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Case Capsule Dr V Gandhi GI & HPB Surgeon

This case study follows the medical history of a 30-year-old lady with abdominal pain, weight loss, and a cystic lesion involving the right lobe of the liver. The patient undergoes surgery, including biliary sphincterotomy and right hepatectomy, and receives post-operative treatment. Another case study involves a 40-year-old female with symptomatic cholelithiasis. The patient undergoes laparoscopic cholecystectomy but develops complications post-surgery, including an external biliary fistula. Subsequent treatments and follow-ups are discussed.

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Case Capsule Dr V Gandhi GI & HPB Surgeon

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  1. Case CapsuleDr V GandhiGI & HPB Surgeon

  2. History • 30 yrs lady • Abdominal pain – right upper quadrant , intermittent, dull ache • Weight loss – unable to quantify • Low grade fever • No other GI symptoms • No icterus • P/A – lump right hypochondrium

  3. Lab • Hb – 10.0, WBC – 12,000, PLT – 3.2 • Total Bilirubin – 1.4, Direct – 0.6 • SGOT/SGPT – 36/40, Alk phos – 100 • Alb – 4.0, Protein – 7.8 • USG abdomen – cystic lesion involving the right lobe of liver CBD dilated, Mild IHBRD Hydatid cyst serology (ELISA) - positive

  4. CECT ABDOMEN

  5. CECT ABDOMEN

  6. CECT ABDOMEN

  7. CECT ABDOMEN

  8. ERCBiliary sphincterotomy + clearance of biliary tree + stenting Pre op Albendazole – 4 days

  9. Surgery Surgery

  10. Surgery Specimen

  11. Right hepatectomy + Right caudate lobectomy • Anterior approach • Parenchymal transection – harmonic + kelly clysis • No clamping – Pringles • Blood loss – 1500 ml • Blood transfusion – 3 pints • Transection time – 2 hrs / 30 min • CVP during transection – 1-2 • No bile leak from cut surface • MHV preserved • RHA/RPV – suture ligation • RHV – vascular stapler

  12. Post op course – uneventful • Discharged – 5 th POD • Biliary stent removed – follow up • Albendazole x 3 months

  13. Gharbi sonar morphological classification Type I is a cyst with clear fluid Type II is a cyst with clear fluid and a split wall Type III is a cyst with septa Type IV with heterogeneous echo pattern Type V are cysts with reflecting thick walls.

  14. History 40 yrs old female Symptomatic cholelithiasis – biliary colics No icterus , no cholangitis LFT - normal USG abdomen – multiple gall stones

  15. Laparoscopic cholecystectomy – OCT 2010 - operative time – 2 hrs - no major blood loss / blood transfusion - drain placed - specimen HPR – no malignancy Drain was removed on 2 nd POD

  16. POD 3 – abdominal pain, fever, breathless • CT scan • Laparoscopy and drainage

  17. External biliary fistula – 500 ml/day • Discharged after 8 days • Bile drainage decreased and stopped after 1 month • Drain was removed subsequently

  18. Jaundice / cholangitis – Feb 2011 • LFT – Total Bil – 10.36, Direct Bil – 9.80, Alk Phosphatase – 514 USG Abdomen – mild IHBRD in both lobes ERC + stenting - attempted and failed

  19. CECT ABDOMEN

  20. CECT ABDOMEN

  21. MRCP

  22. Surgery – March 2011 • Left hepaticojejunostomy • Post op course - uneventful - Bilirubin - normal - Alk phos - normal

  23. Follow up • 4 episodes of cholangitis – last 1 yr • Alk phos – 3 times upper limit • USG – mild IHBRD right system

  24. MRCP

  25. MRCP

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