Hemobilia and cystic artery stump pseudoaneurysm associated with liver abscess after a laparoscopic cholecystectomy: Report of a case

Abstract

A 63-year-old woman was admitted for cholecystitis and underwent a laparoscopic cholecystectomy (LC). She experienced abdominal pain and hemobilia 11 days after the LC. Angiography was performed but it did not show any source of bleeding. Thereafter, at 27 days after LC, a repeat angiogram was performed which revealed a pseudoaneurysm (PA) arising from a cystic artery stump and an embolized PA sack. However, another PA arising from near the embolized PA and liver abscess was observed 4 days after embolization. The arterial collateral flow was evaluated by endovascular balloon occlusion of the right hepatic artery and it was embolized proximal and distal to the bleeding point. The embolization of the partial hepatic artery was effective for PA when packing the PA sack proved to be insufficient. In patients with liver cirrhosis or liver abscess who require an adequate arterial liver flow, it is important to evaluate the collateral arterial flow before hepatic artery embolization.

Hepatic or Cystic Artery Pseudoaneurysms Following a Laparoscopic Cholecystectomy: Literature review of aetiopathogenesis, presentation, diagnosis and management

“…6,7,42 Among the cases treated with TAE, complications included liver abscesses (n = 10; 13.7%), post-embolisation syndrome and hepatic ischaemia (n = 9; 12.3%),postoperative bleeding for a month (n = 1; 1.4%) and erosion of the stent into the common bile duct (CBD; n = 1; 1.4%). 3,15,16,37,45 The overall mortality rate was 2.0% (n = 2). 7,40 One fatality was due to severe haemorrhagic relapse following repair of the PSA, resulting in irreversible hypovolaemic shock despite re-exploration and ligation.…”

“…Among the cases which specified the gender or age of the patient, 45.2% were male and the age ranged from 12-81 years with a mean age of 49.8 years. 4,5,[9][10][11][12][13]15,[17][18][19][20][21][24][25][26][27][28][29][30][31][33][34][35][37][38][39][40][41][42][43][46][47][48]51,57,58,60,62 The time of presentation following the LC procedure ranged from six days to five years with a mean of 36 days. [3][4][5][7][8][9][10][11][12][13]15,…”

“…18,29,31 The size of the PSAs ranged from 13-200 mm, with a mean size of 43 mm. 4,6,13,15,17,26,30,31,33,37,39,42,43,57 The modality of management was transarterial embolisation (TAE) in 72.3%, endovascular stent placement in 4.0%, exploratory laparotomy and ligation of the hepatic artery in 5.0% and thrombin injection in 4.0% of cases. The TAE procedure alone failed to control bleeding in four cases (5.5%), resulting in a 94.5% success rate.…”

“…28,30,32,33,[39][40][41]57 Other involved sites include the cystic artery and, in some cases, the common hepatic and gastroduodenal arteries. 4,9,37,38,44,47,58 a e t i o pat h o g e n e s i s A PSA may arise due to multiple mechanisms of injury, including laceration, transection or occlusion of the blood vessels following a mechanical or thermal injury to the artery. 6,37,51 This may occur when inappropriate energy (thermal/mechanical) is applied during dissection of the Calot's triangle or following dissection with a laser.…”

“…4,9,37,38,44,47,58 a e t i o pat h o g e n e s i s A PSA may arise due to multiple mechanisms of injury, including laceration, transection or occlusion of the blood vessels following a mechanical or thermal injury to the artery. 6,37,51 This may occur when inappropriate energy (thermal/mechanical) is applied during dissection of the Calot's triangle or following dissection with a laser. 5,37 A thermal injury could result from the direct transfer of heat to the vessel by cautery or indirectly via a metal clip in contact with the artery.…”