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 ¤ Introduction
 ¤ Case report
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UNUSUAL CASE
Year : 2015  |  Volume : 11  |  Issue : 2  |  Page : 163-164
 

Obstructive jaundice as a complication of a right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy


Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan

Date of Submission16-Aug-2014
Date of Acceptance25-Aug-2014
Date of Web Publication24-Mar-2015

Correspondence Address:
Ching-Yao Yang
Department of Surgery, National Taiwan University Hospital, No. 7, Chung-shan South Road Taipei 10002
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.144097

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 ¤ Abstract 

A hepatic artery pseudoaneurysm is a rare, but a potentially life-threatening complication after laparoscopic cholecystectomy (LC). Obstructive jaundice owing to a hepatic artery pseudoaneurysm after LC has never been reported. We report a patient with a hepatic artery pseudoaneurysm after LC who presented with tarry stools, bloody drainage and obstructive jaundice.


Keywords: Laparoscopic cholecystectomy, obstructive jaundice, complication, pseudoaneurysm


How to cite this article:
Hsiao CY, Kuo TC, Lai HS, Yang CY, Tien YW. Obstructive jaundice as a complication of a right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy. J Min Access Surg 2015;11:163-4

How to cite this URL:
Hsiao CY, Kuo TC, Lai HS, Yang CY, Tien YW. Obstructive jaundice as a complication of a right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy. J Min Access Surg [serial online] 2015 [cited 2019 Sep 23];11:163-4. Available from: http://www.journalofmas.com/text.asp?2015/11/2/163/144097



 ¤ Introduction Top


Laparoscopic cholecystectomy (LC) has the advantages of limited post-operative pain and shorter hospitalization compared with open cholecystectomy; however, LC has an increased risk of bile duct injury and vascular complications. [1] In a series involving 77,604 cases, the incidence of total vascular complications was 0.25%. [2] A hepatic artery pseudoaneurysm is a rare, but a potentially life-threatening vascular complication after LC. Common symptoms associated with hepatic artery pseudoaneurysms include haemobilia, gastrointestinal tract bleeding and abdominal pain. However, if a hepatic artery pseudoaneurysm had mass effect and compressed bile ducts, obstructive jaundice could be one of presenting symptoms. Early diagnosis and intervention before pseudoaneurysm rupture and massive bleeding occurs are of utmost important in the treatment of this rare, but life-threatening complication after LC.


 ¤ Case report Top


A 40-year-old man with poorly controlled diabetes had undergone LC 2 weeks ago for acute cholecystitis in another hospital. Because the port-site wound infection, debridement with delayed closure was performed 1 week post-operatively. The patient resumed normal oral intake, and was discharged with an intra-abdominal drainage tube. The patient presented to our hospital for evaluation of jaundice, abdominal pain and blood oozing from the drainage tube 2 weeks after LC. On admission, he was febrile (38.6 ° C) and icteric. The total bilirubin (9.3 mg/dL), alkaline phosphatase (510 U/L) and liver function tests (aspartate aminotransferase, 134 U/L; alanine aminotransferase, 87 U/L) were all increased. A contrast-enhanced computed tomography (CT) scan showed a haematoma within the gallbladder fossa, with a dilated intrahepatic duct (IHD) and common bile duct (CBD). A percutaneous transhepatic drainage tube was placed in the CBD through the left IHD. Two days after percutaneous transhepatic cholangiography and drainage (PTCD), abdominal magnetic resonance imaging (MRI) with magnetic resonance angiography (MRA) and magnetic resonance cholangiopancreatography (MRCP) disclosed a 3.3-cm pseudoaneurysm in the right hepatic artery, which caused compression of the upper portion of the CBD [Figure 1].
Figure 1: MRCP revealed compression of the upper portion of the CBD by the hepatic artery pseudoaneurysm

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The patient underwent transcatheter right hepatic arterial embolisation (TAE) with coils [Figure 2]. Based on a cholangiogram 5 days later, the biliary tree was shown to be patent with no anomalies. The fever subsided and the abdominal pain was relieved. The patient was discharged 11 days after embolisation. The total bilirubin and liver function tests returned to the normal range at the outpatient clinic follow-up evaluation.
Figure 2: Angiography confi rmed a right hepatic artery pseudoaneurysm, followed by transcatheter arterial embolisation (TAE) of the right hepatic artery with coils. (a) Before TAE. (b) After TAE

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 ¤ Discussion Top


The mortality rate associated with rupture of a hepatic artery pseudoaneurysm has been reported to be 21%. [3] The mechanisms underlying pseudoaneurysm formation include intra-operative direct burn and thermal injuries, post-operative bile leakage and infections. Patient may present early or late after the procedure. The most common presenting symptoms of hepatic artery pseudoaneurysm are haemobilia, gastrointestinal tract bleeding and abdominal pain, even though the patient may be asymptomatic. [4] Endoscopy is usually performed for identifying the source of gastrointestinal tract bleeding, but may be inconclusive in a patient with a hepatic artery pseudoaneurysm. In such a circumstance, a computed tomographic angiography (CTA) or MRA provides more diagnostic clues. Angiography is the investigation of choice because of the therapeutic potential. When a hepatic artery pseudoaneurysm is identified, endovascular embolisation is the preferred treatment modality because it is less invasive, the ease of access to the pseudoaneurysm and the increased occlusive selectivity. [5] Surgery may be indicated in patients who are haemodynamically unstable, with ruptured pseudoaneurysms and have failed endovascular treatment or in whom endovascular treatment is not available.

Our patient presented with fever, jaundice, right upper abdominal pain and bloody drainage. Jaundice may have represented the iatrogenic bile duct injury, which was later confirmed to be due to the mass effect of the hepatic artery pseudoaneurysm compressing the CBD. PTCD was performed prior to diagnosis of the pseudoaneurysm for relieving severe obstructive jaundice. The oozing from the drainage tube could have been confused with post-operative oozing from the liver surface or cystic stump. Endoscopy was not performed in our patient because there were no symptoms of gastrointestinal tract bleeding. Contrast-enhanced CT was arranged to investigate the aetiologies of abdominal pain, and cholangiography was performed to investigate the aetiologies of obstructive jaundice. We performed embolisation, not specifically of the pseudoaneurysm, but of the right hepatic artery because of the large size of the pseudoaneurysm and concern of rupture during embolisation.

A hepatic artery pseudoaneurysm after LC is a rare, but potentially life-threatening complication. This case illustrates the diversity of the clinical presentations of hepatic artery pseudoaneurysms which may be misleading during the diagnostic process. When a pseudoaneurysm is suspected, angiography provides confirmation of the diagnosis as well as effective treatment. Early diagnosis of hepatic artery pseudoaneurysm and intervention to prevent the risk of rupture requires a high index of suspicion, which can lead to a favourable prognosis.

 
 ¤ References Top

1.
The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1073-8.  Back to cited text no. 1
[PUBMED]    
2.
Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: A national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 1993;165:9-14.   Back to cited text no. 2
    
3.
Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am 1997;77:425-42.  Back to cited text no. 3
    
4.
Tessier DJ, Fowl RJ, Stone WM, McKusick MA, Abbas MA, Sarr MG, et al. Iatrogenic hepatic artery pseudoaneurysms: An uncommon complication after hepatic, biliary, and pancreatic procedures. Ann Vasc Surg 2003;17: 663-9.  Back to cited text no. 4
    
5.
Rivitz SM, Waltman AC, Kelsey PB. Embolization of an hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 1996;19:43-6.  Back to cited text no. 5
    


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