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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
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208
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Fig. 38.3 PTC showing
stenosis hepaticojejunostomy
M.A. Cuesta and C.J.J. Mulder
Fig. 38.4 ( a ) contrast X-ray
stenosis common hepatic
duct, ( b ) PTC balloon
dilatation
a
38 Case on Late Stenosis of Biliodigestive Anastomosis with Cholangitis
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209
Fig. 38.4 (continued)
b
Discussion
Roux-en-Y biliodigestive anastomosis is the most common method to treat surgically the consequences of Bile Duct Injuries (BDI) (see Chaps. 30 – 32 ) [ 1 , 2 ]. In the
case of stenosis of the anastomosis with jaundice or cholangitis, the patency of the
anastomosis must be restored. The problem of this complication is the diffi culty to
reach the anastomosis by gastric route. Therefore, the percutaneous and more
recently the use of Double Balloon Endoscopy (DBE) routes are important to solve
the stricture. The fi rst choice for treatment will be the percutaneous dilatation [ 3 , 4 ].
Nevertheless this treatment has a 27 % of restenosis in 30 months of follow-up.
Creation of transgastric or jejunal routes to intervene repeatedly the anastomosis is
also a procedure that will help the access [ 5 ]. Another nonsurgical alternative is the
use of DBE to reach the anastomosis and proceed to dilate and stent the anastomosis
[ 4 ]. If these procedures are not successful, redo surgery will be performed. Stenosis
is known to relapse frequently after the creation of a new anastomosis.
References
1. Booij KAC, Gouma DJ, van Gulik TM, Busch ORC. Prevention and treatment of major com-
plications after cholecystectomy. In: Cuesta MA, Bonjer HJ, editors. Treatment of complica-
tions after digestive surgery, chapter 12. London: Springer; 2013.
2. Costamagna G, Shah SK, Tringali A. Current management of postoperative complications and
benign biliary strictures. Gastrointest Endosc Clin N Am. 2003;13:635–48.
3. Vos PM, van Beek EJ, Smits NJ, et al. Percutaneous balloon dilatation for benign hepaticojeju-
nostomy strictures. Abdom Imaging. 2000;25:134–8.
4. Parlak E, Cicek B, Disibeyaz S, et al. Endoscopic retrograde cholangiography by DBE in
patients with Roux-en-Y hepaticojejunostomy. Surg Endosc. 2010;24:466–70.
5. Parlak E, Disibeyaz S, Oztas E, et al. Endoscopic treatment of biliary disorders in patients with
Roux-en-Y hepaticojejunostomy via a permanent access loop. Endoscopy. 2011;43:73–6.
Chapter 39
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Case on Complication After Surgical
Treatment of a Klatskin Tumor
Oliver R.C. Busch and Miguel A. Cuesta
Keywords Klatskin tumor • Cholangiocarcinoma • Liver resection • Bile leakage •
Hemihepatectomy • Cholangitis
First Patient
Diagnosis and Indication for Surgery
A 61-year-old male patient presented with jaundice which was caused by a hilar
cholangiocarcinoma. Preoperative staging revealed a Bismuth–Corlette classifi cation type III a (Illustration 39.1a ), and biliary drainage was achieved by percutane-
ous transhepatic cholangiography (PTC) catheter for both left and right hemiliver.
After diagnostic laparoscopy and neoadjuvant short course radiotherapy a liver
resection was performed.
Operation
During surgical exploration, no distant metastases were encountered and a central
liver resection, including segments I, IV, V, and VIII was performed with a hepaticojejunostomy for drainage of the segmental bile duct of segment II/III and VI/VII
O. R.C. Busch , M.D., Ph.D. ()
Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
e-mail: o.r.busch@amc.uva.nl
M. A. Cuesta, M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_39,
© Springer International Publishing Switzerland 2014
211
212
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a
O.R.C. Busch and M.A. Cuesta
VIII
VII
V
VI
IV a
I
IV b
L Bismuth–Corlette
R
type lll a
II
III
b
Illustration 39.1 ( a ) Corlette–Bismuth tumor type III a. ( b , c ) Resection of the Klatskin tumor
Bismuth–Corlette type III a in the fi rst patient with the leakage of the right hepaticojejunostomy,
being fi xed and drained
39 Case on Complication After Surgical Treatment of a Klatskin Tumor
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c
Leakage
right anastomosis
213
Illustration 39.1 (continued)
(Illustration 39.1b ). The PTC catheter in the segmental duct II/III was placed across
the left hepaticojejunostomy.
Postoperative Course: Identifi cation and Treatment
of the Complication
Three days after operation, the clinical condition of the patient deteriorated resulting in a septic shock requiring resuscitation on the intensive care unit. CT of the
abdomen (Fig. 39.1 ) showed a partial infarction of the right hemiliver with normal
arterial and portal blood fl ow. Furthermore, fl uid and air were visualized in the
resection cavity. Based upon these fi ndings and the clinical condition, a relaparotomy was mandatory. During surgical exploration a leakage was found of the right
hepaticojejunostomy which was sutured across a silastic catheter. After 2 days,
patient returned to the general ward. Twelve days after initial operation, the abdominal catheter produced 300 ml a day. Visualization of the different bile duct catheters
revealed no leakage of the hepaticojejunostomy (Fig.
39.2 ) but still some bile
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Fig. 39.1 CT showed partial
infarction of the right
hemiliver and fl uid and air in
the resection cavity
Fig. 39.2 PTC demonstrated
suffi cient
hepaticojejunostomy of the
segmental bile ducts VI and
VII
O.R.C. Busch and M.A. Cuesta
leakage from the remnants of segment IV and VIII into the resection cavity was
seen (Fig. 39.3 ). Therefore, a new PTC catheter was placed to decompress this seg-
mental bile duct (Illustration 39.1c ). Twenty-one days after resection the patient was
discharged from hospital and several drains were removed 3 months after operation.
Histological examination revealed a complete resection of a cholangiocarcinoma
without lymph node metastases.
39 Case on Complication After Surgical Treatment of a Klatskin Tumor
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Fig. 39.3 PTC showed
dilatation of the bile ducts of
remnants of segment IV and
VIII leakage into the
resection cavity
Fig. 39.4 MRCP showing
mass Klatskin tumor with
dilatation left system
215
Second Patient
Diagnosis and Indication for Operation
A 58-year-old metal worker was diagnosed having a mass forming Klatskin tumor
found during study because of silent obstructive jaundice and 10 kg weight loss. His
bilirubin was 275 mmol/l and he was treated initially by a PTC drain. A MRCP was
done showing a tumor of 4 cm at the hepatic bifurcation with dilatation of the left
system (Fig. 39.4 ). Dissemination study showed no distance metastases and he was
proposed to undergo a laparotomy.
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O.R.C. Busch and M.A. Cuesta
Operation
During operation a tumor of 4 cm located on the left hepatic duct was dissected and
an extended left hemihepatectomy was performed (segments 1–5 and 8), with anastomosis of the posterior branch to the common hepatic duct.
a
b
Fig. 39.5 ( a ) CT scan
revealing subfrenic and
paracolic abscess. ( b )
Abscess drained
39 Case on Complication After Surgical Treatment of a Klatskin Tumor
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217
Pathology
Mass forming cholangiocarcinoma, 6 cm, radical resected, with important perineural and intraneural growth. Obstructive cholangitis.
Postoperative Course: Identifi cation and Treatment of the
Complication
From the beginning bile leakage was seen in the drain. Patient was doing well and
conservative treatment was established. In the fi fth day he developed fever and
shivering. Under diagnosis of acute cholangitis or intra-abdominal abscess, a CT
scan revealed an abscess on the hepatic surface and paracolic space right (Fig. 39.5a ).
A percutaneous drainage was performed (Fig. 39.5b ) An ERCP with stenting was
done without decreasing the bile production. Situation became stable, but one week
later patient developed again high fever and abdominal pain. Patient was admitted
to the Medium Care ward and a new CT scan revealed a new abscess, being percutaneously drained. Drain produced 600-800 per day but stools color was normal.
Patient was well and stable and went home with the drain. After two weeks, production decreased progressively and the drain could be retired.
Chapter 40
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Case on Postoperative Bleeding
After Whipple Procedure
Miguel A. Cuesta and Suzanne S. Gisbertz
Keywords Whipple procedure • Peutz Jegher syndrome • Intraabdominal bleeding
First Patient
Postoperative Intraluminal Bleeding Diagnosis
and Indication for Surgery
A 40-year-old male patient was sent to the emergency department because of
obstructive jaundice and abdominal pain. The US and CT scan with double contrast
revealed a possible stone in the papilla of Vater with intrahepatic biliary duct dilatation (Fig. 40.1 ); consequently, an ERCP was proposed. On the ERCP, a polyp mass
was found at duodenum, and a stent was introduced through papilla for bile drainage (Fig. 40.2 ). Biopsies were taken. Moreover, multiple small polyps were seen in
the stomach. The possibility of a familial polyposis coli was considered but not
confi rmed by family history. Post ERCP, the patient developed progressive abdominal pain in the whole abdomen with signs of intestinal obstruction. On the CT scan,
an invagination of a big polyp in the small bowel was seen and the patient was operated on. On operation, multiple polyps were palpated in the small bowel and colon.
The invaginated part of ileum was resected and a primary side-to-side anastomosis
was done. Diagnosis was established as Peutz Jegher syndrome.
M. A. Cuesta , M.D. ()
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
S. S. Gisbertz , M.D.
Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
e-mail: s.gisbertz@antoniusziekenhuis.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_40,
© Springer International Publishing Switzerland 2014
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