Isolated Right Posterior Sectoral Duct Stricture: A Novel Treatment Approach

Introduction: Isolated posterior sectoral duct stricture following a hepaticojejunostomy done for a post open cholecystectomy biliary injury is uncommon. We present a similar case treated with a novel surgical approach. The Case: A 32 years old female, a known case of hypothyroidism on treatment, presented with complaints of recurrent episodes of upper abdominal pain and fever for the past 10 months. She was well till 2009 when she was diagnosed to have cholelithiasis with choledocholithiasis. She underwent open cholecystectomy with common bile duct (CBD) exploration and T- tube placement. T-tube was removed 6 weeks following the operation. She then had recurrent episodes of cholangitis for which endoscopic retrograde cholangio-pancreatography (ERCP) was done and a stent was placed in the CBD. The patient was well for the next 6-7 months but she again started developing recurrent episodes of on and off fever which used to relieve with oral antibiotics. In December 2012 she also developed gradually increasing jaundice which was associated with itching & clay coloured stools. She was evaluated and a diagnosis of CBD stricture (Bismuth type IV) was made on magnetic resonance cholangio-pancreatogram (MRCP) for which she underwent Roux-en-y hepaticojejunostomy (HJ). She then had complaints of recurrent episodes of upper abdominal pain and fever for the past 10 months. There was no history of jaundice, itching and clay coloured stools. Her total leukocyte counts and liver function tests were within normal limits. Ultrasound of the abdomen revealed mild prominence of central intrahepatic biliary radicals with few periportal lymph nodes. MRCP revealed right posterior sectoral duct (RPSD) stricture and a patent HJ anastomosis. Percutaneous transhepatic cholangiogram (PTC) done through segment 5 duct revealed patent hepaticojejunostomy anastomosis and another one done through posterior sectoral duct revealed RPSD stricture. Following the cholangiogram, the respective ducts were externally drained. Computed tomography angiography revealed dilated biliary radicles of the RPSD and non-visualization of right hepatic artery with collaterals from left hepatic artery supplying the right liver lobe across the hilum. She was then planned for right posterior sector internal drainage. Intraoperatively, there were dense perihepatic adhesions. The right hepatic artery pulsations were not palpable. The previous HJ site was intact and the right posterior sector was normal in size. On table cholangiogram through PTBD showed complete stricture of the RPSD. Intraoperative ultrasound of the liver failed to guide a wire into the duct through the undersurface of the liver. Coring of the liver in the gall bladder fossa was done and the right posterior sector duct was identified which was confirmed on cholangiography. The posterior sectoral duct was then anastomosed to the previous HJ loop.   Conclusions: Hepatic artery injury during cholecystectomy results in ascending of the biliary stricture. Perihepatic adhesions and the previous hepaticojejunostomy present a formidable challenge during the reoperation which is compounded by the difficulty in identifying the duct. Coring of the liver in the gall bladder fossa along with the intraoperative cholangiogram is a novel technique in identifying the right posterior sectoral duct.   Â