The patient was a 68-year-old woman who underwent laparoscopic cholecystectomy for chronic cholecystitis with gallbladder stones and suffered intraoperative bile duct injury requiring diversion of the common bile duct (Strasberg E2) about 6 years ago at another hospital. Conversion to open laparotomy and choledochoduodenostomy (C-D) were performed at that time. Two-weeks later, she was found to have leakage of the C-D anastomosis and underwent re-operation with C-J. Subsequently, a biliary-cutaneous fistula persisted for two years and eventually healed with conservative treatment. Three years after healing of the fistula, the patient presented to our hospital with back pain and high fever. On examination, there was tenderness in the right subcostal region without muscle guarding.
Laboratory tests showed that the white blood cell count was 13,350/ul, C-reactive protein was 9.0 mg/dl, total bilirubin was 5.0 mg/dl, direct bilirubin was 3.1 mg/dl, aspartate aminotransferase was 166 U/l, alanine aminotransferase was 133 U/l, alkaline phosphatase was 881 U/I, and gamma-glutamyltransferase was 196 U/l.
Abdominal computed tomography (CT) revealed dilation of intrahepatic bile ducts in the lower left lobe and posterior right lobe, with bile duct stones and/or debris also being visible (Fig. 1A, B). Abdominal ultrasonography (US) also showed that the right hepatic duct was filled with debris (Fig. 1C). Accordingly, percutaneous transhepatic biliary drainage (PTBD) was performed. Cholangiography via the PTBD tube showed a hilar hepatic duct stricture (Fig. 2A, long white arrow) and stones in the left intrahepatic bile duct. It also revealed a fistula between the reconstructed jejunal limb and the duodenum (Fig. 2 A, B, red arrow). Duodenal endoscopy directly revealed the fistula communicating with the reconstructed jejunal limb (Fig. 2C). Balloon dilatation of the hilar hepatic duct stricture was tried twice via the PTBD tube, resulting in failure to sufficiently alleviate the stricture.
Subsequently, surgical exploration was performed. The cause of the bile duct stones and recurrent cholangitis was considered to be the patient's jejunal-duodenal fistula combined with biliary stasis due to the C-J stricture. Hepatic ductoplasty was performed along with H-J and diversion of the jejunal-duodenal fistula. A diagram of the procedure is shown in Fig. 3. First, the previous biliary-enteric anastomosis was resected and the anterior wall of the stenotic shortened hepatic duct was longitudinally incised near the liver parenchyma. Intraoperative cholangioscopy was performed to remove the bile duct stones. Cleavage of stones and washout of the remnant stones and sludge with normal saline were also done. Hepatic ductoplasty was carried out according to the method described previously. Briefly, the anteriorly incised hepatic duct was everted toward the liver parenchyma to make a wide stoma (Fig. 3A). In addition, stricture-plasty of the left intra-hepatic duct orifice was performed to relieve biliary stasis, as shown in Fig. 3B. Subsequently, H-J was performed by monolayer knob hand-sewing via the ante-colic route. Postoperative cholangiography apparently showed wide and broad H-J anastomosis in Fig. 3C. The patient had no further reflux cholangitis or hepatolithiasis when reviewed at one year after surgery.