Foetus in fetu with common bile duct injury: a case report and review of literature

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Six-month-old female child presented with history of abdominal lump of 2 months duration. There was an intra-abdominal mass of about 15 × 10 cm on the right side of the abdomen and laboratory investigations were normal. Roentgenogram showed calcified mass in the region of lumbar vertebrae. Ultrasound of the abdomen revealed a retroperitoneal mass of mixed echogenicity with calcifications. Computerized tomography (CT) scan showed an encapsulated mass with fat densities and rudimentary limbs (Fig. 1). Based on these imaging findings provisional diagnosis of foetus in fetu (FIF) was made preoperatively. Computerized tomography scan image of tumour showing heterogenous mass in upper retroperitonium and showing fat densities and calcifications and early organogenesis. During surgery, the mass was crossing the midline. The duodenum was densely adherent to the mass. During separation of the duodenum, common bile duct thinned out because stretching by the tumour was seen merely as a fold of peritoneum and hence was cut. Single-layer end-to-end anastomosis of the common bile duct was done using vicryl 5-0 and keeping all the knots outside after placing 5 fr infant feeding tube as a stent across the anastomosis (Fig. 2). The feeding tube was cut open along its axis for about 6 cm and one end of the tube was put into distal common bile duct and duodenum and the other end was brought out from the anterior abdominal wall. Complete tumour excision was done. On macroscopic examination, the mass was showing head, trunk and rudimentary limb-like structure (Fig. 3). Histopathology of the specimen confirmed it to be FIF. Common bile duct anastomosed over 5 fr infant feeding tube. Excised specimen showing skull, body and rudimentary limbs of the foetus. Tube cholangiogram was performed on day 14 post-op, and contrast was seen entering into the duodenum without any extravasations. Tube was removed. Hippuran imino diacetic acid scan was performed after 6 weeks showed prompt gut activity. Patient at present is under regular follow-up for the last 1 year and having normal abdominal ultrasound findings. Her liver functions are within normal range and is doing well. Foetus in fetu is a malformed monozygotic diamniotic twin found inside the body of a living child.1-3 Now with CT scan commonly being used, preoperative diagnosis is not difficult. In this case, the common bile duct was so much stretched because of the tumour that it appeared like a thin fold of peritoneum, and it was injured. Once the injury was identified immediately, options were roux – en-y choledocho jejunostomy, choledocho duodenostomy and end-to-end bile duct anastomosis with or without stenting by T tube or by infant feeding tube or cholecystostomy along with common bile duct anastomosis.4 But the placing of stents was difficult because of the small diameter of the bile duct. Same was the reason for not doing other procedures: because of technical difficulties and a high rate of complications of such bilio-enteric anastomosis. Hence, decision for using no. 5 infant feeding tube as a stent and for perfoming end-to-end bile duct repair was made, and it gave us a good result. Literature on such bile duct injury in children was reviewed. Most of the paediatric bile duct injuries are traumatic or iatrogenic but are rare. Transection injury requires surgical repair. Partial tear, avulsion or injuries because of physical trauma can be managed by endoscopic stenting with good results.5 Our case becomes different not only because of its uncommon pathology but also because of management of the complication in such a technically difficult situation and necessitates the importance of versatility of surgical technique.