Teaching Case

A 54-year-old man with a history of cholecystectomy due to chronic cholecystitis 9 days prior was admitted to our hospital with jaundice and itching. Blood samples showed an elevated bilirubin. The cholecystectomy had been uncomplicated, despite leakage from an aberrant bile duct, which was closed with a clip intraoperatively.

MRCP prior to surgery showed normal biliary anatomy (Figure 1). A non-enhanced CT one day prior to admittance at our hospital showed dilatation of the intrahepatic bile ducts, converging near some hilar clips (Figure 2). MRCP on the day of admittance showed no communication between the left and the right biliary tree and no communication with the common bile duct (Figure 3). Percutaneous Transhepatic Cholangiography (PTC) confirmed the missing communication of the right and left hepatic duct with the common hepatic duct (Figure 4), but the patient was left with an external catheter from the right side, as surgery the same day was impossible. PTC after reconstruction with a hepaticojejunostomy revealed a stenosis on the left side, but a catheter was inserted to spare the anastomosis (Figure 5).

The patient underwent cholecystectomy due to gallstones, chronic cholecystitis and several small gallbladder polyps. Although the polyps were small the combination with chronic cholecystitis, gallstones and the patient’s symptoms resulted in surgery according to guidelines [1]. An MRCP was performed prior to surgery to avoid remaining stones in the common bile duct [2]. The laparoscopic cholecystectomy was performed as same-day surgery, which is the norm. The most severe complication of laparoscopic cholecystectomy is an injury to the main bile duct, which occurs in approximately 0.09% of cases [3]. Acute bile duct injury is also more common after laparoscopic than open surgery (incidence of 0.6% vs 0.3%) [4]. Early recognition of this complication is crucial and is usually discovered intraoperatively. Identification of the cystic structures during cholecystectomy is vital and preoperative MRCP may help identify abnormal biliary anatomy.

Our patient presented 9 days after surgery with jaundice and itching. With this presentation and surgical history, the threshold for imaging should be low. Usually, ultrasound or contrast-enhanced CT will be the first method of choice, which was also the case for our patient, and we do not know why the CT was made without contrast agent. It revealed dilatation of the intrahepatic bile ducts converging near some hilar clips with a high suspicion that the main hepatic duct had been accidentally closed during surgery. CT and ultrasound may identify hematoma, retained gallstones, abscess or bowel injury. If there is a suspicion of injury to the biliary tree; MRCP should be performed [5]. In our case, MRCP was performed to know whether there was a complete closure of the main hepatic duct or if there was only partial closure as this would indicate the urgency and type of surgery. Although the MRCP depicted discontinuity between the left and right hepatic duct and the main hepatic duct a PTC procedure was performed, hoping that there might be a small communication between either the left and right biliary duct and the common hepatic duct. A catheter was inserted to try to spare the biliary tree as urgent surgery was impossible due to other urgent liver procedures.

Surgery confirmed the imaging findings with three clips positioned at the hepatic confluence. The liver was almost black due to the retained bile, and the main hepatic duct was partially necrotic making the reconstruction with a hepaticojejunostomy complicated. Therefore, two PTC catheters were inserted the day after surgery to ease the healing of the anastomosis.

MRCP 3 months later revealed a partially stenotic left hepatic duct, but apart from this, the patient was well. Dilatation was performed by PTC.

In conclusion, early diagnosis of biliary complications may facilitate less invasive treatment of the patient and imaging is crucial. The most appropriate imaging modality should be decided on in collaboration between the surgeon and the radiologist according to the patient’s symptoms, prior surgery and lab results. Referral to a reference centre may be indicated.

All patient data have been completely anonymised throughout the entire manuscript and related files.