Complex Reoperation for Biliary Sclerosis: A Case Study

By Charles Miller, MD

History

Our patient is a 62-year-old male with severe secondary sclerosing cholangitis following a complex history of biliary reconstruction at a prestigious out-of-state institution, which resulted in a left and right hepatico-jejunostomy. After that, he suffered from multiple episodes of cholangitis and underwent right PTC stent placement and dilatations without any improvement.

Several surgical consultations at various other institutions concluded that surgery was not possible. Instead, stent replacement and antibiotics were recommended. Because of associated pain, the patient was also opioid dependent.

Presentation

In April 2016, he presented to Cleveland Clinic where he was studied with both with an MRI and a CT scan (see main image above) that showed an atrophic left hepatic lobe, a right-sided internal-external percutaneous transhepatic biliary drainage catheter with mild segmental intrahepatic biliary dilatation in the right lobe, as well as a markedly atrophic left lobe. The left hepatic duct was completely obstructed and undrained.

Preoperative MRI showing right hepatic duct dilation.

Postoperative cholangiogram showing patent hepaticojejunostomy without filling defects.

CT scan showing the liver after left hepatectomy with a new hepaticojejunostomy.

Treatment

In May 2016, the patient underwent a left hepatectomy and removal of the entire left hepatic duct. The biliary drain on the right hepatic duct was exchanged on a wire and a short portion of the right hepatic duct was resected to fresh tissue. The right hepatico-jejeunostomy was also refashioned over a new stent.

Outcome

The patient recovered uneventfully. One month after surgery, a cholangiogram showed a widely patent hepatico-jejunostomy and the biliary drain was removed.

At one-year follow-up, the patient was doing well with no more episodes of cholangitis and normal liver function. He no longer uses opioids.

References

1. Gondolesi G, Varotti G, Florman S, Munoz L, Fishbein T, Emre S, Schwartz M, Miller C. Biliary complications in 96 consecutive right lobe living donor transplant recipients. Liver Transplantation. 2004 Feb;10(2):244-7.
2. Hashimoto K, Miller CM, Quintini C, Aucejo FN, Hirose K, Uso TD, Trenti L, Kelly DM, Winans CG, Vogt DP, Eghtesad B, Fung JJ. Is impaired hepatic arterial buffer response a risk factor for biliary anastomotic stricture in liver transplant recipients? Surgery. 2010 Sep;148(3):582-8.