IMAGES FOR SURGEONS ANZJSurg.com
Cholangitis 3 years after laparoscopic cholecystectomy A 70-year-old man presented with jaundice, right upper quadrant pain and pyrexia. He underwent a laparoscopic cholecystectomy 3 years previously, which had at the time been complicated by a cystic duct stump bile leak. Other past medical history included a Billroth II gastrectomy for peptic ulcer disease several decades earlier. On this admission, observations were as follows: heart rate 110, blood pressure 101/79, temperature 38.2°C, respiratory rate 24, spO2 94% on room air. His abdomen was soft and mildly distended with generalized tenderness, maximally in the epigastrium and right upper quadrant with voluntary guarding in this area. ECG showed sinus tachycardia and chest X-ray showed clear lung fields with no pneumoperitoneum. Bloods tests revealed haemoglobin 9.2g/dL; white cell count 17.1 × 109/L; platelets 173 × 109/L; urea 12.1 mmol/L; creatinine 143 μmol/L; CRP 210 mg/L; bilirubin 78 μg/L; alkaline phosphatase 555 U/L; gamma-glutamyl transpeptidase 443 U/L; alanine transferase 77 U/L; amylase 101 U/L; INR 1.2; ABG: pH 7.31; pO2 10.1; pCO2 3.3; HCO3 22; lactate 2.9 mg/dL. The patient was managed as ascending cholangitis and commenced on intravenous (IV) antibiotics, fluids and analgesia. Magnetic resonance cholangiopancreatography demonstrated biliary dilatation with a large common bile duct (CBD) filling defect. The previous gastrectomy was initially felt to preclude an endoscopic approach to the bile duct, so a percutaneous transhepatic cholangiogram (PTC) was performed.
Fig. 1. X-ray images taken during percutaneous transhepatic cholangiogram (PTC); (a) two metal clips can be visualized within the common bile duct (CBD) during contrast injection, which are thought to have migrated from the cystic duct (CD) stump to become incorporated within a large calculus. (b) Attempting to remove the calculus from the CBD.
© 2015 Royal Australasian College of Surgeons
(a)
The PTC images revealed a CBD calculus containing the two surgical clips originally placed on the cystic duct with no evidence of an ongoing bile leak (Fig. 1a). The PTC tract was dilated, the calculus broken up and most of the debris pushed into the duodenum (Fig. 1b). Owing to technical difficulty, however, an endoscopic retrograde cholangiopancreatography was eventually required to clear the fragments. The patient completed seven days of IV antibiotics as an inpatient and went on to make a full recovery without further complication; at follow-up, liver function tests had returned to within normal limits. The two surgical clips found within the CBD calculus were those originally used to clamp the cystic duct during the initial laparoscopic procedure. It is assumed that, over time, the metal clips had eroded through the cystic stump and into the CBD to become incorporated into a large biliary calculus. Clip migration is described and is associated with complications of cholecystectomy.1 The phenomenon may be more common in patients in whom the initial cholecystectomy has been complicated by a bile leak2 possibly caused by a localized inflammatory reaction and subsequent healing. All metal clips used in general surgery have the potential to migrate over time. The presence of surgical material within the bile ducts can act as a nidus for stone formation. Absorbable polydioxanone clips are available3 and their use may help to prevent this rare complication.
(b)
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
References 1. Chong VH, Chong VF. Biliary complications secondary to post cholecystomy clip migration: a review of 69 cases. J. Gastrointest. Surg. 2010; 14: 688–96. 2. Yoshizumi T, Ikeda T, Shimizu T et al. Clip migration causes choledocolithiasis after laparoscopic cholecystectomy. Surg. Endosc. 2000; 14: 1188. 3. Leung KL, Kwong JK, Lau WY et al. Absorbable clips for cystic duct ligation in laparoscopic cholecystectomy. Surg. Endosc. 1996; 10: 49–51.
Ella Teasdale,* MBChB Neil Masson,† FRCR Ewen M. Harrison* FRCS *Clinical Surgery and †Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, Lothian, UK doi: 10.1111/ans.13033
© 2015 Royal Australasian College of Surgeons
Cholangitis 3 years after laparoscopic cholecystectomy A 70-year-old man presented with jaundice, right upper quadrant pain and pyrexia. He underwent a laparoscopic cholecystectomy 3 years previously, which had at the time been complicated by a cystic duct stump bile leak. Other past medical history included a Billroth II gastrectomy for peptic ulcer disease several decades earlier. On this admission, observations were as follows: heart rate 110, blood pressure 101/79, temperature 38.2°C, respiratory rate 24, spO2 94% on room air. His abdomen was soft and mildly distended with generalized tenderness, maximally in the epigastrium and right upper quadrant with voluntary guarding in this area. ECG showed sinus tachycardia and chest X-ray showed clear lung fields with no pneumoperitoneum. Bloods tests revealed haemoglobin 9.2g/dL; white cell count 17.1 × 109/L; platelets 173 × 109/L; urea 12.1 mmol/L; creatinine 143 μmol/L; CRP 210 mg/L; bilirubin 78 μg/L; alkaline phosphatase 555 U/L; gamma-glutamyl transpeptidase 443 U/L; alanine transferase 77 U/L; amylase 101 U/L; INR 1.2; ABG: pH 7.31; pO2 10.1; pCO2 3.3; HCO3 22; lactate 2.9 mg/dL. The patient was managed as ascending cholangitis and commenced on intravenous (IV) antibiotics, fluids and analgesia. Magnetic resonance cholangiopancreatography demonstrated biliary dilatation with a large common bile duct (CBD) filling defect. The previous gastrectomy was initially felt to preclude an endoscopic approach to the bile duct, so a percutaneous transhepatic cholangiogram (PTC) was performed.
Fig. 1. X-ray images taken during percutaneous transhepatic cholangiogram (PTC); (a) two metal clips can be visualized within the common bile duct (CBD) during contrast injection, which are thought to have migrated from the cystic duct (CD) stump to become incorporated within a large calculus. (b) Attempting to remove the calculus from the CBD.
© 2015 Royal Australasian College of Surgeons
(a)
The PTC images revealed a CBD calculus containing the two surgical clips originally placed on the cystic duct with no evidence of an ongoing bile leak (Fig. 1a). The PTC tract was dilated, the calculus broken up and most of the debris pushed into the duodenum (Fig. 1b). Owing to technical difficulty, however, an endoscopic retrograde cholangiopancreatography was eventually required to clear the fragments. The patient completed seven days of IV antibiotics as an inpatient and went on to make a full recovery without further complication; at follow-up, liver function tests had returned to within normal limits. The two surgical clips found within the CBD calculus were those originally used to clamp the cystic duct during the initial laparoscopic procedure. It is assumed that, over time, the metal clips had eroded through the cystic stump and into the CBD to become incorporated into a large biliary calculus. Clip migration is described and is associated with complications of cholecystectomy.1 The phenomenon may be more common in patients in whom the initial cholecystectomy has been complicated by a bile leak2 possibly caused by a localized inflammatory reaction and subsequent healing. All metal clips used in general surgery have the potential to migrate over time. The presence of surgical material within the bile ducts can act as a nidus for stone formation. Absorbable polydioxanone clips are available3 and their use may help to prevent this rare complication.
(b)
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
References 1. Chong VH, Chong VF. Biliary complications secondary to post cholecystomy clip migration: a review of 69 cases. J. Gastrointest. Surg. 2010; 14: 688–96. 2. Yoshizumi T, Ikeda T, Shimizu T et al. Clip migration causes choledocolithiasis after laparoscopic cholecystectomy. Surg. Endosc. 2000; 14: 1188. 3. Leung KL, Kwong JK, Lau WY et al. Absorbable clips for cystic duct ligation in laparoscopic cholecystectomy. Surg. Endosc. 1996; 10: 49–51.
Ella Teasdale,* MBChB Neil Masson,† FRCR Ewen M. Harrison* FRCS *Clinical Surgery and †Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, Lothian, UK doi: 10.1111/ans.13033
© 2015 Royal Australasian College of Surgeons
