NMS. Casos Clínicos

186

Part II ♦ Specific Disorders

Remnant bile duct

Roux limb

Figure 7-10: Illustration of a Roux-en-Y hepaticojejunostomy. (From Hughes SJ. Operative Techniques in Hepato-Pancreato-Biliary Surgery . Wolters Kluwer Health; 2015, Fig. 8-1.)

Case Variation 7.9.2. No previous cholecystectomy ◆ ◆ The most likely diagnosis is “a common duct stone with biliary obstruction .” An RUQ ultrasound evaluation to examine the gallbladder and the CBD is appropriate. An ultra- sound is good for detecting gallstones and bile duct dilation but not as good at visual- izing distal bile duct stones. If the patient is found to have gallstones, IV antibiotics are warranted, followed by ERCP with stone extraction. A cholecystectomy is necessary afterward.

Case 7.10 C omplications of Laparoscopic Cholecystectomy SAMPLE You perform a laparoscopic cholecystectomy for cholelithiasis in a 40-year-old man. Q: What is the appropriate management in each of the following postoperative situations? Case Variation 7.10.1. Postoperative fever and abdominal pain ◆ ◆ Most patients have an uneventful recovery after laparoscopic cholecystectomy, although they may have significant fever or pain, which may indicate an infection or biliary leak . The two most useful tests are an abdominal ultrasound study and hepatobiliary iminodi- acetic acid (HIDA scan), which involves the IV injection of hepatoiminodiacetic acid. The tracer is absorbed by the liver and excreted into the biliary tree, as long as the bilirubin level is below 8 mg/dL. A HIDA scan is a particularly good test for detecting biliary leaks, as well as acute cholecystitis (the gallbladder fails to visualize in acute cholecystitis) (Fig. 7-11).