Page 11 - World's Most Popular Laparoscopic Journal

Fabio Sansonna et al

Entamoeba histolytica was absent in stool. Consequently, to 12 gr/dl and hematocrit level to 36%. We excluded
no infectious disease was found and the cause of jaundice surgical primary repair because of the high risks related to
remained unexplained. Endoscopic percutaneous possible misinterpretation of anatomy after three weeks of
cholangiopancreatography (ERCP) with endoscopic local inflammation. Further intermittent episodes of melena
papillotomy had definitely ruled out obstruction of the biliary occurred in the following days with hemodynamic stability
tree while laboratory tests confirmed the persistence of and minimal decrease of Hb and Ht levels. White blood cells
nonconjugated bilirubin values comprised between 3 and count was 11.000/mmc, alanine aminotransferase (ALT)
3.5 mg/dl, insofar as her jaundice was attributed to Gilbert's level lowered to 192 U/L and aspartate aminotrasferase to
disease. Besides, she became asymptomatic in a fortnight 141 U/L while the total bilirubin level raised to 12 mg/dl
and was discharged. Elective LC was scheduled, but another with 2.6 mg/dl of nonconjugated bilirubin. Since the patient
20 days later she complained again of abdominal pain in the persisted stability in her hemodynamic parameters without
upper right quadrant and was admitted to our surgical unit fever or abdominal pain and tenderness, we planned to
where we decided to perform LC in emergency. Because perform angiography only in case of rebleeding, so much
the walls of gallbladder were thick and cohesive, dissection more because CT had not shown any arterial blushing which
by monopolar coagulation from liver bed was demanding could make angiograhpy inconclusive. The patient
and took longer time than usual, although no intraoperative underwent ERCP that demonstrated a biliary leak in the
complication occurred. After excision of the gallbladder, gallbladder bed at the level of biliary branch for the V
an intraoperative cholangiography was carried out by segment, therefore a nasobiliary drainage (NBD) was placed.
laparoscopy confirming the complete patency and normality Two days later occurred another episode of severe melena
of the biliary tree, and the absence of stones in bile ducts. with hemodynamic instability, hence transfemoral
The early postoperative course of operation was uneventful angiography was performed revealing the presence of
and the patient was discharged five days after surgery. The pseudoaneurysm sized 2 cm sited on a replaced RHA with
histologic examination was consistent with acute extravasation between the V and VIII segmental branches
inflammation arisen in the context of lithiasis chronic (Figs 1A and B) RHA was an arterial branch arising from
cholecystitis. Oral feeding continued at home, the patient the superior mesenteric artery; TAE was achieved by filling
remained asymptomatic for two weeks until she referred a the entire artery and pseudoaneurysm with coils of 3 and 4
mild epigastric pain irradiated to the right quadrant, although mm (Fig. 2). The patient had an uneventful clinical course
she did not see a doctor. One week later she experienced without rebleeding, NBD was removed and she started oral
sudden hypotension with melena and was admitted to our intake. CT scan proved revascularization of the right hepatic
emergency service. Blood pressure was 100/60 mm Hg, arterial branches with no ischemia of right liver lobe. The
pulse rating was 86 beats/minute, hemoglobin level was patient was discharged two weeks later with no impairment
8 gr/dl, hematocrit level 23%, white blood count was of liver function tests and a magnetic resonance
9.700/mmc, alanine aminotransferase (ALT) level was cholangiography showed a normal biliary tree.
increased to 838 U/L (normal values 3-45), aspartate
aminotransferase (AST) level was elevated to 190 U/L DISCUSSION
(normal values 0-40), alkaline phosphatase level was within
the normal ranges of 35 to 129 U/L, coagulation tests and The case, herein presented of LC-related hemobilia, has
platelets were normal, total bilirubin level was 3.5mg/dl. been the only one we have registered over the last 10 years
Digestive endoscopy showed the presence of blood in the accounting for 0.001% of patients with acute cholecystitis
upper gastrointestinal tract without evidence of ulcers or operated on in emergency (within 72 hours of admission)
other diseases causing bleeding from stomach or duodenum. and including elective surgery accounting for 0.0003% of
Abdominal computed tomography (CT) showed a small all the patients undergoing LC over the same span. Hemobilia
hematoma of 3 cm in the gallbladder bed with no complicating LC has become a well-known serious event
hemoperitoneum or any other peritoneal fluid collection and reported in a plenty of issues. The onset of symptoms and
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iatrogenic pseudoaneurysm of RHA beside titanium clips signs is within four weeks from LC in 80% of cases, and
sized 4 mm without arterial blushing. Resuscitation with only in three cases this complication has occurred one year
transfusional support (3 units of packed red blood cells) after surgery or even later. 12,19,21 Upper gastrointestinal
allowed the patient to reach hemodynamic stability then she bleeding with melena is the commonest sign of hemobilia
was sent to our surgical ward. Hemoglobin level increased and observed in 90% of cases whereas abdominal pain is

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