A 45-year-old woman underwent laparoscopic cholecystectomy 1 year ago. Post-operative period was complicated by pain in the upper right quadrant. CT scan showed a large bilioma (10 cm) that was percutaneously drained. Biliary fistula eventually closed after 2 weeks. Now, she is asymptomatic except for a constant pain in the RUQ. MRI and MRI- cholangiogram main pictures are attached. What is the best approach, in your opinion?
Even if the patient is asymptomatic? Which approach would you suggest? Open or minimally invasive?
Every liver function tests normal, except for elevated ggt.
Is there any associated vascular lesion such as left hepatic artery injury? If not , I think about to watch and wait, if a segmentar cholangitis i would think in resect this segment or even left lobe.
I herewith quote your line, " Now, she is asymptomatic except for a constant pain in the RUQ." CT scan shows stenosis of S4 duct. In such a situation, as we know, S4 is a very minor part of the entire liver both anatomically as well as physiologically, the serum liver functions will not be deranged by and large. However, clinically patient is reporting pain in RH. In such a situation, it may be argued that pain in RH can be due to some other causes. This case history does not report on any such alternative pathology. Hence with the limited history, one should conclude that the cause for pain in RH could arise from this stricture. Now, we first eliminate an obvious discernible cause, i.e. stricture of S4 segment. Excise the S4, which might be easier than trying to repair it in depths and excision of S4 will not make any defieciency clinically. Hence I briefly commented initially to excise S4. I have done such excision in other patients without any clinical impairment or symptoms.
However it is open for further discussion for any better choice. Regards,
Marcel Autran Cesar Machado
Thank you for your kind recommendation of my reply.
Raised GGT should help to conclude that the pain might be arising from S4 duct stricture. There is obvious proximal dilatation of hepatic S4 biliary ducts as I observe in the CT scan picture.
Now, you ask another question, " Even if the patient is asymptomatic? Which approach would you suggest? Open or minimally invasive?" If the patient is asymptomatic, "What is the worry in the first place"? Minimal Access or open surgery question become irrelevant. However, again, if the situation warrants surgery in this case for whatever reason of clinical indication, minimal access surgery is a little demanding procedure both technologically as well as surgeon factor point of view, open excision of S4 could be quite easier and faster.
Dear Marcel,
just see the question today.
Does she need medication as the pain management? If not and there is no sign of cholangitis, I would wait and watch. Usually the segment 4 will be atrophic.
If the pain medication is too frequency to keep a regular life or recurrent cholangitis, a laparoscopic resection of segment 4b or 4 could be taken (i can not rotate the MRCP to have a exact view).
regards
Jun
Dear Dr Sudrania, indeed she complains of a mild pain in the RUQ. I am not sure if it is related to the dilation of S4 bile duct. As you may know, sometimes when the patient is told about some problem she becomes symptomatic. Anyway no medication for this mild tenderness. No signs of cholangitis.
Dear Jun, thank you for your reply. No the medication is not taken regularly, just a mild tenderness. No clinical signs of cholangitis. Here are some other MRCP images. I was thinking about minimally invasive resection but I may wait a little bit.
Marcel Autran Cesar Machado,
Thank you. What is your concern to ask this question primarily because it seems that she may just need some kind of reassurance and wait and watch until further developments clinically. Secondly, she should be assessed for other causes of pain in RHQ.
Regards,
Dear colleague,
be patient, any infection must be managed medically if possible, the evolution of the excluded hepatic territory is atrophy.
any septic collection of Seg 4 is accessible for radiological drainage.
I think that ,in this case the evolution will be favourable.
Good luck.
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