Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy

Right Hepatic Artery Pseudoaneurysm Post-laparoscopic Cholecystectomy: A Case Report of Endovascular Stent-Graft Management

Gallstone-related diseases like cholelithiasis contribute significantly to global morbidity and mortality. Laparoscopic cholecystectomy (LC) is the gold standard for gallbladder removal but is associated with rare but severe complications, including hepatic artery pseudoaneurysms (PAs). A 72-year-old female presented with acute abdominal pain and upper gastrointestinal bleeding following a recent LC. Laboratory studies confirmed anemia with a hemoglobin level of 10 g/dL. Liver function tests were deranged, showing elevated alanine aminotransferase (ALT) at 209 U/L, aspartate aminotransferase (AST) at 472 U/L, total bilirubin levels at 3.29 mg/dL, and direct bilirubin levels at 2.7 mg/dL. A contrast-enhanced computed tomography scan revealed a PA adjacent to the right hepatic artery. Given the strong suspicion of a hepatic PA as the source of her symptoms, an endovascular stent was placed by an interventional radiologist. Post-procedure, the patient showed a favorable clinical course with cessation of symptoms and was discharged after eight days. This case emphasizes the importance of early identification of hepatic artery PAs following LC, a potentially life-threatening complication. It also suggests that endovascular stent placement can be an effective alternative to traditional transarterial embolization for managing these PAs. Additional research is needed to evaluate the long-term effectiveness and safety of these two methods in comparison.

Recurrent right hepatic artery pseudoaneurysm after robotic-assisted cholecystectomy in a patient with Mirizzi syndrome: a case report

Background

Iatrogenic hepatic artery pseudoaneurysm is a rare complication following laparoscopic cholecystectomy. Trans-arterial embolization (TAE) is an effective way to control bleeding after a ruptured aneurysm. But uncommonly, rebleeding may occur which will require a second embolization or even laparotomy.

Case presentation

We report a case of a 45-year-old woman who underwent robotic-assisted cholecystectomy after the diagnosis of type II Mirizzi syndrome. During the operation, the anterior branch of the right hepatic artery was damaged and Hem-o-lok clips were applied to control the bleeding. The postoperative course was smooth, and the patient was discharged 6 days after the procedure. However, one week after hospital discharge, she presented to the emergency department with right upper abdominal tenderness, melena, and jaundice. After examination, the computed tomography angiography (CTA) revealed a 3 cm pseudoaneurysm at the distal stump of the right hepatic artery anterior branch. TAE with gelfoam material was performed. Three days later, the patient had an acute onset of abdominal pain. A recurrent pseudoaneurysm was found at the same location. She underwent TAE again but this time with a steel coil. No further complication was noted, and she was discharged one week later.

Conclusions

Even with the assistance of modern technologies such as the robotic surgery system, one should still take extra caution while handling the vessels. Also, embolization of the pseudoaneurysm with steel coils may be suitable for preventing recurrence.

Symptomatic pseudoaneurysms following laparoscopic cholecystectomy: Focus on an unusual and dangerous complication

BACKGROUND

Laparoscopic cholecystectomy (LC) has been associated with an increase in the incidence of biliary and vascular injuries. Pseudoaneurysms (PAs) following LC are rare life-threatening events with limited available experience regarding diagnosis and treatment.

MATERIALS AND METHODS

An extensive review of literature during a 26-year period (1994-2020) using MEDLINE® database and Google Scholar® academic search engine revealed 134 patients with at least one symptomatic PA following LC.

RESULTS

Nearly.

81% of patients with PAs become symptomatic during the first 8 weeks following LC. The most common symptoms were gastrointestinal bleeding (74%) and abdominal pain (61%). In 28% of cases, there was a concomitant bile duct injury or leak from the cystic duct stump, whereas in about one-third of cases, PAs presented following an uneventful LC. The most common involved arteries were the right hepatic artery (70%), the cystic artery (19%) or both of them (3%). Trans-arterial embolisation was the favoured first-line treatment with a success rate of 83%. During a median follow-up of 9 months, the mortality rate was 7%.

CONCLUSION

Clinicians should be aware of the PA occurrence following LC. Prompt diagnosis and treatment are essential.

Haemobilia secondary to a cystic artery pseudoaneurysm as complication of VLC

INTRODUCTION

The laparoscopic approach has become the gold standard for cholecystectomy. However, it could have some major complications. Among them, it can be considered postoperative pseudoaneurysms of the cystic or hepatic arteries. Haemobilia secondary to a cystic artery pseudoaneurysm is extremely rare.

CASE REPORT

Here we present a case from our centre of haemobilia in association with a cystic artery pseudoaneurysm, as a late complication of VLC. An 18-year-old girl underwent laparoscopic cholecystectomy; during surgery, due to viscero-perietal tight adhesions and due to the close proximity of the cystic duct to the biliary ducts, we suspected a bile duct injury. So, decision was taken to convert to open surgery: a suture was performed to repair the coledocic duct injury and an endoscopic papillotomy was performed with subsequent positioning of an endoscopic plastic biliary endoprothesis at the hepatocholedochus. One month after surgery, the patient showed clinical signs of hypovolemic shock. She underwent Computed Tomography Angiography, showing a possible arterial lesion, just adjacent to surgical clip. Therefore, patient underwent angiographic examination, which confirmed an 8 mm pseudoaneurysm arising from cystic artery, just adjacent to surgical clips. Superselective catheterization of vessel was performed, and two coils were released, until obtaining complete exclusion of the vascular lesion. The patient was discharged five days after procedure, with good general condition.

CONCLUSION

Pseudoaneurysms of the cystic artery are uncommon entities, rarely reported in the literature, and often caused by cholecystitis or iatrogenic biliary injury. All conditions that are responsible for vessels' injuries could also cause haemobilia. Even if pseudoaneurysm of cystic artery with haemobilia is a rare event, it has to be considered as a complication of VLC. Angiographic approach should be the treatment of choice.

Role of Transarterial Embolization in the Management of Hepatic Artery Pseudoaneurysm Postlaparoscopic Cholecystectomy

Purpose To assess the safety and effectiveness of transarterial embolization (TAE) in the management of hepatic artery pseudoaneurysms following laparoscopic cholecystectomy (LC).

Materials and Methods This is a retrospective study consisting of 13 patients who had undergone TAE for management of pseudoaneurysms of the hepatic artery or its branches following LC. Patients presented with symptoms such as hypotension, hematemesis, melena or gradual anemia post LC. Abdominal CT revealed hepatic artery pseudoaneurysm in all patients. TAE was performed with either coils or N-butyl cyanoacrylate or both. We evaluated technical and clinical effectiveness and complications of TAE.

Results TAE was successful both technically and in stopping bleeding in all patients (100% technical and clinical success). No patient had rebleeding after TAE. Four patients required laparotomy for draining hemoperitoneum and clots. Endoscopic retrograde cholangiopancreatography (ERCP) for hemobilia or bile duct injury was done in eight patients. Following TAE, hepatic infarct was observed in three patients. Postembolization syndrome was seen in four patients and one patient died due to sepsis.

Conclusions TAE is effective for treatment of hepatic artery pseudoaneurysms after LC. Hepatic infarcts and postembolization syndrome are the most common complications and can be managed conservatively.

Hemobilia after laparoscopic cholecystectomy that was successfully treated conservatively: Case report

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Hemobilia from pseudoaneurysm rupture after laparoscopic cholecystectomy is rare.

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Due to consequent rapid hemodynamic instability, it could be life threatening.

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Non-contrast CT and ERCP examinations were performed to confirm hemobilia diagnosis.

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Investigations revealed that there was no contrast agent leakage.

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Thus, our patient was treated conservatively as opposed to surgically.

Introduction

Hemobilia due to pseudoaneurysm rupture is a rare, life-threatening complication of laparoscopic cholecystectomy (LC) that can cause rapid hemodynamic instability. Therefore, symptoms of hemobilia must be assessed carefully.

Presentation of case

An 88-year-old woman underwent LC in our hospital, and blood tests revealed elevation of hepatobiliary enzyme levels on postoperative day (POD) 12. Computed tomography (CT) showed a high absorption area in the common bile duct (CBD), and a diagnosis of hemobilia and a pseudoaneurysm without active bleeding into the abdominal cavity was made. There was no leakage of contrast medium outside the CBD during endoscopic retrograde cholangiography; thus, an endoscopic nasobiliary drainage (ENBD) tube was inserted on POD 12 and an endoscopic retrograde biliary drainage (ERBD) stent was placed in the CBD on POD 13. Thereafter, hepatobiliary enzyme levels gradually normalized and the ENBD tube and ERBD stent were removed on POD 27 and POD 54, respectively. The patient was discharged on POD 66.

Discussion

Hemostasis establishment using surgery or intervention radiology is often required for the treatment of hemobilia due to pseudoaneurysms; however, conservative treatment was effective in our case and we were able to pursue a minimally invasive approach. Erosion due to clip penetration or incomplete clipping of the cystic artery or its branches during surgery may have caused the cystic artery pseudoaneurysm.

Conclusion

Hemobilia could be life threatening and cause acute hemodynamic instability; therefore, prompt diagnosis is required. Although the frequency of complication is low, the possibility of hemobilia after LC should be considered.

A pseudoaneurysm of the right hepatic artery treated successfully with a stent graft - A case report

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Haemobilia caused by pseudoaneurysms of the right hepatic artery or the cystic artery are rare with incidences up to 0.6%.

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Pathogenesis of pseudoaneurysms of the cystic or hepatic arteries are described to be cholecystectomy or cholecystitis related.

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Embolization is considered the golden standard. However, stent grafts should be considered a minimal invasive and effective alternative after failed embolization in pseudoaneurysms.

Introduction

Haemobilia caused by pseudoaneurysms of the right hepatic or cystic artery is rare. Haemobilia classically causes gastro-intestinal hemorrhage, jaundice and upper abdominal pain.

Presentation of case

A 76-year old female underwent laparoscopic cholecystectomy because of a severe acute on chronic cholecystitis. A massive arterial bleeding occurred during surgery, which was controlled with hemoclips. Approximately one week after surgery the patient developed severe colic pains and cholestatic liver enzyme alterations. Endo-ultrasound showed normal-width bile ducts, however during a subsequent ERCP haemobilia was observed. On computed tomography a pseudoaneurysm of the right hepatic artery was seen. Selective embolization was initially successful, however, a rebleed was observed two weeks later and a 6 × 50 mm Viabahn stent graft was placed in the right hepatic artery uneventfully. The patient remained free of complaints during 3-years of follow-up.

Discussion

Pseudoaneurysms of the cystic or hepatic arteries are described to be cholecystectomy or cholecystitis related. The etiology of the pseudoaneurysm in this case can be inflammatory or iatrogenic. Embolization is the golden standard in pseudoaneurysm treatment. Stent graft implantation has not been frequently described as an alternative option to surgery after a failed attempt of embolization.

Conclusion

This case report presents a probable cholecystitis related pseudoaneurysm of the right hepatic artery, which caused haemobilia after cholecystectomy. The pseudoaneurysm was successfully eliminated with a stent graft after embolization had failed. Stent grafts should be considered a minimal invasive and effective alternative after failed embolization of a pseudoaneurysm.

Transcatheter Arterial Embolization Treatment for Bleeding Visceral Artery Pseudoaneurysms in Patients with Pancreatitis or Following Pancreatic Surgery

Simple Summary

Transcatheter arterial embolization (TAE) with coils is widely used to treat pseudoaneurysms; recently, the use of N-butyl cyanoacrylate (NBCA) in TAE has been reported as a feasible and effective approach. The purpose of our retrospective study was to evaluate the efficacy and safety of TAE with coils and NBCA for pseudoaneurysms associated with pancreatitis or pancreatic surgery. This retrospective study included 42 consecutive patients. The technical and clinical success rates, incidence of recurrent bleeding, complications, including pancreatitis, and overall survival after TAE were evaluated. All cases obtained hemostasis after TAE (the technical success rate was 100%). Complications were seen in only two patients. Clinical success rate that was evaluated in terms of 30-day mortality was 76.2%. TAE is then an effective treatment modality for pseudoaneurysms associated with pancreatitis or pancreatic surgery. Accurate diagnosis using angiography contributes to the proper choice of embolic agents and management of such hemorrhages.

Abstract

Purpose: To evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for pseudoaneurysms occurring secondary to pancreatitis or because of leakage of pancreatic juice after pancreatectomy. Materials and Methods: This retrospective study included 42 consecutive patients (38 males and 4 females; mean age, 60 years; range, 33–80 years) who underwent TAE for bleeding visceral artery pseudoaneurysms between March 2004 and December 2018. The technical and clinical success rates, incidence of recurrent bleeding, complications, including pancreatitis, and overall survival after TAE were evaluated. Results: Of the 42 enrolled patients, 23 had bleeding due to a complication of pancreatectomy and 19 had bleeding as a complication of pancreatitis. TAE with N-butyl cyanoacrylate (NBCA) or NBCA plus microcoils recurrent bleeding or inability to control bleeding was 15.8% (3 of 19) following TAE with NBCA and 17.4% (4 of 23) following TAE with coils. No clinically significant ischemic events of the pancreas or duodenum were observed in the embolized areas. Serum amylase did not increase compared with the initial levels after any of the procedures. At 30 days after TAE, 32 patients were alive. Conclusion: TAE has a high success rate for the management of hemorrhage, with few complications. The procedure appears to be safe and effective for pseudoaneurysms associated with either pancreatitis or pancreatectomy.

Hemobilia due to cystic artery pseudoaneurysm following cholecystectomy: diagnosis and management, a case report

Hemobilia is an unusal cause of upper gastrointestinal bleeding and may be the result of the formation of an hepatic vessel pseudoaneurysm. This is a rare occurence after laparoscopic or open cholecistectomy. The most importants factor for pathogenesis are direct or indirect iatrogenic injuries during intervention and hepatic trauma. Clinical presentation may also be late and includes more frequently upper gastrointestinal bleeding due to pseudoaneurysm rupture, abdominal pain and jaundice secondary to bile duct compression. Therapies includes trans arterial embolization of feeding artery and percutaneous ingjection of embolic devices into the aneurysm. Surgery must be reserved for cathether based therapy failure. We report a case of a 66 year old man, presenting a month after cholecystectomy, complaining abdominal pain in the upper right quadrant and hematemesis. An EGDS exam showed hemobilia and computed tomography (CT) revealed a cistic artery pseudoaneurysm (PSA) wich have been successfully treated with hyperselective arterial embolization. Although this is a rare complication the surgeon must be aware of related symptoms and signs in order to sospect pseudoaneurysm as prompt recognition and treatment are essential. Untreated haemobilia may determine an immediate threat to life leading to acute haemodynamic instability We describe both diagnostic features and therapeutic strategies in comparison to the most recent literature. (www.actabiomedica.it)

Laparoscopic cholecystectomy complications: a new case report of a right hepatic artery pseudoaneurysm that caused jaundice

Iatrogenic vascular injuries of the hepatic artery are infrequent and a serious complication of LC. There is no doubt about the many advantages of LC when compared to open cholecystectomy. Despite this, there is an increase in the reported incidence (0.3%-1.0%) of biliary and vascular injuries. Most arterial complications are due to direct injury or diathermy shortening on surgical clips and HAP is one of them. We present a case of a 39-year old male patient who presented with this complication and how it was resolved.

Case Report of a Large Common Hepatic Artery Aneurysm

Hepatic artery aneurysm is rare, but appropriate treatment is mandatory. We report a 50-year-old woman with an asymptomatic large hepatic artery aneurysm. The aneurysm was found as a result of abdominal computed tomography (CT) performed as a part of the screening. An open surgery was performed due to the size of the aneurysm. Aneurysmectomy was achieved, and the proper hepatic artery was anastomosed with gastroduodenal artery for adequate blood flow to the liver. Adequate hepatic circulation was confirmed postoperatively by duplex ultrasonography and CT. The patient was discharged on the 9th postoperative day.

Arterio-biliary fistulas: What to choose as endovascular treatment?

Objectives Endovascular procedures are the treatment of choice in cases of intrahepatic fistulas. Arterio-biliary fistulas are the rarest and most difficult to treat, due to high risk of infection. Methods Eight cases of persistent hemobilia that developed as a result of arterio-biliary fistulas are presented. Five cases developed as a result of iatrogenic injury, two cases as a result of chronic infection, one case as a consequence of trauma. Results Patients were treated using endovascular embolization or combined endovascular and endoscopic biliary tract revision. The results were monitored after six to seven days and one month after embolization. The embolizations were considered effective in all cases. One patient had four asynchronous fistulas requiring separate treatments sessions. Four patients required a revision of their biliary ducts after embolization and restoration of patency. In one patient, a migration of the coil to biliary ducts occurred. Conclusion Endovascular treatment of arterio-biliary fistulas is safe and effective. The use of embolization with soft and biodegradable materials like histoacrylic glue or thrombin may be the optimal method of treatment in comparison with coils which have a risk of migration or chronic infection.

Hepatic or Cystic Artery Pseudoaneurysms Following a Laparoscopic Cholecystectomy: Literature review of aetiopathogenesis, presentation, diagnosis and management

Pseudoaneurysms (PSAs) of the hepatic and/or cystic artery are a rare complication following a laparoscopic cholecystectomy (LC). Generally, PSA cases present with haemobilia several weeks following the procedure. Transarterial embolisation (TAE) is considered the optimal management approach. We report a 70-year-old woman who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in 2016 with massive hemoperitoneum two weeks after undergoing a LC procedure in another hospital. She was successfully managed using coil TAE. An extensive literature review revealed 101 cases of hepatic or cystic artery PSAs following a LC procedure. Haemobilia was the main presentation (85.1%) and the mean time of postoperative presentation was 36 days. The hepatic artery was involved in most cases (88.1%), followed by the cystic artery (7.9%) and a combination of both (4.0%). Most cases were managed with TAE (72.3%), with a 94.5% success rate. The overall mortality rate was 2.0%.

Iatrogenic hemobilia: imaging features and management with transcatheter arterial embolization in 30 patients

PURPOSE

We aimed to evaluate the imaging features of computed tomography (CT) and angiography and the efficacy of transcatheter arterial embolization (TAE) in patients with hemobilia of different iatrogenic causes.

METHODS

Thirty patients with hemobilia were divided into two groups according to their iatrogenic causes, i.e., group 1, 11 patients (36.7%) with transhepatic intervention and group 2, 19 patients (63.3%) with surgical procedures in the hilar area. Seventeen patients (56.7%) underwent abdominal contrast-enhanced CT before selective angiography. Polyvinyl alcohol particles, gelatin sponges, and coils were used for TAE. Data from the two groups were compared using Fisher's exact test and the Mann-Whitney U test.

RESULTS

Contrast-enhanced CT showed a hematoma, extravasation of contrast material, and pseudoaneurysm. The bleeding source was determined by angiographic features in all patients, which were not significantly different between the two groups (P = 0.127), and pseudoaneurysm was the most common. The embolic material and number of coils used for TAE were significantly different between the two groups (P < 0.001), but the embolization was technically successful in all patients. The clinical success rate of the first embolization was 100% in group 1 vs. 84.2% in group 2. The overall clinical success rate of TAE was 100% in all patients. The complication rate was 63.6% in group 1 vs. 68.4% in group 2 (P = 1.000).

CONCLUSION

CT was useful in diagnosing hemobilia, and angiograms enabled determination of the bleeding source. Pseudoaneurysm was one of the most common angiographic features. TAE was successfully performed with different embolic materials on the basis of the iatrogenic cause and bleeding location.

Predictive factors of gastroduodenal bleeding after postoperative radiotherapy in biliary tract cancer

Objective

To identify predictive factors for gastroduodenal bleeding after postoperative radiation therapy in patients with biliary tract cancer.

Methods

We identified 186 patients with biliary tract cancer who completed scheduled postoperative radiation therapy from March 2000 to August 2013. To isolate the effects of radiation on gastroduodenal bleeding, patients with pylorus-preserving pancreaticoduodenectomy, pylorus-resecting pancreaticoduodenectomy or Whipple surgery (n = 67) were excluded from this analysis. Postoperative radiation therapy was started at a median 5 weeks (range: 4-12 weeks) after surgery with a median dose of 44 Gy (range: 44-54), and chemotherapy was also concurrently administered to 102 patients.

Results

The median age of the patients was 59 years (range: 36-76 years). Of the 119 patients, 26 had intrahepatic cholangiocarcinoma, 29 had hilar cholangiocarcinoma, while 64 had extrahepatic tumors (gallbladder cancer, n = 53; proximal bile duct cancer, n = 10; choledochal cyst cancer, n = 1). Of all, 11 patients (9%) developed gastroduodenal bleeding. In univariate analyses, hepatic artery resection and gastroduodenal wall thickening on postoperative radiation therapy simulation computed tomography were statistically significant factors for gastroduodenal bleeding. Multivariate analysis by a logistic regression model using those two variables revealed that both parameters were independent predictors for gastroduodenal bleeding.

Conclusions

Concomitant hepatic artery resection and presence of gastroduodenal wall thickening on postoperative radiation therapy simulation computed tomography were predictive factors for gastroduodenal bleeding after postoperative radiation therapy in biliary tract cancer. In such cases, patients should be informed of the high risk of gastroduodenal bleeding, and should be closely observed during and after postoperative radiation therapy.

Hemobilia Due to Cystic Artery Pseudoaneurysm: A Rare Late Complication of Laparoscopic Cholecystectomy

We discuss a patient with late presentation of hemobilia following cholecystectomy, which is unusual because pseudoaneurysm caused by vascular injury during surgery typically presents soon after surgery. Endoscopic retrograde cholangiopancreatography revealed a large blood clot arising from the biliary orifice with subsequent computed tomography angiography diagnosing a large pseudoaneurysm in the region of the cystic artery adjacent to the cholecystectomy clips. Embolization was performed via direct percutaneous puncture of the pseudoaneurysm.

Late-onset severe biliary bleeding after endoscopic pigtail plastic stent insertion

Here, we report our experience with a case of severe biliary bleeding due to a hepatic arterial pseudoaneurysm that had developed 1 year after endoscopic biliary plastic stent insertion. The patient, a 78-year-old woman, presented with hematemesis and obstructive jaundice. Ruptured hepatic arterial pseudoaneurysm was diagnosed, which was suspected to have been caused by long-term placement of an endoscopic retrograde biliary drainage (ERBD) stent. This episode of biliary bleeding was successfully treated by transarterial embolization (TAE). Pseudoaneurysm leading to hemobilia is a rare but potentially fatal complication in patients with long-term placement of ERBD. TAE is a minimally invasive procedure that offers effective treatment for biliary bleeding.

Percutaneous Direct Embolization for Pseudoaneurysm at the Gallbladder Fossa after Cholecystectomy

Postoperative pseudoaneurysm at the gallbladder fossa is a rare complication of cholecystectomy. The typical clinical presentations of this condition are intraparenchymal or intraperitoneal hemorrhage or rupture into the gastrointestinal tract, and this may be life-threatening. For the treatment of pseudoaneurysms, percutaneous transarterial embolization is considered first-line. We present a case of pseudoaneurysm at the gallbladder following cholecystectomy, which was successfully treated with echo-guided percutaneous transhepatic direct embolization using N-butyl cyanoacrylate, after the failure of transarterial embolization.

Hemobilia following laparoscopic cholecystectomy: computed tomography findings and clinical outcome of transcatheter arterial embolization

BACKGROUND

Hemobilia following laparoscopic cholecystectomy (LC) can occur in the early or late postoperative course and poses a diagnostic and therapeutic challenge.

PURPOSE

To assess computed tomography (CT) findings and clinical outcomes after transcatheter arterial embolization (TAE) in patients presenting with hemobilia following LC.

MATERIAL AND METHODS

Fourteen patients treated for hemobilia following LC were included in the study. Three patients were diagnosed by endoscopy and 11 by abdominal contrast-enhanced CT. Coils or microcoils were superselectively deployed to occlude the bleeding vessel during TAE. Abdominal CT findings of hemobilia, and the success rate and complication of TAE were observed.

RESULTS

Abdominal CT provided the following signs of hemobilia: hematoma within the abdominal cavity and gallbladder fossa, blood clots containing high attenuation within the bile duct, biliary dilatation, pseudoaneurysm of the right hepatic artery, contrast extravasation, enhancement of the bile duct wall, and hypoperfusion of the right lobe. The success rate of TAE was 100% and rebleeding did not occur in any patient. Post-embolization syndrome and hepatic ischemia occurred in nine patients, which was associated with age and the time interval between the LC and TAE.

CONCLUSION

Abdominal CT provided direct signs that can aid in the diagnosis of hemobilia after LC. TAE allowed for successful treatment of hemobilia with minor complications.

Hemobilia After Laparoscopic Cholecystectomy: Imaging Features and Management of an Unusual Complication

PURPOSE

To assess the imaging features and the management of hemobilia after laparoscopic cholecystectomy (LC).

MATERIALS AND METHODS

A total of 12 patients who were treated for hemobilia after LC were included in the study. Selective arteriography was performed to find the bleeding artery. Coils or microcoils were deployed superselectively to occlude the bleeding branch. The clinical course, imaging findings, the embolic effect, complications, and follow-up were evaluated.

RESULTS

Risk factors for hemobilia included a variant ductal anatomy, a variant cystic artery, and intraoperative adhesion. Abdominal computed tomography (CT) could provide the diagnostic signs as follows: a hematocele in the abdominal cavity, the gallbladder fossa, and the bile duct, biliary dilation, pseudoaneurysm of the right hepatic artery, and contrast extravasations on contrast-enhanced CT. No rebleeding occurred after the transcatheter arterial embolization in all patients without immediate procedural complications.

CONCLUSIONS

Gallbladder triangle anatomic variation and intraoperative adhesion were the risk factors for hemobilia after LC. Abdominal CT is a useful examination for the diagnosis. Transcatheter arterial embolization is the therapeutic option of choice.

Delayed hemobilia due to hepatic artery pseudo-aneurysm: a pitfall of laparoscopic cholecystectomy

BACKGROUND

Hepatic artery pseudoaneurysm as a complication of laparoscopic cholecystectomy is considered a rare, potentially life threatening condition.

CASE PRESENTATION

We report a case of late onset hemobilia presenting 8 months following elective laparoscopic cholecystectomy with complex biliary and vascular injury. The patient was treated surgically with primary repair of the aneurysm and hepaticojujenostomy.

CONCLUSION

A high index of suspicion should be raised when encountering a patient with massive upper GI bleeding and a previous history of hepatobiliary manipulation or surgery regardless of postoperative period.

Compressive hematoma due to pseudoaneurysm of the right hepatic artery: a rare cause of obstructive jaundice after single-port cholecystectomy

Single-port laparoscopic cholecystectomy is considered as a form of natural orifice surgery with better esthetic outcomes than traditional laparoscopic cholecystectomy. It is a technically demanding procedure, and no adequately powered trial has assessed the safety of this technique. Vascular injuries are less common than bile duct injuries during this procedure, but they can be rapidly fatal. The development of a right hepatic artery pseudoaneurysm is a rare but serious complication associated with single-port laparoscopic cholecystectomy. Two weeks following a single-port laparoscopic cholecystectomy for angiocholitis, a 40-year-old male patient presented with obstructive jaundice and persistent abdominal pain. The diagnosis of compressive hematoma due to a ruptured right hepatic artery pseudoaneurysm was confirmed by computed tomography scan and angiography. It was successfully treated by selective embolization of the right hepatic artery. In our experience, endovascular management was a noninvasive and effective treatment of ruptured pseudoaneurysms.

Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation

Background

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.

Case presentation

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.

Conclusion

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.

Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy has many complications which may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the biliary system.

PRESENTATION OF CASE

A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient, Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiography were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed. The patient recovered completely.

DISCUSSION

Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure.

CONCLUSION

In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients.

Ruptured aneurysm of an aberrant left hepatic artery

Although rare, the high mortality associated with visceral artery aneurysms highlights the importance of their prompt diagnosis and treatment. This report details the acute presentation, diagnosis and management of a 51-year-old man with a non-traumatic ruptured aneurysm of an aberrant left hepatic artery. This is just the second case of a rupture of this aberrant artery reported in the literature, and the only one to be treated using endovascular techniques. An up-to-date review of the investigation and surgical/endovascular management of visceral aneurysms in relation to this case is included.

Haemobilia causing cholangitis in a patient on dual anti-platelet treatment suffering from acute acalculous cholecystitis

INTRODUCTION

Haemobilia is a rare cause of upper gastro-intestinal haemorrhage which can be difficult to diagnose.

PRESENTATION OF CASE

We present the case of a patient who suffered from acute acalculous cholecystitis while on dual anti-platelet therapy with aspirin and clopidogrel. We describe the diagnostic and treatment challenges arising from the patient's complicated past history and the steps leading to the diagnosis of haemobilia causing biliary obstruction and cholangitis. Our patient did not, at any point, manifest anaemia or evidence of haemorrhage.

DISCUSSION

Haemobilia has a varied aetiology. To our knowledge there is no association with dual anti-platelet treatment in the literature to date. Diagnosis is difficult and relies on multiple modalities. In our patient the final diagnosis was only made in the course of open bile duct exploration.

CONCLUSION

In acute biliary obstruction we recommend the consideration of haemobilia in the differential diagnosis, especially in patients with a bleeding tendency.

Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of the literature

OBJECTIVE

Hemobilia is an uncommon cause of gastrointestinal bleeding. The etiology is diverse, but most often, it is iatrogenic. The present study aims to reassess the clinical picture and the treatment of choice.

METHODS

We describe a case series from a single center of patients who presented with nontraumatic iatrogenic hemobilia.

RESULTS

Over a period of 8 years, hemobilia occurred in 12 patients: following liver biopsy in six patients and after endoscopic biliary interventions in four patients, with a respective prevalence of 0.1 and 0.04%. The clinical presentation was characterized by an upper gastrointestinal bleeding (n=11) and/or biochemical signs of sudden biliary obstruction (n=9). The onset of the symptoms occurred after a median of 6 days (range: 1-23). Ultrasound and computed tomography scan missed the diagnosis in, respectively, 4/5 and 2/5 of patients. On arteriography, pseudoaneurysm (6/12) was the most common finding. Transcatheter arterial embolization controlled the bleeding in all cases (12/12) without major complications.

CONCLUSION

The delay between the intervention and the clinical presentation and the fact that imaging studies may fail to diagnose hemobilia may mislead the physician. Transcatheter arterial embolization is the treatment of choice for hemobilia. It has proven to be effective and safe and it offers a long-term definitive cure.

Severe hemobilia from hepatic artery pseudoaneurysm

Background. Hemobilia is a rare, jeopardizing complication of laparoscopic cholecystectomy coming upon usually within 4 weeks after surgery. The first-line management is angiographic coil embolization of hepatic arteries, which is successful in the majority of bleedings: in a minority of cases, a second embolization or even laparotomy is needed. Case Presentation. We describe the case history of a patient in which laparoscopic cholecystectomy was complicated 3 weeks later by massive hemobilia. The cause of haemorrhage was a pseudoaneurysm of a right hepatic artery branching off the superior mesenteric artery; this complication was successfully managed by one-stage angiographic embolization with full recovery of the patient.

Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review

AIM

To assess the published evidence on the endovascular treatment of non-variceal upper gastrointestinal haemorrhage.

MATERIALS AND METHODS

An Ovid Medline search of published literature was performed (1966-2009). Non-English literature, experimental studies, variceal haemorrhage and case series with fewer than five patients were excluded. The search yielded 1888 abstracts. Thirty-five articles were selected for final analysis.

RESULTS

The total number of pooled patients was 927. The technical and clinical success of embolization ranged from 52-100% and 44-100%, respectively. The pooled mean technical/clinical success rate in primary upper gastrointestinal tract haemorrhage (PUGITH) only, trans-papillary haemorrhage (TPH) only, and mixed studies were 84%/67%, 93%/89%, and 93%/64%, respectively. Clinical outcome was adversely affected by multi-organ failure, shock, corticosteroids, transfusion, and coagulopathy. The anatomical source of haemorrhage and procedural variables did not affect the outcome. A successful embolization improved survival by 13.3 times. Retrospective comparison with surgery demonstrated equivalent mortality and clinical success, despite embolization being applied to a more elderly population with a higher prevalence of co-morbidities.

CONCLUSIONS

Embolization is effective in this very difficult cohort of patients with outcomes similar to surgery.

Impact of concomitant arterial injury on the outcome of laparoscopic bile duct injury

BACKGROUND

Concomitant injury to the bile duct and hepatic artery is an increasingly recognized complication of laparoscopic cholecystectomy (LC). The impact of a concomitant arterial injury in patients with a bile duct injury (BDI) remains debatable. Early reports described a high incidence of septic complications, difficulty of biliary repair, and increased the risk of recurrent stricture.

DATA SOURCES

A literature search on the clinical significance and management of a concomitant hepatic artery injury (HAI) to the outcome of biliary-enteric reconstruction following BDI was reviewed. Relevant articles were extracted through MEDLINE, with secondary references obtained from key articles.

CONCLUSIONS

The association between failure of biliary repair and concomitant arterial injuries is not confirmed by the largest studies, which showed no difference in anastomotic stricture rate between patients who had an isolated BDI and those who had a combined HAI and BDI. However, right arterial injury associated with liver necrosis or damage to the right hepatic duct may require right hepatectomy.

Reversed arterial flow in the paramedian segments of the liver after pancreaticoduodenectomy

Variation of splanchnic arterial anatomy is frequent and may complicate pancreatic surgery, leading to life-threatening postoperative complications. We report a case of severe hepatic dysfunction after pancreaticoduodenectomy due to accidental section of the right hepatic artery. Bedside ultrasound examination showed a reversed arterial flow in the paramedian segments of the liver. Based on intraoperative and ultrasound findings, a retrograde arterial supply of the right liver from the left hepatic artery through spontaneous anastomosis between the arteries of segment 4 and the right paramedian segments was assumed and confirmed by postoperative CT examination.

Postlaparoscopic iatrogenic pseudoaneurysms of the arteries of the peritoneal and retroperitoneal space: case report and review of the literature

BACKGROUND AND AIMS

Laparoscopic surgery procedures are associated with a low percentage of cases of iatrogenic traumatic laceration of the arteries of the peritoneal and retroperitoneal space. These lesions rarely lead to pseudoaneurysm formation. In 1 case, we performed a meta-analytic review of the literature on postlaparoscopic iatrogenic pseudoaneurysms focusing on specific parameters: (1) artery involved, (2) type of laparoscopic operation, (3) time interval between the laparoscopic operation and the final diagnosis of the pseudoaneurysm, (4) clinical presentation, (5) diagnostic tools used, (6) mode of treatment applied, and (7) clinical outcome.

MATERIALS AND METHODS

We searched Medline for pseudoaneurysms developing as complications of laparoscopic procedures. The search terms used were "iatrogenic pseudoaneurysm," "complications after laparoscopic procedures," "traumatic arterial laceration," "pseudoaneurysm formation," and "postoperative hematoma" in various combinations.

RESULTS AND CONCLUSIONS

A total of 66 cases were retrieved. Postlaparoscopic iatrogenic pseudoaneurysms are late manifestations of arterial complications developing during routine laparoscopy. There are 66 reported cases of this type of complication in the literature. The majority occurs in the arteries of the operation field of the respective laparoscopic procedure. Distal vessels are involved less frequently. They usually present after a mean period of approximately 6 weeks. The hepatic and renal arteries are usually affected. The clinical picture includes upper and lower gastrointestinal bleeding, diffuse or localized abdominal pain, hematuria, and drain bleeding.

Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy

Hepatic artery pseudoaneurysm is a rare and potentially fatal complication of laparoscopic cholecystectomy that often presents with abdominal pain, anemia, hemobilia, and liver function elevations. The authors report a case of hepatic artery pseudoaneurysm diagnosed by abdominal computed topography in a 54-year-old man who had undergone laparoscopic cholecystectomy the previous month. Definitive treatment was angiography with embolization.

[Radiological interventional procedures for the acute abdomen]

In patients with acute thrombo-embolic occlusion of the superior mesenteric artery, catheter-assisted thrombolytic therapy represents a procedure of increasing importance in addition to surgery and intensive care treatment. The thrombolytic drugs utilized for this purpose are urokinase, streptokinase and recombinant tissue plasminogen activator (rtPA).Therapeutic embolization is predominantly used in the treatment of arterial bleeding from the gastro-intestinal tract, the liver, the intestines (due to an aneurysm or vascular malformation) and in bleeding from intestinal anastomoses. Polyvinyl alcohol particles, embospheres, gelfoam and microcoils can be utilized as embolic agents. Percutaneous transhepatic cholangiodrainage and stent implantation are applied in patients with biliary obstructions caused by inoperable tumors of the gall bladder or bile ducts, of the pancreatic head or duodenum and by metastases located in the liver parenchyma or hepatic hilum.Image-guided percutaneous drainage is a valuable option in the management of abscesses in the peritoneal cavity; less common indications are lymphoceles, biliomas, urinomas, hematomas, necrosis and pseudocysts.

Transcatheter embolization for peripheral pseudoaneurysms with n-butyl cyanoacrylate

The purpose of this study is to evaluate the clinical efficacy of transcatheter embolization for pseudoaneurysms of peripheral arteries with n-butyl cyanoacrylate (NBCA). From November 2000 to February 2008, 17 patients with 18 pseudoaneurysms were treated by transcatheter embolization at our affiliated hospitals. The locations of the pseudoaneurysms were right hepatic artery (n=3), renal artery (n=5), splenic artery (n=2), gastroduodenal artery (n=2), common hepatic artery (n=1), pancreatic arcade (n=1), external iliac artery (n=1), internal iliac artery (n=1), internal thoracic artery (n=1), and left gastric artery (n=1). We assessed technical success rate, embolization methods, and clinical course in this study. The technical success rate was 94.4% (17/18 cases). Embolization methods were isolation (n=17) and packing (n=1). Only NBCA was used in 14 cases, both coils and NBCA were used in four cases. Six patients were in shock prior to the procedure, but all patients recovered immediately after embolization procedure including transfusion. None of the patients died of procedure-related factors or had notable postoperative complications, but three patients died within a week of the procedure because of deterioration of the underlying disease. In conclusion, transcatheter embolization of pseudoaneurysms with NBCA is a safe and effective technique for treatment.

Hepatic artery pseudo aneurysm rupture precipitated by pneumonia: An Unusual Case

We present a unique case of hepatic artery pseudo aneurysm rupture associated with pneumonia. A 67 year old woman admitted to our hospital with productive cough, pleuritic chest pain and shortness of breath. She was diagnosed to have community acquired pneumonia and was treated with antibiotics. On third day of admission she developed acute abdominal pain and haemorrhagic shock. Contrast CT scan showed left hepatic artery pseudo aneurysm rupture, a rare emergency condition associated with high mortality rate. She underwent percutaneous endovascular coiling and made a complete recovery.

Management of massive haemobilia in an Indian hospital

INTRODUCTION

Massive haemobilia carries a mortality of 25% in most reports. Although previously it was mainly due to road accidents or homicidal attempts it is now more often due to iatrogenic trauma like percutaneous liver biopsy and biliary drainage. However the management protocol is not established and there have been few reports of this serious condition from India.

AIM

To review the causes of massive haemobilia and outline its management in an Indian hospital.

PATIENTS AND METHODS

We retrospectively analysed the records of 20 consecutive patients with massive haemobilia (blood requirement more than 1400 ml/day) admitted to our department over six years from a prospectively maintained database. There were 10 males and 10 females who had a mean age of 43 (range 15-65) years.

RESULTS

Haemobilia accounted for 9 percent of patients admitted with upper gastrointestinal bleeding who were seen over this period. The commonest cause was iatrogenic (11) including laparoscopic cholecystectomy (6), Whipple's operation, endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), hepatic stone extraction and removal of biliary stent (1 each). The others had accidental trauma (4), visceral aneurysms (2), biliary stones (2) and chronic pancreatitis (1). The commonest clinical presentation was massive gastrointestinal bleeding. The dual phase computed tomography (CT) scan correctly identified the site of bleeding and other associated conditions in all the 11 patients in whom it was done. Conventional angiography was done in 8 patients with transarterial embolisation (TAE) being attempted in 6 and successful in 2 patients. Operations were performed in 18 patients for the following indications - failure of angiographic embolisation (6), failure of endoscopic sclerotherapy (EST) (1), duodenal erosion (2), portal biliopathy (1), haemoperitoneum (1), bile leak (1), pseudocyst (1), liver necrosis (1) and other hepatobiliary conditions (4). The surgical procedures to control bleeding were ligation of aneurysms (8), repair of the hepatic artery (4), right hepatectomy (3), lienorenal shunt, cholecystectomy and under-running of the duodenal papilla (1 each). The overall mortality was 4 patients (20 percent). There was no mortality in patients with bleeding aneurysms; the mortality being significantly higher in patients with non-aneurysmal bleeding (p=0.0049: Fishers' exact test).

CONCLUSIONS

In our experience haemobilia was usually due to an iatrogenic cause with a pseudoaneurysm following a diagnostic or therapeutic intervention(most often laparoscopic cholecystectomy) being the commonest aetiology. A dual phase CT scan accurately identified the site of bleeding. Angiographic embolisation often failed to stop bleeding and mortality was significantly higher in patients with non-aneurysmal bleeding. We should perhaps consider early surgery for haemobilia once the bleeding site has been localised by CT scan.

Hemobilia and cystic artery stump pseudoaneurysm associated with liver abscess after a laparoscopic cholecystectomy: report of a case

A 63-year-old woman was admitted for cholecystitis and underwent a laparoscopic cholecystectomy (LC). She experienced abdominal pain and hemobilia 11 days after the LC. Angiography was performed but it did not show any source of bleeding. Thereafter, at 27 days after LC, a repeat angiogram was performed which revealed a pseudoaneurysm (PA) arising from a cystic artery stump and an embolized PA sack. However, another PA arising from near the embolized PA and liver abscess was observed 4 days after embolization. The arterial collateral flow was evaluated by endovascular balloon occlusion of the right hepatic artery and it was embolized proximal and distal to the bleeding point. The embolization of the partial hepatic artery was effective for PA when packing the PA sack proved to be insufficient. In patients with liver cirrhosis or liver abscess who require an adequate arterial liver flow, it is important to evaluate the collateral arterial flow before hepatic artery embolization.

Emergency percutaneous treatment in iatrogenic hepatic arterial injuries

The purpose of this report is to present our experience in the emergency percutaneous treatment of patients with iatrogenic hepatic arterial injury (IHAI). Seven patients (six men, one woman; age range 19-78 years; mean age 63 years) with IHAI secondary to surgical or percutaneous procedures were treated with endovascular percutaneous procedures. We performed six transhepatic arterial embolization (TAE) and one placement of an endograft stent. Follow-up was carried out by ultrasound (US) or computed tomography (CT) after 1, 3, 6, and 12 months, yearly thereafter and by laboratory tests in the first 6 months to completely exclude occult and asymptomatic bleeding. All procedures had 100% technical success. No case of further bleeding was seen at follow-up. In one patient, we detected one abscess after 3 weeks, which was treated by antibiotic therapy. In conclusion, endovascular treatment currently represents a valid option in emergency settings, as it the enables diagnosis and treatment of IHAI in a single session.

Arterial embolization for hemorrhage caused by hepatic arterial injury

Fewer than 10% of patients with major liver trauma have life-threatening bleeding. Laparoscopic operations, endoscopic procedures, and percutaneous interventions such as drainages, vascular or tumor sclerosis, biopsies, and transjugular intrahepatic portocaval shunt (TIPS) have increased the number of iatrogenic vascular and bile duct injuries. Due to its therapeutic success, arterial embolization (AE) has become the standard treatment for late complications of hepatic injury. In some cases, this procedure may be used as the first approach on accidental or iatrogenic arterial trauma and in several hepatic arterial diseases. The result of this method depends on physician experience, size of the wound, and stability of the patient. Persistent hemorrhage and rebleeding may be treated with a new AE or an operation. Precise indication and a correctly performed AE are key factors for a successful treatment. Rebleeding episodes are a rare occurrence, which may be treated with AE as well.