Taj Mahal Liver Resection for High-level Bile Duct Injury: A First Case Report in Bangladesh

Abstract

Resection of stricture part and reconstruction in very high-level bile duct injury is challenging work. Taj Mahal liver resection provides a good space to dissect out the first or second generation of bile ducts. We are reporting a patient with Bismuth type IV bile duct stricture, successfully treated by applying Taj Mahal liver resection. The 38-year-old diabetic lady underwent open cholecystectomy for symptomatic gallstone disease after which she developed biliary peritonitis on second postoperative day (POD). A plastic stent was inserted endoscopically in the common bile duct (CBD) on the 10^th POD which also did not improve her condition. Exploratory laparotomy, thorough peritoneal toileting and controlled fistula was performed on 16^th POD. Postoperatively she developed acute respiratory distress syndrome (ARDS) and was cured with ICU support. She was symptom free for 1.5 months, thereafter CBD stent was removed. Six months later she developed progressive jaundice and was admitted to our hospital for further management. Magnetic resonance cholangiopancreatography (MRCP) confirmed bile duct stricture (Bismuth type IV). On the basis of MRCP, we decided to perform the right hepatectomy for total removal of stricture and perform biliary enteric anastomoses. But liver volumetry showed that remnant liver volume would be less than 40% which is essential for preventing postoperative liver failure in jaundiced patients. Therefore, the Taj Mahal hepatectomy was applied on the patient to ensure reduced parenchymal loss by resecting Segment 5 and Segment 4b (Fig-2). We performed jejunal anastomosis with 5 intrahepatic ducts in this patient. She recovered from surgery without any biliary leakage from anastomotic sites or postoperative liver dysfunction / liver failure.

Fig-1: Biliary System Anatomy¹

Fig-2: Segments of the Liver²

Taj Mahal hepatectomy is a good option for reconstructing very high-level bile duct injury. However, more patients and long term follow up is required for final conclusion.

Introduction

Taj Mahal liver resection is a rare and less heard procedure included in the hepatectomy list. It was invented by a Japanese surgeon (Yoshifumi Kawarada) and his team who published the procedure in 1999.¹ This procedure was employed for hilar cholangiocarcinoma and gallbladder carcinoma invading the hepatic ducts.^1,2 The advantage of this procedure is i) it helps to get tumor free or fibrous tissue free margin bile duct cut end, which prevents tumor recurrence or development of re-stricture after reconstruction. ii) it also provides a large cut surface which allows easy access for performing intrahepatico-jejunostomy. iii) the procedure only takes out the segments 5 (S5) and Segment 4b (S4b) with or without caudate lobe (S1) which is minimum parenchymal loss in comparison to right or left hepatectomy or extended hepatectomy in treating patient with jaundice. The disadvantage is to face multiple cut ends of bile duct which needs to be anastomosed individually or combined.

Table-1 Bismuth Classification based on the level of bile duct stricture.³

Fig-3: Levels of stricture in the hepatic ducts⁴

Iatrogenic bile duct injury after laparoscopic cholecystectomy remains a substantial problem in our country. The rate of clinically relevant bile leaks after open cholecystectomy ranges between 0.1 and 0.5% ^3-5 and after laparoscopic cholecystectomy (LC) by up to 3% ^6-9 worldwide. Although in Bangladesh we have no such data, the incidence will be more than that. Our observation, even though it is not backed by evidence, is that the incidence of high-level injuries (Type III and IV) is more common than low level injury (Type I and II) (Reference- Table-1 & Fig-4). Reconstruction is easy and re-stricture rate is rare in type I and II level stricture because of available bile duct stump. In contrast reconstruction is difficult and re-stricture rate is more common in type III and IV stricture because of unavailability of bile duct stump and location of stricture inside the liver. Therefore, we believed that Taj Mahal liver resection may provide easy reconstruction and prevent re-stricture rate. We are reporting a case of Type IV biliary stricture who was treated successfully with Taj Mahal liver resection procedure.

Case report

A 38-year-old diabetic lady underwent an open cholecystectomy for symptomatic gallstone disease in a district level private hospital by a non-qualified surgeon. On the second POD, she developed abdomen pain, fever, tense, and tender abdomen. She was then referred to an endoscopic centre where one plastic stent was placed in common bile duct (CBD) endoscopically ten days after operation. But her symptoms did not improve. Complete blood count showed neutrophilic leucocytosis, USG and CT scan of whole abdomen showed huge fluid collection inside abdomen. MRCP showed non dilated intrahepatic biliary tree and huge abdominal collection. She was diagnosed as a case of biliary peritonitis. Exploratory laparotomy and thorough peritoneal toileting were done keeping 4 drains inside (one in subphrenic, one in subhepatic, one in pelvis and one in left paracolic gutter) 16 days after primary surgery. Postoperatively she developed ARDS and required ICU support. She recovered from ARDS and developed wound infection which was improved with regular dressing and wound was closed secondarily 24 days after primary operation. Three drains were removed except the right subhepatic drain through which bile was coming 300-500 ml per day. She was discharged from hospital keeping the drain in situ and was advised to come to our hospital when drain output become nil. One and half months later when the right subhepatic drain output became zero, it was removed. As she was symptom free, 5 months after peritoneal toileting, CBD stent was removed. One month after removing biliary stent she developed progressive jaundice and was admitted to our hospitals for further management. MRCP (Fig-4) confirmed the bile duct stricture (Bismuth type IV), and Magnetic Resonance Angiography (MRA) showed a stricture at right hepatic artery level with good distal perfusion (Fig-5); portal and hepatic veins were normal. On the basis of MRCP, we decided to perform right hepatectomy for total removal of stricture and for perfect biliary-enteric anastomosis. But liver volumetric analysis showed that after right hepatectomy, the remnant liver volume would be less than 40% (Fig-6) which is essential for preventing postoperative liver failure. Therefore, Taj Mahal hepatectomy (removal of S5 and S4b) was applied on our patient (Fig-7). It provided less liver parenchymal loss and good intrahepatic left and right sided ductal system for intrahepatic-jejunal anastomosis. In the present case we performed jejunal anastomosis with 5 intrahepatic ducts (Fig-8). Patient recovered from surgery without any biliary leakage from anastomotic sites or postoperative liver dysfunction / liver failure except wound infection which was healed after regular dressing and secondary suturing.

Fig-4: MRCP shows Bismuth type IV stricture.

Fig-5: CT angiogram of liver showing a stricture at right hepatic artery with proximal good flow.

Fig-6: CT volumetry of liver. Total liver volume = 2342 CC, Right liver volume = 1430 CC, Future remnant liver (FLR) right = 61%, Future remnant liver (FLR) left: 39%

Fig-7: Taj Mahal Hepatectomy

Fig-8. Five intrahepatic ducts are anastomosed with jejunum.

Discussion

Criteria for good hepaticojejunostomy are: i) to have a good bile duct stump, ii) to have a no tension jejunostomy loop, iii) to have good blood supply to both jejunum and bile duct end. Unless these criteria are maintained during anastomosis, bile leakage immediately after operation or anastomotic stricture in the long run is very common. Achievement of no tension jejunal loop and having good blood supply to jejunal end is easy during hepaticojejunostomy, but to have a good bile duct stump and its blood supply is a challenging one. Low level stricture (type I and II) has a considerable length of bile duct stump and its blood supply. Therefore, reconstruction is relatively easy in low level stricture and a result anastomotic leakage and anastomotic stricture is rare. In contrast, the high-level stricture (type III and IV) does not have bile duct stump, stricture either involves the confluence or to the first-generation duct. Therefore, for getting clear bile duct stump and its blood supply, removal of part of liver parenchyma is essential for high level bile duct stricture.  Taj Mahal hepatectomy^1,2 or Dumbbell-Form Resection¹⁰ are popularized for getting tumor free bile duct margin for hilar cholangiocarcinoma and gallbladder carcinoma invading the common hepatic duct. In both operations S5 and S4b segments of liver with or without S1 parenchyma is removed, although the nomenclature is different which is because of cut surface appearance. Removal of the part of liver parenchyma provides first generation bile ducts and adequate space where intrahepatic bile duct end and jejunum anastomosis can be done easily and safely while maintaining the ideal criteria of anastomosis. The major cumbersome part of this operation is getting two or more bile duct ends which will require multiple anastomosis. Hemi-hepatectomy or extended right or left hepatectomy is recommended for getting stricture or malignant free margin of intrahepatic bile duct.¹¹ But morbidity and mortality are more after hemi or extended hepatectomy as most of the patients of hilar cholangiocarcinoma or iatrogenic high-level stricture present with obstructive jaundice.  Reports also demonstrated that patients with obstructive jaundice have compromised liver function, and the operation-related morbidity and mortality is further increased after hemi-hepatectomy or extended hemi-hepatectomy.^12–14 Preoperative biliary drainage (PBD) and percutaneous transhepatic portal vein embolization (PTPE) are used to decompress liver and make hypertrophy of remnant liver before hemi or extended hemi-hepatectomy.^15-19 But several studies have shown that PBD does not decrease the overall postoperative mortality^20-23 because of PBD related complications, that includes cholangitis, pancreatitis and even implantation metastasis^24,25. Therefore in the present case we applied Taj Mahal hepatectomy and we successfully removed the stricture part involving the confluence that extended to both right and left hepatic duct. After removal of S5 and S4b, we encountered three ducts opening on the right side and two ducts opening on left side. All five ducts were anastomosed with single opening on Roux-en-Y jejunal loop putting stent in each branch (5 stents).  No bile leak was observed postoperatively, and she was discharged from hospital 1 month after operation without major complication except for wound infection which was treated by regular dressing. However, to see the long-term complication we have to wait some more time to reach a final conclusion. For now, it can be concluded that Taj Mahal hepatectomy is a good option for reconstructing very high-level bile duct injury.