Subcapsular Hepatic Hematoma Post-Endoscopic Retrograde Cholangiopancreatography Requiring Surgical Necrosectomy

Cholelithiasis is a common gastrointestinal pathology with a prevalence of over 6% in the USA. Symptomatic patients can develop cholangitis, biliary colic, pancreatitis and cholecystitis. Surgical management involves laparoscopic or open cholecystectomy. Stones within the common bile duct can be treated with endoscopic retrograde cholangiopancreatography (ERCP). Well-known ERCP complications include pancreatitis, perforation, bleeding and cholangitis. Hepatic hematomas as a complication of ERCP are extremely rare, with fewer than 50 reported cases in the literature. Approximately 22% have required operative management. We present an extremely rare case of ERCP-associated subcapsular hepatic hematoma in a 43-year-old lady that was initially non-operatively managed. She did not improve with antibiotics alone and underwent attempted interventional radiology drainage. Despite this, due to on-going sepsis, the patient underwent laparoscopic necrosectomy and drain placement with continued post-operative irrigation. After a long course of antibiotics and drain irrigation, the patient was discharged with repeated computed tomography imaging showing almost total resolution of the infected collection. This case highlights the extreme rarity of surgical management for post-ERCP subcapsular hepatic hematoma and its successful outcome.

Use of fully covered self-expanding metal stents in benign biliary diseases

Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate efficacy and cost-effectiveness