Name : Madhuben khatri Age: 60 yr / F DOA: 4/ 09/08 DOO: 21/10/08 DOD: 05/11/08

1. Name : Madhuben khatri • Age: 60 yr / F • DOA: 4/ 09/08 • DOO: 21/10/08 • DOD: 05/11/08

2. History • No MRF • Open cholecystectomy at devangiri for gallstone on 29/07/08 • Bile leak from day 1st – 700ml/ day • Drain pulled out on day 2nd – not draining – block. • Developed bilioma and sepsis, transferred to manipal hospital, banglore.

3. History Cont. • PCD done – perihepatic and subhepatic and developed control fistula ~ 300ml/ day in total. • Ventilatory support for 10 day and antibiotics for sepsis • Rt. Side bronchopneumonia – improved with treatment. • Patient send to rajasthan with PCD in situ.

4. History cont. • Patient developed biloma with PCD tube get blocked. • Referred to sterling hospital. • Imaging: rt. Subphrenic collection – 500ml , PCD done. • Pt. had rt. Encysted pleural effusion with decreased air entry. • Seen by pulmonologist and pleuroscopy and adhesiolysis, ICD insertion done.

5. Biloma

6. History Cont. • Her general condition improved, TC- decreased from 30000 to 8000 and afebrile. • Fistula output was 100ml/ day with no residual collection. • On day of discharge patient has slipped PCD – CT plane done – not showed significant collection – so patient discharged with plan for reinsertion of PCD once collection develop.

7. History Cont. • 4 day later: patient reevaluated, had perihepatic collection, PCD done – drain 400ml bile • PCD output remain 200ml/ day, she also develop a collection just beneath wound near hilum and need 2nd PCD for the same. • USG abdomen revealing – dilated lt. system with partially filled rt.system , s/o type 4 block with rt. Side fistula.

8. History cont. • Seg 8 PTBD done by intervention radiologist Dr. Ajay Desai, cholangiogram showed leak from hilum and type 4 stricture with left system not opacify. • Post PTBD – bile leak stoped and PTBD output was ~ 250ml/ day. • Patient general condition was poor with Alb. 2.0, TLC 10000, KPS -70, pedal edema

9. History Cont.. • Patient given 3 unit of albumin, started on TPN as oral intake inadequate and chest physiotherapy and incentive spirometry continued. • Patient developed depression symptoms. • Surgery was planed with explained risk for early intervention.

10. Pre op cholangiogram • Type 3-b stricture

11. RYHJ • Done at medisurge hospital, on 21/10/08 • Findings: perihepatic and subhepatic dense adhesions with oosing for liver surface, liver congested and lt. lobe hypertrophy. • Hilum showed ~1.5 cm rent with suture ball coming out within it. Rt. PTBD reaching upto hilum. • Lt. system not freely draining

12. Hilar Fistula

13. Perioperative cholangio- intubation

14. Stented Anastomosis

15. Post operative course: • Patient on epidural analgesia for 3 days. • Day 1sthemodynamically stable, hb: 11%, CVP 6cm of water, u/o adequate • Day 2nd developed tachycardia, CVP low , given fluid , colloids (FFP, albumin),- CVP – 13cm of water.-- fall in hb 7%. Wound soackage, subhepatic drain – 150ml hemorrhagic, usg abdomen lt. subphrenic collection with no significant internal echoes, rest of abdomen- minimal interbowel fluid, no pelvic collection

16. Day 3- 4th: 2 PCV / day given, hb: 13% with no fall in hb on serial hemogram, patient developed hypertension and persistant tachycardia, cardiologist opinion taken and amlodipine started. • Day 5th : patient had HR: 120/min, BP: 130/90, no fever, RR: 28/min, SpO2: 98% with 2 liter oxygen, stool passed – started clear liquid orally. Rt. PTBD not draining, lt. BD- 200ml bile, subhepatic drain -25ml altered blood. Review usg not showed significant collection. Patient shifted to room

17. Day 6-10th: • Patient developed gradual abdominal distension with b/s present, passing flatus, no fever • RT insertion , no significant output, x ray abdomen showed gas filled large bowel loops, no significant small bowel dilatation. • P: 110/min, BP : 120/80 (no antihypertensive), u/o 100ml/ hr with CVP ~ 6cm , no fever, on room air sPO2- 98%, patient mobile on partial parenteral nutrition (celemin and dextrose 25%) , hypokalemia corrected with k+ infusion.

18. Patient reviewed by medical gastroenterologist dr. umang rathi, evaluated by procalcitonin – 0.5, TSH: 1.3 ( WNL) and planed for conservative management. • Bilirubin level fall from 10 (preop) to 6 on day 4th then rise to 11 with SAP: 251 , sgpt :44. • Evaluated by PTC on day 7 th :

19. PTC –day 7th

20. Day 10-15th: • CECT abd; showed no anastomotic leak, no bowel obstruction, collection ~ 50ml anterior to HJ loop and 20ml posteriorly with drain in situ. Small collection in lt. paracolic and interbowel. • Usg guided infracolic free fluid – old hemorrhagic – (250ml) aspirated, c/s – sterile. • Subhepatic collection drained by opening lateral part of wound

21. Patient started liquids orally and tolerating ~ 1.2 liter/ day. • She developed fever (104) with chills on day 14th , TLC: 9800, bili: 12, sgpt: 112, SAP: 312 • Blood c/s – klebsiella pneumonia (ESBL strain) • CVP removed • Started on Imipenem-cilastatin according to c/s report. • RT. PTBD withdrawn above anastomosis draining 30ml/ day bile, s.bili: 9.0

22. Subhepatic drain – 25ml/ day – shortened and applied stoma bag. • Lt. PTBD- 150ml/ day • S. albumin 2.2, given h. ablumin x 3 days • Ambulation done • Presently: no fever, P: 100-108/min, BP:120/90, RR: 20-22/min, chest clear, p/a: soft , passing stool, minimal pedal edema

23. Icterus ++, Hb: 10, tolerating oral feeds ~ 1500 kcal. • Rt. PTBD: 50ml/ day, lt. PTBD: 100ml/day, subhepatic drain: 30ml /day. Usg abdomen: no significant residual collection, no cholengiolytic abscess or IHBRD.

24. Patient improved over 2 weeks with parenteral and enteral nutrition . • Discharged on oral diet with PTBD cathetar in situ. • On Follow up patient’s LFT normalised, catheter removed • Evaluation at 6 months with HIDA scan and usg abdomen, LFT showed normal study.