Succesful Reconstruccion of Bile Duct Injury in COVID 19 Patient: A Case Report

A 37-year-old woman presented to the emergency room with a 1-week history of abdominal pain. On examination, she had pain in the right upper quadrant that worsened after meals and was febrile with a temperature of 38.3°. Laboratory studies demonstrated leukocytosis (white blood cell count of over 13,000), elevated inflammatory markers, and normal liver function tests. An ultrasound confirmed acute cholecystitis and pericholecystic fluid. Per hospital protocol, COVID-19 PCR was performed despite no respiratory symptoms. The PCR detected SARS-CoV-2. The risk-benefit was analyzed and the patient was taken to the operating room for an open cholecystectomy. The gallbladder was found with severe inflammation. A cholecystectomy was performed with a fundus-cystic technique. During the procedure, a choledochal duct injury was identified, and an intraoperative cholangiogram was requested, showing lesion Strasberg-E1. The hepatobiliary surgeon was requested who evaluated the case and decided to perform an early biliodigestive derivation (hepaticojejunal anastomosis). After the procedure, the patient developed respiratory acidosis and hemodynamic instability and was classified as having COVID-19 with severe illness. The patient was intubated for 6 days, then extubated and kept on high flow oxygen and nasal cannula as respiratory parameters improved. Eighteen days after admission, she was discharged to go home. Results: During the subsequent follow-up visit, a postoperative day 30 there were no operative or medical complications. A Cholangioresonance was requested, on day 90 postoperative, which showed functional hepaticojejunal anastomosis. [Formula presented] Conclusion: As described in the literature, up to 50 percent of patients with perioperative COVID-19 infection develop pulmonary complications. This patient presented metabolic and respiratory deterioration, requiring mechanical ventilation for 6 days. The case presented a surgical challenge due to the type of injury and the infectious control precautions required to operate on SARS-CoV-2 positive patients. Complex medical management was also required. Careful multidisciplinary management results in positive patient outcomes when dealing with complicated surgical cases.