Introduction and Case Report
Endoscopic retrograde cholangiopancreatography (ERCP) is indicated in both the diagnosis and the management of a bile duct leak following hepatobiliary surgery. In the following case, a history of recent cholecystectomy prompted an initial suspicion of a bile duct leak. However, a thorough investigation ultimately led to the recognition of a congenital bile duct disorder.
A 50-year-old man was referred to Brigham and Women's Hospital for an evaluation of persistent bilious drainage from a percutaneous right upper quadrant abdominal drain which was placed 1 month earlier during an open cholecystectomy. Surgery was initially attempted via a laparoscopic approach, but during the dissection a bile-filled cavity was encountered, requiring conversion to an open approach. Further examination revealed a cavity communicating with the right main hepatic duct. Following cholecystectomy, a T-tube was placed in this area and was left to drain.
The first ERCP demonstrated extravasation of contrast from the right main hepatic duct filling an adjacent 4-cm cavity (Figure 1). The right intrahepatic system had an otherwise normal cholangiographic appearance (Figure 2). The initial suspicion was that these findings represented an extensive bile leak, but how this injury could have occurred was unclear. Direct cholangioscopy was subsequently performed and dark fluid was noted within the cavity. The walls could not be clearly demarcated as being epithelial or granulating. The bile duct proximal to this area was visualized, and a wire was placed into the upstream right hepatic duct. A 10-French, 15-cm long plastic biliary stent was then placed across the defect. Upon injection of contrast through the stent, no further extravasation was seen.
During the next 2 weeks, no decrease occurred in the amount of bilious drainage from the T-tube. Abdominal computed tomography (CT) scan revealed an area of air and fluid collection in the region of the porta hepatis, adjacent to the biliary stent (Figure 3).
A second ERCP was performed. After the stent was removed again, cholangiography was performed and demonstrated extravasation of contrast from the right main hepatic duct. Two plastic biliary stents (a 10-French, 15-cm long, and 7-French, 15-cm long) were then placed across the defect into the proximal right hepatic duct system. Shortly thereafter, an evaluation performed via the T-tube was interpreted as showing the T-tube to be situated in a biloma rather than an intraductal location (Figure 4). The T-tube was removed and a percutaneous pigtail drainage catheter was placed. However, no subsequent decrease occurred in the amount of bilious drainage.
A third ERCP was performed. The 2 previously placed biliary stents were removed and a new stent was placed (Figure 5). Unlike the previous 2 stents, whose proximal ends were placed in the right hepatic duct and above the site of the presumed leak, the new stent was deployed such that the proximal end was placed in the cavity itself.
CT scan demonstrating air and fluid collection in the region of the porta hepatis, adjacent to the biliary stent.
Evaluation performed via T-tube interpreted as showing T-tube situated in a biloma rather than an intraductal location.
Ultimately, the drainage through the T-tube did not abate and the patient returned to the operating room for laparotomy. Contrast injection through the percutaneous catheter demonstrated filling of the previously noted cavity. The endoscopically placed stent was seen bordering this cavity. Bile leakage in the porta hepatis was not evident. By following the catheter into the porta hepatis, the surgeon was able to enter the cavity which was then opened and explored. The endoscopically placed stent could be palpated within the cavity and was noted to extend into and communicate with the right hepatic duct.
The operative findings were consistent with the presence of an intrahepatic choledochal cyst, and a choledochojejunostomy was performed. Although the patient's further recovery has been uneventful, a postoperative MRI suggests a persistent intrahepatic fluid collection (Figure 6).
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