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Cystic artery pseudoaneurysm and haemobilia following laparoscopic cholecystectomy
ri PB 2000
Volume 2, Number 3 355- 358
Case report
Cystic artery pseudoaneurysm and haemobilia following laparoscopic cholecystectomy NC Chol, IY Kiml, I Department
os Kiml,YJ
Kim 2 and BS Rhoe l
of Surgery and 2Radiology, Yonsei University Wonju College of Medicine, Wonju, Korea
Background
blood. Selective hepatic angiography revealed a pseudo-
Laparoscopic cholecystectomy has been accepted as the
aneurysm at the cystic artery stump approximately I cm in
procedure of choice for treating cholelithiasis because of
diameter.Transcatheter embolisation of the aneurysm with
its acceptable complication rate. Haemobilia is a rare and
platinum coils was performed twice with a 21-day interval.
potentially lethal complication that may occur weeks to
The haemobilia was successfully controlled. and he remains
months after the operation.
well one year later.
Case outline A 52-year-old man who had undergone laparoscopic
Discussion To prevent this kind of complication. it is important to mini-
cholecystectomy was admitted with upper gastrointestinal
mise mechanical or thermal injury to the hepatic artery
bleeding and right upper quadrant pain. Emergency gastro-
and its branches with meticulous dissection and careful use
duodenoscopy did not identify a source of bleeding. The
of electrocautery and metal clips. Selective hepatic angi-
bleeding ceased. but I I days after admission he developed
ography can be an important diagnostic and therapeutic
haematemesis and obvious jaundice.
Results
modality.
Keywords
Endoscopic retrograde cholangiopancreatography (ERCP)
haemobilia.laparoscopic cholecystectomy, selective arterial
showed bulging of the duodenal papilla with spurting of
embolisation.
Introduction
Case report
Laparoscopic cholecystectomy has recently been accepted as the operation of choice in the treatment of gallstones, gallbladder polyps and early gallbladder cancer because of several advantages, such as minimal pain and an excellent cosmetic result. As for the safety of the operation, the rates of
A 52-year-old man who had undergone laparoscopic cholecystectomy for chronic cholecystitis one month earlier was
complication and death are comparable to those of open cholecystectomy, although the experience of the surgeon
SGOT 277 U/L (normal <38 U/L), SGPT 341 U/L «41 U/L), alkaline phosphatase 663 U/L «128 U/L) and total
affects the results [1,2]. Because laparoscopic cholecystectomy is a recent development, the rate of serious complications such as haemobilia or bile duct injury cannot yet be defini-
bilirubin 53 Ilmol/L (3.1 mg/dl: normal <17 Jlmol/L). Oesophagogastroduodenoscopy (OGD) revealed a healing duodenal ulcer without bleeding. Abdominal ultrasonography and DrSrDA scan failed to provide a diagnosis. There
tively compared with the risks of open operation [1-4] . H aemobilia is very rare after cholecystectomy, but can be a lethal complication that occurs weeks to months later [5-9] . We report a case of haemobilia caused by cystic artery pseudoaneurysm and occurring one month after laparoscopic cholecystectomy, which was successfully diagnosed and treated angiographically.
Correspondence to: NC Cho, Deportment of Surgery, Yonsei University Wonju College of MediCine, 162 IIson-dong, Wonju, Kongwon-do, 220-701, Republic of Korea
admitted to hosp ital with right upper quadrant pain and upper gastrointestinal bleeding. There was no visible jaundice. Laboratory tests included a haematocrit of 37 .3%,
were no more bleeding episodes thereafter for 10 days. On the 11 th hospital day, the patient developed haematemesis, tachycard ia, hypotension and anaemia. OGD at that time revealed active bleeding from the ampulla of Vater (Figure 1). Selective hepatic angiography showed a pseudoaneurys~ between the right hepatic artery and the
© 2000 Isis Medical Media Ltd.
355
NC Cho
Figure I. Duodenoscopy shows bulging
of the papilla of Vater with spurting
Figure 3. More seleaive hepatiC angiography showing the pseudoaneurysm
blood.
and clips.
remnant cystic artery (Figures 2 and 3). Embolisation of the pseudoaneurysm was performed using platinum coils.
14 days later without problems and has remained well during 1 year of follow-up.
Thereafter, the aneurysm was seen to be occluded, while normal flow was maintained in the hepatic artery. ERCP was normal 12 days later. The patient was discharged on the day after ERCP but
Discussion
was readmitted after 8 days with recurrent upper gastrointestinal bleeding. OGD demonstrated bleeding from the
About half the cases of haemobilia follow accidental or iatrogenic injuries to the liver and bile ducts. Other causes are inflammatory, vascular and neoplastic disease and cholelithiasis [7] . Development of invasive diagnostic or
ampulla of Vater, and hepatic angiography now showed a communication between the pseudoaneurysm and the common bile duct (Figure 4). Embolisation with platinum coils was repeated (Figure 5). The patient was discharged
surgical procedures, such as percutaneous transhepatic cholangiography or biliary drainage, ERCP, needle biopsy and biliary stenting, may explain the increasing incidence
Figure 2. Hepatic angiography shows a small psedoaneurysm between the cystic artery stump and right hepatic artery, proximal to the metal clips (arrow).
Figure 4. Seleaive hepatic angiography taken at the time of recurrent haemcr bilia shows bleeding from the aneurysm into the common bile dua. Note the platinum coil (arrow).
356
Hoemobilio following loporoscopic cholecystectomy abscess, fibrosis of th e gallbladder and rupture of the aneurysm, but they are rarely reported [13 ,15]. Recent embo lisation materials such as Ethibloc and platinum coils may decrease the complication rate [9]. Sometimes repeated embolisation is needed, as in the present case, because of collateral circu lation and incomplete occlusion of the aneurysm. The success rate of embo lisation has been quoted as between 81 and 96% [6,9, 11,1 6]. Operative (selective ) ligation of the right hepatic artery should be reserved for those patients in whom se lecti ve angiography is unsuccess(
ful or unavailable. An attempt should also be made to ligate the artery distal to the aneurysm because of the rapid development of a dista l collateral supply. In conclusion, haemobilia should be suspected in any
Figure 5. Post·embolisation angiograPhy shows no bleeding.
[5 ,10]. Haemobilia after laparoscopic cholecystectomy h as rarely been described [5-9, 11] . On ly one case of severe haemobilia was reported among 77 ,604 cases of laparoscopic cholecystectomy in the USA [1] . However, the complicat ion may be becoming more common, in part owing to the wide use of electrocauterisation, which can injure arteries e ither directly or by transmi sion of heat through the metal clips [1]. Other causes are structural changes within the cystic artery, injury of the vessels during dissection of the cystic duct or artery, and injury by clips [7 ,9, 11]. Even the clip on the cystic artery may injure the right hepatic artery by continued contact and result in a pseudoaneu rysm [8]. The class ica l triad for a diagnos is of haemobilia is upper gastrointestinal bleeding, co licky abdominal pain and jaun dice , but all three features are only prese nt in a minority of cases [1 2,13 ]. Severe bleeding requiring emergency treatment is infrequent but can arise after several weeks or even months . In the present case, we did not suspect haemob ilia at the time of first episode of bleed ing, and routine gastroscopy fa iled to identify it. Once hae mobilia is suspected (in our case at the time of repeat bleeding), angiography should be performed not only for diagnosis but also for embolisation. Walter [14] first succe sfull y reported angio-
patient with upper gastrointestinal bleeding and recent biliary surgery. Once suspected, angiography shou ld be performed for diagnos is and treatment. To prevent this serious complication, careful selection of patients, meticulous dissection, careful use of clips and avoiding excessive use of electrocauterisa tion are essential.
References
2 3
4
5
6
graphic embolisat ion in the treatment of hae mobilia in 1976, and since that t ime it has become the mainstay of treatment for most cases. The major advantages of this
7
technique include easy access to the pseudoaneurysm, more selectivity in occlusion , less morbidity, avoidance of laparotomy and no interference with any prev ious opera-
8
tive procedures such as bilio-enteric anastomos is. The disad vantages of embolisation include liver ce ll necrosis, li ver
9
Deziel OJ, Milli kan KW, Economou SG et al. Complications of lapa roscopic cho lecys tecto my: a nati ona l surv ey of 4,292 hosp ita ls and an ana lys is of 77,604 cases. Am j Surg 1993 ;165:9- 14 Pete rs )H , G ibbons GO, In nes )T et al. Co mplication of laparoscop ic cho lecystecto my. Surgery 199 1;11 0: 769-78 McA llister ) 0, D'A lto ri o RA, Snyder A . CT findi ngs after un co mpli cated percuta neo us lapa roscopic cholecystectomy. j Comput Assist Tomogr 199 1; 15: 770-2 Sacki er )M , Berc i G, Phillips E et al. The ro le of cholangiograp h y IJ1 laparoscopic cho lecys tectomy. Al'eh SUl'g 1991;1 26: 1021-6 Ge nyk YS, Keller FS, Halpern NB. Hepat ic artery pse udoaneurysm and hemobilia fo llowing laser laparoscop ic cho lecystecto my. SUl'g Endose 1994;8: 20 1- 4 S iab lis 0 , Tepetes K, Vas ious K, Karn avatidis 0, Perifa nos S , T zorako lefth eraki s E. Hepatic artery pseudoan uerysm fo llowing laparoscop ic cho lecystectomy: transcatheter intraa rterial embo li za tion. He/Jaw-Gas troenterolog), 1996;43: 1343-6 Zilberstein B, Cecconello I, Ramos AC et al. Hemobili a as a complication of laparoscpo ic cho lecystectomy. Surg Laparose Enclose 1994;4 :30 1-3 Bloch P, Mod iano P, Foster 0, Bouhot F, Gompel H . Rec urrent hemobilia after lapa roscop ic cholecystecto my. Surg Laparose Enclose 1994;4 :3 75- 7 S tewart BT, Ab rah am R), Thomso n KR, Co llier NA. Post-cholecystectomy hae mobilia: e nj oying a rena issa nce in the laparoscop ic era ? ALLst NZ j Surg 1995;65:1 85-8
357
NC Cho 10 Sandblom P. Iatrogenic hemobilia. Am] Surg 1986;151:754-8 11 Rivitz SM, Waltman AC, Kelsey PB. Embolization of a hepatic artery pseudo aneurysm following laparoscopic cholecystectomy. Cardiovasc Intervent RadiolI996;59:43-6 12 Sandblom P. Haemobilia. In: Blumgart LH (ed.J. Surgery of the liver and biliary tract. Edinburgh: Churchill Livingstone, 1988;1074-89 13 Kelley CJ, Hemingway AP, McPherson GAD et aL Nonsurgical management of post-cholecystectomy hemobilia. Br] Surg 1983;70:502-4
358
14 Walter JF, Passo BT, Cannon WB. Successful transcatheter embolic control of massive haemobilia secondary to liver biopsy. Am] RadiolI976;127:847-9 15 Salam TA, Lumsden AB, Martin LG, Smith RB III. Nonoperative management of visceral aneurysms and pseudoaneurysms. Am ] Surg 1992;164:215-21 16 Wagner WH, Lundell CJ, Donovan AJ. Percutaneous angiographic embolization for hepatic arterial hemorrhage. Arch Surg 1985;120:1241-9
Volume 2, Number 3 355- 358
Case report
Cystic artery pseudoaneurysm and haemobilia following laparoscopic cholecystectomy NC Chol, IY Kiml, I Department
os Kiml,YJ
Kim 2 and BS Rhoe l
of Surgery and 2Radiology, Yonsei University Wonju College of Medicine, Wonju, Korea
Background
blood. Selective hepatic angiography revealed a pseudo-
Laparoscopic cholecystectomy has been accepted as the
aneurysm at the cystic artery stump approximately I cm in
procedure of choice for treating cholelithiasis because of
diameter.Transcatheter embolisation of the aneurysm with
its acceptable complication rate. Haemobilia is a rare and
platinum coils was performed twice with a 21-day interval.
potentially lethal complication that may occur weeks to
The haemobilia was successfully controlled. and he remains
months after the operation.
well one year later.
Case outline A 52-year-old man who had undergone laparoscopic
Discussion To prevent this kind of complication. it is important to mini-
cholecystectomy was admitted with upper gastrointestinal
mise mechanical or thermal injury to the hepatic artery
bleeding and right upper quadrant pain. Emergency gastro-
and its branches with meticulous dissection and careful use
duodenoscopy did not identify a source of bleeding. The
of electrocautery and metal clips. Selective hepatic angi-
bleeding ceased. but I I days after admission he developed
ography can be an important diagnostic and therapeutic
haematemesis and obvious jaundice.
Results
modality.
Keywords
Endoscopic retrograde cholangiopancreatography (ERCP)
haemobilia.laparoscopic cholecystectomy, selective arterial
showed bulging of the duodenal papilla with spurting of
embolisation.
Introduction
Case report
Laparoscopic cholecystectomy has recently been accepted as the operation of choice in the treatment of gallstones, gallbladder polyps and early gallbladder cancer because of several advantages, such as minimal pain and an excellent cosmetic result. As for the safety of the operation, the rates of
A 52-year-old man who had undergone laparoscopic cholecystectomy for chronic cholecystitis one month earlier was
complication and death are comparable to those of open cholecystectomy, although the experience of the surgeon
SGOT 277 U/L (normal <38 U/L), SGPT 341 U/L «41 U/L), alkaline phosphatase 663 U/L «128 U/L) and total
affects the results [1,2]. Because laparoscopic cholecystectomy is a recent development, the rate of serious complications such as haemobilia or bile duct injury cannot yet be defini-
bilirubin 53 Ilmol/L (3.1 mg/dl: normal <17 Jlmol/L). Oesophagogastroduodenoscopy (OGD) revealed a healing duodenal ulcer without bleeding. Abdominal ultrasonography and DrSrDA scan failed to provide a diagnosis. There
tively compared with the risks of open operation [1-4] . H aemobilia is very rare after cholecystectomy, but can be a lethal complication that occurs weeks to months later [5-9] . We report a case of haemobilia caused by cystic artery pseudoaneurysm and occurring one month after laparoscopic cholecystectomy, which was successfully diagnosed and treated angiographically.
Correspondence to: NC Cho, Deportment of Surgery, Yonsei University Wonju College of MediCine, 162 IIson-dong, Wonju, Kongwon-do, 220-701, Republic of Korea
admitted to hosp ital with right upper quadrant pain and upper gastrointestinal bleeding. There was no visible jaundice. Laboratory tests included a haematocrit of 37 .3%,
were no more bleeding episodes thereafter for 10 days. On the 11 th hospital day, the patient developed haematemesis, tachycard ia, hypotension and anaemia. OGD at that time revealed active bleeding from the ampulla of Vater (Figure 1). Selective hepatic angiography showed a pseudoaneurys~ between the right hepatic artery and the
© 2000 Isis Medical Media Ltd.
355
NC Cho
Figure I. Duodenoscopy shows bulging
of the papilla of Vater with spurting
Figure 3. More seleaive hepatiC angiography showing the pseudoaneurysm
blood.
and clips.
remnant cystic artery (Figures 2 and 3). Embolisation of the pseudoaneurysm was performed using platinum coils.
14 days later without problems and has remained well during 1 year of follow-up.
Thereafter, the aneurysm was seen to be occluded, while normal flow was maintained in the hepatic artery. ERCP was normal 12 days later. The patient was discharged on the day after ERCP but
Discussion
was readmitted after 8 days with recurrent upper gastrointestinal bleeding. OGD demonstrated bleeding from the
About half the cases of haemobilia follow accidental or iatrogenic injuries to the liver and bile ducts. Other causes are inflammatory, vascular and neoplastic disease and cholelithiasis [7] . Development of invasive diagnostic or
ampulla of Vater, and hepatic angiography now showed a communication between the pseudoaneurysm and the common bile duct (Figure 4). Embolisation with platinum coils was repeated (Figure 5). The patient was discharged
surgical procedures, such as percutaneous transhepatic cholangiography or biliary drainage, ERCP, needle biopsy and biliary stenting, may explain the increasing incidence
Figure 2. Hepatic angiography shows a small psedoaneurysm between the cystic artery stump and right hepatic artery, proximal to the metal clips (arrow).
Figure 4. Seleaive hepatic angiography taken at the time of recurrent haemcr bilia shows bleeding from the aneurysm into the common bile dua. Note the platinum coil (arrow).
356
Hoemobilio following loporoscopic cholecystectomy abscess, fibrosis of th e gallbladder and rupture of the aneurysm, but they are rarely reported [13 ,15]. Recent embo lisation materials such as Ethibloc and platinum coils may decrease the complication rate [9]. Sometimes repeated embolisation is needed, as in the present case, because of collateral circu lation and incomplete occlusion of the aneurysm. The success rate of embo lisation has been quoted as between 81 and 96% [6,9, 11,1 6]. Operative (selective ) ligation of the right hepatic artery should be reserved for those patients in whom se lecti ve angiography is unsuccess(
ful or unavailable. An attempt should also be made to ligate the artery distal to the aneurysm because of the rapid development of a dista l collateral supply. In conclusion, haemobilia should be suspected in any
Figure 5. Post·embolisation angiograPhy shows no bleeding.
[5 ,10]. Haemobilia after laparoscopic cholecystectomy h as rarely been described [5-9, 11] . On ly one case of severe haemobilia was reported among 77 ,604 cases of laparoscopic cholecystectomy in the USA [1] . However, the complicat ion may be becoming more common, in part owing to the wide use of electrocauterisation, which can injure arteries e ither directly or by transmi sion of heat through the metal clips [1]. Other causes are structural changes within the cystic artery, injury of the vessels during dissection of the cystic duct or artery, and injury by clips [7 ,9, 11]. Even the clip on the cystic artery may injure the right hepatic artery by continued contact and result in a pseudoaneu rysm [8]. The class ica l triad for a diagnos is of haemobilia is upper gastrointestinal bleeding, co licky abdominal pain and jaun dice , but all three features are only prese nt in a minority of cases [1 2,13 ]. Severe bleeding requiring emergency treatment is infrequent but can arise after several weeks or even months . In the present case, we did not suspect haemob ilia at the time of first episode of bleed ing, and routine gastroscopy fa iled to identify it. Once hae mobilia is suspected (in our case at the time of repeat bleeding), angiography should be performed not only for diagnosis but also for embolisation. Walter [14] first succe sfull y reported angio-
patient with upper gastrointestinal bleeding and recent biliary surgery. Once suspected, angiography shou ld be performed for diagnos is and treatment. To prevent this serious complication, careful selection of patients, meticulous dissection, careful use of clips and avoiding excessive use of electrocauterisa tion are essential.
References
2 3
4
5
6
graphic embolisat ion in the treatment of hae mobilia in 1976, and since that t ime it has become the mainstay of treatment for most cases. The major advantages of this
7
technique include easy access to the pseudoaneurysm, more selectivity in occlusion , less morbidity, avoidance of laparotomy and no interference with any prev ious opera-
8
tive procedures such as bilio-enteric anastomos is. The disad vantages of embolisation include liver ce ll necrosis, li ver
9
Deziel OJ, Milli kan KW, Economou SG et al. Complications of lapa roscopic cho lecys tecto my: a nati ona l surv ey of 4,292 hosp ita ls and an ana lys is of 77,604 cases. Am j Surg 1993 ;165:9- 14 Pete rs )H , G ibbons GO, In nes )T et al. Co mplication of laparoscop ic cho lecystecto my. Surgery 199 1;11 0: 769-78 McA llister ) 0, D'A lto ri o RA, Snyder A . CT findi ngs after un co mpli cated percuta neo us lapa roscopic cholecystectomy. j Comput Assist Tomogr 199 1; 15: 770-2 Sacki er )M , Berc i G, Phillips E et al. The ro le of cholangiograp h y IJ1 laparoscopic cho lecys tectomy. Al'eh SUl'g 1991;1 26: 1021-6 Ge nyk YS, Keller FS, Halpern NB. Hepat ic artery pse udoaneurysm and hemobilia fo llowing laser laparoscop ic cho lecystecto my. SUl'g Endose 1994;8: 20 1- 4 S iab lis 0 , Tepetes K, Vas ious K, Karn avatidis 0, Perifa nos S , T zorako lefth eraki s E. Hepatic artery pseudoan uerysm fo llowing laparoscop ic cho lecystectomy: transcatheter intraa rterial embo li za tion. He/Jaw-Gas troenterolog), 1996;43: 1343-6 Zilberstein B, Cecconello I, Ramos AC et al. Hemobili a as a complication of laparoscpo ic cho lecystectomy. Surg Laparose Enclose 1994;4 :30 1-3 Bloch P, Mod iano P, Foster 0, Bouhot F, Gompel H . Rec urrent hemobilia after lapa roscop ic cholecystecto my. Surg Laparose Enclose 1994;4 :3 75- 7 S tewart BT, Ab rah am R), Thomso n KR, Co llier NA. Post-cholecystectomy hae mobilia: e nj oying a rena issa nce in the laparoscop ic era ? ALLst NZ j Surg 1995;65:1 85-8
357
NC Cho 10 Sandblom P. Iatrogenic hemobilia. Am] Surg 1986;151:754-8 11 Rivitz SM, Waltman AC, Kelsey PB. Embolization of a hepatic artery pseudo aneurysm following laparoscopic cholecystectomy. Cardiovasc Intervent RadiolI996;59:43-6 12 Sandblom P. Haemobilia. In: Blumgart LH (ed.J. Surgery of the liver and biliary tract. Edinburgh: Churchill Livingstone, 1988;1074-89 13 Kelley CJ, Hemingway AP, McPherson GAD et aL Nonsurgical management of post-cholecystectomy hemobilia. Br] Surg 1983;70:502-4
358
14 Walter JF, Passo BT, Cannon WB. Successful transcatheter embolic control of massive haemobilia secondary to liver biopsy. Am] RadiolI976;127:847-9 15 Salam TA, Lumsden AB, Martin LG, Smith RB III. Nonoperative management of visceral aneurysms and pseudoaneurysms. Am ] Surg 1992;164:215-21 16 Wagner WH, Lundell CJ, Donovan AJ. Percutaneous angiographic embolization for hepatic arterial hemorrhage. Arch Surg 1985;120:1241-9