J Surg Rad

Journal of Surgical Radiology

Saturday, 10 July 2010 19:49 Prateek K Gupta, MD 0 Comments
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Original Article: Bile Leak After Laparoscopic Redo Fundoplication

Figure-IndexNissenOverview Laparoscopic antireflux surgery is the gold standard treatment for gastro-esophageal reflux disease (GERD). The most commonly reported severe complications include pneumothorax, gastro-esophageal perforation, and splenic injury. Rare complications such as aortic injury, major liver injury, mesenteric artery thrombosis, ventricular laceration, and pancreatitis have also been reported. We describe the first reported case of a bile leak after redo laparoscopic Nissen fundoplication presenting as symptomatic right-sided bilious hydrothorax. This injury was most likely a result of dissecting the undersurface of the liver from adhesions formed after the previous fundoplication.

Bile Leak After Laparoscopic Redo Fundoplication

Prateek K Gupta, MD, Brittany L Willer, MD, Tommy H Lee, MD, and Sumeet K Mittal, MD
Department of Surgery, Creighton University, Omaha, Nebraska.

Contact: Sumeet K Mittal, MD E-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Citation: Gupta PK, Willer BL, Lee TH, and Mittal SK. Bile Leak After Laparoscopic Redo Fundoplication. J Surg Radiol. 2010 Oct 1;1(2).

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Received July 10, 2010. Accepted August 4, 2010. Epub August 5, 2010.

Copyright: © 2010 Surgisphere Corporation. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

 

Contents

- Introduction
- Case Report
- Discussion
- Disclosures
- References

Introduction

Since the first laparoscopic Nissen fundoplication in 1991, laparoscopic surgery has become the gold standard treatment of GERD.1-3 Compared to open procedures, the laparoscopic approach has been shown to significantly decrease hospital stay, reduce time to return to normal activity, and have fewer postoperative complications.4

Due to the large number of laparoscopic fundoplications being performed worldwide, rare and unusual complications are occasionally seen. Infrequent, but serious intraoperative complications have been reported. These include major liver injury (laceration, necrosis, and hematoma), ventricular perforation, esophagogastric perforation, aortic laceration, vena caval injury, and pancreatitis. Reoperative antireflux surgery has a higher incidence of intra and postoperative complications, which may be attributed to the adhesions from prior fundoplications that increase the difficulty of the procedure significantly. It is necessary to report these complications to enable rapid recognition of similar problems in the future so as to enhance patient safety, help in management, and advise patients regarding procedure risks.5 Here, we present an unusual complication of bile leak after laparoscopic redo Nissen fundoplication.

Case Report

 

A 64 year old female, with severely impaired lung function (COPD Gold stage 3),6 chronic cough, and pathologic reflux disease presented with symptoms of regurgitation, morning cough, and worsening asthma. She had undergone a laparoscopic Nissen fundoplication 10 years earlier at an outside facility with early surgical failure. Her symptoms were uncontrolled despite maximal medical therapy with high-dose proton pump inhibitor and H2 receptor antagonist at night. She reported sleeping in a recliner most evenings and was on 2 liters/minute of oxygen by nasal cannula. Other surgical history included laparoscopic cholecystectomy and a left video-assisted thoracoscopic lung biopsy for tissue diagnosis to rule out interstitial lung disease.

She underwent a thorough preoperative evaluation for reoperative fundoplication. Endoscopy was performed which identified a disrupted fundoplication with the gastro-esophageal (GE) junction at 35 cm from the incisors and the crus at 39 cm, indicating a 4 cm recurrent hiatal hernia. The fundoplication was located at the level of the hiatus giving the patient a slipped fundoplication. Reflux esophagitis was noted on biopsies of the distal esophagus. Gastric emptying study and manometry were normal. A 24 hour pH study performed a year prior was grossly abnormal with a DeMeester score of 43. After adequate counseling and evaluation, a redo procedure for definitive treatment of GERD was offered, in view of her worsening lung function.

The patient underwent a laparoscopic repair of a recurrent hiatal hernia with takedown of previous fundoplication, redo Nissen fundoplication, and Stamm gastrostomy. Briefly, the steps included lysis of adhesions between the undersurface of the liver and stomach. Then, the hiatus was circumferentially dissected to identify the right and left limbs of the crus. A Penrose drain was placed encircling the stomach at the level of the crus. Using this for retraction, the herniated stomach was dissected out of the mediastinum. An extensive mediastinal dissection was performed to obtain adequate esophageal length. Both vagus nerves were carefully identified and preserved. The anterior and posterior limbs of the fundoplication were then identified and divided to completely undo the fundoplication. An intraoperative endoscopy confirmed that the fundoplication was completely dismantled and that there was no enteral injury. The crus was closed with a non-absorbable interrupted suture. The hiatus was then reinforced with mesh due to her increased risk for recurrent herniation, given her recent use of corticosteroids and chronic cough. A floppy Nissen fundoplication was created over a 60 Fr. Bougie. An endoscopy was done to evaluate the fundoplication. The stomach was distended under water and no leak was noticed. A percutaneous gastrostomy was placed endoscopically. This technique has been described in detail elsewhere.7 

A swallow study on postoperative day number (POD #) 1 showed no leak; oral intake was subsequently started. The postoperative course was unremarkable except for a slight deterioration of pulmonary function requiring a short course of high-dose corticosteroids. The patient was discharged on POD #5, tolerating a soft diet and having normal bowel function. Chest X-ray on the day of discharge showed a moderate right-sided effusion, which we elected to observe.

Five days later (POD #10), the patient developed chest tightness and shortness of breath at home, and went to an outside Emergency Department. Chest X-ray revealed a massive right pleural effusion. Tube thoracostomy was placed and returned bilious drainage. She was then transferred to our hospital for further management and started on broad-spectrum antibiotics and an antifungal, for a significant leukocytosis and bile leak. Contrast study with gastrograffin followed by thinned barium per oral and through the gastrostomy tube showed no evidence of a leak, with an intact fundoplication. Upper endoscopy confirmed the absence of perforation.

A hepatobiliary iminodiacetic acid (HIDA) scan (Figure 1) was obtained which showed movement of radioactivity from the proximal part of the biliary tree towards the anterior margin of the left lobe of the liver, and eventually into the chest. This represented a biliary leak from the region of the left lobe of the liver, possibly due to an injury to a major bile duct. Endoscopic retrograde cholangiopancreatogram (ERCP) confirmed it to be from the left liver lobe, arising from a tributary of the left ductal system. Contrast was seen leaking out of the distal left hepatic duct and into the thorax (Figure 2).

  Fig-1-TIFF

 

Figure 1. HIDA scan showing radioactivity going from the proximal biliary tree toward the anterior margin of the left lobe of the liver. The tracer eventually leaks into the chest.

 

 

 

Fig-2-TIFF

Figure 2. ERCP demonstrating leakage of bile from the left lobe of the liver arising from a tributary of the left hepatic duct. Contrast can be seen leaking into the chest.

The patient was started on oral and tube feeds and continued on antibiotics. Corticosteroids were stopped after tapering. The chest tube output was seen to gradually decline and tissue plasminogen activator (TPA) was administered. Computed tomography (CT) scan of the chest was obtained showing a loculated right pleural effusion (Figure 3). A pigtail was subsequently placed by interventional radiology to obtain better drainage and TPA was continued. A HIDA scan after a few days showed resolution of the bile leak. For the residual loculated fluid collection, we proceeded with a video-assisted thoracoscopic surgery (VATS) for definitive management. Over the next few days, output from the chest tube gradually decreased and it was removed. The patient was discharged on POD #34 tolerating a soft esophageal diet and supplemental tube feeds. Medications included PRN inhalers.

Fig-3-TIFF

 Figure 3. CT scan of the chest showing a loculated right pleural effusion.

The patient was seen in clinic 6 months later and reported resolution of cough and regurgitation. She was off corticosteroids, theophylline and used only inhalers as needed (roughly 2 times a day). 

 

Discussion

 

With the increasing number of laparoscopic fundoplications being performed, unusual intraoperative complications have been reported in the literature. Some of these include omental hematoma, pancreatitis, ventricular laceration with cardiac tamponade, aortic injury, mesenteric artery thrombosis, as well as liver laceration, necrosis and hematoma.5,8-11 A bile leak after laparoscopic redo antireflux surgery has been previously reported as part of a larger case series.12

In our patient, a likely explanation for development of a bile leak after the procedure include thermal/mechanical injury to the liver during dissection of the fundoplication off the undersurface of the left lobe of the liver. The increased adhesions encountered during a redo fundoplication make it more difficult to identify tissue planes. An injury may have been caused to the liver during the takedown of the adhesions.

Another less likely explanation for the bile leak is injury to the liver by the liver retractor. At our institute, we use a Nathanson self-retaining liver retractor. This retractor is rod-shaped with a curve to facilitate entry through the abdominal wall. It lifts the liver on its undersurface, parallel to its edge, making it a safe instrument.

Liver injuries are not uncommon during either antireflux surgery or laparoscopic surgery in general.8,13-17 Many of these reported cases of liver injury were attributed to retractors causing necrosis or parenchymal trauma due to pressure. Most of these cases involved fan-shaped retractors. Some injuries were also due to assistants manually holding the liver retractor.

In our patient, ERCP showed the leak to be from the left liver lobe arising from a tributary of the left ductal system. Contrast was seen leaking out of a distal left hepatic duct tracking superiorly into the thorax. It would be hard to imagine the liver retractor causing a significantly large enough injury to result in a bile leak in the absence of evidence of liver parenchymal damage on the CT scan. It was more likely due to direct injury while taking down the fundoplication.

The first step in management of bile leak after antireflux surgery is to rule out gastro-esophageal perforation. We elected to use both gastrograffin swallow and endoscopy to decrease the likelihood of missing a micro perforation. During endoscopy, it is imperative to retroflex and insufflate.

Bile leaks identified postoperatively are typically managed using endoscopy coupled with adequate external drainage. If intra-operatively placed drains are not adequate, tube thoracostomy or image-guided drainage may be required. The philosophy of endoscopic procedures is to reduce the bile duct to duodenum pressure gradient and divert bile away from the leak site, hence promoting healing.18 These procedures include endoscopic sphincterotomy (ES) alone, ES with stenting or nasobiliary drain placement without stenting. The appropriate choice remains controversial, with no one method universally shown to be better than the other.18-22

To conclude, although laparoscopic redo antireflux surgery can be performed safely with low morbidity, complications do occur. Bile leak is an extremely rare potential complication. Care must be taken to minimize trauma to the liver during retraction and dissection, particularly in the setting of reoperative surgery. We recommend a multimodal approach to diagnosis including ERCP, CT scan, contrast esophagogram, and scintigraphy. With adequate drainage, conservative management can be successful.

 

Disclosures

The authors have no disclosures or conflicts of interest related to this manuscript.

References

         

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