Portobiliary fistula following laparoscopic cholecystectomy

Abstract

The laparoscopic approach has replaced open surgery as the gold standard for cholecystectomy. This technique is, however, associated with a greater incidence of bile duct injuries (BDIs). We report a case of portobiliary fistula (PBF), a rare complication of BDI, occurring post laparoscopic cholecystectomy (LC). PBF has been reported after procedures such as endoscopic retrograde cholangiopancreatography and pathologies such as liver abscesses, but only once previously in the setting of LC. We discuss the management of this patient with apparent dual pathology, and summarise other aetiologies that may give rise to this condition. KEYWORDS Laparoscopic cholecystectomy -Bile ducts -FistulaAccepted 31 January 2016Laparoscopic cholecystectomy (LC) has replaced open surgery as the gold standard for cholecystectomy due to reduced postoperative pain and length of hospital stay, and a faster return to activities of daily living. Despite a reduction in both surgical and systemic-related complications, there remains a significant risk of bile duct injuries (BDIs) with the laparoscopic technique. Although this was initially attributed to a 'learning curve' effect, it has persisted for two decades.1 We report on a rare complication of BDI following LC. Case ReportA 48-year-old female of Chinese origin presented 3 days after an intially uncomplicated laparoscopic cholecystectomy with abdominal pain radiating to her shoulder tip. Blood tests on admission showed raised inflammatory markers (white cell count 14.8x10 9 /L, C-reactive protein 183 mg/L) and deranged liver function tests (alanine transaminase 132 IU/L, alkaline phosphatase 148 IU/L). A suspected bile leak was investigated with a computed tomography (CT) scan. This revealed subphrenic free fluid with air locules, free intraperitoneal air and focal intrahepatic biliary dilatation in the left lobe of liver.Endoscopic retrograde cholangiopancreatography (ERCP) was attempted, but the patient did not tolerate the procedure. An emergency exploratory laparotomy was undertaken, which revealed a Bismuth Grade IV injury to the distal right hepatic duct. After thorough peritoneal lavage, a T-tube was inserted across the identified site of injury, with placement of a 20 FG Robinson's drain behind the portal triad. Following

Portobiliary Fistula in a Liver Transplant Recipient Treated With an Endoscopically Deployed Fully Covered Self-Expandable Biliary Metal Stent

“…Possible treatment strategies include medical management, balloon tamponade, coil embolization, percutaneous or transjugular stent placements, and surgical repair. 1 In addition, So et al reported a successful treatment of a portobiliary fistula with a FCSEMS. 3 In their case, the fistula, caused by a biliary stent for management of obstructive jaundice in a palliative setting in a patient diagnosed with hepatocellular carcinoma, led to recurrent bacteremia and upper gastrointestinal bleeding.…”

“…To date, only 2 cases of portobiliary fistulas after liver transplantation (LT) and only 6 cases related to endoscopic retrograde cholangiopancreatography (ERCP) have been reported in the literature. 1 The etiologies range from iatrogenic injuries to hepatobiliary pathologies (eg, cholangitis and stone erosion) but may also be caused by recurrent or chronic inflammatory processes and vascular pathologies. 2 To our knowledge, this is the first reported case of a portobiliary fistula in a liver transplant recipient treated with endoscopically deployed biliary fully covered self-expandable metal stent (FCSEMS).…”

A case report of bloody pancreatitis

“…In the case highlighted a two-year period elapsed prior to the onset of symptoms related to the porto-biliary fistula. There has been two previously documented cases of haemobilia due to a porto-biliary fistulae complicating laparoscopic cholecystectomy [12], [13].…”

Porto-biliary fistula as an uncommon cause of haemobilia: A case report and literature review

“…Porto-biliary fistula is an uncommon cause of haemobilia. It is a complication after bile duct procedures and manipulation [7] . It is a rare entity and the literature on this topic is restricted to case reports [7] , [8] , [9] .…”

“…It is a complication after bile duct procedures and manipulation [7] . It is a rare entity and the literature on this topic is restricted to case reports [7] , [8] , [9] . To date, less than 30 cases have been described.…”