Introduction

 

Cholecystectomy is the commonest operation performed for the biliary tract.[1] Pseudoanuerysms of the hepatic artery or its branches following cholecystectomy is one the causes responsible for the postoperative bleed.[2,3,4,5,6,7,8,9,10] Most of these cases  are managed with embolization. We report our experience of two such cases managed surgically.

 

Case Reports

 

Case 1

 

A 75-year-old man had an open cholecystectomy and common bile duct (CBD) exploration for symptomatic gallstones. Two months later, he had recurrent episodes of abdominal pain and hematemesis. At presentation to us, he was pale and icteric but hemodynamically stable. His hemoglobin was 10 g/dl, total bilirubin 5.4 mg/dl and alkaline phosphatase 267 IU/dl (normal  80-240 IU/dl). Abdominal ultrasonography and contrast enhanced CT scan showed dilated intrahepatic radicals, CBD  filled with hyperdense material suggestive of clots and a 2.9 x 2.5 cm pseudoaneurysm in the gallbladder fossa (Figure 1).  As embolization was technically not feasible, an emergency laparotomy was done which revealed a 2 x 1.5 cm pseudoaneurysm arising from the cystic artery and eroding the CBD. The common hepatic duct was dilated and the distal CBD had clots. The cystic artery was ligated, the pseudoaneurysm and the eroded CBD were excised, and a Roux-en-Y hepaticojejunostomy done. His postoperative course was uneventful and he is asymptomatic after 1 year.

 

Case 2

 

A 28-year-old woman developed abdominal pain and jaundice 2 weeks after an open cholecystectomy. An endoscopic  retrograde cholangiopancreaticography (ERCP) and biliary stenting was done for suspected CBD stones. Subsequently, she developed fever and an ultrasonography showed a subhepatic collection, which on aspiration revealed blood. At presentation to us she was toxic, febrile, pale and icteric. Her hemoglobin was 9.3 mg/dl, white cell count 10.9 x 103 cells/ cmm, total bilirubin 7.5 mg/dl, AST 204 IU, ALT 289 IU and alkaline phosphatase 354 IU/dl. Ultrasonography showed a large hyperechoic mass in the gall bladder fossa compressing the CBD with a stent in situ. CT angiography showed a pseudoaneurysm arising from the right hepatic artery compressing the CBD with multiple cholangiolar abscesses in the liver. In view of ongoing cholangitis and cholangiolar abscesses, we decided to manage her surgically. Emergency laparotomy showed a large pseudoaneurysm extending from the right paraduodenal fossa to the root of mesocolon, eroding the postero-lateral wall of duodenum and lateral wall of CBD.

 

The pseudoaneurysm was opened, clots evacuated and the rent in the hepatic artery was repaired. The biliary stent was removed through the damaged CBD wall, which was repaired over a T-tube. The first part of the duodenum was repaired along with pyloric exclusion, a diverting reterocolic gastrojejunostomy and feeding jejunostomy. Postoperatively, the patient developed a bile leak, which subsided in 3 weeks. A dye study showed no leak from the duodenum or CBD and hence the T-tube was removed. The patient is asymptomatic after 10 months.

 

Discussion

 

Pseudoaneurysms arise as a consequence of visceral inflammation adjacent to the arterial wall, which leads to damage to the adventitia and thrombosis of the vasa vasorum resulting in localized weakness in the vessel wall. They are prone to rupture.

 

 Gallstone related pseudoaneurysm could form either postcholecystectomy[2,3,4,5,6,7,8,9,10] or following attack of cholecystitis.[11,12] Following cholecystectomy, psuedoaneurysm formation is the least common form of arterial injury.[2] The most common is intra operative hemorrhage, which is usually tackled on table. Second commonest is occlusion or ligation of right hepatic artery without intra operative hemorrhage. Right hepatic artery ligation is often unreported as usually this doesn’t cause any serious clinical consequences.[2,3] Delayed bleeding originating from pseudoaneurysm is the least common complication with fewer than 60 cases reported in the literature. Most have described origin of pseudoaneurysm from cystic and/or hepatic artery branches. [2,3,4,5,6,7,8,9,10]There is growing evidence that laparoscopic  cholecystectomy increases the risk of inadvertent right hepaticartery and proper hepatic artery injury with subsequent development of a pseudoaneurysm.[6] In one review of 1513 laparoscopic cholecystectomies, 9 (0.6%) developed significant upper GI bleed secondary to hepatic artery pseudoaneurysms.[10]

 

Pseudoaneurysms of the hepatic artery and its branches usually manifest with upper abdominal pain, jaundice andmelaena (Quincke’s triad). Bleeding usually occurs within 8 weeks following cholecystectomy, but can be delayed.[11] Other unusual presentations include massive upper gastrointestinal bleeding or pain with localized rupture leading to postoperative collections. Our first patient presented with hemobilia while the second one presented with features of cholangitis and sepsis.

 

Ultrasonography with color Doppler is considered as 1^st  line investigation for patient suspected to have pseudoaneurysm.[12] It often detects the lesion (anechoic lesion with color flow) but may not localize the vessel involved. A  contrast enhanced CT scan demonstrates a hyper dense lesion on non contrast phase, which enhances on arterial phase. It helps in confirming the diagnosis in patients with an equivocal Doppler before proceeding for an invasive procedure and may suggest the vessel involved. In both cases CT scan demonstrated typical findings suggestive of pseudoaneurysm.  Angiography followed by embolization of the involved blood vessel is the preferred modality for the management of these lesions.[3] However, in the presence of associated complications such as sepsis (our second patient) or when embolization fails/is technically not feasible (our first patient), surgical management is indicated. Proximal control of hepatic  artery should always be the first step of this operation if the patient is hemodynamically stable and there is no active bleeding. Serious bleeding can be precipitated, when dissection is performed in an area where there is evidence of acute inflammation containing a pseudo-aneurysm. Due to inflammation there is a definite risk of injury to adjacent visceral structures. One patient had iatrogenic duodenal injury which was managed accordingly.

 

In conclusion, though rare, pseudoaneurysms following cholecystectomy can have varied presentations, may be associated with sepsis and gastrointestinal bleeding and need to be managed energetically to avoid morbidity and mortality.  Surgery has a definitive role in managing patients with failed embolization and those having associated complications like sepsis.

 

References

1.     Ahrendt SA, Pitt HA. Biliary Tract. In: Townsend CM (ed), Beauchamp RD, Evers BM, Mattox KL (associate ed). Sabiston textbook of surgery 116 th edn. Philadelphia:WB saunders Company; 2001.p.1076–111.

2.     Yelle JD, Fairfull-Smith R, Rasuli P, Lorimer JW. Hemobilia complicating elective laparoscopic cholecystectomy: a case report. Can J Surg. 1996;39:240–2.

3.     Halasz NA. Cholecystectomy and hepatic artery injuries. Arch Surg. 1991;126:137–8.

4.     Sibulesky L, Ridlen M, Pricolo VE. Hemobilia due to cystic artery pseudoaneurysm. Am J Surg. 2006;191:797–8.

5.     Journe S, De Simone P, Laureys M, Le Moine O, Gelin M, Closset J. Right hepatic artery pseudoaneurysm and cystic duct leak after laparoscopic cholecystectomy. Surg Endosc. 2004;18:554–6.

6.     Stewart BT, Abraham RJ, Thomson KR, Collier NA. Post cholecystectomy haemobilia: enjoying a renaissance in the laparoscopic era? Aust N Z J Surg. 1995;65:185–8.

7.     Bergey E, Einstein DM, Herts BR. Cystic artery pseudoaneurysm as a complication of laparoscopic cholecystectomy. Abdom Imaging. 1995;20:75–7.

8.     Clements WD, Wilson RH, Crothers JG, McIlrath EM, Johnston GW. Pseudoaneurysm of the cystic artery following cholecystectomy. J R Coll Surg Edinb. 1993;38:348–9.

9.     Bulut T, Yamaner S, Bugra D, Akyuz A, Acarli K, Poyanli A. False aneurysm of the hepatic artery after laparoscopic cholecystectomy. Acta Chir Belg. 2002;102:459–63.

10.   Nicholson T, Travis S, Ettles D, Dyet J, Sedman P, Wedgewood K, et al. Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol. 1999;22:20–4

11.   Maw A, Mander BJ, Nandi SC, Taube M, Evans HJ. Pseudoaneurysm of the cystic artery. Eur J Surg. 1997;163:307–9

12.   Barba CA, Bret PM, Hinchey EJ. Pseudoaneurysm of the cystic artery: a rare cause of hemobilia. Can J Surg. 1994;37:64–6. Review.