Raptured gas forming pyogenic liver abscess with a biliary fistula in Botswana: a case report.

We report a case of gas-forming pyogenic liver abscess (GFPLA) with a ruptured abscess and biliary fistula presenting with peritonitis. The patient had poorly controlled diabetes mellitus and was extremely ill at presentation. The diagnosis was delayed until the abscess ruptured, owing to nonspecific abdominal symptoms at the initial presentation and delayed follow-up radiological investigations. The patient had a high-output biliary fistula post-operatively, which was managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting with fistula drainage reduction within four weeks. This case highlights the need for follow-up radiological investigations and prompt intervention in patients with diabetes mellitus presenting with fever and vague abdominal pain.

Special presentation of bronchobiliary fistula after transcatheter arterial chemoembolization: A case report.

RATIONALE: Transcatheter arterial chemoembolization (TACE) is a widely adopted treatment for advanced stage hepatocellular carcinoma (HCC). Nevertheless, several complications may occur, such as hepatic artery injury, nontarget embolization, pulmonary embolism, hepatic abscess, biloma, biliary strictures, and hepatic failure. However, bronchobiliary fistula is rarely mentioned before. PATIENT CONCERNS: A 65-year-old man with HCC underwent the TACE procedure, and then he encountered fever, dyspnea, abdominal pain, and abundant yellowish purulent bronchorrhea. DIAGNOSIS: Bronchobiliary fistula was diagnosed based on the computed tomography (CT) scan of his chest, which revealed the right lower lobe of his lung was connected to a hepatic cystic lesion. INTERVENTIONS: Percutaneous transhepatic cystic drainage was performed, and we obtained yellowish bile, showing the same characteristics as the patient's bronchorrhea. OUTCOMES: We kept drainage of his biloma and provided supportive care as the patient wished. Unfortunately, the patient passed away due to progressive right lower lobe pneumonia 2 weeks later. LESSONS: This case exhibits a typical CT scan image that was helpful for the diagnosis of post-TACE bronchobiliary fistula. Post-TACE bronchobiliary fistula formation hypothesis includes biliary tree injuries with subsequent biloma formation and diaphragmatic injuries. Moreover, the treatment of bronchobiliary fistula should be prompt to cease pneumonia progression. Therefore, we introduce this rare complication of post-TACE bronchobiliary fistula in hopes that future clinicians will keep earlier intervention in mind.

Application of Damage Control Tactics and Transpapillary Biliary Decompression for Organ-Preserving Surgical Management of Liver Injury in Combat Patient.

The combat penetrating gunshot injury is frequently associated with damage to the liver. Bile leak and external biliary fistula (EBF) are common complications. Biliary decompression is commonly applied for the management of EBF. Also, little is known about the features of combat trauma and its management in ongoing hybrid warfare in East Ukraine. A 23-year-old male was diagnosed with thoracoabdominal penetrating gunshot wound (GSW) by a high-energy multiple metal projectile. Damage control tactics were applied at all four levels of military medical care. Biliary decompression was achieved by endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and the placement of biliary stents. Occlusion of the stent was treated by stent replacement, and scheduled ERCP was performed. Partial EBF was diagnosed from the main wound defect of the liver and closed without surgical interventions on the 34th day after the injury. A combination of operative and nonoperative techniques for the management of the combat GSW to the liver is effective along with the application of damage control tactics. A scheduled ERCP application is an effective approach for the management of EBF, and liver resection could be avoided. A successful biliary decompression was achieved by the transpapillary intervention with the installation of stents. Stent occlusion could be diagnosed in the early post-traumatic period, which is effectively managed by scheduled ERCP as well as stent replacement with a large diameter as close as possible to the place of bile leak.

[Surgical treatment of hydatid cysts with large biliocystic fistula in conservative strategy]. / Prise en charge des larges fistules bilio-kystiques lors de la chirurgie conservatrice du kyste hydatique du foie.

INTRODUCTION: the treatment of large biliocystic fistulas is not unanimous among authors in the absence of consensus or a high level of evidence. There is a controversy over the use of a radical approach which allows the fistula to be sutured in a healthy area or conservative treatment that poses repair issues. The purpose of this study is to compare different conservative techniques to treat large biliocystic fistulas. METHODS: we conducted a retrospective study of 54 patients with large fistulas in the Department of General Surgery at the Habib Bourguiba University Hospital in Sfax over a period of 9 years (2010 - 2018). RESULTS: fourty-four patients were enrolled in the study. Abdominal ultrasound suggested opening of the bile ducts in 18 cases (47.4%) while computed tomography (CT) scan suggested opening in 28 patients (68.3%). The treatment of fistulas was based on DITFO (internal trans-fistulary drainage) in 18 cases (33.3%), cystobiliary disconnection (PERDROMO) in 11 cases (20.4%) and bipolar drainage in 25 cases. Specific surgical morbidity rate was 31.5% and it was dominated by postoperative biliary fistula in 18.5% of cases. DITFO technique was associated with shorter hospital stay (p=0.028) and lower morbidity rates (22.2%) with no statistically significant difference. CONCLUSION: DITFO technique is the gold standard technique in the treatment of biliocystic fistula because it is associated with lower morbidity rates and the shortest hospital stay.

Percutaneous Treatment of Bronchobiliary Fistula: Report of a Successful Transhepatic Embolization and a Decision-Making Strategy Driven by Systematic Literature Review.

Bronchobiliary fistula is a rare condition characterized by bile leaking into the bronchial tree causing biliptysis. It may arise from liver infection or as a consequence of resection and thermal ablation of cancer. Currently, there is no consensus about the treatment strategy. Surgery is considered the main therapy by most authors. However, this systematic literature review shows that the success rate of percutaneous treatments may reach 75%. Adding to such evidence, we also report the case of a woman affected by iatrogenic bronchobiliary fistula secondary to liver thermal ablation, successfully treated with percutaneous drainage plus embolization. Summarizing these results, we encourage the percutaneous management of bronchobiliary fistula by providing a 3-step decision-making algorithm, aimed at reducing the need for major surgery.

Severe complications of chronic cholelithiasis treatment.

BACKGROUND: Gallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible. CASE PRESENTATION: We present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management. CONCLUSION: Special care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.

Mistaken identity: an unexpected case of spontaneous cholecystocutaneous fistula formation.

We describe the case of a 78-year-old woman who presented to the emergency department with a 2-week history of a superficially developing mass in the lower right abdominal wall, fluctuant and non-tender with overlaying erythematous skin changes. Though resembling an abdominal wall abscess and initially listed for a simple incision and drainage, diagnostic uncertainty encouraged further investigation. CT and ultrasound confirmed the mass appeared to be in continuity with the gallbladder fossa, with the lumen also containing small bowel medially. While awaiting a multidisciplinary team discussion, the patient re-presented with concern over discharge appearing at the site of the mass. On inspection, we noted black flecks and small stones. This case describes the unusual and rare presentation of a cholecystocutaneous fistula. The patient was managed conservatively and remains clinically well.

Spontaneous cholecystocutaneous fistula: an uncommon complication of acute cholecystitis.

A 78-year-old man presented to the hospital with acute right upper quadrant pain, fever and nausea. A focused abdominal ultrasound and abdominal CT scan were performed demonstrating an acute calculous cholecystitis with gallbladder perforation. Although a CT-guided cholecystostomy was performed and a pericholecystic abscess was relieved promptly, the patient developed a cholecystocutaneous fistula in the right hypochondriac region. A cholecystocutaneous fistula is an extremely rare complication that may occur in patients with acute calculous or acalculous cholecystitis, chronic gallstone disease, gallbladder carcinoma or prior hepatobiliary surgery.

Association of marked prolongation of prothrombin time-international normalized ratio with warfarin and endoscopic nasobiliary drainage for biliary fistula after left hemihepatectomy.

WHAT IS KNOWN AND OBJECTIVE: Vitamin K deficiency is known to cause impaired coagulation. We report a case of marked prolongation of the prothrombin time-international normalized ratio (PT-INR) associated with warfarin and vitamin K deficiency caused by endoscopic nasobiliary drainage (ENBD). CASE PRESENTATION: Oral administration of warfarin was initiated in a 67-year-old man after left hemihepatectomy. He developed a biliary fistula after surgery that was treated by ENBD, which resulted in significant prolongation of the PT-INR. WHAT IS NEW AND CONCLUSION: The effect of warfarin was enhanced in this patient due to reduced absorption of vitamin K as a result of external biliary drainage.

Biliary Leakage After Hepatobiliary and Pancreatic Surgery: A Classification System to Guide the Proper Percutaneous Treatment.

PURPOSE: To investigate the effectiveness of percutaneous approaches to treat bile leak and to propose an anatomical classification of biliary fistula to guide the most appropriate percutaneous approach. MATERIALS AND METHODS: Fifty-six patients with bile leakage after hepatobiliary surgery were included. Based on preoperative images and postoperative fistulogram images, three categories of bile leakage were defined. Every category was treated with non-surgical approaches (internal-external percutaneous drainage, percutaneous/endoscopic biliodigestive anastomosis with rendez-vous technique and biliodigestive percutaneous anastomosis with totally radiologic rendez-vous). RESULTS: In 44/56 (78%) patients, anatomical conformation was "direct communication" (bile ducts upstream from the leak present a direct communication with downstream ducts) and their treatment was conventional percutaneous drainage. In 5/56 (9%), anatomical conformation was "indirect communication" (bile ducts upstream from the leak communicate with downstream ducts through a bile collection) and treatment was percutaneous/endoscopic rendez-vous technique. In 7/56 (12%), anatomical conformation was "no communication" (ducts upstream from the leak are completely excluded from ducts downstream) and treatment was totally radiologic rendez-vous. In 54/56 (96%) during the follow-up, cholangiography revealed complete resolution of the leak without residual stenosis and drains were removed. Complications occurred in 12/56 (21%). Procedure-related mortality was 0%. Ten patients, after > 6 months from resolution of their fistula and drain removal, died due to cancer recurrence. Currently, 44/56 patients (77%) at long-term follow-up (> 12 months) are alive, without bile leak. CONCLUSION: Our classification helps to choose the most proper percutaneous approach in all kinds of bile leakage, even in severe cases; these are safe techniques with a high success rate.

Embolization for delayed arterial bleeding after percutaneous self-expandable metallic stent placement in patients with malignant biliary obstruction.

OBJECTIVES: To retrospectively evaluate the safety and efficacy of transcatheter arterial embolization (TAE) for delayed arterial bleeding secondary to percutaneous self-expandable metallic stent (SEMS) placement in patients with malignant biliary obstruction (MBO). METHODS: From January 1997 to September 2017, 1858 patients underwent percutaneous SEMS placement for MBO at a single tertiary referral center. Among them, 19 patients (mean age, 70.2 [range, 52-82] years; 13 men) presented with delayed SEMS-associated arterial bleeding and underwent TAE. RESULTS: The incidence of delayed arterial bleeding was 1.0% (19/1858) after SEMS placement, with a median time interval of 225 days (range, 22-2296). Digital subtraction angiography (DSA) showed pseudoaneurysm alone close to the stent mesh (n = 10), pseudoaneurysm close to the stent mesh with contrast extravasation to the duodenum (n = 3), pseudoaneurysm close to the stent mesh with arteriobiliary fistula (n = 1), in-stent pseudoaneurysm alone (n = 4) and in-stent pseudoaneurysm with arteriobiliary fistula (n = 1). Bleeding was stopped after the embolization in all patients. Overall clinical success rate was 94.7% (18/19). One patient with recurrent bleeding was successfully treated with a second embolization. Overall 30-day mortality rate was 26.3% (5/19). A major procedure-related complication was acute hepatic failure in one hilar bile duct cancer patient (5.3%), which was associated with an obliterated portal vein. CONCLUSION: TAE is safe and effective for the treatment of delayed arterial bleeding after percutaneous SEMS placement for MBO. ADVANCES IN KNOWLEDGE: This study demonstrated TAE is safe and effective for arterial bleeding after SEMS placement after MBO through the largest case series so far.