YAJEM-159931; No of Pages 8

American Journal of Emergency Medicine xxx (xxxx) xxx

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Severe complications of chronic cholelithiasis treatment: A case series

Ludmila M. Mikhaleva a, Aleksandr I. Mikhalev b, Sergey G. Shapovaliants b, Olesya A. Vasyukova a,
Stanislav A. Budzinskiy b, Valentina V. Pechnikova a, Andrey E. Birjukov a,
Konstantin Yu. Midiber a, Mikhail Y. Sinelnikov a,⁎
a
Research Institute of Human Morphology, Moscow, Russia
b
Pirogov Russian National Research University, Moscow, Russia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Gallstone disease is a burden affecting about 15% percent of the population around the world. The
Received 27 February 2021 complications of gallstone disease are numerous and many require emergency care. Severe complications are
Accepted 18 March 2021 not uncommon and require special attention, as lethal outcome is possible.
Available online xxxx Case presentation: We present a retrospective analysis of eight cases describing severe complications of gallstones
in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our
Keywords:
emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and out-
Choledocholithiasis
Gallstones complications
comes are presented. The associated risk factors and preventative measures are discussed. Two patients devel-
Severe conditions oped profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications.
Endoscopic treatment complications One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in
Case series two cases lethal outcome was a result of co-morbidity and difficulties in management.
Conclusion: Special care should be taken in patients with risk factors of severe complications in order to improve
outcome and prevent the development of life-threatening conditions.
© 2021 Elsevier Inc. All rights reserved.

1. Introduction
Gallstone disease affects up to 15% percent of the world population
[1]. Current standards regarding treatment strategies have been chang-
ing in response to new data on clinical outcome and disease progression
[2-4]. Emergency medical treatment is often required in case of severe
complications [5,6]. Severe complications and lethal outcome are often
a result of significant co-morbidities, postoperative complications and
incorrect treatment strategy [7]. Several life-threatening complications
with a mortality rate of up to 22.5% are associated with endoscopic in-
terventions and include: bleeding, duodenum perforation, acute post-
operative pancreatitis, bile duct injury [8-10]. Most often these
conditions are difficult to diagnose, and go unnoticed until the severity
of the patient's condition is unmanageable. Several extremely rare pa-
thologies are underreported (bilioma, hidden perforation) and require
improved reporting for stratification of knowledge.
1.1. Materials and methods
We present a case series including eight patients who developed se-
vere complications following endoscopic retrograde cholangiopan-
creatography (ERCP), endoscopic papillosphincterotomy (EPST) or
⁎ Corresponding author at: Udaltzova 4, 370, 119415 Moscow, Russia.
E-mail address: mikhail.y.sinelnikov@gmail.com (M.Y. Sinelnikov).
cholecystectomy. Patient consent was acquired for publication of all asso-
ciated data and images. Patients included in this study were admitted to
the emergency care department with signs of severe complications fol-
lowing chronic cholelithiasis treatment. A summary of data according to
CARE guidelines is presented in Table 1.
1.2. Case 1
Patient С., male, 38 years old, was admitted to the emergency de-
partment with jaundice, persistent pain in the right hypochondrium,
and a low fever. Jaundice onset was two weeks. Ultrasonic evaluation
revealed signs of chronic cholecystitis, choledocholithiasis, biliary hy-
pertension. Laboratory tests showed hyperleukocytosis (12.9*109/l),
thrombocytopenia (134.0*109/l), hyperbilirubinemia (total bilirubin
- 409.2 μmol/l; direct bilirubin 226.9 μmol/l; indirect bilirubin
183.3 μmol/l), and elevated liver enzymes (aspartate transaminase
(AST) 123 U/L; alanine transaminase (ALT) 19.3 U/L; alkaline phos-
phatase (ALP) 208.5 U/L). An urgent ERCP revealed common bile
duct stenosis, choledocholithiasis, biliary hypertension (Fig. 1). A
classic endoscopic papillosphincterotomy and balloon dilation were
performed. A 4 cm long dilator with a diameter of 12 mm was intro-
duced into the duct. Balloon dilatation was performed for 30 s, at up
to 3 atm. After dilation, the choledochal orifice expanded to 6–7 mm
in diameter. Cholangioscopy with lithotripsy and lithoextraction were

Please cite this article as: L.M. Mikhaleva, A.I. Mikhalev, S.G. Shapovaliants, et al., Severe complications of chronic cholelithiasis treatment: A case
series, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2021.03.052
L.M. Mikhaleva, A.I. Mikhalev, S.G. Shapovaliants et al. American Journal of Emergency Medicine xxx (xxxx) xxx

Table 1
Patient information, clinical findings, diagnostic assessment results, intervention, outcome data

No. Age Sex Diagnosis Surgery Complication Management Outcome

1 38 M Chronic calculous cholecystitis, endoscopic papillosphincterotomy, post-ERCP-pancreatitis non-surgical treatment Lethal outcome
choledocholithiasis, common bile duct balloon dilation, bile calculi extraction
stenosis, jaundice
2 40 F Chronic calculous cholecystitis, endoscopic papillosphincterotomy, gastrointestinal laparotomy, Lethal outcome
choledocholithiasis, common bile duct balloon dilation, bile calculi extraction
bleeding (from choledochotomy
stenosis, jaundice porto-biliary fistula)
3 58 F Postcholecystectomy syndrome, endoscopic papillosphincterotomy, bile post-ERCP pancreatitis selective stent placement in Recovery
choledocholithiasis, jaundice calculi extraction the pancreatic duct
4 64 F Chronic calculous cholecystitis, endoscopic papillosphincterotomy, bile Gastro-intestinal papillosphincteroplasty Recovery
choledocholithiasis, jaundice calculi extraction bleeding
5 29 F Chronic calculous cholecystitis, endoscopic papillosphincterotomy, bile retroduodenal self-expanding stent Recovery
choledocholithiasis, acute extrahepatic bile calculi extraction perforation placement
duct obstruction (jaundice, pancreatitis)
6 41 F Chronic calculous cholecystitis, endoscopic papillosphincterotomy, bile retroduodenal self-expanding stent Recovery
choledocholithiasis calculi extraction perforation placement
7 36 F Chronic calculous cholecystitis, Mirizzi cholecystectomy, hepaticostoma, common bile duct Hepaticoenteroanastomosis, Liver cirrhosis,
syndrome, common bile duct injury hepaticoenteroanastomosis injury percutaneous-transhepatic awaiting
percutaneous-transhepatic biliary biliary drainage transplantation
drainage
8 67 F Chronic calculous cholecystitis, injury of cholecystectomy, Bilioma endoscopic retrograde Recovery
the common bile duct choledochodenostomy cholangiography, biliary
stenting

stent placement were performed. Balloon dilation and lithotripsy were

then performed. During balloon dilation of the common bile duct,
bleeding occurred. The intensity of bleeding significantly decreased
after rinsing. A lithotripter was then inserted into the common bile
duct lumen; the gallstones were successfully removed. Several hemor-
rhagic clots were then extracted with the lithotripter from the proximal
end of the common bile duct. Active bleeding resumed from the
choledochal lumen. Attempts to aspirate and rinse incoming blood
were unsuccessful, and accompanied by rapid deterioration in cardio-
vascular and respiratory indicators. The decision made to converse to
laparotomy. Upon surgical revision, no active bleeding was found. A
cholecystectomy, choledochotomy, T-tube placement into the common
bile duct, and abdominal drainage were performed. No signs of choleli-
thiasis or bleeding from the biliary tract remained. No wall defect in the
duct was detected. The total blood loss was 3000 ml, of which 500 ml
during laparotomy procedure. The patient was transferred into the in-
tensive care unit, where she went into cardiac arrest. Attempts to save

Fig. 1. Endoscopic retrograde cholangiopancreatography showing secondary common bile

duct stenosis due to choledocholithiasis, signs of biliary hypertension.

performed. Contrast evacuation of 10 ml of counterstain was ob-

served within 10 min. Three hours after intervention, the patient de-
veloped acute pancreatitis, which was complicated by pancreatogenic
shock. Multiple organ dysfunction syndrome developed. The patient
underwent extracorporeal detoxification with no positive effect. A le-
thal outcome was pronounced 48 h after intervention.

1.3. Case 2

Patient N., 40 years old, was admitted with complaints of pain in the
upper abdomen, darkening of urine, and yellowing of the eyes. Symp-
toms persisted for over a week, yet the patient did not seek medical at-
tention. Ultrasonic evaluation revealed signs of biliary hypertension and
an enlarged pancreas. Laboratory tests showed signs of obstructive
jaundice (total bilirubin 64.2 μmol/l; direct bilirubin 44.6 μmol/l; indi-
rect bilirubin 19.6 μmol/l). Urgent ERCP revealed biliary tract compres- Fig. 2. Endoscopic retrograde cholangiopancreatography showing signs of biliary tract
sion (Fig. 2). An endoscopic papillosphincterotomy and choledochal compression.

2
L.M. Mikhaleva, A.I. Mikhalev, S.G. Shapovaliants et al.
the patient's life were unsuccessful. A lethal outcome was pronounced
1 h and 15 min after intervention. An autopsy revealed the presence
of a porto-biliary fistula 4.5 cm from the distal choledochal orifice
(Fig. 3). Pathohistological examination of the common bile duct tissue
showed severe sclerotic changes, lympho-neurophil infiltration (Fig. 4).
1.4. Case 3
Patient D, female, 58 years old, was admitted with post-
cholecystectomy syndrome (PCS) and obstructive jaundice. Three
years before the current admission, the patient received a laparoscopic
cholecystectomy. Laboratory results showed hyperbilirubinemia (total
bilirubin 98.4 μmol/l; direct bilirubin 72,8 μmol/l) and high levels of
aspartate aminotransferase (116 U/l), alanine aminotransferase
(19.3 U/l), and alkaline phosphatase (108.5 U/l) were noted. Ultraso-
nography revealed an expanded common hepatic duct, up to 10 mm
in diameter. ERCP showed dilatated biliary ducts up to 11 mm in diam-
eter with a tapered narrowing in the terminal part of the common bile
duct, and inhomogeneity in the distal part of the common bile duct
(Fig. 5). The contrast agent filled the major pancratic duct and remained
in its lumen for an extended time. Choledocholithiasis and Grade 3
papillostenosis were diagnosed. An EPST was performed with a tissue
biopsy. Pathohistological evaluation showed significant fibrotic
changes. On the first day after surgery, the patient developed post-
ERCP-pancreatitis. As a result, an emergency endoscopic procedure
was performed. Stent deployment into the major pancreatic duct (7Fr
diameter, 5 cm length) and enteral feeding tube placement were per-
formed. The patient was treated in the ICU for three days, and then
discharged into the clinic. At two months follow up, a stent removal
was performed. The outcome was complete recovery.
1.5. Case 4
Patient B, female, 64 years old, was admitted acute choledocholithi-
asis and obstructive jaundice. Laboratory examination showed
hyperbilirubinemia (total bilirubin 209.4 μmol/l; direct bilirubin
172,8 μmol/l), increased levels of hepatic enzymes (AST 116 U/l, ALT
Fig. 3. Post-mortem visualization of porto-biliary fistula: the source of severe
gastrointestinal bleeding.
3
American Journal of Emergency Medicine xxx (xxxx) xxx
112 U/l). Ultrasonography revealed biliary hypertension and calculous
cholecystitis. ERCP showed expanded biliary ducts (up to 18 mm)
with two calculi (8 and 17 mm in diameter) (Fig. 6). After selective cath-
eterization of the common bile duct, an EPST was performed with bal-
loon dilation, lithotripsy and lithoextraction. The common bile duct
orifice opened up to 4 mm. No bleeding was observed. The gallstone
was successfully removed (Fig. 7). The procedure was complicated by
profuse bleeding in the dilation area. Attempts at endoscopic hemosta-
sis were ineffective. 800 ml of blood were lost, so an emergency laparot-
omy was performed and hemostasis was achieved. Postoperative care
stabilized the patient and he was discharged in a satisfactory condition.
Complete recovery was achieved.
1.6. Case 5
Patient A., 29-year-old, female, was admitted to the emergency de-
partment with signs of acute extrahepatic bile duct obstruction
(EHBDO) of the terminal choledochal portion, multiple choledocholithi-
asis, acute obstructive jaundice, acute biliary pancreatitis. This condition
required urgent surgical intervention. Duodenoscopy revealed a hyper-
emic and edematous orifice of the major duodenal papilla. ERCP re-
vealed dilated (up to 8 mm) bile ducts with five stones (from 6 to
8 mm in diameter) in their lumen (Fig. 8). EPST with gallstone and
biliary sludge removal were performed. The procedure was compli-
cated by intraoperative bleeding from the upper incision during
papillosphincterotomy. Bleeding was stopped via coagulation. A pan-
creatic drainage (7Fr dimeter; 3 cm length) was placed for preventive
purposes. A perforation (1.5 mm in diameter) was revealed below and
to the right of the common bile duct orifice during post-papillotomy re-
vision. The catheter went up to 5 cm into the retroduodenal space. Con-
trast probe showed a tubular structure (5 mm in diameter) with
indistinct contours running next to the common bile duct, which con-
firmed retroduodenal perforation (Fig. 9). 30 ml of dioxidine solution
was injected into the defect margins and a biliary self-expanding stent
(8 cm length; 10 mm diameter) closed the defect completely. The post-
operative period was uneventful. The patient was discharged on the
10th day after surgery. The stent was removed after 1.5 months,
followed by laparoscopic cholycystectomy. Complete recovery was
achieved.
1.7. Case 6
Patient K., female, 41 years old, was admitted with a 5-year history of
obstructive jaundice episodes. Sonography revealed calculous cholecys-
titis, biliary hypertension, multiple choledocholithiasis. A planned ERCP
confirmed the diagnosis (Fig. 10). An EPST with lithotripsy and
lithoextraction was then planned. During EPST, a wall defect was de-
tected area immediately below and to the left from the common bile
duct orifice (up to 3 mm in diameter). Contrast probe showed a
pericholedocheal “cloud” (4 × 2.5 cm), indicating the retroduodenal
perforation. 20 ml of dioxidine solution was injected into the defect
area, and a biliary self-expanding stent (8 cm length; 10 mm diameter)
was installed. The defect was closed entirely. The postoperative period
was uncomplicated. The patient was discharged on the 9th day after
surgery. The stent was removed on the 28th day. Overal outcome was
complete recovery.
1.8. Case 7
Patient N., female, 36 years old, was admitted to the emergency de-
partment with symptoms of acute calculus cholecystitis. No signs of
jaundice or pancreatitis were present. An ultrasound scan revealed
signs of chronic calculous cholecystitis without biliary hypertension.
Laboratory test results showed no pathological alterations. A laparo-
scopic cholecystectomy was performed. Intraoperatively, a small-sized
gallbladder with a scar-modified wall, an infiltrate in the gallbladder
L.M. Mikhaleva, A.I. Mikhalev, S.G. Shapovaliants et al.
Fig. 4. Pathological evaluation of common bile duct tissue. Signs of severe fibrosis. Mallory stain (A – magnification x10; B – magnification x20).
Fig. 5. Endoscopic retrograde cholangiopancreatography showing signs of biliary tree
dilation, papillary stenosis.
Fig. 6. Endoscopic retrograde cholangiopancreatography showing signs of calculous
masses in the biliary duct and dilation.
4
American Journal of Emergency Medicine xxx (xxxx) xxx
neck region was found. A fistula between the common bile duct and the
gallbladder was found. Considering intraoperative findings, the decision
was made to refrain from hepatico-jejunal anastomosis and divide the
surgical treatment into two stages. A hepaticostoma was placed during
the first stage. This succesfully brought the bile flow rate up to 500 ml/
day (data from magnetic resonance cholangioscopy). The patient was
discharged with normal laboratory results and recommendations for
second stage surgical intervention in 6 weeks. However, in 2 weeks
spontaneous drainage removal occurred. The patient developed jaun-
dice (total bilirubin at 270 μmol/l). PA percutaneous transhepatic drain-
age (8Fr) was placed. After eliminating jaundice, the patient was
discharged with a functioning drainage for ambulatory rehabilitation
prior to reconstructive surgery.
A planned hepatico-jejunal anastomosis was performed by Roux-
technique. The previously installed percutaneous transhepatic drainage
was not removed. Bile flow through the drainage was absent. The pa-
tient was discharged in satisfactory condition. Two months later, the pa-
tient was once again admitted to the clinic with obstructive jaundice
and cholangitis. We identified hepatico-jejunal anastomosis stricture
and drainage obstruction. The external-internal biliary drainage was re-
vised and replaced (Fig. 11). Over the next two years, the patient had
four more jaundice episodes associated with drainage obstruction,
which required its replacement. The patient developed biliary hepatitis
associated with secondary sclerosing cholangitis leading to liver cirrho-
sis. The patient is hereby on the waiting list for liver transplantation. The
outcome was negative.
1.9. Case 8
Patient H., 67-year-old female, was admitted to the emergency
department with complaints of pain in the right hypochondrium, low-
grade fever, general discomfort, and lack of appetite. Patient history re-
vealed acute phlegmonous cholecystitis treated by cholecystectomy,
choledocholithotomy, choledochoduodenostomy. The procedure was
complicated by pancreatic necrosis which required laparotomy and
drainage placement into the subhepatic space. No other symptoms oc-
curred until this admission. Upon admission, two drainage tubes were
observed in the right mesogastric area. The skin around the tubes was
reddened with maceration. No pathological formations were palpable.
There were no signs of peritonitis. Laboratory findings included mild
anemia and lymphopenia. A chest X-ray showed right-sided hydrotho-
rax, treated by a thoracostomy (800 ml of fluid evacuated). Pleural fluid
testing demonstrated abundant growth of Klebsiella Oxytoka.
Fistulography showed an irregular shaped cavity (2.9 × 4.8 cm) in the
subhepatic space, with discharge into the duodenum. A bilioma was
L.M. Mikhaleva, A.I. Mikhalev, S.G. Shapovaliants et al.
Fig. 7. Endoscopic resolution of a choledocholithiasis with a large gallstone (A – balloon dilation; B – lithoextraction).
diagnosed. The second drainage was also located in the abdominal cav-
ity. No counterstain was observed in the bile ducts (Fig. 12). After the
fistulography, the abdominal cavity drains were removed. A Foley cath-
eter (No.6) was installed. Ultrasound examination showed diffuse
changes in the liver and pancreas, and a circumscribed fluid collection
in the subhepatic space with a diameter of 5 cm was detected. By con-
trasting the bile tree through the choledochoduodenostomy orifice an
oval-shaped leakage (5x3cm biloma) was determined, from which the
contrast agent entered the right segmental ducts of the liver. Treatment
included installation of a 7Fr nasobiliary drainage into the biloma
(Fig. 12).
Adequate bile flow was achieved. On the 4th day after biloma drain-
age, balloon dilatation of the distal section of the right lobar duct and the
biloma orifice was performed up to 8 mm. A plastic Olympus stent (5Fr)
was then placed into one of the segmental ducts via choledochoscopy.
The surgery was completed by directing biloma drainage into the duo-
denum with an Olympus endoprosthesis (8.5Fr). After both stents
were placed, they facilitated active flow of unchanged bile. After this
procedure, no bile flow through the Foley drainage was seen. The tube
was removed, and the patient was discharged. Four weeks later, the fis-
tula on the anterior abdominal wall closed completely. A retrograde
cholangiography, revision of previously installed biliary stents, their la-
vage, and an additional plastic Olympus bilioduodenal drainage (8.5Fr)
Fig. 8. Diagnostic procedures (A – duodenoscopy revealing a gallstone wedged in the major duodenal papilla; B – ERCP with signs of dilation, choledocholithiasis).
5
American Journal of Emergency Medicine xxx (xxxx) xxx
placement was performed. ERCP showed a decrease in biloma size
(3 × 2 cm). The postoperative period was uneventful, and the patient
was discharged 3 days after intervention. One month later, ERCP
showed complete reduction of the biloma. The bile duct contours
were clear and even, corresponding to stent diameter, no leakage was
seen (Fig. 13).All three biliary stents were removed. It took 4 min for
full counterstain evacuation from the entire biliary tract. After dis-
charge, during dynamic follow-up over the next four months no signs
of biloma recurrence or impaired bile outflow were noted.
2. Discussion
One of the most common complications of endoscopic transpapillary
interventions is acute pancreatitis. It can be caused by balloon dilation of
the major duodenal papilla, atypical (non-cannulation) EPST technique,
pancreatic sphincterotomy, multiple attempts at major duodenal pa-
pilla cannulation, and litoextraction of large stones and fragments
from the bile ducts [11,12]. Other risk factors include papillary stenosis,
Oddi sphincter dysfunction, female sex, history of prior acute pancreati-
tis, age, non-dilated bile duct, and normal biochemical bloodwork
[13,14]. In our case series, two patients developed acute pancreatitits
following transpapillary intervention (Case 1, 3). Both patients had as-
sociated risk factors. Lethal outcome in a case of acute pancreatitis
L.M. Mikhaleva, A.I. Mikhalev, S.G. Shapovaliants et al.
Fig. 9. Signs of endoscopic perforation (A – endoscopic visualization of duodenal wall defect; B – visible retroduodenal leakage of contrast agent).
Fig. 10. ERCP showing dilation of the biliary tree and biliary sludge content.
Fig. 11. Percutaneous transhepatic cholangiography showing active external and internal
bile drainage.
6
American Journal of Emergency Medicine xxx (xxxx) xxx
(Case 1) was due to a presumably long history of disfunction (based on
admission status), present stenosis and balloon dilation, which exacer-
bated post-manipulation edema. A lethal outcome could have been
avoided if the patient received preventative measures. Endoscopic
stent placement into the pancreatic ducts is currently one of the most
reliable methods for post-endoscopy-pancreatitis prevention [15],
along with pharmaceutical therapy (non-steroidal anti-inflammatory
drugs; somatostatin analogs) [16].
The main cause of post-ERCP-pancreatitis is disorder of pancreatic
juice discharge due to evolving edema of the EPST zone involving the
pancreatic duct orifice [17]. Many healthcare specialists dismiss
performing emergency pancreatic stent placement in cases of acute
pancreatitis [18]. This can be explained by the significant technical diffi-
culties arising while carrying out pancreatoduodenal drainage during
increasing edema and changes associated with acute pancreatitis. Risk
of post-ERCP-pancreatits aggrivation due to additional manipulations
should be noted. We are inclined to support clinicians who recommend
the earliest possible endoscopic stenting of the pancreatic duct
when clinical, lab and instrumental tests results imply post-ERCP-
pancreatitis onset [19].
A dangerous complication of endoscopic procedures on the biliary
tree is perforation of the duodenum, hepatic or pancreatic ducts
[20,21]. Several factors contribute to this life-threatening condition:
major duodenal papilla stenosis, female sex, age (>50), individual vari-
able anatomy of the upper GI-tract, factors associated with intervention
(complex cannulation, intramural administration of a contrast agent,
long intervention duration, non-cannulation papillotomy, balloon dila-
tation of biliary strictures, low experience of the endoscopy specialist).
The management tactics in patients with perforations rely on a timely
diagnosis, the severity of the patient's condition, the type and mecha-
nism of defect formation, its localization and size, the possibility of en-
doscopic intervention, leakage characteristics, and the presence of
peritonitis [22-26]. Nasobiliary drainage [27], clipping of the defect
[28], bilioduodenal stent placement [29], fibrin glue [30] are most com-
monly used to treat perforations. Timely diagnosis in both such cases
(Cases 5, 6) allowed us to use endoscopic techniques for sealing the per-
forations with stent placement overlapping the defect with positive
outcome.
Bleeding risk factors following endoscopic transpapillary procedures
include: coagulopathy, anticoagulant usage, chronic cholangitis, termi-
nal stenosis of common bile duct, atypical non-cannulation papillotomy,
hemodialysis, severe obstructive jaundice [17]. A portobiliary fistula is a
very dangerous condition, often leading to profound bleeding. It is
caused by various digestive tract diseases, including neoplasms,
L.M. Mikhaleva, A.I. Mikhalev, S.G. Shapovaliants et al.
Fig. 12. Subhepatic biloma on ERCP (A – retrograde contrasting; B – nasobiliary drainage placed into the biloma).
Fig. 13. ERCP control shows complete reduction of biloma, active stent drainage and no
leakage.
cholelithiasis, inflammatory diseases [31,32] and is known to be difficult
to diagnose intraoperatively [33]. One case of portobiliary fistula forma-
tion caused by acute hemorrhagic pancreatitis has been described [34].
We presented two cases of gastrointestinal bleeding following endo-
scopic intervention (Cases 2, 4). A lethal outcome in Case 2 was associ-
ated with a portobiliary fistula, which was not diagnosed during
intervention or revision. This underlines the importance of thorough re-
vision and preventative measures in case of associated risk factors.
Iatrogenic lesions of the extrahepatic bile ducts occur rarely (0.06%–
0.3%) [35-37]. Damage associated with these conditions require surgical
revision. We present a case of common bile duct trauma (Case 7) which
noticed during surgery. However, technical conditions did not allow
one-stage Roux-en-Y anastomosis. Therefore multi-stage treatment
was required: hepaticostomy and later hepato-jejunal anastomosis.
Despite these procedures, biliodigestive anastomosis strictures were a
recurrent problem in this patient. This condition eventually led to
biliary liver cirrhosis, which requires organ transplantation. This case
represents a rare persistent complication, which may be associated
with sclerosing cholangitis, and may persist even after liver transplanta-
tion [38-40].
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American Journal of Emergency Medicine xxx (xxxx) xxx
Bilioma formation requires reconstructive surgery performed after
preliminary percutaneous [41]. This treatment type is very traumatic
for patients who have to undergo one or more additional surgical inter-
ventions. Minimally invasive surgeries in a conventional extent, such as
retrograde or percutaneous-transhepatic stent placement are an alter-
native to complex reconstruction. In our patient (Case 8) with a bilioma,
we utilized minimally invasive methods to correct such complications
successfully, despite their technical complexity. Biliomas are quite rare
and often sever complications associated with trauma, fistulas, iatro-
genic damage [42].
As a result, the presented cases included patients who developed se-
vere complications of common procedures due to the presence of asso-
ciated complicating factors. Preventative measures in several cases
could have improved the outcome, yet were not undertaken due to
lack of specific signs of developing complications. Therefore, it is neces-
sary to perform preventative procedures despite subjective manifesta-
tion of signs associated with severe complications.
Chronic gallstone disease has many various symptoms and manifes-
tations and may lead to life-threatening severe complications that
should always be kept in mind. During endoscopy manipulations and
open surgeries, health care specialists should always consider the possi-
bility of post-manipulative pancreatitis and biliary fistula formation as a
probable and dangerous complications in patients with long-term cho-
lelithiasis and severe chronic inflammation leading to bile duct stenosis.
Special care should be made to prevent these complications, especially
in patients with associated risk factors.
Funding
None.
Ethics approval and consent to participate
The current study was approved by the institutional ethics commit-
tee Pirogov National Research University. Patient consent was acquired
from all participants.
Consent for publication
Consent for publication was acquired from all patients, or their legal
representatives.
L.M. Mikhaleva, A.I. Mikhalev, S.G. Shapovaliants et al.
Data availability
All data and materials are available from the corresponding author
upon reasonable request.
Authors' contributions
Mikhaleva L.M. - investigation, formal analysis, data curation.
Mikhalev A.I., Shapovaliants S.G., Vasyukova O.A., Sinelnikov M.Y., and
Budzinskiy S.A. - conceptualization, writing - original draft, writing - re-
view & editing. Pechnikova V.V., Birjukov A.E., Midiber K.Yu., - data
curation, methodology. Mikhaleva L.M. and Sinelnikov M.Y. - validation,
project administration. All authors approved the final version of the
manuscript.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Acknowledgements
None.
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