Cystic artery pseudoaneurysm with haemobilia after laparoscopic cholecystectomy

摘要

A 56-year-old man underwent laparoscopic cholecystectomy for acute cholecystitis at another hospital in December 2013. The cholecystectomy was uneventful and the patient was discharged home 3 days later. However, after hospital discharge, the patient presented with recurring upper abdominal pain, tarry stool, and fever. He was admitted to another hospital 4 weeks after the cholecystectomy because of fever, right upper quadrant pain, and haematemesis. Emergency oesophagogastroduodenoscopy and colonoscopy were performed. No bleeding source was identified. Computed tomography (CT) revealed subhepatic fluid collection; old-blood–stained fluid was drained by image-guided catheter drainage. The patient was transferred to the Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, for further treatment. When the patient arrived at hospital, his blood pressure was approximately 90/60 mm Hg and his pulse rate was 110 beats per minute. Laboratory studies revealed the following values: haemoglobin level, 72 g/L; white blood cell count, 20.3 × 109 /L; platelet count, 388 × 109 /L; total bilirubin, 164 μmol/L; alanine aminotransferase, 187 IU/L; and alkaline phosphatase, 337 IU/L. The patient was treated with intravenous fluid hydration and was transfused with three units of packed red blood cells. He was also given a course of antibiotics. Abdominal CT showed a cystic artery pseudoaneurysm of 1.22 × 1.96 × 1.38 cm (anterior-posterior × transverse × longitudinal dimensions). Two subhepatic collections with haematoma were also visible, over the gallbladder fossa and below hepatic segment 6. Selective right hepatic artery angiography revealed a pseudoaneurysm at the cystic artery. This aneurysm was embolised with stainless steel coils ( Fig 1 ). The catheter for subhepatic collection drainage was then replaced with one with better positioning. Endoscopic retrograde cholangiopancreatography was performed the next day. The cholangiogram showed a dilated biliary tree with haemobilia; most of the blood clots were extracted using a balloon. A cystic duct stump leak was observed after blood clot removal, and a 10-cm-long 11.5-F biliary stent was inserted for biliary drainage ( Fig 2 ). Liver function improved gradually. The patient was discharged from hospital 2 weeks after admission. Figure 1. (a) Computed tomogram showing pseudoaneurysm of the cystic artery (large arrow), and two subhepatic collections with haematoma over the gallbladder fossa and below hepatic segment 6 (small arrows). (b) Angiogram showing pseudoaneurysm of the cystic artery (arrow) and the pseudoaneurysm after embolisation (inset) Figure 2. Cholangiogram showing haemobilia before blood clot removal, and cholangiogram (inset) showing cystic duct stump leakage (arrow) after blood clot removal and controlled with biliary stenting Follow-up CT no longer showed pseudoaneurysm and instead showed a resolving collection. Endoscopic retrograde cholangiopancreatography with stent removal was performed 3 months later. The cholangiogram showed a normal biliary tree. The patient recovered and liver function test results were normal. Discussion Hepatic artery or cystic artery pseudoaneurysms are rare complications of laparoscopic cholecystectomy, with cystic artery involvement being reported much less frequently in the literature. Pseudoaneurysm formation is a consequence of vascular injury; important causes include arterial access procedures, accident trauma, and surgical trauma. 1 Two-thirds of cases are iatrogenic. 1 With the advent of laparoscopic cholecystectomy, iatrogenic hepatobiliary injury is now another cause. Concomitant formation of cystic artery pseudoaneurysm and cystic duct stump leak is a rare complication of laparoscopic cholecystectomy. The majority of pseudoaneurysms present within 6 weeks after the operation. 2 3 We have reported a case of laparoscopic cholecystectomy that was complicated by a cystic artery pseudo-aneurysm and a cystic duct stump bile leak, which were managed with angiographic coil embolisation and endoscopic biliary drainage, respectively. The patient presented with the classic Quincke’s triad of haemobilia, namely upper gastrointestinal bleeding, right upper quadrant pain, and obstructive jaundice. The aetiology most likely originated from the infected fluid collection after cholecystectomy, which caused a series of events, including cystic duct stump leak, cystic artery pseudoaneurysm, and haemobilia, in that order. First, bile leakage is a potential complication of cholecystectomy and the cystic duct stump is the most common site of leakage. 4 The contributing factor of cystic duct stump leak in the current case was likely cystic duct stump necrosis secondary to mechanical or thermal injury during cholecystectomy, as well as adjacent infection. Second, haemobilia can occur secondary to a cystic artery pseudoaneurysm, although extremely rarely. Artery pseudoaneurysm is a continuous inflammatory process that l