The local inflammation and gangrenous aspect of gallbladder (as the pathological report #ABT-263 supplier randurls[1|1|,|CHEM1|]# confirmed) did allow us to place a trans-cystic T-tube, to use as a biliary tutor and/or as a device, through which a cholangiography could be run, and an abdominal drainage. Post-operative clinical course progressively improved, but the T-tube flow was low (between 100-300 cc) and bilirubin level began to increase from the 5-th day after operation, while the abdominal drainage began to drain bile (500 cc). The patient’s conditions were good, without any signs of localized or generalized peritonitis or

intraperitoneal bile collections: there was a controlled high flow external fistula. check details A conservative treatment was instituted, so

the patient was nourished by parenteral way, deficits of electrolytes and vitamins (mostly vitamin K) were corrected and octreotide (somatostatin analogue) was delivered to reduce biliary secretion. Therefore we performed a trans- Kehr cholangiography to assess the origin of fistula, the anatomy of the entire biliary tree and the presence and extent of the injury to the biliary system. Cholangiography showed a separation between right and left biliary ducts, a failure opacification of intrahepatic biliary tracts and of common biliary duct because of a non complete transaction (figure 1), so we decided to position a percutaneous transhepatic biliary drainage (PTHBD) on the right biliary emisistem

(figure 2) and to perform ERCP to reconstruct biliary tract. Figure 1 Failure opacification of intrahepatic biliary tracts and of common biliary duct. Figure 2 Separation between right and left biliary ducts, abdominal drainage (black arrow), PTHBD (white arrow). Post-operative control showed a well-positioned drainage but a biliary leakage (figure 3). Figure 3 Control: PTHBD is correctly positioned into the right biliary tract with distal tip around the surgical drainage. We resisted the temptation to attempt primary repair at this stage Cell press because of local inflammation. This conservative treatment was prosecuted for 3 weeks with the hope of a spontaneous closure of the fistula. But it was not so and because of the better condition of the patient, we decided to perform a new operation. After an intra-operative cholangiography we executed an hepaticojejunostomy on left hepatic duct (the only one which was accessible) with Roux reconstruction and positioning of biliary tutor and abdominal drainage. General condition of the patient did not improve because of 3 severe episodes of cholangitis, treated with antibiotics and because a progressive anaemia.