Ann Hepatobiliary Pancreat Surg.  2019 May;23(2):138-144. 10.14701/ahbps.2019.23.2.138.

Post-cholecystectomy acute injury: What can go wrong?

• Gupta V
• Gupta A
• Yadav TD
• Mittal BR
• Kochhar R

• KMID: 2448767
• DOI: http://doi.org/10.14701/ahbps.2019.23.2.138

Abstract

BACKGROUNDS/AIMS
Most of the emphasis of postcholecystectomy injuries is laid on iatrogenic bilary trauma. However, they can involve a wide spectrum of injuries.
METHODS
We prospectively evaluated 42 patients with postcholecystectomy injuries referred to us from July 2011 to December 2012. Based on spectrum of injuries, we proposed an algorithm of management.
RESULTS
Injuries occurred following laparoscopy in 20 (2 converted) patients and open in 22 patients. Mean time of detection of injury was 4.32±2.33 days. The nature of drainage was bilious in 36, bile with blood in 2, only blood in 2, and enteric in 2. Nine had organ failure at presentation. Six (14%) needed re-operation. Source of hemorrhage was from right hepatic artery in three and small bowel mesentry in 1. Enteric injuries were one each to duodenum and colon. Six patient (14%) died. Advancing age and organ failure were the predictors of mortality. Persistant biliary fistula was seen in 5 (14%). Ten had lateral leaks that closed at 28.89±2.34 days. Twenty-two formed stricture which was successfully managed with definitive hepaticojejunostomy.
CONCLUSIONS
Post cholecystectomy acute injury does not limit itself to bile duct or vascular injury but it can traumatize adjacent hollow viscus or mesentery. It is important to diagnose and intervene enteric injury early. Presentation and management for such injury should be followed as per the proposed algorithm.

Keyword

Acute; Bile duct; Injury; Cholecystectomy; Vascular; Enteric; Stricture; Fistula

MeSH Terms

Bile
Bile Ducts
Biliary Fistula
Cholecystectomy
Colon
Constriction, Pathologic
Drainage
Duodenum
Fistula
Hemorrhage
Hepatic Artery
Humans
Laparoscopy
Mesentery
Mortality
Prospective Studies
Vascular System Injuries

Figure

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  Fig. 1 Flow chart to show the management protocol.

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  Fig. 2 (A) CT showing multiple bile collections after cholecystectomy. (B) Reconstructed CT image to show pseudoaneurysm arising form replaced right hepatic artery. (C) Contrast study done through drainage tube in patient with persistent fistula shows delineation of the biliary system. Note right posterior sectoral duct is not visualized on this image, which was later seen on MRI (D). This patient had type E5 injury.

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