Severe Hemobilia from Hepatic Artery Pseudoaneurysm

Abstract

Background. Hemobilia is a rare, jeopardizing complication of laparoscopic cholecystectomy coming upon usually within 4 weeks after surgery. The first-line management is angiographic coil embolization of hepatic arteries, which is successful in the majority of bleedings: in a minority of cases, a second embolization or even laparotomy is needed. Case Presentation. We describe the case history of a patient in which laparoscopic cholecystectomy was complicated 3 weeks later by massive hemobilia. The cause of haemorrhage was a pseudoaneurysm of a right hepatic artery branching off the superior mesenteric artery; this complication was successfully managed by one-stage angiographic embolization with full recovery of the patient.

Hepatic or Cystic Artery Pseudoaneurysms Following a Laparoscopic Cholecystectomy: Literature review of aetiopathogenesis, presentation, diagnosis and management

“…3,63 The incidence of haemobilia following an emergency LC for acute cholecystitis (within 72 hours) has been reported to be 0.001%, while it has been observed to be 0.0003% for those undergoing an elective LC. 31 A higher incidence of PSAs involving the hepatic artery has been reported in patients with a concomitant bile duct injury (4.5%). 4 However, the RHA is usually the most commonly involved vessel.…”

“…Among the cases which specified the gender or age of the patient, 45.2% were male and the age ranged from 12-81 years with a mean age of 49.8 years. 4,5,[9][10][11][12][13]15,[17][18][19][20][21][24][25][26][27][28][29][30][31][33][34][35][37][38][39][40][41][42][43][46][47][48]51,57,58,60,62 The time of presentation following the LC procedure ranged from six days to five years with a mean of 36 days. [3][4][5][7][8][9][10][11][12][13]15,…”

“…In two cases, the RHA arose from a replaced superior mesenteric artery and, in one case, it was an accessory artery. 18,29,31 The size of the PSAs ranged from 13-200 mm, with a mean size of 43 mm. 4,6,13,15,17,26,30,31,33,37,39,42,43,57 The modality of management was transarterial embolisation (TAE) in 72.3%, endovascular stent placement in 4.0%, exploratory laparotomy and ligation of the hepatic artery in 5.0% and thrombin injection in 4.0% of cases.…”

“…5,37 A thermal injury could result from the direct transfer of heat to the vessel by cautery or indirectly via a metal clip in contact with the artery. 3,18,31 Injury of the vessel could also be due to clip intrusion, bile leakage or infection. 4,9,31 In numerous cases, the PSA has been found directly adjacent to a clip.…”

“…3,18,31 Injury of the vessel could also be due to clip intrusion, bile leakage or infection. 4,9,31 In numerous cases, the PSA has been found directly adjacent to a clip. 31,43,46,51 Bile acids are powerful solubilisers of membrane lipids due to their cytotoxic and amphipathic properties, causing cell death in Table 1: Literature review of cases of pseudoaneurysm of the cystic and/or hepatic arteries following a laparoscopic cholecystectomy Author and year of article patients with bile leaks; this has been postulated to cause direct weakening and erosion of the vascular wall, leading to a PSA.…”