Transcript Slide 1

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Name : Madhuben khatri
Age: 60 yr / F
DOA: 4/ 09/08
DOO: 21/10/08
DOD: 05/11/08
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.
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.
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.
Biloma
History Cont.
• Her general condition improved, TCdecreased 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.
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.
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
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.
Pre op cholangiogram
• Type 3-b stricture
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
Hilar Fistula
Perioperative cholangio- intubation
Stented Anastomosis
Post operative course:
• Patient on epidural analgesia for 3 days.
• Day 1st hemodynamically 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 abdomenminimal interbowel fluid, no pelvic collection
• 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
• 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.
• 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 :
PTC –day 7th
• 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
• 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
• 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
• 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.
• 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.