic six months postoperatively. In this case, Strasberg E4 BDI resulted in separated left and right hepatic duct stumps, which require a double-barreled dual hepaticojejunostomy to address multiple hepatic duct stumps. Multiple anastomoses, smaller stumps, and the narrow space inside the liver hilum significantly increased the difficulty of the repair. Due to the rarity of double-barreled dual hepaticojejunostomy, further studies are needed to assess its feasibility, mortality, and morbidity.