|Discussion in 'All Categories' started by Dr Ehsan - Jan 18th, 2014 7:55 pm.|
This is regarding a case I operated on Wednesday evening.
The patient is a 38y/F, case of recurrent calculous cholecystitis with CBD stones and underwent ERCP and stone removal and CBD stenting abroad in Nov 2011 (as it is not available in our country Maldives).
She came back without a cholecystectomy and presented to our ER with acute cholecystitis. She was managed conservatively and advised surgery after 6 weeks. However she presented again with cholecystitis after about 4 weeks. She was managed conservatively for another 3 weeks before we took her up for surgery. The surgery was difficult as the Calot's triangle was not visualized properly due to fibrosis. During dissection a small cavity like area opened in the area where I believed was the cystic duct although there was NO bile or any fluid coming from the area. I managed to make a window closer to the GB than the opening and due to increased thickness applied 3 extracorporeal Meltzer's and cut leaving 2 sutures on the stump. I approximated the opening I mentioned above with a single suture 2-0 Vicryl. I left a 12 size Romovac Drain in the Morrison's pouch.
The GB was thickened with more than 20 4-6mm faceted stones. There was only one opening at the cut end of the GB. Today is the 2nd day after surgery and she developed vomiting and diffused abdominal tenderness. There was about 15 ml of bilious drainage this morning. I changed the negative pressure to free drainage by removing the suction bottle and connecting a urobag. Now the bag has collected about 150ml straw to yellow colored fluid over 8 hours (not pure bile and more like serous).
Vitally patient is stable. Counts at 15lacs and neutrophilia 90%. Total bilirubin is at 2.2. Alkaline phosphatase is marginally elevated. I sent the fluid for biochemistry but will receive the reports by 21st Jan. In the meanwhile what do you suggest I do?
I think the area I injured (and later sutured) was the cystic duct, closer to the CBD than my ligatures. If it is a bile leak how do I proceed? And how long should I wait before I do a laparoscopy to evaluate? We don't have ERCP or MRCP. Else it would have given us some information.
Thanking you and hoping to receive a reply soon.
Best wishes to Dr. Mishra, Dr. Chauhan and the team.
re: Bile leak by Dr J S Chowhan - Jan 18th, 2014 8:10 pm
Dr J S Chowhan
|I have discussed your case with Dr Mishra at it is probable case of CBD injury. Do you have the video of surgery then you can upload it to see by our surgeon. In our opinion MRCP is essential, so you should refer the patient to a centre where MRCP and ERCP is possible.
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