Rare bile leak from left triangular ligament

Abstract

Variations of the biliary system present challenges to abdominal operations and can affect postoperative outcomes. Bile leak is an uncommon complication of total gastrectomy. However, any procedure that involves mobilisation of the left lobes of the liver should be executed with additional caution. A thorough assessment including preoperative imaging for aberrant anatomy should be performed, especially aberrant bile ducts in the left triangular ligament. Ligation or suturing of the left triangular ligament should be considered when the aberrant anatomy suggests, to decrease the risk of postoperative bile leak. In addition, the left lateral segment of the liver should be thoroughly inspected on initial completion of the operation.

Background

A wide anatomic variation exists in the extrahepatic biliary system.¹ These variations of the biliary system present challenges to an operation and can affect postoperative outcomes. Aberrant bile ducts are a scarce variation that include a network of bile ducts located in the perihepatic capsule.² These ducts are often discovered intraoperatively and increase the risk of bile duct injury.

In a total gastrectomy, the entirety of the stomach is resected and then reconstructed in a Roux-en-Y fashion. Injury to the bile ducts during a gastrectomy is uncommon, as gastrectomy does not involve direct manipulation of the biliary system. However, a gastrectomy does include mobilising the left lateral section of the liver to expose the hiatus, which involves mobilising the left triangular ligament. This can cause damage to the aberrant bile ducts,³ which may be attached to the left triangular ligament of the liver. Although the presence of bile ducts along the left lobe of the liver is a rare occurrence, it may result in a significant complication.

Case presentation

A 57-year-old woman presented with abdominal pain and a history of gastritis. On oesophagogastroduodenoscopy (OGD), the patient was found to have a 15 mm nodular gastric polyp, along the lesser gastric curve, approximately 4–5 cm from the gastro-oesophageal junction. A biopsy was performed, revealing an intramucosal gastric adenocarcinoma.

The patient’s surgical history includes a cholecystectomy and hysterectomy. The patient denies tobacco, alcohol and illicit drug usage. She is currently taking pantoprazole, sucralfate and dicyclomine as medications.

An endoscopic ultrasound was performed that revealed a T1a lesion, confirming that the tumour had infiltrated into the mucosal lamina propria and muscularis mucosa. Endoscopic mucosal resection was performed to excise the lesion. On pathology, it was a poorly differentiated adenocarcinoma with a positive deep margin. Hence, a surgical resection was planned.

The patient underwent an open total gastrectomy with Roux-en-Y oesophagojejunostomy and jejunostomy tube (J-tube) placement. An intraoperative OGD confirmed location of the lesion. After resection, the patient’s left triangular ligament was mobilised using electrocautery, and the oesophagojejunal anastomosis was fashioned in a handsewn manner. The jejunojejunostomy was created using a stapled technique. A J-tube was placed in a Witzel fashion. A 24-Fr round Blake drain was left near the oesophagojejunal anastomosis.

On postoperative check in the recovery room, bilious output was noted in the drain within a few hours of the primary operation. The patient’s vital signs were normal otherwise and the patient was doing clinically well. The patient was taken to the operating room for exploration. A decision was made to explore the patient due to unexpected bile leak, in order to determine the source of the leak likely from a technical error and potentially facilitate resolution.

On exploration, the duodenal stump, J-tube site and enteroenterostomy were all thoroughly assessed and no leak was noted. However, bile was noted near the oesophagojejunal anastomosis. A saline immersion leak test was negative. The Raytec surgical sponge overlying the reflected left of the liver was noted to have bile staining. There was no bile staining from the oesophagojejunal anastomosis. The saline immersion leak test was repeated again without any evidence of leak. A small biliary radicle was noted at the mobilised left triangular ligament of the liver (figure 1). We were able to milk a small volume of bile from the radicle. This area was sutured with the 4-0 monofilament absorbable suture.

Figure 1.

Location where bile leak was noted intraoperatively at the left triangular ligament of the liver.

Postoperatively, the patient recovered well in the hospital and was discharged appropriately.

Differential diagnosis

The bile leak found postoperatively was predicted to originate from the duodenal stump, J-tube site or the oesophageal anastomosis. However, a saline immersion leak test was negative for the oesophageal anastomosis and no leak was noted at the J-tube entrance site or at the duodenal stump.

Treatment

At the mobilised left triangular ligament of the liver, a small biliary radicle was noted. Additionally, we were able to milk a small volume of bile from the radicle. This area was sutured with a 4-0 monofilament absorbable suture.

Outcome and follow-up

The patient recovered after the procedure. Upper gastrointestinal series on postoperative day two showed prompt contrast passage with no leak. On postoperative day 3, the patient’s bowel function had returned. The patient was subsequently started on a liquid diet and advanced. The J-tube feeds were gradually advanced to goal. At 6-month follow-up, the patient was without evidence of disease on imaging and clinically doing very well.

Discussion

Bile leak from a gastrectomy is an uncommon complication. A gastrectomy procedure does not involve direct manipulation of the biliary system, however mobilisation of the left lateral segments of the liver and the left triangular ligament can cause damage to aberrant bile ducts. The presence of extrahepatic bile ducts along the left lobe of the liver is a rare occurrence but can result in a major complication.

There is limited research regarding the presence of aberrant bile ducts in the left triangular ligament. A similar case report was published by the Department of General Surgery at the Suleyman Demirel University Medical School that presented a case of 67-year-old woman who underwent hiatal hernia repair.⁴ Her procedure involved mobilisation of the left liver lobe by dissecting the left triangular ligament. Postoperative findings included a 150 mL bile leak within 24 hours of the procedure. During reoperation, an aberrant bile duct with bile leakage was found at the site where the left triangular ligament was dissected. The injured bile duct was ligated and the patient was discharged without complications. The importance of ligating the region of the left triangular ligament is emphasised by the authors.

A cadaver liver study performed by the Athens Medical Center in Greece suggested the ligation or suturing of the left triangular ligament edge after its division to prevent postoperative bile leak. Furthermore, it was suggested the ‘left triangular ligament be incised along its attachment to the diaphragm’ to prevent bile leakage.³

Learning points.

• Assess preoperative imaging for aberrant anatomy.

• Thoroughly inspect the left lateral segment on initial case completion.

• Evaluate the possibility of aberrant bile ducts in the left triangular ligament.

• Consider ligation or suturing the left triangular ligament of the liver to prevent postoperative bile leak.