Multimodality Surgical, Endoscopic, Radiological, Interventi
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Dr. Pratyaksh Vaishnav
Multimodality Surgical, Endoscopic, Radiological, Interventional Radiological Rescue for a complicated case of Simple Laproscopic Cholecystectomy
Case History
A 39 year old man came with complains of pain abdomen (epigastric
region). History of multiple episodes of vomiting yellow colored for 4 days, and history of alcohol consumption on 9/12/2014.
The patient has history of chronic alcohol consumption.
O/E— Vital signs— Temp 98.6°F, Pulse : 92bpm, BP: 120/82, RR: 22cpm.
P/A– Right hypogastric tenderness, BS+
RS– B/L crepts with basal Wheeze.
CVS- Normal
U/s– Acute calculus cholecystitis
MRI— Mirrizi syndrome Type1

ERCP performed with needleknife papillotomy, but CBD cannulation failed.

Lap. Cholecystectomy was performed on same day(9/12/2014).

Post op., LFT altered.
USG— Abdomen on 11/12/14 shows no fluid collection in GB fossa or elsewhere in the abdomen, small right pleural effusion

MRI Abdomen and Pelvis , MRCP done on 12.12.2014 showed mild
prominence of the right and left hepatic ducts at the porta hepatis,
hepatic duct confluence appears intact. Upper CHD is visualized for about 1 to 1.5 cm in length.
Mid CBD– about 2 to2.5 cm is not visualized, lower CBD along with the cystic duct stump, small radio dense calculus measuring about 0.4 to 0.5 cm within the CBD, superior to cystic duct confluence, mild perihepatic free fluid extending into sub diaphragmatic space. Minimal fluid along the both paracolic gutter about 60 to 70 mL.

Complimentary CT ABD Pelvis done on the mild prominence on the right and left hepatic ducts and porta hepatis is seen. Hepatic duct confluence appears intact, upper CHD is visualized for about 1 to 1.5 cm in length,. Mid CBD - about 2 to 2.5 cm not visualized, lower CBD along with cystic duct stump, small radio dense calculus measuring 0.4 to 0.5 cm within the CBD, superior to superior to cystic duct confluence, mild perihepatic free fluid extending into sub diaphragmatic space. Minimal fluid along the both paracolic gutter about 60 to 70 mL.

HPE report showed gall bladder chronic cholecystitis.

In view of CBD stone/stricture repeat ERCP done on 12.12.2014— billiary sphincterotomy done, but CBD could not be cannulated.

Diagnosis:
Persistent leak from segment 4 duct and CHD stricture, and CBD calculus.

He underwent ROUX EN Y hepaticojejunostomy, with internal access loop under GA on 15.12.2014. Post operatively, patient shifted to ward. Sub hepatic drains were draining bilious fluid. Patient managed on
antibiotics, IV fluids and TPN.
Liver biopsy showed chronic hepatitis.
Patient discharged on 24.12.2014 with 2 subhepatic drain, hepatic duct stent and stoma bag.

ADMISSION 2
On 29.12.2014 the patient complained of intermittent fever associated with chills for 3 days, sudden onset and constant in nature, with no history of vomiting or giddiness.
O/E no pallor, icterus, cyanosis, clubbing, pedal edema
Temp-98.6°F
CVS –normal RS—normal P/A-Normal CNS-NAD
A drop in HB with melena was seen.
Pig tail catheter inserted under CT guidance
On endoscopy, clot was found at the site of anastomosis. Pt was shifted to MICU in view of tachychardia. Pt was hemodynamically unstable. Pt was transfused with multiple blood components.
After evaluation, pt underwent reexploratory surgery under GA on 3.01.2014. he continued to be hemodynamically unstable and was taken up for laparotomy + oversuturing for gastrojejunostomy
abcess loop on 4.01.2014 under GA. Pt stabilized and discharged.

ADMISSION 3
On 18.01.2015 pt came with complaints of fever, pain abdomen, vomiting, anorexia and generalized weakness.
O/E pallor+, icterus +
Temp 101°F; Pulse 92bpm; BP 120/80mmHg; RR 22cpm
P/A whole abdomen- tender, bowel sounds sluggish, stoma bag/drain tube draining bile
CVS normal RS normal CNS normal.
Massive upper GI bleed with hypotension was detected along with septicemia. There was drop in Hb levels
USG Abdomen showed pelvic fluid collection.
Angiography done, no bleeder detected. Pt was stabilized and
managed conventionally, with IV fluids, ionotrophs, blood and blood products and shifted to ward.
On 31.01.2015 Pt had another massive upper GI bleed in the ward. On CT Abdomen pseudo aneurysm seen at sight of drain tip from hepatic artery branch.
Interventional Radiology—Pseudo aneurysm was coiled.
Pt became hemodynamically stable, shifted to ward, tolerated nj feeds, liquids orally (small quantities) , ambulated and had bowel movements. NJ tube was removed on 9.02.2015 as he was
tolerating soft diet well. LFT showed ALT 66, AST 49 T.Bil 1.74 D.Bil 1.6 ALKPOS 179 GGT 127
Drain output was nil since 5 days and stoma bag output 50mL
Pt finally discharged on 10.02.2015.

Conclusion
This case shows the need for multimodality and multispecialty discipline requirement in every hospital.

It also shows that the simplestof surgeries may end in serious and unexpected complications, which may require the combined skill of surgeon, invasive gastroenterologist and invasive radiologist.

The case shows the need for the requirement of multiple repeat admissions to ensure final corrections of all complications.

Finally it showsx that patience, confidence, skill, appropriate investigations& interventions will show light at the end of a dark tunnel.
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