Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy.

PURPOSE: The effectiveness of angiography and embolization in diagnosis and treatment were assessed in a cohort of patients presenting with upper gastrointestinal hemorrhage secondary to hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. METHODS: Over a 6-year period 1513 laparoscopic cholecystectomies were carried out in our region. Nine of these patients (0.6%) developed significant upper gastrointestinal bleeding, 5-43 days after surgery. All underwent emergency celiac and selective right hepatic artery angiography. All were treated by coil embolization of the right hepatic artery proximal and distal to the bleeding point. RESULTS: Pseudoaneurysms of the hepatic artery adjacent to cholecystectomy clips were demonstrated in all nine patients at selective right hepatic angiography. In three patients celiac axis angiography alone failed to demonstrate the pseudoaneurysm. Embolization controlled hemorrhage in all patients with no further bleeding and no further intervention. One patient developed a candidal liver abscess in the post-procedure period. All patients are alive and well at follow-up. CONCLUSION: Selective right hepatic angiography is vital in the diagnosis of upper gastrointestinal hemorrhage following laparoscopic cholecystectomy. Embolization offers the advantage of minimally invasive treatment in unstable patients, does not disrupt recent biliary reconstruction, allows distal as well as proximal control of the hepatic artery, and is an effective treatment for this potentially life-threatening complication.

Palliation of malignant oesophageal perforation and proximal oesophageal malignant dysphagia with covered metal stents.

Twelve patients underwent placement of nine polyethylene-covered self-expanding metal stents (Cook), and three polyurethane-covered Wallstents (Schneider). All obstructing lesions were crossed fluoroscopically and stents placed under fluoroscopic control. Eleven of the 12 patients had recently undergone failed endoscopic stent insertion, which had resulted in oesophageal perforation. Technical success was achieved in 100% of patients, with no immediate complications. The stents were well tolerated and allowed the patients to eat within 12 h of their insertion. Covered stents are technically safe to insert, are best inserted fluoroscopically, and are particularly cost-effective in proximal oesophageal lesions and perforations, where Atkinson tubes are often not tolerated.