Late Hemorrhage Following Laparoscopic Cholecystectomy.

Background: Excruciating generalized abdominal pain with features suggestive of shock, at the end of the first or early second week after laparoscopic cholecystectomy (LC), is a frightening and formidable diagnostic predicament. This is because the early known complications like biliary leak or vascular injuries are unlikely diagnoses. Hemoperitoneum, is not usually considered, but instead more common occurrences like acute pancreatitis, choledocholithiasis, and sepsis are suspected. A delay in diagnosis and subsequent management of hemoperitoneum could have disastrous consequences. Case Studies: Two patients presented with hemoperitoneum, in the second week after laparoscopic cholecystectomy. The first was because of a leak from a pseudoaneurysm of the right hepatic artery and the other was a bleed from a subcapsular liver hemangioma as a part of Osler Weber Rendu syndrome. Initially, a clinical assessment in both the patients was diagnostically inconclusive. Ultimately the diagnosis could be made, based on computed tomography angiography and visceral angiography. In the second patient, a positive family history and genetic testing were helpful. The first patient was successfully managed by intravascular embolization, while the second patient was successfully managed conservatively with intraperitoneal drains and conservative management of comorbidities. Conclusions: The presentation is to generate awareness that hemorrhage could be a presentation, in the early second week, after LC. A common cause to be considered is a pseudo aneurysmal bleed. Secondary hemorrhage and other rare coincidental unassociated conditions could also be responsible for the hemorrhage. A high index of suspicion, and early and timely management are keys to a successful outcome.

An Unusual Fatal Outcome of Laparoscopic Cholecystectomy: A Case Report.

Clostridium perfringens (C. perfringens) and Klebsiella oxytoca (K. oxytoca) are pathogenic human bacteria. Clostridium perfringens sepsis with intravascular hemolysis is a catastrophic process with an extremely high mortality rate (70 to 100%). A 74-year-old male submitted to an elective laparoscopic cholecystectomy due to cholelithiasis and develops severe abdominal pain only 10 hours after being discharged from hospital. He was admitted to the emergency department with associated jaundice, fever, and hematuria. On arrival, his hemoglobin level was 9.2 g/dL but fell to 3.4g/dL within two hours. Massive intravascular hemolysis was diagnosed and a liver abscess with gas gangrene was shown in the contrast-enhanced computed tomographic. Despite proper management, a fatal outcome was unavoidable and the patient died eight ours later. Microbiological examination isolated C. perfringens and K. oxytoca. Liver abscesses caused by C. perfringens and K. oxytoca are extremely rare complications of laparoscopic cholecystectomy. Early recognition and prompt antibiotic therapy as well as control of septic focus are essential to minimize this fatal outcome.

Post-cholecystectomy Hepatic Artery Pseudoaneurysm Rupture.

Pseudoaneurysm of the hepatic and/or less frequently the cystic artery is a rare but potentially fatal complication following laparoscopic cholecystectomy. While the procedure is safe with minimal morbidity, complications do occur even in experienced hands. Moreover, patient selection is of utmost importance. These aneurysms usually present with hemobilia a few weeks after surgery; however, free rupture into the peritoneal cavity can occur. Transarterial embolization is the initial management approach when available and feasible. We present a case of a ruptured hepatic pseudoaneurysm three weeks after laparoscopic conversion to open cholecystectomy. The aim is to shed light on this rare but potentially fatal complication.

Idiopathic Benign Impulsive Bilomas.

"Biloma" is a collection of bile outside of the biliary tree that could occur postoperatively in patients who undergo laparoscopic cholecystectomy or in patients with blunt trauma to the liver. Spontaneous or impulsive bilomas with no identifiable cause occur rarely. We report a case of a 60-year-old woman with no history of hepatobiliary surgery or trauma, who was admitted for right upper quadrant pain. An abdominal examination revealed tenderness in the right upper quadrant (RUQ). Her alkaline phosphatase level was 2,343 IU/L. Computed tomography of the abdomen and pelvis with contrast showed perihepatic, periduodenal, and right paracolic gutter ascites. The image-guided aspiration of the peritoneal cavity yielded greenish fluid that was determined to be bile. The cytological studies were negative for malignancy and microorganisms. The ultrasound images of the RUQ were negative for cholecystitis and gallstones, and the results of the hepatobiliary nuclear scan study (HIDA) were unremarkable. Magnetic resonance cholangiopancreatography (MRCP) revealed an intact intrahepatic and extrahepatic biliary tree and confirmed the presence of multiple lakes of bile ascites. During the entire hospital stay, the patient remained stable without any unifying diagnosis and she was discharged with a pigtail catheter. A follow-up abdominal CT scan revealed a complete resolution of the bilomas. We consider this as a spontaneous extra- and intrahepatic biloma of unknown etiology and should be in our differentials when a patient presents with right upper quadrant abdominal pain.

A Review of the Management of Bile Leaks.

Bile leaks can be a complication of abdominal surgeries, specifically trauma to the biliary system during laparoscopic cholecystectomy, and can occur from a variety of sources, commonly a bile duct injury (BDI). Their management involves a multidisciplinary approach and depends on a multitude of factors. This consequence has also led to increased health care costs and morbidity and mortality for patients. Currently, there are no professional society-initiated guidelines that provide surgeons with a clear algorithm for managing bile leaks, as there are for other operative approaches and management in various surgical diseases. Thus, a literature search was performed that surveyed current research on the effective prevention and management of the different types of bile leaks. This review aims to provide all clinicians with an overview of factors to consider in the management of bile leaks and supports referral to a tertiary center with a hepatobiliary specialist.