• Name : Madhuben khatri• Age: 60 yr / F• DOA: 4/ 09/08• DOO: 21/10/08• DOD: 05/11/08

History

• No MRF• Open cholecystectomy at devangiri for

gallstone on 29/07/08• Bile leak from day 1st – 700ml/ day• Drain pulled out on day 2nd – not draining –

block.• Developed bilioma and sepsis, transferred to

manipal hospital, banglore.

History Cont.

• PCD done – perihepatic and subhepatic and developed control fistula ~ 300ml/ day in total.

• Ventilatory support for 10 day and antibiotics for sepsis

• Rt. Side bronchopneumonia – improved with treatment.

• Patient send to rajasthan with PCD in situ.

History cont.

• Patient developed biloma with PCD tube get blocked.

• Referred to sterling hospital.• Imaging: rt. Subphrenic collection – 500ml ,

PCD done.• Pt. had rt. Encysted pleural effusion with

decreased air entry.• Seen by pulmonologist and pleuroscopy and

adhesiolysis, ICD insertion done.

Biloma

History Cont.

• Her general condition improved, TC- decreased from 30000 to 8000 and afebrile.

• Fistula output was 100ml/ day with no residual collection.

• On day of discharge patient has slipped PCD – CT plane done – not showed significant collection – so patient discharged with plan for reinsertion of PCD once collection develop.

History Cont.

• 4 day later: patient reevaluated, had perihepatic collection, PCD done – drain 400ml bile

• PCD output remain 200ml/ day, she also develop a collection just beneath wound near hilum and need 2nd PCD for the same.

• USG abdomen revealing – dilated lt. system with partially filled rt.system , s/o type 4 block with rt. Side fistula.

History cont.

• Seg 8 PTBD done by intervention radiologist Dr. Ajay Desai, cholangiogram showed leak from hilum and type 4 stricture with left system not opacify.

• Post PTBD – bile leak stoped and PTBD output was ~ 250ml/ day.

• Patient general condition was poor with Alb. 2.0, TLC 10000, KPS -70, pedal edema

History Cont..

• Patient given 3 unit of albumin, started on TPN as oral intake inadequate and chest physiotherapy and incentive spirometry continued.

• Patient developed depression symptoms.• Surgery was planed with explained risk for

early intervention.

Pre op cholangiogram

• Type 3-b stricture

RYHJ

• Done at medisurge hospital, on 21/10/08• Findings: perihepatic and subhepatic dense

adhesions with oosing for liver surface, liver congested and lt. lobe hypertrophy.

• Hilum showed ~1.5 cm rent with suture ball coming out within it. Rt. PTBD reaching upto hilum.

• Lt. system not freely draining

Hilar Fistula

Perioperative cholangio- intubation

Stented Anastomosis

Post operative course:

• Patient on epidural analgesia for 3 days.• Day 1st hemodynamically stable, hb: 11%, CVP

6cm of water, u/o adequate• Day 2nd developed tachycardia, CVP low , given

fluid , colloids (FFP, albumin),- CVP – 13cm of water.-- fall in hb 7%. Wound soackage, subhepatic drain – 150ml hemorrhagic, usg abdomen lt. subphrenic collection with no significant internal echoes, rest of abdomen- minimal interbowel fluid, no pelvic collection

• Day 3- 4th: 2 PCV / day given, hb: 13% with no fall in hb on serial hemogram, patient developed hypertension and persistant tachycardia, cardiologist opinion taken and amlodipine started.

• Day 5th : patient had HR: 120/min, BP: 130/90, no fever, RR: 28/min, SpO2: 98% with 2 liter oxygen, stool passed – started clear liquid orally. Rt. PTBD not draining, lt. BD- 200ml bile, subhepatic drain -25ml altered blood. Review usg not showed significant collection. Patient shifted to room

• Day 6-10th: – Patient developed gradual abdominal distension with

b/s present, passing flatus, no fever– RT insertion , no significant output, x ray abdomen

showed gas filled large bowel loops, no significant small bowel dilatation.

– P: 110/min, BP : 120/80 (no antihypertensive), u/o 100ml/ hr with CVP ~ 6cm , no fever, on room air sPO2- 98%, patient mobile on partial parenteral nutrition (celemin and dextrose 25%) , hypokalemia corrected with k+ infusion.

• Patient reviewed by medical gastroenterologist dr. umang rathi, evaluated by procalcitonin – 0.5, TSH: 1.3 ( WNL) and planed for conservative management.

• Bilirubin level fall from 10 (preop) to 6 on day 4th then rise to 11 with SAP: 251 , sgpt :44.

• Evaluated by PTC on day 7 th :

PTC –day 7th

• Day 10-15th:– CECT abd; showed no anastomotic leak, no bowel

obstruction, collection ~ 50ml anterior to HJ loop and 20ml posteriorly with drain in situ. Small collection in lt. paracolic and interbowel.

– Usg guided infracolic free fluid – old hemorrhagic – (250ml) aspirated, c/s – sterile.

– Subhepatic collection drained by opening lateral part of wound

• Patient started liquids orally and tolerating ~ 1.2 liter/ day.

• She developed fever (104) with chills on day 14th , TLC: 9800, bili: 12, sgpt: 112, SAP: 312

• Blood c/s – klebsiella pneumonia (ESBL strain)• CVP removed• Started on Imipenem-cilastatin according to c/s

report.• RT. PTBD withdrawn above anastomosis draining

30ml/ day bile, s.bili: 9.0

• Subhepatic drain – 25ml/ day – shortened and applied stoma bag.

• Lt. PTBD- 150ml/ day • S. albumin 2.2, given h. ablumin x 3 days• Ambulation done• Presently: no fever, P: 100-108/min,

BP:120/90, RR: 20-22/min, chest clear, p/a: soft , passing stool, minimal pedal edema

• Icterus ++, Hb: 10, tolerating oral feeds ~ 1500 kcal.

• Rt. PTBD: 50ml/ day, lt. PTBD: 100ml/day, subhepatic drain: 30ml /day. Usg abdomen: no significant residual collection, no cholengiolytic abscess or IHBRD.

• Patient improved over 2 weeks with parenteral and enteral nutrition .

• Discharged on oral diet with PTBD cathetar in situ.

• On Follow up patient’s LFT normalised, catheter removed

• Evaluation at 6 months with HIDA scan and usg abdomen, LFT showed normal study.