A 35 year old healthy lady presented to our department on sixth postoperative day [POD] with an external biliary fistula and intra-abdominal sepsis. She had undergone laparoscopic converted to open cholecystectomy for acute calculous cholecystitis. She had a biliary injury that was identified intra-operatively, managed by Roux-en-y hepaticojejunostomy[RYHJ]. The anastomosis leaked. An interno-external percutaneous transhepatic biliary drainage[PTBD] extending across the leak was performed at our hospital on POD 7 for both right and left hepatic ducts.
On POD nine, she had an upper gastrointestinal bleed. Esophagogastroduodenoscopy and Contrast enhanced computed tomography [CECT] abdomen did not reveal the source of bleeding. On conventional hepatic arteriogram, a leaking cystic artery pseudoaneurysm was identified (Fig. 1). During angioembolisation, due to a short stump of cystic artery, coils were placed in right hepatic artery [RHA]. However, one of the coils accidentally migrated into the left hepatic artery [LHA] and could not be retrieved. LHA stenting was performed, with good flow of contrast across the stent (Fig. 2). However, LHA developed spasm in its distal part, resulting in complete block of LHA and RHA.
On first day after coiling, there was significant elevation of liver enzymes with features of ischemic hepatitis. CECT abdomen with arteriography revealed poor enhancement of hepatic arterial tree in the segmental branches with partial revascularization from inferior phrenic and retroperitoneal arteries. The patient's relatives were explained the possibility of a need for an emergency liver transplant. The patient improved over the next 48 h, was transferred out of intensive care unit and oral feeds were started. Abdominal drain was removed after it stopped draining bile. She was discharged on POD 28 with PTBD catheters in situ. On POD 33, her liver function tests were within normal limits, percutaneous transhepatic cholangiogram showed trickle of contrast across the RYHJ, and the PTBD catheters were clamped. PTBD catheters were kept longer than 6 months and intervening periodic cholangiograms revealed anastomotic narrowing. Balloon dilatation of the stenosed anastomosis was performed on multiple occasions. Liver function was normal all along.
Fourteen months after surgery, cholangiogram revealed a worsening of RYHJ stricture (Fig. 3). A CECT abdomen and conventional angiogram performed at 18 months showed a blocked RHA and LHA. Multiple collaterals were seen arising from the right inferior phrenic artery, retroperitoneum and along the hepatoduodenal ligament (Fig. 4). In view of the collateral formation and persistent tight stricture with failed multiple dilatations, a surgical revision of the anastomosis was planned. Prior to surgery, right PTBD catheter was maneuvered from right to left duct across the hilum, draining externally.
During surgery, utmost care was taken not to release any adhesions in the hepatoduodenal ligament and not to mobilize liver from the diaphragmatic attachments to preserve all collaterals. Hilar dissection was kept to a minimum and the PTBD catheters guided the identification of biliary hilar confluence. A minor segement IV hepatotomy was done to expose the left hepatic duct and the roof of biliary confluence. Previous anastomosis was resected, and a Roux loop was prepared. A 2 cm single layer, interrupted 5-0 polydioxanone RYHJ was fashioned to the anterior wall of the biliary confluence with an extension onto the left duct.
Her postoperative recovery was uneventful. Cholangiogram on POD 10 showed a good flow across the anastomosis with no sign of a leak, and she was discharged with a clamped PTBD catheter. The PTBD catheter was removed 6 weeks after the surgery. The patient is doing well at 1 year follow up. Liver function is normal. She is being followed up to evaluate for secondary patency.