Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation

A previously healthy 37-year old man was transferred to our service with high volume bilious drainage immediately following an elective LC for gallstone pancreatitis. An endoscopic retrograde cholangiopancreatography (ERCP) showed no flow above the mid common bile duct (CBD). Laparotomy found that the CBD was divided at the level of the cystic duct with segmental resection of the common hepatic duct involving the confluence of the hepatic ducts with separation of the right and left hepatic ducts (Strasberg-Bismuth E4 injury). A bile duct reconstruction was performed, bringing together the separated adjacent walls of the right and left hepatic ducts together and suturing them to form a common wall. The bilio-enteric anastomoses were then performed over separate externalised stents via a modified Terblanche Roux-en-Y limb [7]. The anastomoses on subsequent imaging gave the appearance of a preserved confluence, because of the sutured common adjoining walls of the right and left separated ducts. There was an uneventful recovery and he was discharged 10 days post-operatively with the biliary stents in situ.

One week after discharge, the patient experienced a gastrointestinal bleed and presented with melaena to a nearby hospital. He was found to have a haemoglobin level of 90 g/L (Reference range: 130 – 180 g/L) and was transfused with two units of packed red blood cells. He underwent a gastroscopy and colonoscopy to investigate this. No obvious cause for his bleeding was found, and one colonic pedunculated polyp was removed. His bleeding settled and he was discharged three days after admission. Our unit was not notified of this admission.

Two days following this discharge, the patient had an episode of haematochezia associated with collapse at home. He was taken to the emergency department of our hospital where he was hypotensive (blood pressure 92/63 mmHg) and tachycardic (heart rate 115 beats/min). His abdomen was soft and non-tender, and digital rectal examination revealed dark red blood. His haemoglobin level was 111 g/L. He was initially resuscitated with crystalloids, but had further episodes of fresh rectal bleeding. Repeat haemoglobin was 58 g/L, and packed red blood cell transfusion was commenced. Urgent selective computed tomography angiography was performed revealing a 2 × 2 centimetre aneurysm arising from the RHA/cystic artery adjacent to surgical clips. The aneurysm was embolised with platinum and stainless steel radiological coils (Figure 1, Figure 2). A tubogram through the biliary stents after the procedure showed no evidence of leakage or stricture of the biliary anastomoses. He had no further bleeding and was discharged three days later. Four weeks later, the stents were removed in the outpatient rooms.

Two months later the patient developed intermittent fevers, rigors, jaundice and right upper quadrant pain. His liver function tests revealed a cholestatic picture with an elevated bilirubin of 59 μmol/L (Reference range: 0 – 17 μmol/L), ALP 473 U/L (Reference range: 30 – 115 U/L) and GGT 721 U/L (Reference range: < 66 U/L).

A magnetic resonance cholangiopancreatography (MRCP) was performed, showing slight prominence of the intrahepatic biliary radicles above the level of the right and left main hepatic ducts, with preservation of the contour of the biliary ducts without evidence of irregularity or stenosis. A hepatobiliary iminodiacetic acid (HIDA) scan to assess biliary excretion showed mild retention of tracer in left hepatic lobe inferiorly in pre- and post-cholecystokinin images but no evidence to suggest biliary stenosis. It also suggested poor emptying from the Roux loop and it was felt that associated bacterial overgrowth within the Roux loop may have been responsible for his symptoms and he was kept on low dose oral antibiotics with improvement of his liver function tests at six weeks (bilirubin 9 U/L, ALP 361 U/L and GGT 504). Progress MRCP two months later revealed increasing intrahepatic biliary dilatation with the left main hepatic duct increasing in diameter from 6.6 mm on the previous MRCP to 9.8 mm, suggesting a significant bilio-enteric anastomotic stricture.

Thus, approximately 10 months after his BD reconstruction, he was admitted electively for percutaneous transhepatic cholangiography (PTC) and balloon dilatation of this bilio-enteric anastomosis. After confirmation of the stricture by PTC, a 4 French catheter was inserted into his left ductal system and an 8.5 French pigtail catheter was placed into his right ductal system but neither could be advanced into the enteric limb (Figure 3). Two further attempts were made at PTC balloon dilatation, but both failed. It was decided to attempt to visualise the anastomosis through the Terblanche access limb. Choledochoscopy through the modified Terblanche access limb showed multiple radiological coils from the previous embolisation of the RHA pseudoaneurysm at the site of the anastomoses, causing a mechanical obstruction (Figure 4, Figure 5). Laparotomy was performed and the bilio-enteric anastomoses were taken down to remove the coils. The right and left ductal systems were evaluated with intraoperative cholangiogram and the bilio-enteric anastomoses were revised using the existing Roux limb around 10 French infant feeding catheters, which were externalised again through the modified Terblanche limb.

Post-operative recovery was uneventful. A cholangiography through the catheters showed good drainage of contrast through the bilio-enteric anastomoses. The patient was discharged 10 days after his operation, with total resolution of his jaundice and improvement in eating, drinking and general daily function. The stents were removed at six weeks and six years later the patient remained well with normal liver function tests and no further episodes of cholangitis.

Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.