Sir,

First of all, I would like to extend my thanks to Dr. Hsiao and co-authors for the interesting report of an unusual case, ‘Obstructive jaundice as a complication of a right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy’.[1] I read the article with enthusiasm but got a bit confused. Therefore I would like to present two comments.

First comment: The authors stated that obstructive jaundice due to hepatic artery pseudoaneurysm had never been reported before. However, Peter et al. published a case of obstructive jaundice in a patient with severe haemobilia due to common hepatic artery pseudoaneurysm (5.7 × 5.3 cm) in 2014.[2]

Second comment: This involves the pathophysiology of obstructive jaundice. Starting with the abstract, I realised that the condition the patient had was haemobilia because of the clinical presentation, that is, tarry stools and obstructive jaundice. But later in the discussion it is stated that endoscopy was not performed because of the absence of gastrointestinal bleeding. So the key question is: What is the pathogenesis of obstructive jaundice, common bile duct (CBD) compression or Quincke's triad? If the patient had haemobilia, the clinical presentation of haemobilia is Quincke's triad (biliary colic, melena and obstructive jaundice). Of these elements, obstructive jaundice is seen in 60% of all haemobilia cases, biliary colic in 70% and melena in 90%.[3] The pathophysiological mechanism of jaundice in haemobilia is CBD obstruction by blood clots formed in pseudo-aneurysmal sac and transferred to CBD via fistula. Thus, CBD compression is not mandatory for the development of obstructive jaundice in a patient with haemobilia. Regarding imaging, air bubbles, blood clots and metallic clips in CBD can also lead to false positive diagnoses of choledocholithiasis or CBD obstruction.

To conclude, the case presented by Hsiao et al. is an interesting case with informative high-quality figures, but the aetiology of obstructive jaundice is debatable. In addition, it is worth emphasising that haemobilia, which is encountered in surgical practice increasingly owing to the development of minimally invasive surgery, is still a challenge requiring prompt and adequate diagnosis and treatment; moreover, requiring prevention by improving navigation in minimally invasive liver procedures and precise surgical technique.