Raashed Soondoos, Chandrasegaram Manju D, Alsaleh Khaled, Schlaphoff Glen, Merrett Neil D
Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia.
Division of Surgery, School of Medicine, University of Western Sydney, Sydney, Australia.
BMC Surg. 2015 Apr 29;15:51. doi: 10.1186/s12893-015-0039-8.
Right hepatic arterial injury (RHAI) is the most common vascular injury sustained during laparoscopic cholecystectomy, occurring in up to 7% of cholecystectomies. RHAI is also the most common vascular injury associated with a bile duct injury (BDI) and is reported to occur in up to 41 - 61% of cases when routine angiography is employed following a BDI. We present an unusual case of erosion of vascular coils from a previously embolised right hepatic artery into bilio-enteric anastomoses causing biliary obstruction. This is on a background of biliary reconstruction following a major BDI.
A 37-year old man underwent a bile duct reconstruction following a major BDI (Strasberg-Bismuth E4 injury) sustained at laparoscopic cholecystectomy. He had two separate bilio-enteric anastomoses of the right and left hepatic ducts and had a modified Terblanche Roux-en-Y access limb formed. Approximately three weeks later he was admitted for significant gastrointestinal bleeding and was hypotensive and anaemic. Selective computed tomography angiography revealed a 2 x 2 centimetre right hepatic artery pseudoaneurysm, which was urgently embolised with radiological coils. Two months later he developed intermittent fevers, rigors, jaundice, and right upper quadrant pain with evidence of intrahepatic biliary dilatation on magnetic resonance cholangiopancreatography. The degree of intrahepatic biliary dilatation progressively increased on subsequent imaging over several months, suggesting stricturing of the bilio-enteric anastomoses. Several attempts to traverse these strictures with a percutaneous transhepatic approach had failed. Then, approximately ten months after the initial BDI repair, choledochoscopy through the Terblanche access limb revealed multiple radiological coils within the bilio-enteric anastomoses, which had eroded from the previously embolised right hepatic artery. A laparotomy was performed to remove the coils, take down the existing obstructed bilio-enteric anastomoses and revise this. Following this the patient recovered uneventfully.
Obstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication. In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI.
右肝动脉损伤（RHAI）是腹腔镜胆囊切除术期间最常见的血管损伤，在高达7%的胆囊切除术中发生。RHAI也是与胆管损伤（BDI）相关的最常见血管损伤，据报道，在BDI后采用常规血管造影时，高达41%-61%的病例会发生这种情况。我们报告了一例罕见病例，即先前栓塞的右肝动脉中的血管线圈侵蚀至胆肠吻合口，导致胆道梗阻。这是在一次严重BDI后的胆道重建背景下发生的。
一名37岁男性在腹腔镜胆囊切除术时发生严重BDI（Strasberg-Bismuth E4损伤）后接受了胆管重建。他对左右肝管进行了两次独立的胆肠吻合，并形成了改良的Terblanche Roux-en-Y入路肢体。大约三周后，他因严重的胃肠道出血入院，出现低血压和贫血。选择性计算机断层扫描血管造影显示一个2×2厘米的右肝动脉假性动脉瘤，紧急用放射学线圈进行了栓塞。两个月后，他出现间歇性发热、寒战、黄疸和右上腹疼痛，磁共振胆胰管造影显示肝内胆管扩张。在随后几个月的后续影像学检查中，肝内胆管扩张程度逐渐增加，提示胆肠吻合口狭窄。多次尝试通过经皮肝穿刺途径穿过这些狭窄均失败。然后，在初次BDI修复后大约十个月，通过Terblanche入路肢体进行的胆管镜检查发现胆肠吻合口内有多个放射学线圈，这些线圈是从先前栓塞的右肝动脉侵蚀而来的。进行了剖腹手术以取出线圈，拆除现有的梗阻性胆肠吻合口并进行修复。此后，患者顺利康复。
血管造影放置的栓塞线圈侵蚀继发的梗阻性黄疸和胆管炎是一种很少被描述的并发症。鉴于严重胆管损伤后动脉损伤和并发症的相对发生率，我们建议在严重BDI后对这些患者进行相关动脉损伤的正式评估。
