Perforation Of Common Hepatic Duct Research Articles

S1940 Time, Nature's Duct Tape: Nonoperative Management of a Common Hepatic Duct Perforation

S1940 Time, Nature's Duct Tape: Nonoperative Management of a Common Hepatic Duct Perforation

Spontaneous perforation of common hepatic duct: an intraoperative surprise

BackgroundPediatric spontaneous bile duct perforation is one of the rare causes of acute abdomen in infants. With a highly variable presentation, diagnosis and treatment can prove challenging. We report a case of spontaneous common hepatic duct perforation mistaken for appendicular peritonitis.Case presentationAn otherwise healthy 3-year-old boy presented to the emergency department with complaints of abdominal pain, distention, bilious vomiting, and fever evolving for 4 days. Preoperative ultrasound was suggestive of appendicular peritonitis. Laparotomy revealed abundant biliary fluid, a distended gallbladder with thickened and inflammatory wall, and a macroscopically normal appendix. Intraoperative cholangiography showed a leak of contrast from the anterior wall of the common hepatic duct, 2–3 mm below the upper biliary confluence and 2 cm above the junction of the cystic duct to the common hepatic duct. A cholecystostomy was performed, and two external intraabdominal drains were placed. A retrograde cholangiogram was performed on postoperative day 21 showing no extravasation of contrast product. The patient was discharged on postoperative day 25.ConclusionSpontaneous perforation of the common hepatic duct is a rare phenomenon. It should be considered as a differential diagnosis in pediatric patients that present with unexplained peritonitis. The optimal method of diagnosis and management remains controversial.

Spontaneous extrahepatic biliary tree perforation

Spontaneous perforation of the common bile duct is an extremely uncommon cause of an abdominal emergency. Owing to the rarity of the condition it is seldom suspected or diagnosed preoperatively. We report a case of a 42-year-old female presenting with features of severe biliary pancreatitis who responded well to organ support. Five days post admission she was deemed fit for cholecystectomy to prevent further attacks of pancreatitis. Surgery revealed a common hepatic duct perforation treated with cholecystectomy, lavage and common hepatic duct drainage. This was followed by postoperative biliary stenting which led to complete resolution without further surgery. This conservative staged approach obviated the need for major biliary reconstruction and is a viable strategy when confronted with this rare complication without prior ductal imaging.

Infundibulinės laparoskopinės cholecistektomijos metodika turi kokybiškai atsinaujinti: 18 metų 13 274 cholecistektomijų analizė, 45 jatrogeninių tulžies latakų sužalojimų aptarimas ir įvertinimas

ĮžangaAtliktas Respublikinės Vilniaus universitetinės ligoninės 1996–2013 metų tulžies pūslės chirurgijos retrospektyvusis auditas, apibendrinantis 18 metų operacijų patirtį. Svarbiausias tyrimo tikslas – apibūdinti su laparoskopine cholecistektomija (LC) siejamą tulžies latakų sužalojimo riziką.MetodaiLC metu, siekdami identifikuoti tulžies pūslės lataką ir jos arteriją, laikėmės infundibulinės metodikos principų. Jatrogeniniai tulžies latakų sužalojimai susisteminti į penkias klases pagal Bismutho ir Strasbergo klasifikaciją. Siekdami nustatyti Lietuvos gydytojų publikacijas, kuriose analizuojamos laparoskopinės cholecistektomijos komplikacijos, naudojomės http://scholar.google.co.uk paieškos sistema. Taikyti standartiniai vienfaktoriai ir daugiafaktoriai statistinės analizės būdai.RezultataiAtliktos 13 274 cholecistektomijos, iš jų LC – 11 189 kartus (84,29 %). 5241 (39,48 %) pacientas laparoskopiškai operuotas dėl ūminio, 8033 (60,52 %) – dėl lėtinio cholecistito. Tulžies latakai sužaloti 45 ligoniams, iš jų 42 sužalojimai siejami su LC. Laparoskopinės operacijos metu tulžies latakai buvo sužaloti 2,7 karto dažniau nei per atvirąją (0,38 % vs 0,14 %, ŠS = 2,6149, 95 % PI 0,8097–8,4442, z = 1,607, p = 0,1080). Operuojant pacientus dėl ūminio cholecistito, jatrogeninių tulžies latakų sužalojimų pasitaikė du kartus dažniau (0,5 % vs 0,24 %, ŠS = 2,1029, 95 % PI 1,1627–3,8034, z = 2,459, p = 0,0140). Su LC siejamų jatrogeninių tulžies latakų sužalojimų rizika yra 1:261. 2010–2013 metais jų padaugėjo. Tulžies pūslės latako nesandarumo rizika po LC yra 1:323 (tai didele dalimi atspindi specifinę technologijos problemą). Pagrindinių šoninių tulžies latakų sužalojimų rizika yra 1:247 (tai chirurginės technikos problema). E klasės sužalojimo rizika 1:1243. 2000–2013 metais su LC siejama 40 % (17/42) jatrogeninių tulžies latakų sužalojimų. Hospitalinis mirštamumas nuo tulžies latakų sužalojimo buvo 11 % (5/45).IšvadosJatrogeniniai tulžies latakų sužalojimai yra nedažni, bet pavojingi. Tyrimas išryškino koncepcinius, sisteminius ir techninius LC trūkumus. Kadangi laparoskopinės cholecistektomijos kultūra prasideda nuo operacijai tinkamų pacientų atrankos, išsamiai infomuoto paciento sutikimo, šiuolaikinių pripažintų technologinių ir techninių priklausinių bei racionalių, pacientų saugumą užtikrinančių sprendimų, ji turi keistis. Ir ne tik įstaigoje, kurioje buvo atliktas šis klinikinis tyrimas, bet ir visose kitose geografinio regiono gydymo įstaigose, jeigu jose praktikuojama tokia pati arba metodologiškai panaši tulžies pūslės chirurgija.

Intact Choledochal Cyst With Spontaneous Common Hepatic Duct Perforation

A 3-month-old girl admitted for lower respiratory infection developed constipation and abdominal distension 3 days later. On examination, she had mild abdominal distension with absent bowel sounds. Abdominal sonography showed a normal biliary tract and pancreas. Computed tomography of abdomen revealed minimal localized fluid collection in the right upper quadrant. Abdominal paracentesis done 24 hours later revealed bile-stained ascitic fluid. Exploratory laparotomy on the same day revealed intact cystic dilation of common bile duct (type 1). Operative cholangiography revealed leakage of contrast from the distal common hepatic duct with a 4-mm perforation that was sutured securely (Fig. 1). Complete excision of the cyst, cholecystectomy, Roux-en-Y hepatojejunostomy, and jejunojejunostomy were performed (Fig. 2).FIGURE 1: Sutured perforation site at the distal common hepatic duct.FIGURE 2: Excised intact choledochal cyst with gallbladder.Both spontaneous bile duct perforation and common hepatic duct perforation are rare in children (1). The unusual combination of common hepatic duct perforation coexisting with an intact choledochal cyst has not been reported previously. Clinical presentations of spontaneous perforation of bile duct and choledochal cyst are similar. Our case suggests a common underlying pathogenesis, and supports the theory that these 2 separate entities are related to weakness of the biliary canal wall during embryogenesis with pancreaticobiliary malunion (2,3). Pathobiology of spontaneous biliary perforation could be similar to that of choledochal cyst as is evident in the present case.

NONTRAUMATIC PERFORATION OF COMMON HEPATIC DUCT.

IN 1882, JOHN FREELAND 5 described the first case of nontraumatic perforation of the common hepatic duct. Since then, only eight cases have been reported. When confronted with two cases within a six-month period at St. Luke's Hospital, we felt that a report of these two cases and a brief review of the previously reported cases would be of special interest. Report of Cases (No. 44-64-30): A 56-year-old male was admitted to St. Luke's Hospital with abdominal pain of ten hours' duration. In 1939 the patient had a plication of a perforated duodenal ulcer, followed by a subtotal gastric resection in 1952. He was apparently well until the morning of admission when he was awakened with severe midabdominal pain associated with vomiting of bile-stained material. There were no other gastrointestinal symptoms. The past history was significant in that pulmonary tuberculosis was suspected in 1952. The patient was a well-developed, thin