42 yrs who was treated for lymphoma 5yrs ago and is completely resolved developed symptomatic Gall bladder stones and small stones in the CBD(MRCP).He underwent diagnostic laparotomy and subsequently Gastro jejunostomy and cholecysto jejunostomy elswhere for gastric outlet obst and for CBD obst.History was that of upper abd pain ,mild fever on and off with shivering.LFT Bilirubin -N but ALP and GGTP are raised but not significantly.Diag lap was carried out showed extensive adhesions dueto previous open surgeries and chemo reaction causing tough layer over the tissues.
with difficulty C-J was dissected,stapled and devided followed by difficult cholecystectomy.CBD could not be explored or bypassed due to tecqnical problems.Pt developed biliary leak on day3 which is decresing from 350mls to 150 mls.CBC is -N,u/s is essentially N,Bulida isotope scan was done good liver uptake but no excretion in to the ducts,delayed films are awaited,Spect ct supplementation shows the intact CBD.Pt is well ,no jaundice,no fever abdmen is soft.He is on IV fluids,antibiotics.
It is good that the patient is well
I can imagine how difficult the surgery was,in the 1st or second surgery (in resource limited set up like us) i would have been considering opening the duodenum and doing Sphincterotomy
As long as the patient is vitally stable ie. Hemodynamically stable with no or low grade fever about 38.5 degrees and no signs of toxemia ie. No leucocytosis, keep patient on conservative treatment and follow the output of the biliary fistula. You can even start oral feeding as long as the patient tolerate it. However, it is better to repeat pelvi-abdominal u/s every two to three days to exclude biliary obstruction and pelvic collection that may be due to internal leak. At any time patient become unstable, external biliary drainage and peritoneal lavage via laparotomy is indicated
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