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CASE REPORT |
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Year : 2013 | Volume
: 3
| Issue : 1 | Page : 63-65 |
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Empyema: A rare complication of biloma
Nissar Shaikh1, Rashid Mazhar2
1 Consultant, SICU, Hamad Medical Corporation, Weil Connell Medical College, Hamad Medical Corporation, Doha, Qatar 2 Consultant, Department of Cardiology and Cardiothoracic Surgery, Hamad Medical Corporation, Doha, Qatar
Date of Web Publication | 28-Aug-2013 |
Correspondence Address: Nissar Shaikh Department Anesthesia/ICU, Hamad Medical Corporation, Doha Qatar
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/2278-9596.117135
Laparoscopic cholecystectomy (LC) has become the standard treatment for symptomatic cholelithiasis. Bile duct injury remains worrisome complication. We report a case of post-LC biloma causing empyema, respiratory distress and sepsis that was managed successfully. A 44-year-old male had bile leak post-LC. Endoscopic retrograde cholangiopancreatography showed common bile duct (CBD) injury. CBD stenting was done. 2 days later he developed severe sepsis due to Klebsiella pneumoniae biloma and empyema. Both were drained by computerized tomographic scan guided pigtail catheter. Empyema required further video-assisted thoracoscopic surgery. Bile leak following LC may progress to biloma and K. pneumoniae empyema with sepsis. Minimal invasive surgical procedure is a helpful and effective treatment. Keywords: b0 iloma, empyema, endoscopic retrograde cholangiopancreatography, laparoscopic cholecystectomy, video-assisted thoracoscopic surgery
How to cite this article: Shaikh N, Mazhar R. Empyema: A rare complication of biloma. Arch Int Surg 2013;3:63-5 |
Introduction | | |
Laparoscopic cholecystectomy (LC) is the procedure of choice for treatment of symptomatic gallstone disease. But LC is not free from complications and extra hepatic bile duct injuries mainly occur during LC. [1] Bile leak occurs in up to 2% of post-LC, [1] patients resulting in biliary peritonitis, fistula formation or localized sub-hepatic collection of bile called biloma. Biloma is reported to occur in 1.6-2.5% of post-LC patients. [2],[3]
The estimated bile duct injuries following open cholecystectomy is 0.3% and 0.6% in the era of LC. [4] 12% of gallstones spillage patients during LC will have thoracic abscess or empyema. [5] We report a case of post-LC biloma leading to Klebsiella pneumoniae multi-loculated empyema requiring surgery.
Case Report | | |
A 44-year-old male patient referred to our hospital with sepsis and history of LC for chronic cholecystitis 1 week prior to presentation. He had abdominal J Vac drain in situ that was draining bile. He was febrile (38.9°C), tachycardic (heart rate 110-120/min) with stable blood pressure (120-110/70 mm of Hg). His abdomen was slightly distended, with right upper quadrant tenderness. There was decreased air entry on the right lower chest. He was admitted in surgical ward and started on empirical piperacillin and tazobactam (Tazocin ® ) 4.5 g intravenously every 8 h. On the second day of admission he had endoscopic retrograde cholangiopancreatography (ERCP). It revealed proximal common bile duct (CBD) injury without any tissue loss (Schmidt class C); which was successfully stented. On day 3 the patient developed shortness of breath with respiratory rate of 32-40/min tachycardia (Heart Rate of 130-140/min) and decreased urine output (80 ml for last 4 h). Abdominal distension increased with an intra-abdominal pressure (measured through urinary catheter with a transducer) of 16-18 mm of Hg. He was transferred to the surgical intensive care (SICU).
In SICU invasive lines were inserted. Chest X-ray showed right basal collapse and consolidation. He was connected to non-invasive ventilation (face mask: Positive End Expiratory Pressure 5, Pressure Support 10 and Fio2 0.4%) and his resuscitation was guided by pulse induced continuous cardiac output (PiCCO ® ) parameters. Computerized tomographic scan (CT) showed a sub-hepatic collection [Figure 1] and right pleural collection. CT guided sub-hepatic and right pleural 10 French pigtail catheters were inserted. Right pleural pigtail catheter initially drained 150 ml and sub-hepatic 435 ml of pus. Both drainages grew K. pneumoniae. sensitive to meropenam. He was started on meropenam 1 g every 8 hly. By day 5 he improved but remained febrile and tachypnic. His chest X-ray showed collapsed consolidation of right lower lobe with effusion. Right pleural pigtail catheter was not draining and was thought to be blocked; aspirating with a syringe, while manipulating and milking the pigtail catheter was not successful; and we inserted a size 28 chest drain [Figure 2]. It did not help and drained only 76 ml in 24 h. The patient remained clinically in the same condition with same radiological findings. CT of the chest showed multiple loculated collections in right pleural space with adjacent lung compression [Figure 3]. Thoracic surgeons were consulted and it was decided to do video-assisted thoracoscopic surgery (VAT). The patient had VAT surgery on day 8. VAT showed inspissated, multi-loculated sero-sanguineous empyema with inflamed and trapped right middle as well as lower lung lobes. More than 500 ml of thick pus was drained. Posterior-lateral decortication was done. The middle lobe expanded fully and lower lobe partially at the end of VAT. Chest drain was removed on day 11. Patient improved clinically, could walk and X-ray of the chest showed full expansion and aeration of the previously collapsed right middle lobe. He was discharged home on day 14 on amoxicillin + clavulanic acid and followed up after a week in outpatient clinics. | Figure 3: Computerized tomographic scan chest showing multiloculated empyema
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Discussion | | |
Post-LC bile duct injuries are preventable catastrophe associated with significant increased perioperative morbidity and mortality. [6] Cases of spilled gall stones causing erosion of diaphragm leading to thoracic empyema have been reported. [7] Our case was unique as not the spilled stones but the biloma lead to empyema. Causative organism was K. pneumoniae which are known to form multiple loculated abscesses requiring surgery as was seen in our patient.
Following CBD injury ERCP is diagnostic and therapeutic by stenting the biliary tree to block the leakage; it decompresses the bile duct to enhance healing and facilitate minimally invasive computerized tomographic or ultrasound guided drainage of biloma. [8] In our patient there was no spillage of gallstones either in the abdomen or in the thoracic cavity. Infected biloma may have transmitted the infection to the chest cavity through natural orifices in the diaphragm or the reactionary pleural effusion got an infection from biloma.
As this was a K. pneumoniae empyema it was multi-loculated and not able to drain by pigtail catheter or even a chest tube. What we initially thought of pigtail catheter blockage after looking at the chest X-ray was not appropriate and CT chest cleared the picture and VAT surgery did the job. VAT is the appropriate choice being less invasive. It allows direct visualization of the pleural cavity and lungs as well as therapeutic surgery. [9]
In conclusion, although laparoscopic CBD injury is not uncommon biloma resulting in empyema thoracic has not been previously reported. Aggressive antibiotic therapy and appropriate drainage of the empyema would lead to a satisfactory outcome.
References | | |
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8. | Christoforidis E, Vasiliadis K, Goulimaris I, Tsalis K, Kanellos I, Papachilea T, et al. A single center experience in minimally invasive treatment of postcholecystectomy bile leak, complicated with biloma formation. J Surg Res 2007;141:171-5. [PUBMED] |
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[Figure 1], [Figure 2], [Figure 3]
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