Choloperitoneum causes extensive coloring of the abdominal wall skin

image of Figure Unlabelled image Case Report

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American Journal of Emergency Medicine

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Choloperitoneum causes extensive coloring of the abdominal wall skin?

Abstract

Laparoscopic cholecystectomy, because it is the less invasive surgical procedure, has been established as the procedure of choice for the treatment of patients with symptomatic gallBladder stones. However, bile leakage after laparoscopic cholecystectomy should not be overlooked. It is generally due to a minor biliary complication, although it can sometimes herald a major duct injury. Bile leakage rates of 1.2% to 4.0% in laparoscopic cholecystectomies have been reported, which are higher than the incidence with open cholecystectomies.

Cystic stump leakage can occur from faulty clip application, slipping of the clips, or necrosis of the cystic duct stump proximal to the clip, probably related to diathermy injury. The bile leakage can cause Biliary peritonitis, which is one of the most serious complica- tions in surgery with severe abdominal pain, high fever, ileus, and shock; in some cases, this situation can be fatal.

This study reports an extremely rare clinical finding presenting with extensive coloring of the abdominal wall skin as the result of cystic duct leakage in a female patient 3 days after laparoscopic cholecystectomy. We found no reports in the literature describing this impressive clinical image as the result of choloperitoneum 3 days after laparoscopic cholecystectomy due to the slipping of the clips.

We present the case of a 72-year-old woman who was admitted to the hospital 3 days after laparoscopic cholecystectomy complaining about abdominal pain, constipation, nausea, and fever. The patient was distressed and hemodynamically unstable (blood pressure 100/55 mm Hg and 165 beats per minute). Her abdomen was distended with marked diffuse tenderness and no bowel sounds. The most impressive finding was the extensive change of the patient’s abdominal wall Skin color (Figure). Laboratory tests revealed a white blood cell count of 17,980/mm³, with 92.5% neutrophils, and elevated C-reactive protein and amylase levels.

Abdominal ultrasonography demonstrated large amount of fluid in the abdominal cavity.

Emergency Exploratory laparotomy with a middle incision was performed. A large quantity of bile fluid was suctioned out, whereas the open cystic duct was found and ligated. The reason of the opening was slippage of the clips that should secure the duct. The patient had an uncomplicated postoperative course.

Cholecystectomy is one of the commonest laparoscopic proce- dures worldwide. In the United States alone, nearly 0.8 million laparoscopic cholecystectomies are performed annually [1]. However, the laparoscopic procedure has been associated with a higher

? Conflict of interest: none.

incidence of biliary complications, particularly in the early years of its adoption [2].

Bile leak is defined as a persistent leakage of bile into the peritoneal cavity or through the drain, if the drain presents. Although the bile leakage after laparoscopic cholecystectomy is uncommon, this situation can be potentially serious, causing fatal sepsis [3]. The reported incidence ranges from 0.3% to 3% [3].

The main causes of bile leakage after laparoscopic cholecystectomy include cystic duct stump leak, injury to major bile ducts, injury of the duodenum, and leaking from accessory bile ducts (duct of Luschka). When symptomatic, the patients present with pain, nausea, vomiting, abdominal distension, ileus, fever and jaundice or bile leakage in a surgical drain, and shock. In a prospective study on patients after laparoscopic cholecystectomy, the following Predisposing factors in favor of a clip migration were described: short cystic stump, inadvertent clip dislodgment or incorrect placement, cystic duct Ischemic necrosis, and local suppurative complications [4]. Further- more, when metallic clips have been improperly applied, they do not guarantee complete closure of the cystic duct.

Tzovaras et al [5] reported a series of bile leakage following laparoscopic cholecystectomies, nearly 80% of which originated from the cystic duct. In 50%, the diagnosis was made while the patient was in hospital. They suggested that cystic duct stump leakage can occur from clip dislodgement, imperfect clip application, necrosis of the cystic duct stump, or an electrosurgery-related injury.

image of Figure

Figure. Extensive coloring of the patient’s abdominal wall skin due to cystic duct leakage after laparoscopic cholecystectomy.

http://dx.doi.org/10.1016/j.ajem.2014.03.030

On the other hand, Barkun et al [6] noted that the incidence of cystic duct stump leakage was higher in patients who had intraoperative complications, converted procedures, or wide cystic ducts. They suggested that it is safer to suture ligate the cystic duct rather than clip application.

Endoscopic retrograde cholangiopancreatography has a pivotal role in the management of this kind of leaks [7]. However, in some cases, especially in those with extended and massive choloperitoneum or with patient’s instability, exploratory laparotomy or laparoscopy is performed. In this reported case, the patient was discharged on the first postoperative day in a good condition. On the third postoperative day, her first symptom was a sudden onset of pain in the right upper quadrant radiating to her back; and 6 hours later, she was admitted to the hospital with extensive change of her abdominal wall skin color. Exploratory laparotomy was performed because of the patient’s instability. This was the reason we did not perform laparoscopy and we did not try to manage the patient with endoscopic retrograde cholangiopancreatography. During the surgery, it was confirmed that cystic duct’s opening and bile leakage was due to the slippage of

the clips.

It is necessary to mention that, during the initial laparoscopic cholecystectomy, neither intraoperative complications nor wide or short cystic duct was observed. The placement of the clips (a total number of 2) was correct, and there was no extended use of diathermy that could cause ischemic necrosis of the cystic duct. A surgical drain was used and was removed on the first postoperative day with no signs of bile leakage.

The case was remarkable for the rapidly progressive symptoms during the third postoperative day and especially for the extensive change of the patient’s abdominal wall skin color. Although the initial procedure was uneventful, the patient was admitted with hemody- namic instability; and the surgeons had to operate her immediately to safe her life. The complications of laparoscopic cholecystectomy could

be prevented by adequate surgical experience, carefulness, and case selection. Repeated laparotomy, when adequate, permits drainage of bile collection and direct control of the site of the leakage.

Stavros Mathioulakis, MD Evangelia Liverakou, MD Stavros Gourgiotis, MD, PhD First Surgical Department

417 NIMTS Military Veterans‘ Fund Hospital of Athens, Greece E-mail address: [email protected]

Nikolaos S. Salemis, MD, PhD

Second Surgical Department 401 General Army Hospital of Athens, Greece

http://dx.doi.org/10.1016/j.ajem.2014.03.030

References

AJEM

Choloperitoneum causes extensive coloring of the abdominal wall skin

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