Portobiliary fistula following laparoscopic cholecystectomy

Bile Duct Injuries after Cholecystectomy: An Individual Patient Data Systematic Review

Background: Post-cholecystectomy bile duct injuries (BDIs) represent a challenging complication, with negative impacts on clinical outcomes. Several surgical and endoscopic/interventional radiologist (IR) approaches have been proposed to manage these damages, though with high failure rates. This individual patient data (IPD) systematic review analyzes the potential risk factors for failure after treatment interventions for BDIs, both surgical and endoscopic/IR. Methods: An extensive literature search was conducted on MEDLINE and Scopus for relevant articles published in English on the management of BDIs after cholecystectomy, between 1 January 2010 and 31 December 2023. Our series of BDIs was included. BDIs were always categorized according to the Strasberg's classification. The composite primary endpoints evaluated were the failure of treatment interventions, defined as patient death or the requirement of any other procedure, whatever surgical and/or endoscopic/IR, after the primary treatment. Results: A total of 342 cases were retrieved from our literature analysis, including our series of 19 patients. Among these, three groups were identified: "upfront surgery", "upfront endoscopy and/or IR" and "no upfront treatment", consisting of 224, 109 and 9 patients, respectively. After eliminating the third group, treatment intervention failure was observed overall in 34.2% (114/333) of patients, of whom 80.7% (92/114) and 19.3% (22/114) in the "upfront surgery" and in the "upfront endoscopy/IR" groups, respectively. At multivariable analysis, injury type D and E, and repair in a non-specialized center represented independent predictors of treatment failure in both groups, whereas laparoscopic cholecystectomy (LC) converted to open and immediate attempt of surgical repair exclusively in the first group. Conclusions: Significant treatment failure rates are responsible for remarkable negative effects on immediate and longer-term clinical outcomes of post-cholecystectomy BDIs. Understanding the important risk factors for this outcome may better guide the most appropriate therapeutical approach and improve clinical decisions in case this serious complication occurs.

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

Background

Haemobilia is a rare cause of gastrointestinal bleeding. It can be related to iatrogenic injuries, inflammatory diseases, and, more recently, postoperative, or post-procedure complications. Porto-biliary fistula is an uncommon case of haemobilia and has been related to iatrogenic injury or chronic inflammatory processes. To date, less than 30 cases of Porto-biliary fistula have been reported.

Case presentation

We present a 53 years-old woman with a history of biliary obstruction due to a choledochal cyst that required hepaticojejunostomy with evidence of anastomotic stricture. A percutaneous transhepatic biliary drainage (PTBD) was performed, with 3 failed attempts of percutaneous dilatation. A new hepaticojejunostomy was completed, however, 45 days later the patient presented to the emergency room with haemobilia and secondary hemodynamic instability. An emergency damage control laparotomy was performed, achieving bleeding control. In the second procedure, there is evidence of an ulcerative injury of the biliary tract secondary to a Porto-biliary fistula.

Conclusion

Porto-biliary fistula is an entity that cannot be ruled out in cases of haemobilia, especially in cases with a history of bile duct surgical or percutaneous procedures. The prognosis is usually good if multidisciplinary management is performed, and the source of the bleeding is identified early.

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Portobiliary is a rare condition with increased risk of mortality.

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Clinical suspicion should be present in patients with multiple procedures in the bile tract.

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Multidisciplinary management increases the rate of successful management.

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Ureteroscopy could be an alternative to choledocoscopy in emergency context.

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

Biliary complications following liver transplantations, with leaks and bile duct strictures being the most common ones, are greatly feared. Portobiliary fistulas are rare, but may cause potentially life-threatening complications. The presented case shows the first successful treatment of a portobiliary fistula by an endoscopically deployed fully covered self-expandable metal stent after liver transplantation. In accordance to the already established use in refractory bile leaks, we believe that fully covered self-expandable metal stent is a safe and efficient treatment option for portobiliary fistula.

A case report of bloody pancreatitis

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Haemobilia is a rare complication of laparoscopic cholecystectomy.

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Pancreatitis is not usually caused be an obstructing thrombus.

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Advances in surgical practise predisposes to haemobilia occurring as a complication.

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Surgeons must be aware of spectrum of complications related to modern techniques.

Introduction

Haemobilia is an uncommon entity even though its frequency has increased with hepato-biliary instrumentation and procedures. It can be associated with obstructive jaundice and pancreatitis (Green et al., 2001) [1]. Haemobilia following cholecystectomy has frequently been reported in association with hepatic artery pseudo-aneurysm (Curet et al., 1981; Ribeiro et al., 1998) [2,3]. The authors wish to report a case of haemobilia due to a porto-biliary fistula presenting as acute pancreatitis.

Presentation of case

A 34-year-old female admitted as an urgency with upper abdominal pain for 3 weeks. She had, in the preceding days, been admitted to another hospital with acute pancreatitis. She reported an episode of rectal bleeding during that admission and possessed an abdominal ultrasound scan (USS) and magnetic resonance cholangiopancreatography (MRCP) which suggested the presence of a biliary tract neoplasm. The patient was also found to be jaundiced and the diagnosis of a porto-biliary fistula was made at operation.

Conclusion

The diagnosis in this case was found to be a portal vein-biliary tract fistula occurring post cholecystectomy. An awareness of the spectrum of complications related to modern surgical techniques may aid timely diagnosis and the achievement of favourable outcomes.