Retroperitoneal Biloma Secondary to Operative Common Bile Duct Injury

Abstract

Encapsulated collections of bile ("biloma") may be a sequela of liver trauma, operative injury or disease. Such collections may be intrahepatic or extrahepatic and usually in the supramesocolic compartment of the abdomen. This is a report of a retroperitoneal biloma, an entity that has been reported only twice to date but this is the first secondary to an operative common bile duct lesion.Evacuation of the biloma and reconstruction of the associated biliary stricture were successfully carried out. The patient remains sympton free with normal clinical and laboratory data more than 14 months after surgery.Operative common bile duct (CBD) injury may be followed by a number of complications. To our knowledge retroperitoneal biloma secondary to a CBD lesion has not been previously reported. CASE REPORTA 54 year old lady was submitted to elective cholecystectomy in a district hospital on 15/09/1988. Operative cholangiography was not performed. Soon after operation bile drainage through a subhepatic drain appeared and continued for four weeks. The patient subsequently developed bile peritonitis and was reoperated upon on 21/10/1988 and the abdominal cavity was drained. Bile drainage stopped by mid-January 1989 but was followed by jaundice. A third operation was performed on 23/02/89 for obstructive jaundice. The CBD could not be found and the abdomen was closed with drainage. In March 1989 percutaneous transhepatic cholangiography (PTC) was carried out clearly demonstrating a high CBD stricture. The procedure was followed by frequent attacks of severe cholangitis with a temperature of up to 40C.. Once while vomiting she felt "that something broke in the abdomen". After this episode the fever abated somewhat and the attacks of cholangitis became less severe. However, a painful enlarging right lower quadrant abdominal mass appeared.At the time of admission to our Institution on 31/03/1989 she was deeply jaundicied with a large tender right lower abdominal mass. Laboratory data indicated biliary obstruction (total serum bilirubin 302.5 mmol/l, serum alkaline phosphatase 6.9 U/I (normal value 1 to 2.5 U/l).

Retroperitoneal bile leak after laparoscopic cholecystectomy

“…Such a mechanism has been described before in a case of retroperitoneal bile leak that was not due to cholecystectomy 15. In 1990, Cólović and Perisić-Savić performed a surgical exploration on a patient who had right lower quadrant abdominal pain after a severe vomiting episode on the background of recurrent cholangitis from a Bismuth 3 stricture after cholecystectomy 15. They found that the patient had an internal biliary fistula that extended along the hepatoduodenal ligament to behind the duodenum and into the retroperitoneal space 15…”

“…The bile can then track downwards until where the peritoneum diverges and escapes into the retroperitoneal space. Such a mechanism has been described before in a case of retroperitoneal bile leak that was not due to cholecystectomy 15. In 1990, Cólović and Perisić-Savić performed a surgical exploration on a patient who had right lower quadrant abdominal pain after a severe vomiting episode on the background of recurrent cholangitis from a Bismuth 3 stricture after cholecystectomy 15.…”

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

“…Only one-half of our PCBL cohort required US, CT or MRI scans showing fluid collections. These may be subhepatic, intrahepatic, subcapsular or rarely in the retroperitoneal space [25,26]. HIDA scans may show continuity between a biloma and the biliary tree [25][26][27][28][29].…”

“…These may be subhepatic, intrahepatic, subcapsular or rarely in the retroperitoneal space [25,26]. HIDA scans may show continuity between a biloma and the biliary tree [25][26][27][28][29]. However, ERCP and percutaneous transhepatic cholangiography (PTC) are the most accurate at demonstrating the exact site of a leak [5][6][7].…”

Spontaneous biloma: a case report

“…US findings suggesting biloma are a hypo-anechoic fluid collection, well-defined margins, sometimes encapsulated, mono-or pluriconcamerate appearance, in a typical location (right upper abdominal quadrant: sub-or intrahepatic, below the diaphragm) and no vascularity on color Doppler US. The size of a biloma may vary from a few centimeters up to 40 cm in diameter [6].…”