Uncommon Complication of a Biliary Leak After Adjustable Gastric Band Removal: A Case Report.

In the context of adjustable gastric band (AGB) placements and the prevalent issue of weight regain with associated complications, revision surgery for gastric bands becomes imperative. Such revisions may encompass band removal or conversion to bariatric procedures, often accompanied by an escalated risk profile, potentially contributing to a 20% morbidity rate. Laparoscopic sleeve gastrectomy (LSG) has gained prominence due to its technical simplicity, effectiveness in weight loss, and lower complication rates. Specific cases involving LSG post-AGB complications are associated with staple line disruptions and leaks. This case report describes a rare complication in a 59-year-old patient following AGB removal and subsequent laparoscopic sleeve gastrectomy. The complication emerged six hours after the surgery, with approximately 400 cc of bile material reported in the drainage. A laparoscopic reintervention was conducted, revealing bile leakage from the second Couinaud hepatic segment. Successful management of the leakage was achieved through simple hepatic suturing using non-absorbable monofilament. Within 24 hours, no further leakage occurred, and the patient was discharged without additional complications. Our case also demonstrates how complex it can be to switch between different medical procedures, and it emphasizes the need for careful planning and precise surgery in the evolving world of bariatric medicine. It is worth noting that there is a dearth of literature addressing this specific complication. Consequently, this study has the potential to provide valuable insights for surgeons who may encounter a similar scenario in their clinical practice.

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.

Spontaneous Bile Leak in a Patient Without Recent Abdominal Surgery or Trauma.

Bile leaks are a rare occurrence most often seen as a complication of cholecystectomy. Other less common etiologies include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), liver surgery, percutaneous drainage of liver abscesses, living donor hepatectomy, and non-iatrogenic abdominal trauma. In this case study, we present a 67-year-old female with morbid obesity who presented with abdominal pain and was diagnosed with a spontaneous bile leak. She had no history of recent surgery or abdominal trauma. CT revealed that the patient's gallbladder was located in the right lower quadrant, most likely due to mass effect from a large ventral hernia, and possible fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe. Hepatobiliary iminodiacetic acid (HIDA) was performed due to a concern for cholecystitis. HIDA demonstrated a bile leak in the right upper abdomen of unknown etiology. Initially, there was a concern for gallbladder obstruction. Gastroenterology recommended magnetic resonance cholangiopancreatography (MRCP), however, MRCP was not possible due to the patient's body habitus. The patient had normal liver function tests, was tolerating oral intake, and her abdominal pain resolved, therefore, we became less suspicious of gallbladder obstruction. This case suggests that bile leak should be included in the differential diagnosis for abdominal pain even in patients who have not had recent abdominal surgery or procedures. This case also highlights the unique anatomical finding of a right lower quadrant gallbladder secondary to mass effect from a large ventral hernia.

Biloma: A Rare Manifestation of Spontaneous Bile Leak.

A biloma is an intrahepatic or extrahepatic encapsulated collection of bile outside of the biliary tree and within the abdominal cavity. Hepatobiliary interventions and laparoscopic cholecystectomy are the most common etiologies of biloma followed by abdominal trauma, choledocholithiasis, and biliary dilation secondary to biliary stricture. We report a case of a 91-year-old female who presented to the emergency room with an acute onset of epigastric and right upper quadrant sharp pain for one day that radiated to the back, and was associated with two to three episodes of vomiting. Initial abdominal imaging including CT scan, ultrasound and magnetic resonance cholangiopancreatography (MRCP) of the abdomen and pelvis revealed a distended gallbladder with wall thickening, but without evidence of pancreatitis or gallstones. Hepatobiliary iminodiacetic acid (HIDA) scan findings were consistent with extrahepatic biliary leakage into the peritoneum. A cholangiogram demonstrated a perihepatic biloma. A combined approach using fluoroscopic-guided biloma drainage and endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary stent placement across the site of the biliary leak resulted in the complete resolution of symptoms. Biloma should be included in the differential diagnosis of right upper quadrant abdominal pain. A high index of clinical suspicion is required for early diagnosis and treatment.

Bilioescroto secundario a bilioma retroperitoneal como presentación extremadamente rara de fuga biliar espontánea / Biliscrotum secondary to retroperitoneal biloma, as an extremely rare presentation of spontaneous bile leak

Objetivo. Presentar el segundo caso descrito en la bibliografía de bilioescroto secundario a bilioma retroperitoneal espontáneo y mostrar a su vez de manera escalonada el tratamiento que se le suministró hasta la resolución completa del cuadro. Caso clínico: Varón de 69 años que debutó con dolor escrotal derecho en relación con bilioescroto secundario a bilioma retroperitoneal espontáneo. Discusión: El bilioma retroperitoneal es un hecho poco habitual; generalmente se debe a complicaciones quirúrgicas o de procedimientos invasivos (intervencionismo radiológico, CPRE y esfinterotomía endoscópica), aunque puede ser consecuencia de roturas espontáneas de la vesícula o la vía biliar principal. La bilis en el retroperitoneo puede discurrir hasta el escroto, originando la rara entidad conocida como bilioescroto. Generalmente se presenta simulando una hernia inguinal incarcerada. No existe un manejo estandarizado de esta patología ya que está escasamente descrita.

Objective: To present the second case described in the literature of biliscrotum secondary to spontaneous retroperitoneal biloma and show a sequential treatment that we provided until complete resolution. Clinical case: We report the case of a man 69 years old, who debuted with right scrotal pain related to biliscrotum secondary to spontaneous retroperitoneal biloma. Discussion: The retroperitoneal biloma is a rare event, usually due to surgical or invasive procedures complications (radiological interventionism, ERCP and endoscopic sphincterotomy), although it may be the result of spontaneous rupture of the gallbladder or bile duct. Bile in the retroperitoneum may extend into the scrotum, causing the rare condition known as biliscrotum. Usually it occurs simulating an incarcerated inguinal hernia. Does not exist a standardized management of this condition because is poorly described.