Aritake Tsukasa, Takagi Kenji, Nagano Natsuki, Kobayashi Ryutaro, Maeda Takashi, Kawai Kiyotaka, Kawai Satoru, Kamiya Satoaki
Department of Surgery, Tsushima City Hospital, 3-73, Tachibana Town, Tsushima City, Aichi, 496-8537, Japan.
Surg Case Rep. 2020 May 24;6(1):111. doi: 10.1186/s40792-020-00876-z.
Subtotal cholecystectomy is an effective surgical method to decrease the risk of complications for gallbladders that are difficult to remove. However, there is a risk for postoperative refractory bile leakage through the gallbladder stump. Here, we report a new management technique involving the use of argon plasma coagulation (APC) to stop bile leakage after a subtotal cholecystectomy.
A 74-year-old man was referred to our hospital for abdominal pain and fever. Contrast-enhanced computed tomography of the abdomen showed fluid collection, such as an abscess, surrounding the gallbladder and hepatic flexure colon. The patient was diagnosed with colonic perforative peritonitis, and he underwent emergency surgery. On laparotomy, the abscess was observed outside of the hepatic flexure colon and gallbladder necrosis was detected. The neck of the gallbladder and the area close to the hepatoduodenal ligament was severely inflamed prohibiting dissection. The hepatic flexure colon was part of the abscess wall, and resection was needed. A subtotal cholecystectomy and right hemicolectomy confirmed peritonitis caused by cholecystic perforation. The mucous membrane of the gallbladder neck that remained was necrotic or detached. Therefore, the stump of the gallbladder was closed by primary sutures without cauterization of the mucosa. On postoperative day 6, bile leakage from the gallbladder stump was revealed. Percutaneous and endoscopic retrograde cholangiography drainage were performed. However, the liquid, which seemed to be secreted from the mucosa of the remnant gallbladder, was continuously obtained. We used APC to cauterize the gallbladder mucosa through the fistula of the abdominal drainage tube. Bile leakage and mucus discharge were improved after three rounds of APC cauterization.
APC effectively treated refractory bile leakage from a gallbladder stump after subtotal cholecystectomy for severe cholecystitis.
胆囊次全切除术是一种降低难以切除胆囊并发症风险的有效手术方法。然而，存在通过胆囊残端发生术后难治性胆漏的风险。在此，我们报告一种新的处理技术，即使用氩等离子体凝固术（APC）来阻止胆囊次全切除术后的胆漏。
一名74岁男性因腹痛和发热被转诊至我院。腹部增强计算机断层扫描显示胆囊和肝曲结肠周围有液体积聚，如脓肿。患者被诊断为结肠穿孔性腹膜炎，并接受了急诊手术。剖腹手术时，在肝曲结肠外侧观察到脓肿，检测到胆囊坏死。胆囊颈部和靠近肝十二指肠韧带的区域严重发炎，无法进行解剖。肝曲结肠是脓肿壁的一部分，需要切除。胆囊次全切除术和右半结肠切除术证实了胆囊炎穿孔引起的腹膜炎。残留的胆囊颈部黏膜坏死或脱落。因此，胆囊残端通过单纯缝合关闭，未对黏膜进行烧灼。术后第6天，发现胆囊残端有胆漏。进行了经皮和内镜逆行胆管造影引流。然而，似乎从残留胆囊黏膜分泌的液体持续引出。我们通过腹腔引流管瘘口使用APC烧灼胆囊黏膜。经过三轮APC烧灼后，胆漏和黏液排出情况得到改善。
对于严重胆囊炎行胆囊次全切除术后胆囊残端难治性胆漏，APC能有效治疗。
