Lynn Patricio Bernardo, Warnack Elizabeth Mesa, Parikh Manish, Ude Welcome Akuezunkpa
General Surgery Division, NYU Langone Health - Bellevue Hospital, 550 1st Avenue, New York, NY, |10016, USA.
J Gastrointest Surg. 2020 Nov;24(11):2703. doi: 10.1007/s11605-020-04664-w. Epub 2020 Jun 30.
Hemobilia is the presence of blood in the biliary tree and is a frequent complication after percutaneous transhepatic biliary drainage (PTBD). Most of these episodes are self-limited; nevertheless, in less than 5% of cases, hemobilia is clinically significant, requiring an intervention (hepatic artery embolization, stenting, or percutaneous thrombin injection). Adequate treatment requires control of hemorrhage and restoration of bile flow. Surgery is the last resort and is indicated when the other modalities fail.
A 65-year-old man with multiple comorbidities was admitted with cholangitis. The patient underwent PTBD (Figure 1) but had persistent cholestasis. Thus, he underwent endoscopic cholangiopancreatography (ERCP), in which a plastic stent was misplaced within the common bile duct (CBD) and could not be removed (Figure 2). Afterwards, as the patient had persistently high bilirubin levels and the previously placed stent was malpositioned, the decision was made to proceed with laparoscopic cholecystectomy and CBD exploration.
The operation was performed with choledocoscope guidance, and the CBD was closed over a T-tube. The operative time was 280 min. Postoperative course was uneventful; the T-tube was clamped 1 week after discharge. Four weeks postoperatively, the T-tube cholangiogram showed a patent extrahepatic biliary tree with no filling defects (Figure 3). The T-tube was then removed.
Biliary obstruction secondary to hemobilia is a rare occurrence after PTBD. Surgical CBD exploration is required when conservative management and endoscopic treatment fail and can be done successfully through a minimally invasive approach.
胆道出血是指血液在胆管系统中出现，是经皮肝穿刺胆道引流术（PTBD）后常见的并发症。这些情况大多为自限性；然而，在不到5%的病例中，胆道出血具有临床意义，需要进行干预（肝动脉栓塞、支架置入或经皮注射凝血酶）。充分的治疗需要控制出血并恢复胆汁流动。手术是最后的手段，当其他方法失败时才考虑使用。
一名患有多种合并症的65岁男性因胆管炎入院。患者接受了PTBD（图1），但胆汁淤积持续存在。因此，他接受了内镜逆行胰胆管造影（ERCP），结果在胆总管（CBD）内误置入了一个塑料支架且无法取出（图2）。此后，由于患者胆红素水平持续居高不下且先前置入的支架位置不当，决定进行腹腔镜胆囊切除术和胆总管探查。
手术在胆道镜引导下进行，胆总管在T管上方闭合。手术时间为280分钟。术后过程顺利；出院1周后夹闭T管。术后4周，T管胆道造影显示肝外胆管树通畅，无充盈缺损（图3）。然后取出T管。
PTBD后因胆道出血继发胆道梗阻较为罕见。当保守治疗和内镜治疗失败时，需要进行手术胆总管探查，且可通过微创方法成功完成。
