1. Major bile duct injury after open cholecystectomy
Case report

2. 50 years old female patient referred from thoracic ward, complaining from jaundice and bile leak from recent rt. Thoracotomy incision. she was complaining from rt. Subphrenic collection missed dx as empyema of rt. Chest ( by US &CXR).

3. The chest was clear ,the diaphragm was bulged, opened and drainge of pus and bile, subphrenic tube drain and chest tube were inserted.postop. bile leak through tube drain followed by ext. biliary fistula through thoracotomy incision (postop. US findings were mild intrahepatic biliary dilatation & NO collection).

4. The patient referred to GIT center, for further management
The patient referred to GIT center, for further management. Detailed history was taken : open cholecystectomy was done 14 months ago followed by postop. Bile leak and intermittent jaundice more than 2 m. ,then the pt. deteriorated and 2nd laparotomy done in another hosp. (unknown op. data), on and off jaundice with s&s of cholangitis for more than 6 m. readmission and treated conservatively , then the pt. complaining from dyspnoe ,fever and illhealth made her sought advice of th. Surgeon.

5. Haematological &biochemical investigations were done (mild anaemia,leukocytosis, elevated ESR, increased liver enzymes&TSB).
Test for hepatitis viruses(negative).

6. ERCP was the next step in mx
ERCP was the next step in mx. There was complete cutoff in the distal CBD.

7. MRCP was done to delinate the biliary anatomy: reveal proximal extrabiliary &intrabiliary ductal dilatation, with rt. Subphrenic collection?

8. The pt. arranged for operation: generous midline incision, very dense adhesions in the area of porta hepatis with complete transaction of common hepatic duct.
Roux-en-y choleduchjejunostomy (with difficulty) was done with stenting the site of anastomosis by foley's cath. Size 8, brought out through jejunum &skin.

9. preoperative MRCP

13. Postoperative cholangiography via transcutaneous biliary stent