major CBD injury after open cholecystectomy

50 years old female patient referred from thoracic ward, complaining from jaundice and bile leak from recent rt. Thoracotomy incision. she was complaining from rt. Subphrenic collection missed dx as empyema of rt. Chest ( by US &CXR).

Pastsurgical history : open cholecystectomy 14 months in another city hospital, complicated by postoperative collection treated by twice reexplorations for drainage? And no further informations were available.

Open thoracotomy findings:

The chest was clear ,the diaphragm was bulged, opened and drainge of pus and bile, subphrenic tube drain and chest tube were inserted.

Postoperative bile leak through tube drain followed by external biliary fistula through thoracotomy incision (postoperatve. Ultrasound findings were mild intrahepatic biliary dilatation & NO collection).

The patient referred to GIT center, for further management. Detailed history was taken : open cholecystectomy was done 14 months ago followed by postop. Bile leak and intermittent jaundice more than 2 m. ,then the pt. deteriorated and twice laparotomies done in another hospital within one month (unknown operative data), On and off jaundice with signs & symptoms of cholangitis for more than 6 months.

Readmission and treated conservatively , then the pt. complaining from dyspnoe ,fever and illhealth made her sought advice of thoracic Surgeon.

Haematological &biochemical investigations were done (mild anaemia,leukocytosis, elevated ESR, increased liver enzymes&TSB).

Test for hepatitis viruses(negative).

ERCP was the next step in the management. There was complete cutoff in the distal CBD.

MRCP was done to delinate the biliary anatomy: reveal proximal extrabiliary &intrabiliary ductal dilatation,missed distan CBD segment with right. Subphrenic collection?

The pt. arranged for operation in January 2010.

generous midline incision, very dense adhesions in the area of porta hepatis with complete transaction of common hepatic duct.

Roux-en-y choleduchjejunostomy (with difficulty) was done with stenting the site of anastomosis by foley’s cath. Size 8, brought out through jejunum &skin.

75 days postoperative, subphrenic thick collection+pleural thickening, without fever was drained by chest tube 12 under L.A. with US guide.

LFT was normal and pt. clinically well.

Follow up till 2016 ,the patient doing well apart from intermittent cholangitis, treated conservatively.