1. Name : Madhuben khatri Age: 60 yr / F DOA: 4/ 09/08 DOO: 21/10/08 DOD: 05/11/08

2. History No MRF Open cholecystectomy at devangiri for gallstone on 29/07/08 Bile leak from day 1 st – 700ml/ day Drain pulled out on day 2 nd – not draining – block. Developed bilioma and sepsis, transferred to manipal hospital, banglore.

3. History Cont. PCD done – perihepatic and subhepatic and developed control fistula ~ 300ml/ day in total. Ventilatory support for 10 day and antibiotics for sepsis Rt. Side bronchopneumonia – improved with treatment. Patient send to rajasthan with PCD in situ.

4. History cont. Patient developed biloma with PCD tube get blocked. Referred to sterling hospital. Imaging: rt. Subphrenic collection – 500ml, PCD done. Pt. had rt. Encysted pleural effusion with decreased air entry. Seen by pulmonologist and pleuroscopy and adhesiolysis, ICD insertion done.

5. Biloma

6. History Cont. Her general condition improved, TC- decreased from 30000 to 8000 and afebrile. Fistula output was 100ml/ day with no residual collection. On day of discharge patient has slipped PCD – CT plane done – not showed significant collection – so patient discharged with plan for reinsertion of PCD once collection develop.

7. History Cont. 4 day later: patient reevaluated, had perihepatic collection, PCD done – drain 400ml bile PCD output remain 200ml/ day, she also develop a collection just beneath wound near hilum and need 2 nd PCD for the same. USG abdomen revealing – dilated lt. system with partially filled rt.system, s/o type 4 block with rt. Side fistula.

8. History cont. Seg 8 PTBD done by intervention radiologist Dr. Ajay Desai, cholangiogram showed leak from hilum and type 4 stricture with left system not opacify. Post PTBD – bile leak stoped and PTBD output was ~ 250ml/ day. Patient general condition was poor with Alb. 2.0, TLC 10000, KPS -70, pedal edema

9. History Cont.. Patient given 3 unit of albumin, started on TPN as oral intake inadequate and chest physiotherapy and incentive spirometry continued. Patient developed depression symptoms. Surgery was planed with explained risk for early intervention.

10. Pre op cholangiogram Type 3-b stricture

11. RYHJ Done at medisurge hospital, on 21/10/08 Findings: perihepatic and subhepatic dense adhesions with oosing for liver surface, liver congested and lt. lobe hypertrophy. Hilum showed ~1.5 cm rent with suture ball coming out within it. Rt. PTBD reaching upto hilum. Lt. system not freely draining

12. Hilar Fistula

13. Perioperative cholangio- intubation

14. Stented Anastomosis

15. Post operative course: Patient on epidural analgesia for 3 days. Day 1 st hemodynamically stable, hb: 11%, CVP 6cm of water, u/o adequate Day 2 nd developed tachycardia, CVP low, given fluid, colloids (FFP, albumin),- CVP – 13cm of water.-- fall in hb 7%. Wound soackage, subhepatic drain – 150ml hemorrhagic, usg abdomen lt. subphrenic collection with no significant internal echoes, rest of abdomen- minimal interbowel fluid, no pelvic collection

16. Day 3- 4 th : 2 PCV / day given, hb: 13% with no fall in hb on serial hemogram, patient developed hypertension and persistant tachycardia, cardiologist opinion taken and amlodipine started. Day 5 th : patient had HR: 120/min, BP: 130/90, no fever, RR: 28/min, SpO2: 98% with 2 liter oxygen, stool passed – started clear liquid orally. Rt. PTBD not draining, lt. BD- 200ml bile, subhepatic drain - 25ml altered blood. Review usg not showed significant collection. Patient shifted to room

17. Day 6-10 th : – Patient developed gradual abdominal distension with b/s present, passing flatus, no fever – RT insertion, no significant output, x ray abdomen showed gas filled large bowel loops, no significant small bowel dilatation. – P: 110/min, BP : 120/80 (no antihypertensive), u/o 100ml/ hr with CVP ~ 6cm, no fever, on room air sPO2- 98%, patient mobile on partial parenteral nutrition (celemin and dextrose 25%), hypokalemia corrected with k+ infusion.

18. Patient reviewed by medical gastroenterologist dr. umang rathi, evaluated by procalcitonin – 0.5, TSH: 1.3 ( WNL) and planed for conservative management. Bilirubin level fall from 10 (preop) to 6 on day 4 th then rise to 11 with SAP: 251, sgpt :44. Evaluated by PTC on day 7 th :

19. PTC –day 7th

20. Day 10-15 th : – CECT abd; showed no anastomotic leak, no bowel obstruction, collection ~ 50ml anterior to HJ loop and 20ml posteriorly with drain in situ. Small collection in lt. paracolic and interbowel. – Usg guided infracolic free fluid – old hemorrhagic – (250ml) aspirated, c/s – sterile. – Subhepatic collection drained by opening lateral part of wound

21. Patient started liquids orally and tolerating ~ 1.2 liter/ day. She developed fever (104) with chills on day 14 th, TLC: 9800, bili: 12, sgpt: 112, SAP: 312 Blood c/s – klebsiella pneumonia (ESBL strain) CVP removed Started on Imipenem-cilastatin according to c/s report. RT. PTBD withdrawn above anastomosis draining 30ml/ day bile, s.bili: 9.0

22. Subhepatic drain – 25ml/ day – shortened and applied stoma bag. Lt. PTBD- 150ml/ day S. albumin 2.2, given h. ablumin x 3 days Ambulation done Presently: no fever, P: 100-108/min, BP:120/90, RR: 20-22/min, chest clear, p/a: soft, passing stool, minimal pedal edema

23. Icterus ++, Hb: 10, tolerating oral feeds ~ 1500 kcal. Rt. PTBD: 50ml/ day, lt. PTBD: 100ml/day, subhepatic drain: 30ml /day. Usg abdomen: no significant residual collection, no cholengiolytic abscess or IHBRD.

24. Patient improved over 2 weeks with parenteral and enteral nutrition. Discharged on oral diet with PTBD cathetar in situ. On Follow up patient’s LFT normalised, catheter removed Evaluation at 6 months with HIDA scan and usg abdomen, LFT showed normal study.