Conservative Management of Pneumoperitonitis after Percutaneous Transhepatic Insertion of Metallic Biliary Stents

摘要

The occurrence of pneumoperitoneum after a percutaneous transhepatic intervention is an exceptionally rare event. Generally it resolves spontaneously or with minimally invasive management even in symptomatic conditions (pneumoperitonitis); resorting to surgical approach is exceptional. What is still unclear is the question as to whether the airflow has an intestinal or atmospheric source. Our report lends support to the former hypothesis, as argued hereafter. A 60-year-old woman with inoperable adenocarci-noma of the pancreatic head was referred to our surgical evaluation for the development of abdominal distension and right hypochondrial pain. Two days before, as jaundice treatment, a percutaneous transhepatic puncture of the right biliary tree was performed and a self-expandable metallic Wallstent was placed across the biliary stricture. The procedure resulted successful and uneventful and the external drain was removed the coming day. Two days after, however, the aforementioned clinical scenario manifested and dedicated imaging studies were commenced. A plain abdominal X-ray documented an important pneumoperitoneum (Fig. 1). CT scan showed abundant ascites and, of interest, an intrahepatic gaseous content, presumably corresponding to the previous puncture site, was identified along with pneumobilia and pneumo-gallbladder (Fig. 2). Due to hemodynamic stability of the patient and after excluding biliary injury by a control endoscopic retrograde cholangiopancreatography, a nonoperative management with analgesic therapy and radiological surveillance was undertaken.