The authors declare that they have no competing interests.
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.
Right 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.
A 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.
Obstructive 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.
Strasberg S, Helton W. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford). 2011;13(1):1–14. CrossRef
Terblanche J, Worthley C, Spence R, Krige J. High or low hepaticojejunostomy for bile duct strictures? Surgery. 1990;108(5):828–34. PubMed
Sansonna F, Boati S, Sguinzi R, Migliorisi C, Pugliese F, Pugliese R. Severe hemobilia from hepatic artery pseudoaneurysm. Case Rep Gastrointest Med. 2011;2011:1–5. CrossRef
Milburn J, Hussey J, Bachoo P, Gunn I. Right hepatic artery pseudoaneurysm thirteen months following laparoscopic cholecystectomy. EJVES Extra. 2007;13(1):1–3. CrossRef
AlGhamdi HS, Saeed MA, AlTamimi AR, O’Hali WA, Khankan AA, AlTraif IH. Endoscopic extraction of vascular embolization coils that have migrated into the biliary tract in a liver transplant recipient. Dig Endoscopy. 2012;24(6):462–5. CrossRef
- Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation
Manju D Chandrasegaram
Neil D Merrett
- BioMed Central
Neu im Fachgebiet Chirurgie
Mail Icon II