Iatrogene biliovenöse Fistel

Summary

A 44-year-old man had suffered from cholecystolithiasis with recurrent jaundice for many years, and a cholecystectomy was carried out. Because of a radiomanometric obstruction of the common bile duct, the intra- and extrahepatic bile ducts were also scanned. One day after the operation the jaundice increased (serum bilirubin max. 742 μmol/l). The cause of the icterus was found in a small biliovenous fistula, and diverse surgical and angiological attempts to resect or close the fistula failed. In the third post-operative week renal failure developed, followed by a disturbance of coagulation and insufficient respiration and circulation. The man died 33 days after the operation. Autopsy showed massive jaundice, gastrointestinal bleeding, and cholemic nephrosis. Extensive preparation of liver resulted in a 20 × 8 × 15 mm fistula in the right lobe 9 cm proximal to the choledochotomy and anastomosing a thin branch of the right hepatic duct and a small hepatic vein. Long-time bilhemia resulted from this fistula and entailed renal failure and finally death. The fistula obviously resulted from scanning the bile ducts when the catheter was accidentally deviated into a biliary duct that was too small.

Zusammenfassung

Bei einem 44jährigen Patienten kam es bei der Sondierung der intrahepatischen Gallenwege mit einem Fogarty-Katheter im Rahmen einer Cholecystektomie wegen Cholecystolithiasis zur Perforation eines Seitenastes des D. hepaticus dexter und einer kleinen Lebervene, so daß eine biliovenöse Fistel entstand, über die wochenlang ein erheblicher Galleeinstrom in das Blut erfolgte (Serumbilirubin max. 742 μmol/l). Trotz klinischer Diagnose der Fistel und intensiver Bemühungen gelang es nicht, den tödlichen Ausgang abzuwenden. Infolge der Bilhämie kam es zur schweren cholämischen Nephrose, zum Nierenversagen, später zur Gerinnungsstörung, zur Atem- und Kreislaufinsuffizienz und schließlich zum therapie-resistenten Schock.