Abstract
BackgroundRight hepatic arterial injury (RHAI) is the most common vascular injury sustained during laparoscopic cholecystectomy, occurring in up to 7% of cholecystectomies. RHAI is also the most common vascular injury associated with a bile duct injury (BDI) and is reported to occur in up to 41 – 61% of cases when routine angiography is employed following a BDI.We present an unusual case of erosion of vascular coils from a previously embolised right hepatic artery into bilio-enteric anastomoses causing biliary obstruction. This is on a background of biliary reconstruction following a major BDI.Case presentationA 37-year old man underwent a bile duct reconstruction following a major BDI (Strasberg-Bismuth E4 injury) sustained at laparoscopic cholecystectomy. He had two separate bilio-enteric anastomoses of the right and left hepatic ducts and had a modified Terblanche Roux-en-Y access limb formed.Approximately three weeks later he was admitted for significant gastrointestinal bleeding and was hypotensive and anaemic. Selective computed tomography angiography revealed a 2 x 2 centimetre right hepatic artery pseudoaneurysm, which was urgently embolised with radiological coils.Two months later he developed intermittent fevers, rigors, jaundice, and right upper quadrant pain with evidence of intrahepatic biliary dilatation on magnetic resonance cholangiopancreatography. The degree of intrahepatic biliary dilatation progressively increased on subsequent imaging over several months, suggesting stricturing of the bilio-enteric anastomoses. Several attempts to traverse these strictures with a percutaneous transhepatic approach had failed. Then, approximately ten months after the initial BDI repair, choledochoscopy through the Terblanche access limb revealed multiple radiological coils within the bilio-enteric anastomoses, which had eroded from the previously embolised right hepatic artery. A laparotomy was performed to remove the coils, take down the existing obstructed bilio-enteric anastomoses and revise this. Following this the patient recovered uneventfully.ConclusionObstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication. In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI.
Highlights
In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI
Right hepatic arterial injury (RHAI) is the commonest vascular injury associated with major BDI, with centers employing routine angiography following a BDI reporting RHAI rates of up
We present an unusual case of BDI repair complicated by right hepatic artery (RHA) pseudoaneurysm requiring radiological coil embolisation, with a delayed complication of biliary obstruction secondary to erosion of coils into the hepato-enteric anastomosis
Summary
Obstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication following treatment of arterial injury subsequent to iatrogenic BDI. In view of the relative frequency of arterial injury and complications following major BDI, we would suggest that these patients be formally assessed for associated arterial injury. Consent Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Competing interests The authors declare that they have no competing interests. Authors’ contributions SR, MC, KA, GS and NM were involved in the conception and design of the case report and ongoing critical revisions of the manuscript. All authors gave final approval of the version to be published
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